ABORTION AND POST-ABORTAL CARE

Definition

■ Termination of pregnancy before the age

of viability which is taken as 28 weeks of
gestation in our environment.
■ WHO : expulsion of fetus weighing less
than 500g. This corresponds to the
gestational age of <20-22 weeks.
Incidence
■ About 10-15 % of confirmed pregnancies
end in spontaneous abortion
(miscarriage)
Aetiology
(a)Fetal factors
- Chromosomal abnormalities :
responsible for 70% of abortion in the 1st
trimester. Commonest abnormality is
trisomies eg Down’s syndrome
(b) Maternal factors
- Maternal infections : malaria, UTI, TORCH
infections, gastro-enteritis, etc
- Endocrine disorders : DM, hypo-thyroidism, luteal
phase deficiency, polycystic ovarian syndrome
- Other medical conditions : hypertension, renal
disease
- Uterine abnormalities : congenital (septate uterus),
acquired (uterine synechie, submucous fibriod,
cervical incompetence)
- Severe malnutrition
- Truama : RTA, uterine surgery during pregnancy
- Drugs : cytotoxic drugs, oxytocics,tobacco,alcohol,
pesticides
- Psychological disorders
- Immunological factors : failure of those factors that
prevent rejection of the fetus which is an allograft
Classification

■ Based on the mode of onsent : spontaneous abortion

( miscarriage) & induced abortion

■ Clinical varieties :
- Threatened abortion
- Inevitable abortion
- Complete abortion
- Incomplete abortion
- Missed abortion
- Septic abortion
- Therapeutic abortion
- Illegal abortion
Threatened Abortion

■ Bleeding from the uterus before 28 weeks of gestation but the product of conception
(POC) is intact

■ Clinical Features :
- Mild vaginal bleeding
- Low backache & mild lower abdominal pain
- On vaginal examination, the cervical os is closed &
uterine size compatibl with GA

■ Investigations :
- FBC & blood group
- Ultrasound scan for viability,morphology, GA & location of the placenta

■ Complications :
- May be pointer to placenta praevia
- Inevitable abortion, incomplete abortion or missed abortion
- Anaemia (rare)
■ Treatment :
- Admit for bed rest
- Give sedative like diazepam
- Avoid coitus for at least 1week after the last
spotting
- Give haematinics
- Treat any detected cause
- Give anti-D if the patient is Rhesus negative

Inevitable Abortion

■ A type of abortion in which the cervix is effaced and dilated but

the POC is not expelled
■ Clinical features :
- Increasing episodes of vaginal bleeding often associated
with passage of blood clots
- Increase in severity & frequency of colicky lower abdominal
pain
- On V/E, the cervix is effaced & dilated and POC may be felt at
cervical os

■ Investigations :
- FBC
- Blood grouping & crossmatching

■ Differential diagnosis :
- Ectopic pregnancy & molar pregnancy which is being
expelled
- The 3 conditions usually present with a triad of
amenorrhoea, vaginal bleeding & lower abdominal pain

■ Complications :
- Hypovolaemic shock ( if there is remarkable haemorrhage)
- Residual anaemia
■ Treatment :
- Admit in the hospital
- Any POC felt at the cervix should be removed digitally or with
sponge holding forceps to minimize blood loss
- Setup IVF with 5% Dextrose or 5% D/S or N/S
- Administer iv 0.5mg ergometrine to control bleeding
- Administer narcotic analgesic like pentazoscine to alleviate
pain
- Take the patient to MVA room or theatre and evacuate the
uterus using sponge holding forceps , Karman’s syringe &
cannula
- For mid-trimester abortion augement uterine contractions
with oxytocin to expidite the expulsion of POC
- Where indicated , blood should be transfused
- After evacuation, prophylactic antibiotics eg ampiclox should
be given
- Give anti-D if the patient is Rhesus negative
Complete Abortion
■ This is a type of abortion in which all the POC have been expelled
■ Clinical features :
- Minimal or ceased vaginal bleeding
- Mild or subsided abdominal pain
- On V/E, the cervical os is closed and
uterine size is smaller than GA
■ Investigations :
- Pelvic ultrasound to confirm empty uterus
- PCV if anaemia is suspected
- Blood group
■ Treatment :
- Reassure, haematinics & give anti-D if the patient
is Rhesus negative
Incomplete Abortion

■ This is a type of abortion in which some POC are expelled while others are retained in the uterine
cavity.

■ Clinical features :
- Vaginal bleeding which may be moderate
or profuse
- Lower abdominal pain which is usually moderate
- History of passage of some POC
- On V/E, the cervical os is dilated & POC may be
felt. The uterine size is usually smaller than GA

■ Investigations :
- FBC
- Blood grouping & crossmatching
- Pelvic ultrasound if in doubt

■ Complications :
- Anaemia
- Intra-uterine infection which can lead to infertility, ectopic pregnancy
& chronic pelvic pain
■ Treatment :
- Admit in the hospital
- Set up IVF
- Give 0.5mg ergometrine to control
bleeding
- Give analgesic like pentazoscine to
alleviate pain
- Transfuse blood if indicated
- Evacuate the uterus in MVA room or the theatre
using sponge holding forceps & Karman’s syringe
& cannula
- Administer prophylactic antibiotics eg ampiclox &
metrodinazole
- Give anti-D if the patient is Rhesus negative
- Send POC specimen for histology to exclude molar
pregnancy
Missed Abortion

■ This is a type of abortion in which the fetus dies before 28 weeks of gestation but the
uterus fails to expel it

■ Clinical features :
- Regression of symptoms of pregnancy
- Absence of fetal movement
- There may be intermittent vaginal
bleeding which may be mistaken for
threatened abortion
- Breasts may be secreting milk
- Fetal heart sounds may be absent at the gestational age in
which they are expected to be present ( 24 weeks with
Pinnard’s stethoscope and 12 weeks with sonicaid or
doppler)
- The uterus if palpable per abdomen will be less than GA
- On V/E, the cervical os is closed and the uterine size will be
smaller than the GA
■ Complication :
- DIC : due to release of thromboplastin
by the degenerating placenta. DIC
occurs about 4-6 weeks after fetal
demise
- Intra-uterine sepsis

■ Investigations :
- Ultrasound for confirmation
- FBC
- Blood grouping & cross matching
- CT, PT & serum fibrinogen assay

■ Treatment :
- Admit in the hospital
- If uterine size is ≤ 12 weeks, take the patient to the theatre for
cervical dilatation and uterine evacuation under GA. The
uterus is evacuated using Karman’s syringe & cannula.
- If the uterus is > 12 weeks, ripen the cervix with misoprostol
and induce induce uterine contractions with oxytocin
infusion. If expulsion of POC is incomplete, MVA should be
performed.
- Blood should be transfused if indicated
- Give prophylactic antibiotics
- Give anti-D if the patient is Rhesus negative
- If DIC is encountered, treat with fresh whole blood, fresh frozen plasma or
fibrinogen concentrate.

Septic Abortion

● This is a type of abortion that is complicated by infection or sepsis. It can occur both in
spontaneous & induced abortion. However it is commoner induced abortion
● Blood clots & retained POC serve as a fertile media for bacterial proliferation
● Implicated organisms include anaerobic streptococcus, Staph. aureus, non-haemolytic
streptococcus, gonococcus, E.coli, Clost. tetani, Clost. Welchii & Bacteriodes fragilis

■ Clinical features :
- Intermittent vaginal bleeding
- Foul swelling vaginal discharge
- Lower abdominal pain
- Fever
- In severe cases, there may be vomiting, generalized abdominal pain, oliguria & bleeding from
orifices
- Pyrexia & pallor
- Tachycardia & hypotension
- Uterine tenderness & signs of generalised peritonitis
- On V/E, there are usually offensive vaginal discharge, CET, tender uterus & adnexal tenderness

■ Investigations :
- FBC, blood grouping & cross matching
- S/E/U/C
- Serial blood culture
- Cervical swab & msu for m/c/s
- Coagulation profile : CT, PT,PTT & serum fibrinogen assay
- LFT in severe cases
■ Complications :
- Endotoxic shock
- Renal failure
- DIC
- Secondary infertility, EP, chronic pelvic pain
- Death : occurs in 50-75% of severe form.
■ Treatment :
- Admit in the hospital

- Commence IVF while blood is awaited.

Transfuse as soon as blood is available
( preferably fresh whole blood)

- Give massive broad spectrum antibiotics eg ampiclox

for gram positive, gentamycin for gram negative &
metronidazole for anaerobes. Antibiotics should be
given at least 12 hours before uterine evacuation to
minimize septicaemia. If renal failure is suspected
the dose of gentamycin should be reduced

- Evacuate the uterus. This is because retained POC is the

usual cause of the sepsis

- Any complication detected should be managed accordingly

Habitual or Recurrent Abortion

- Occurrence of 3 or more consecutive spontaneous abortion

- Common causes in 2nd trimester : (1) cervical incompetence, (2)

congenital abnormalities of the uterus eg septate uterus, (3)
uterine fibroid (4) diabetes mellitus

- Cervical incompetence is treated by application of cervical

cerclage at 14 weeks of gestation either by Mac Donald or
Shirodkar’s technique

NB : In Mac Donald’s technique, some parts of the suture are with in

the substance of the cervix while some are not but in
Shirodkar’s technique most part of the suture are within the
substance of the cervix
Therapeutic Abortion

- Planned termination of pregnancy in the hospital

- Indications : (1) when the pregnancy threatens the life of the

mother as in cases of advanced cancer, severe cardiac
disease, severe renal disease, severe hypertension (2) severe
fetal congenital abnormalities

- It requires 2 registered physicians for its certification

- Methods : 1st trimester ( MVA or D&C), 2nd trimester ( oxytocin

infusion after cervical ripening, intra or extra amniotic
prostaglandin administration, intra-amniotic injection of
hypertonic saline or urea & hysterotomy)
Illegal or Criminal Abortion

● When an abortion is performed against the existing abortion

law. This abortion tend to be performed in secrecy and is
frequently complicated sepsis

● Section 297-299 of Nigerian Criminal Code states that any

person with intent to procure a miscarriage of a woman
(whether the woman is pregnant or not) unlawfully administers
a substance or uses any means is guilty of felony and is liable
to 14 years imprisonment. The same applies to the woman who
does it herself. Exception : when it is performed by medically
qualified person to save the woman’s life.
Post-abortal Care

● It consist of management packages introduced by IPAS

( International Product Assistance Services) to deal primarily
with the problems associated with induced abortion

● It has 5 components:
- Treatment of incomplete abortion via
uterine evacuation
- Counselling of the patient on methods of
treatment
- Provision of post-abortal family planning
- Linkages with other reproductive health services
- Community participation for sustainability