The document discusses abortion, including its definitions, types (spontaneous and induced), clinical presentations, and complications associated with various abortion scenarios. It provides detailed information on management strategies for different types of abortion and associated risks, highlighting the clinical aspects of spontaneous abortion and septic abortion. Post-abortion care, including counseling and family planning, is also emphasized as an essential component of abortion management.

1. ABORTION
Department of Obstetrics and
Gynecology
UMTH
Presented by: Dr Zannah Usman
Date: 27/08/2024

2. outline
• Introduction
• Types
• Clinical Presentation
• Investigation
• Treatment
• Complications
• Post abortion care

3. intro
• Defined as termination of pregnancy before
the age of extra uterine viability (28wks)
• Expulsion of fetus weighing less than 1000g
• Commonest condition in Gyn. Emergency
• Fetal death ≥ 28 week – fetal death(still birth)
• Delivery of live fetus b/w 28weeks and
36week /6days – preterm delivery

4. • First trimester pregnancy loss is defined as
- non viable, intrauterine preg. with either an
empty gestational sac or
- gestational sac containing an embryo or fetus
without fetal cardiac activity in preg. ≤ 12week/6days
• Spontaneous abortion occurs in approx. 10-15% of
confirmed pregnancies
• Over 80% of spontaneous abortion occur in first trimester

5. • Embryonic ≤ 10 weeks or
• Fetal ≥ 11 week
Biochemical miscarriage
- loss that occur after + urine test (hCG) or
- a raised serum β-Hcg before ultrasound scan
or histological verification and confirmation
Clinical miscarriage
- is diagnosed when ultrasound examination
or histological evidence has confirmed the
existence of intrauterine preg.
- classified as early(˂ 12wks) or late (12-27wks)

6. Risk factors
• Age <20yrs , > 35yrs
• Male age > 40yrs
• Very low or very high BMI(18.5-24.9kg/m²)
• Black ethnicity
• Previous miscarriage (20%, 28% & 43%)
• Smoking

7. • Alcohol
• Stress
• Air pollutant
• Exposure to pesticide
• Working night shift
• The consequence of miscarriage are both
physical and psychological

8. • Types
- Spontaneous
- Induced

9. Clinical aspects of spontaneous abortion
Spontaneous Abortion
Threatened Abortion Inevitable Abortion
(including Anembryonic or Blighted ovum and missed
abortion)
Incomplete Abortion Complete Abortion

10. Threatened abortion
• Does not usually as emergency
• Mild to moderate vaginal bleeding
• Uneffaced and undilated cervix
• No abdominal pain
• Fetus often viable
• Conservative management

11. Inevitable Abortion
• Bleeding of intrauterine origin before 28
completed wks
• Severe effacement and dilatation of the cervix,
without passage of products of conception ---
- Missed abortion is death and retention of the
fetus between 12 and 28 weeks
- Anembryonic or Blighted ovum(gestational sac
forms and grows while an embryo fails to
develop)

12. Clinical picture
• Bleeding per vaginum in excessive, may be
associated with clot
• Colicky lower abdominal pain which radiated
to the back
• Uterus may be less than or compatible with
period of amenorrhoea
• Severe effacement and dilatation of the cervix,
with passage of products of conception
• Rupture of membrane before the age of
viability is also considered inevitable abortion

13. Treatment
Expectant mgt
• Active mgt
- expedite the process -
ABCD of resuscitation
- if < 14 weeks do MVA
- if > 14 weeks; oxytocin via intravenous drip if
placenta is retained remove under general
anesthesia
- Antibiotics and analgesics -
13-26 weeks : 200µg pv/sl/buccal every 6hrs

14. Incomplete abortion
• There is expulsion of some not all product of
conception
• It is the commonest type of abortion
• Clinical picture i-
hx of passage of product of conception -
continuous bleeding -
lower abd. Pain is continuous crampy ii-
o/e uterus less than the period of amenorrhoea and
cervix may be dilated t may be retained product
may be felt through it iii- Uss
shows echogenic mass within the uterine cavity

15. Treatment
1- expectant
2- medical
3- surgical
• Expectant mgt
- suitable for those not bleeding heavily
- TVS should be done after 2 wk to assess for
completeness
- resolution will take week with intact sac

16. • Medical mgt
- < 13wks misoprostol 600µg PO, 400µg Sl or
400-800 PV as single dose
- 14 -28 wks : 200µg PV, SL or bucally atleast 6
hourly max 6 doses
- 14 + weeks in pt with previous scar 25µg PV 6
hourly or 25µg orally 2 hourly or
- > 14 wks , oxytocin 20- 40 IU in 500mL of IVF
at 40 – 60 dpm set up and evacuation with
ovum forceps

17. - Ant emetic, analgesics, antibiotics and
hematinic should be given to those under
going medical mgt
- if PT is still +ve after 3 wks of medical mgt,
evaluate for molar or ectopic preg.
- if preg. Is < 9 weeks success rate is 80-90%

18. • Surgical mgt
- commonest method of treatment of incomplete
abortion
- MVA should be done if < 14 weeks gestation
-IM Ergometrine 0.5mg start if bleeding is excessive
prio to MVA
- complications
profuse bleeding (hemorrhage),infection,
perforation, infertility

19. Missed abortion
- the embryo or fetus dies , but product of
conception is retained in utero
- clinical picture
symptoms of threatened abortion may or may not
be seen, regression of preg. symptoms, abd. does
not increase in size, absent fetal movement, milk
secretion may start particularly in 2nd
trimester
abortion and dark brown vaginal discharge may be
seen

20. • Signs include
uterus will fail to grow, cervix is close and absent fetal
heart beat on Uss
• Investigations
- PT may become –ve within 2wks of embryo/ fetal
death but may remain +ve for longer period due to
viable chorionic villi
- Uss shows embryo with absent heart beat, collapsed
GS or even snow storm appearance
• Complications
- DIC may occur if the death conceptus is retained for
more than 4 wks. It is self limiting resolving after 2wks
- infection

21. Treatment
- spontaneous expulsion by 3wk in most cases (85%)
- evacuation of uterus is indicated in the following
condition
i - spontaneous expulsion dose not occur
ii - excessive bleeding
iii - infection or DIC develops
- the advice is evacuation of uterus once diagnosis is
confirmed

22. • Evacuation is carried out as follows
- uterine size < 14 wks gestation MVA
- uterine size > 14 wks gestation
i - prostaglandins eg misoprostol. 800µg PV every
3hourly (x2) or SL 600µg every 3hourly (x2)
ii - oxytocin infusion
iii - combination of i & ii
iv - dilatation and evacuation/extraction

23. • Hysterotomy rarely in 2nd trimester missed
abortion if med. induction fails initialy and
after repetition a few days later
• Do not offer mifepristone as a treatment of
missed abortion
• For cervical preparation for MVA, 400µg
misoprostol PV or bucally 3 hours before the
procedure or SL 2hours before the procedure

24. Septic abortion
- any type of abortion accompanied with
clinical evidence of infection
- often polymicrobial, common organism
include E.coli, bacteriodes, anaerobic
streptococci, clostridia, staphylococci and
Group B β- haemolytic streptococci
- 80% of organism are endogenous in origin

25. Mgt of septic abortion
• Hx of abortion i.e spontaneous or induced
i - fever usually with chills and rigor
ii - abdominal pain
iii - foul smelling vaginal discharge
• O/e febrile, tachycardia indicating spread beyond
uterus
i - pale and dehydrated
ii - tenderness in the suprapubic area and iliac fossa
iii - guarding and rebound tenderness (peritonitis)

26. Pelvic examination
- offensive vaginal discharge
- lower genital tract trauma may be seen in unsafe
abortion
- product of conception may be felt
- tender uterus and adnexae
- fullness and tenderness in the pouch of Douglas
pelvic abscess
- positive cervical motion tenderness

27. • Clinical grading of septic abortion
Grade I :infection localized to the uterus, suprapubic
tenderness. Is the most commonest usually follows
spontaneous abortion
Grade II : infection has spread to the parametrium,
tubes, ovaries or peritoneum, there will be
tenderness in the suprapubic area and illic fossa
Grade III : Generalized peritonitis and /or endotoxic
shock, jaundice or acute renal failure, there will be
generalized tenderness with guarding and
commonly follows unsafe abortion

28. Investigations
• HVS/ ECS for M/C/S
• FBC + differential count APC
• Bld grouping and cross matching
• Bld culture
• E/U/Cr
• Coagulation screening
• Viral screening( RVS, hepatitis B&C)
• Plain abdominal X-ray and chest X-ray
• Abdomino-pelvic scan
• Urinalysis

29. Treatment
• Admit and resuscitate
• Depending on the clinical presentation
- administer oxygen by face mask or nasal catheter at 6-
8L/min if required
- IVF 1L 6-8hourly
- broad spectrum iv antibiotics like cephalosporin
(ceftriazone) with metronidazole or penicillin with
gentamycin and metronidazole
- oxytocin infusion to control bleeding and enhance
expulsion of the retained products.

30. - TT 0.5ml and ATS 3000unit IM
- analgesics eg 50-100mg IM pethidine, 50-100mg IM
Tramadol or 30-60mg pentazocine
- transfuse bld if patient is anaemic
- maintain NPO
- if DIC develops give fresh whole blood, fresh frozen
plasma or IV heparin 5000-10,000unit 6 hourly.

31. - pass urethral catheter to monitor urine output
- surgical evacuation of the uterus 2-6 hours of
commencement of IV antibiotics but may be
earlier in case of sever bleeding or
deteriorating condition
- posterior colpotomy is performed if there is
pelvic abscess to drain the pus preferably
under ultra sound guidance

32. • Indication for laparotomy are
- condition of patient is deteriorating
- evidence of uterine perforation
- bowel injury
- presence of hematoma
- infection not responding to antibiotics
• Hysterectomy may be required

33. Septic shock
-Apply ABCD of resuscitation, patent airway and
breathing using face mask or intra nasal oxygen 6-
8L/min
- place patient in left lateral position
- secure large wide bore access and take bld sample
- transfuse bld when required
- raise the foot end of the bed and keep the pt warm
- monitor urine output
- monitor vital sign closely for improvement i.e
SBP>100mmHg, PR<90bpm

34. Complications of septic abortion
• Early
- Haemorrhage
- Genital tract injury
- Bowel injury
- Endotoxic shock
- Acute renal failure
- Thrombophlebitis
- DIC
• Late
- Chronic pelvic pain
- Infertility
- Ectopic pregnancy
- Dyspareunia
- Asherman
syndrome -
Psychological sequalae

35. Complications of MVA
• During the procedure
- Hemorrhage
- Cervical tear
- Uterine perforation
- Bowel injury
- Pain
• After the procedure
- Infection
- RPOC
- Intra-uterine
adhesion
- Sheehans syndrome
- Infertility

36. Element of post abortion care(PAC)
• Counselling
• Treatment
• Post abortion family planning
• Community and service provider partnerships
• Linkage to other reproductive health services
ca cervix screening, breast ca screening and
HIV testing services

37. Thank you