ABORTIONSABORTIONS

OBJECTIVESOBJECTIVES

At the end of this session you At the end of this session you should be able to:should be able to:

1.1. Define various types of abortions.Define various types of abortions.

2.2. Outline the causes and management Outline the causes and management

approach for various types of abortions.approach for various types of abortions.

3.3. Describe the relation between Describe the relation between

complications of abortions and maternal complications of abortions and maternal

mortalitymortality

DEFINITIONS OF ABORTIONDEFINITIONS OF ABORTION

1.1. Termination of pregnancy Termination of pregnancy

before 28/40before 28/40

2.2. Delivery of a fetus of Delivery of a fetus of

weight less than 500 gramsweight less than 500 grams

STATISTICS OF ABORTIONSSTATISTICS OF ABORTIONS

• 50 - 60% of all pregnancies end in 50 - 60% of all pregnancies end in spontaneous abortion (SAB) since 2-4 wk spontaneous abortion (SAB) since 2-4 wk pregnancies will often go unnoticed.pregnancies will often go unnoticed.

• 15% of all recognized pregnancies 4-20 wks 15% of all recognized pregnancies 4-20 wks end in SAB.end in SAB.

• 30% lost between implantation and the 630% lost between implantation and the 6 thth wk.wk.

• 70% of first trimester losses are due to 70% of first trimester losses are due to

chromosomal abnormalitieschromosomal abnormalities

TYPESTYPES

1.1. InducedInduced

2.2. ThreatenedThreatened

3.3. InevitableInevitable

4.4. Incomplete Incomplete

5.5. CompleteComplete

6.6. Septic Septic

7.7. MissedMissed

8.8. RecurrentRecurrent

TYPES OF ABORTIONSTYPES OF ABORTIONS

1. INDUCED ABORTION1. INDUCED ABORTION

• Intentional medical or surgical Intentional medical or surgical termination of a pregnancytermination of a pregnancy

• TypesTypes– Elective:Elective: if performed for a woman’s if performed for a woman’s

desiresdesires

– Therapeutic:Therapeutic: if performed for reasons if performed for reasons of maintaining health of the motherof maintaining health of the mother

INDUCED ABORTION – INDUCED ABORTION – MEDICO-MEDICO-LEGAL ASPECTS IN TANZANIALEGAL ASPECTS IN TANZANIA

• Only allowed for medical indicationsOnly allowed for medical indications

– If continuation of pregnancy is risk to If continuation of pregnancy is risk to

life of the womanlife of the woman

• At least two medical doctors should At least two medical doctors should

reach the decision and signreach the decision and sign

• Elective abortionsElective abortions – are unlawful – are unlawful

INDUCED ABORTIONS INDUCED ABORTIONS - - COMPLICATIONSCOMPLICATIONS

Because most induced abortions are done by Because most induced abortions are done by less skilled persons they are usually associated less skilled persons they are usually associated with fatal complications including:with fatal complications including:

1. Perforation of uterus, intestines, etc1. Perforation of uterus, intestines, etc 2. Severe haemorrhage,2. Severe haemorrhage, 3. Sepsis and its associated complications,3. Sepsis and its associated complications, 4. Asherman’s syndrome, etc4. Asherman’s syndrome, etc

2. THREATENED ABORTION2. THREATENED ABORTION

Refers to a stage in the abortion Refers to a stage in the abortion that suggests potential that suggests potential miscarriage may take place may take place..

SymptomsSymptoms• Minimal or no lower abdominal pain or

cramps• Slight abd pain• Minimal draining of liquor

Threatened abortion Threatened abortion contcont

SignsSigns

• Stable general condition

• Fundal height corresponds to

GA

• Cervix closed

Management of threatened Management of threatened

abortionabortion

1.1. Bed restBed rest

– Avoid strenuous exercisesAvoid strenuous exercises

2.2. If GA > 16/40 give - tocolyticsIf GA > 16/40 give - tocolytics

3. INEVITABLE ABORTION3. INEVITABLE ABORTION

Refers to a stage in the Refers to a stage in the

abortion when it is not abortion when it is not

possible for the pregnancy possible for the pregnancy

to continue.to continue.

INEVITABLE ABORTION INEVITABLE ABORTION CONTCONT

SymptomsSymptoms

• Moderate to severe vaginal bleedingModerate to severe vaginal bleeding

• Severe abd painSevere abd pain

• Significant draining of liquorSignificant draining of liquor

SignsSigns

• Dilatation of cervix with evidence of imminent Dilatation of cervix with evidence of imminent expulsion of the PoCexpulsion of the PoC

• Fundal height corresponds to GAFundal height corresponds to GA

• Presence of contractionsPresence of contractions

Management of Inevitable abortionManagement of Inevitable abortion

1.1. Resuscitation: Resuscitation: IV fluids: RL, NSIV fluids: RL, NS

2.2. Blood grouping & Cross matchingBlood grouping & Cross matching

3.3. EvacuationEvacuation

• MVA for GA < 12/40MVA for GA < 12/40

• Augment if the GA > 12/40 Augment if the GA > 12/40

OxytocinOxytocin

If some PoC remain after abortion If some PoC remain after abortion manage like incomplete abortion.manage like incomplete abortion.

MANUAL VACUUM ASPIRATORMANUAL VACUUM ASPIRATOR

4. INCOMPLETE ABORTION4. INCOMPLETE ABORTION

• Some POC have been expelled from the Some POC have been expelled from the uterine cavity and other are retained uterine cavity and other are retained inside.inside.

SymptomsSymptoms– Moderate to severe vaginal bleedingModerate to severe vaginal bleeding– Cramping/severe abd painCramping/severe abd pain– Partial expulsion of POCPartial expulsion of POC

SignsSigns– Uterus smaller than datesUterus smaller than dates– Cervix is dilated of cervix Cervix is dilated of cervix

Management of Incomplete abortionManagement of Incomplete abortion

1.1. Resuscitation: Resuscitation: IV fluids: RL, NSIV fluids: RL, NS2.2. Blood grouping & Cross matching → BT if indicatedBlood grouping & Cross matching → BT if indicated3.3. EvacuationEvacuation

– MVA for GA < 12/40MVA for GA < 12/40– Augment if the GA > 12/40 Augment if the GA > 12/40

• OxytocinOxytocin• If some PoC remain after abortion manage like If some PoC remain after abortion manage like

incomplete abortion.incomplete abortion.

4. 4. Antibiotics: ampicilin, metronidazoleAntibiotics: ampicilin, metronidazole5. Analgesics5. Analgesics

5. SEPTIC ABORTION5. SEPTIC ABORTION

An abortion complicated by infectionAn abortion complicated by infection

SymptomsSymptoms– Abdominal painAbdominal pain– FeverFever– Vaginal discharge (foul smelling)Vaginal discharge (foul smelling)

SignsSigns– Sick looking, febrile or jaundicedSick looking, febrile or jaundiced– Tender uterusTender uterus– Offensive vaginal discharge or bleedingOffensive vaginal discharge or bleeding– Cervix is usu. soft and may be dilatedCervix is usu. soft and may be dilated

Complications of septic abortionsComplications of septic abortions

Immediate cpxImmediate cpx• HaemorrhageHaemorrhage• PeritonitisPeritonitis• Pelvic abscess, Pelvic abscess,

endometritis,endometritis,• Septicemia,Septicemia,• Septic/haemorrhagic Septic/haemorrhagic

shockshock

Late cpxLate cpx

• PIDPID

• Pelvic adhesionsPelvic adhesions

• 2° Infertility2° Infertility

• Chronic LAPChronic LAP

ManagementManagement

1.1. ResuscitationResuscitation

– IV fluids: RL, NSIV fluids: RL, NS

2.2. Insert urethral catheterInsert urethral catheter

– Monitor Input/outputMonitor Input/output

3.3. Blood grouping & Cross matchingBlood grouping & Cross matching

4.4. Antibiotics: Antibiotics:

• Preferably cephalosporins, if not available Preferably cephalosporins, if not available ampicilin and metronidazoleampicilin and metronidazole

5.5. EvacuationEvacuation

6.6. HaematenicsHaematenics

6. RECURRENT PREGNANCY 6. RECURRENT PREGNANCY LOSSESLOSSES

• Defined as 3 or more consecutive Defined as 3 or more consecutive pregnancy lossespregnancy losses

Other names: Other names: •habitual abortionshabitual abortions

•habitual miscarriagehabitual miscarriage

•recurrent abortionsrecurrent abortions

•recurrent miscarriagesrecurrent miscarriages..

Aetiology of RPLAetiology of RPL

• Genetic FactorsGenetic Factors

• Endocrine Factors Endocrine Factors

• Anatomic CausesAnatomic Causes

– Congenital anomalies, in competenciesCongenital anomalies, in competencies,,

• Infectious causesInfectious causes

• Immunologic problemsImmunologic problems

Aetiology: Can be established in only 30%