This document discusses abortion and its management. It begins by listing group members and defining abortion as termination of pregnancy before fetal viability, usually considered 20 weeks. Worldwide, 80 million abortions occur annually, with 40% being unsafe. Abortions are categorized as spontaneous, induced, early or late. Etiologies include genetic, infectious, uterine and endocrine factors. Clinical types include threatened, inevitable, incomplete, complete, missed and recurrent abortions. Diagnosis involves symptoms, signs and tests. Management depends on type and presence of infection, and involves medical, surgical and counseling approaches. Complications can include hemorrhage, infection and injury.

1. GYN/OBY WARD

2. Group MEMBERS
1. Assefa Mekonnen
2. Alemayehu Tarekegn
3. Albab Weyessa
4. Andualem Wondimu
5. Amanuel Teno
6. Ayalkbet Mindaye
7. Abenezer Yohannis
8. Behailu Zegeye
9. Besufikad Mathewos

3.  Definition of abortion
 Epidemiology of abortion
 Categories of abortion
 Etiologies of abortion
 Clinical types of abortion
 Diagnosis of abortion
 Management of abortion
 Complications of abortion
 References

4.  Abortion (miscarriage) is termination of pregnancy
before fetal viability
 Fetus acquires potential viability starting from a
gestational age of 24 weeks, when the alveolar
development and surfactant production begins in the
fetal lungs.
 WHO considers a gestational age of 20 weeks as the
cut off for fetal viability and thus for the definition of
abortion versus delivery

5.  World wide, total pregnancies 208 million: 2 in 5
pregnancies were unintended, and 1 in 5 end in
abortion.
 Spontaneous abortion complicates 10-20% of
pregnancies
 Incidence of induced abortion varies from country to
country based on the availability and accessibility of
contraception
 WHO estimates that there are 80 million abortions
annually of which 40% are unsafely induced
 Nearly 80,000 maternal deaths (20% of total annual
global maternal mortality) is due to unsafe abortions

6. 1. Based on etiology – Spontaneous versus Induced
abortion
2.Based on gestational age – Early (less than 12 weeks)
versus Late abortion(greater than 12weeks) – late
abortions have more complication risk than early
abortions
3.Based on clinical presentations – Different clinical types
4.Based on site of termination in induced abortions – Safe
versus unsafe abortion ( performed by unskilled person on
in an ill equipped setting)

7.  Spontaneous Abortion is a death of a fetus, sometimes
with a passage of products of conception( fetus and
placenta), before 20 weeks of gestation.

8. 1.Genetic abnormalities – up to 60%
◦ Chromosomal
◦ Gene defects
2. Infections
◦ Maternal infections – e.g. malaria, pyelonephritis
◦ Perinatal infections – e.g. syphilis, mycoplasma,
3. Uterine factors
◦ Uterine myomata
◦ Mullerian abnormalities or defects – septate, bicornuate uterus
◦ Cervical incompetence

9. 4.Endocrine abnormalities
◦ Hypothyroidism; hyperthyroidism
◦ Uncontrolled diabetes mellitus
◦ Luteal phase defects (Progesterone deficiency)
5.Immunological factors – autoimmune diseases
◦ Anti-phospholipid syndrome, SLE
6.Abdominal trauma

10.  Induced abortion is a pregnancy that is intentionally
terminated early, using either a surgical procedure or
medication.

11.  Termination of pregnancy by a recognized medical
institution within the period permitted by the profession is not
punishable where:
The pregnancy is a result of rape or incest; or
The continuation of the pregnancy endangers the life of the
mother or the child or the health of the mother or where the
birth of the child is a risk to the life or health of the mother;
or
The fetus has an incurable and serious deformity; or
The pregnant woman, owing to a physical or mental
deficiency she suffers from or her minority, is physically as
well as mentally unfit to bring up the child.

12. 1.Therapeutic Abortion(maternal)
◦ Persistent cardiac decompensation
◦ Severe diabetes
◦ Advanced hypertensive vascular disease
◦ Invasive carcinoma of the cervix
◦ Rape
◦ Incest
◦ Fetus with a significant anatomic or mental deformity
◦ IUFD

13. 2. Fetal indications for abortion
Fetal cardiac anomalies
Trisomy 21,13, 18,
Open and closed neural tube defects
Anencephaly, some hydrocephalic cases
Cystic kidneys , hydronephrosis, renal agenesis
Intracranial calcifications suggestive of viral
disease

14. 3. Elective (Voluntary) Abortion
◦ At the request of the woman, but not for medical reasons

15. 1. Threatened abortion
◦ Minimal vaginal bleeding and lower abdominal cramps
◦ Closed cervix and uterine size comparable to gestational age
◦ Alive fetus
◦ 60-80% continue the pregnancy
2. Inevitable abortion
◦ Heavier vaginal bleeding and more severe cramps
◦ Open cervix but no expulsion of conceptus yet
◦ Leakage of liquor even without open cervix

16. 3. Incomplete abortion
 Features of inevitable abortion with additional feature
of expulsion of conceptus parts outside the cervix
4. Complete abortion
• Complete expulsion of all conceptus parts which are identified
by provider including the fetus, placenta, membranes and cord
• Uterus well contracted and cervix closed
• Cessation of vaginal bleeding

17. 5.Missed abortion
• Initial symptoms of abortion subside with cessation of vaginal
bleeding and uterine contractions
• Regression of symptoms and signs of pregnancy
• Closed cervix and uterine size less than calculated weeks of
amenorrhea
6.Recurrent (habitual) abortion
• Three or more consecutive abortions
7.Septic (infected) abortion
• Any of the abortion types complicated by infection

18.  Diagnosis of a pregnancy less than fetal viability
 Symptoms
◦ Vaginal bleeding
◦ Abdominal cramps
◦ Leakage of liquor or expulsion of conceptus
◦ Regression of pregnancy symptoms in missed abortion
 Signs
◦ Hemodynamic instability
◦ Vaginal bleeding
◦ Cervical changes and reduced uterine size
◦ Visualization of expelled conceptus

19.  Hemoglobin ( hematocrit)
 Blood group and RH type
 Pregnancy test if necessary
 Ultrasonography to document fetal viability
 Blood cross match if necessary
 In cases of septic abortion – as required
WBC and differential
Coagulation profile
Liver and renal function tests …

20.  Depends on:
◦ Clinical type of abortion
◦ Gestational age: early versus late
◦ Presence or absence of infection
 Elements of abortion management:
◦ Medical/surgical management of abortion
◦ Counseling
◦ Post abortion family planning
◦ Linkages with other reproductive health services
◦ Community partnerships and involvement

21.  Threatened abortion
◦ Bed rest, avoidance of coitus
◦ Advice to return if heavy bleeding or passage of conceptus
 Inevitable abortion
◦ Early – Suction curettage (manual vacuum aspiration)
◦ Late- Expel conceptus with oxytocin drip and supplement with
curettage as required
 Incomplete abortion
◦ Early – Suction curettage
◦ Late – Suction or metallic curettage as convinient

23.  Diagnose and date pregnancy
◦ Confirm gestation is ≤ 63 days/9 weeks
 Pain medication
 Providers training
◦ use of the medications
◦ assessment of completion of abortion
◦ management of complications
 Surgical evacuation – back-up

24. 1. Medical abortion in the first trimester
 Three highly effective regimens
• Mifepristone (RU-486) + misoprostol
• Methotrexate + misoprostol
• Misoprostol alone

25.  Anti-progesterone - blocks progesterone receptors,
 Mechanism: increases sensitivity of uterus to PGs
cervical softening
 Effect develops over 24-48 hours
 Effectiveness - alone 60-80%, combination with a
prostaglandin > 97% (9 wks GA)
 Optimal dose not known – 200mg Vs 600mg

26. To the drug
 Allergy to mifepristone
 Current use of long-term systemic corticosteroids
 Chronic adrenal failure
 Hemorrhagic disorder
 Current anticoagulant therapy
 Inherited porphyria

27. To the process (precautions)
 Ectopic pregnancy, undiagnosed adnexal mass
 IUD in place (remove before giving mifepristone)
 Severe anemia

28.  Prostaglandin analogue
 Binds selectively to EP-2/EP-3 prostanoid receptors that
stimulate uterine contractions
 Routes - vaginal, rectal, oral , buccal, sublingual
 Inexpensive, stable at room temperature
 Side effects: dose- dependent
◦ shivering (18% - 72%)
◦ Nausea (0.8% - 31%), vomiting (0.4% - 18%)
◦ diarrhea (0.4% - 4%)

29.  Client safety and convenience
 Effectiveness: 85-90% ≤ 63 days/9 weeks LMP
 Most 90% expel within 6 hours of vaginal dose
 After 7 wks vaginal doses are more effective
 Current FIGO recommended regimen:
◦ 1st trimester - 800 µcg misoprostol PV,
12 hourly, maximum 3 doses
◦ 2nd trimester - 400 µcg misoprostol PV,
3 hourly, maximum 5 doses

30.  A folic acid antagonist - cytotoxic to the trophoblast
 Use of methotrexate with misoprostol first introduced
in 1993
 Combination effectiveness – > 90%
 Route – oral, IM – same effectiveness

31.  GA < 7 wks: Mifeprestone 200 mg PO followed
36 – 48 hrs later by misoprostol 400 µg PO
 GA < 9 wks: Mifeprestone 200 mg PO followed
36 – 48 hrs later by misoprostol 800 µg PV
◦ GA 7 – 9 wks, a second dose of misoprostol PO or PV if
abortion fails to occur within 4 hrs of first dose of misoprostol

32.  Mifepristone PO 200 mg followed 24–48 hrs. later by
misoprostol 400 µg PO Q 3 hours up to 5X.
 Mifepristone 200 mg followed after 24 – 48 hours by
misoprostol 800 µg PV.
◦ If abortion does not occur a total of four consecutive doses of
400 µg of misoprostol administered PO Q 3 hrs.
 Misoprostol or gemeprost alone
 Non-narcotic analgesic-during & after medical abortion

33.  Oxytocin:
◦ high dose in drips
 Hypertonic solutions
◦ Rarely used now
 Combination

34.  Few serious complications
◦ Blood transfusion - 0.2%
 Occasionally:
◦ failed abortion
◦ continuing pregnancy – ? fetal malformation
◦ hemorrhage
◦ infection

35.  Vaginal Prostaglandin E2
◦ Highly effective after fetal death
◦ Producing fetal abortion in about 10 hours
◦ >24 wks, don’t use full dose of 20mg -> uterine
rupture
 Misoprostol
◦ Vaginal 100/200µg at 6 hour intervals , max 4 doses
◦ Safe and effective in the second trimester
◦ The dose should be reduced in the third trimester
 Initial dose of 25µg at 6 hour intervals
 Increasing to a maximum of 50µg at 6 hr intervals

36. 1. Manual Vacuum Aspiration --- 4-10 wks 99.2%
effective.
◦ Suction curettage --- 6-14 weeks.
2. Sharp curettage --- 4-14 weeks.
◦ increased blood loss and retained product of conception
compared with suction.
3. Dilation& Evacuation--- 14-24 weeks.
4. Dilation& Extraction ≥ 18 weeks, with prior
feticide treatments
5. Hysterotomy 12-24 weeks.
6. Hysterectomy : Last Resort

37.  Septic shock
 Perforated bladder or bowel
 A possible ectopic pregnancy
 Infection and sepsis
 Infertility later in life
 Psychological trauma

38. 1. Harrisons principle of internal
medicine,Abortion
2. Dipiro-pharmacotherapy 12th Edition
3. Standard treatment guideline, Ethiopia
4. WHO, safe and Unsafe abortion