Management of Abortion

and Post abortion Care

Dr.Tadesse G.

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Definitions
► Abortion: is the process of termination or expulsion
of the pregnancy before the 28th completed weeks
of gestation or less than 1000gm weight.
► Based on gestational age – Early (< 12 weeks)
versus Late abortion(>12weeks) – late abortions
have more complication risk than early abortions
► WHO considers a gestational age of 20 weeks as the
cut off for fetal viability
► Unsafe abortion: characterized by lack or
inadequacy of provider skills, hazardous technique,
and unsanitary facilities or both.

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Cont….
► Recurrent abortion: three or more
consecutive spontaneous termination of
pregnancies.
► Therapeutic abortion: Termination of
pregnancy before the time of fetal viability
for the purpose of saving the life of the
mother
► Septic abortion: When any of the stages
of abortion complicated by pelvic infection.

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Epidemiology of Abortion
► Abortion is one of the leading causes of maternal mortality
in the world
► At least 15% of pregnancies end in spontaneous abortion
► Unsafe abortion is a major public health problem and at
least 20 million women undergo unsafe abortion each year
► Abortion complications are responsible for around 14% of
the approximately 500,000 maternal death each year and
with millions of others suffering chronic morbidities and
disabilities.
► In Ethiopia maternal losses from abortion and its
complication account for 25-50%
► Nearly 80,000 maternal deaths

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► Risk factors
► Multiple pregnancy
► Pregnancy interval
► Gravidity
► Previous abortion
► Early menarche
► Infections
► Endocrine
► Social drugs
► IUCD
► Radiation
► Chronic diseases
► Immunological
► Toxins
► Malnutrition
► Uterine defects
► Trauma– iatrogenic

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Abortion in Ethiopia Law
 medical institution within the period permitted by the
profession is not punishable where:
1. The pregnancy is a result of rape or incest; or
2. The continuation of the pregnancy endangers the
life of the mother or the child or the health of the
mother
3. The fetus has an incurable and serious deformity;
or
4. The pregnant woman, owing to a physical or
mental illness she suffers from or her minority, is
physically as well as mentally unfit to bring up the
child
5. Maternal age <18yrs &with family mamber
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 Clinical Stages of Abortion

► Threatened abortion
► Inevitable abortion
► Incomplete abortion
► Complete abortion
► Missed abortion

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i, Threatened abortion
 Minimal vaginal bleeding and lower abdominal
cramps
 Closed cervix and uterine size comparable to
gestational age
 Viable fetus
 60-80% continue the pregnancy
II, Inevitable abortion
 Heavier vaginal bleeding and more severe
cramps
 Open cervix but no expulsion of conceptus yet
 Leakage of liquor even without open cervix
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Cont…..
III, Incomplete abortion
 Features of inevitable abortion with additional
feature of expulsion of conceptus parts outside
the cervix
IV, 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

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Cont…
V, Missed abortion
 Initial symptoms of abortion subside with cessation of
vaginal bleeding and uterine contractions
 Regression of symptoms and signs of pregnancy
 Retention of conceptus within the uterus for more than
two weeks
 Closed cervix and uterine size less than calculated
weeks of amenorrhea
VI, Recurrent (habitual) abortion
 Three or more consecutive abortions
VII, Septic (infected) abortion
 Any of the abortion types complicated by infection
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Diagnosis of Abortion
► Diagnosis of a pregnancy less than fetal viability
► Symptoms
 Vaginal bleeding
 Abdominal cramps
 Leakage of liquor or expulsion of conceptus

NB. In any women of reproductive age experiencing at least two of the

following symptoms abortion should be considered:
 Vaginal bleeding
 Cramping and/or lower abdominal pain
 A possible history of amenorrhea

► Signs
 Hemodynamic instability
 Vaginal bleeding
 Cervical changes and reduced uterine size
 Visualization of expelled conceptus
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 Initial Assessment
History:
► Length of amenorrhea
► Bleeding (duration, amount)
► Cramping (duration and severity)
► Abdominal or shoulder pain
► Drug allergy
► History of interference and method employed
► Symptoms of infection

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 Initial Assessment (2)
Physical examination
► Check V/S (T, PR, RR, B/P)
► Note general health of the women
► General systemic examination
► Pelvic examination

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 Initial Assessment (3)
Laboratory examination:
► Hgb/Hct, blood group & Rh
Based on clinical assessment when indicated
► WBC,ESR
► Urinalysis
► RFT, LFT
► Platelet count, PT, PTT
► Plain film of the abdomen (Erect)
► Pelvic ultrasonography
► Pregnancy test

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Management of Abortion
► Depends on:
 Clinical type of abortion
 Gestational age: early versus late
 Presence or absence of infection

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

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Cont..
► Missed abortion
 Early – Suction curretage
 Late- Expel conceptus with oxytocin drip and follow up
with curretage as required
► Recurrent abortion
 Manage accordingly and investigate for possible causes
to avoid recurrence
► Infected or septic abortion
 Cover with broad spectrum antibiotics to cover both
gram positive as well as gram negative aerobic and
anaerobic organisms
 Pelvic infections are often polymicrobial

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Complication of Abortion
► Heavy bleeding and shock
► Uterine perforation
► Infection and sepsis
► Infertility later in life
► Ectopic pregnancy later in life
► Psychological trauma – depression

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 Methods of Uterine evacuation

Determined by uterine size

► If uterine size < 14 weeks
 MVA/EVA
D&C
 E & C if cervix is open

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 Methods of Uterine evacuation

If uterine size > 14 weeks

► Prostaglandin
► Oxytocin
► E & C, D & C, D & E when appropriate
► Condom catheter + Oxytocin
► Hysterotomy

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NB. General principle
► Confirm the Dx.
► Counseling
► Anti-pain
► Antibiotics
► Iv fluid
► Treatment of complication(Medical& surgical)
► For GA <9wks..Mifeprstone 200mg po stat then after 48hr
Misopristone 800mcg ,,bucal,vaginal
► For GA 9-12wks.. Mifeprstone 200mg po stat then after
48hr Misopristone 800mcg ,,bucal,vaginal then 400mcg
every 3hrs for 5max dose until expulsion
► For GA..12-24 same but Misopristone 200mcg every 4hrs
► Surgical MVA Should be done
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POST ABORTION Care &FAMILY PLANNING
All women receiving post abortion care.
► Community-service provider partnership
► Counseling
► Emergency treatment of incomplete
abortion and its complications
► FP services
► Linkage with other RH services
► anti-D, iron/folate, antibiotics, TAT(septic)

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