Abortion

Definition

Age of viability in different places

WHO definition

Extraction of the POC in whole or part via the birth canal before the age of viablilty

Nigeria: 28wks

Europe: 22wks

US: 20wks

WHO: 24wks

Expulsion of fetus weighing less or equal to 500g

Types

Spontanous(miscarriage)

Induced( abortion)”

Types of spontanous abortion

• Threatened

• Inevitable

• Incomplete

• Missed

•Recurrent or habitual

• Septic.

Causes of Abortion

Clinical features for

1. Threatened

2. Inevitable

3. Incomplete

4. Complete

5. Missed

Use Amenorrhea, Bleeding PV, Abdominal pain, Uterine size, Cervical os

Other features for diagnosing and threatened abortion and how to manage

Viable pregnancy(FHR is heard)

Normal HCG for GA

Reassurance

Bed rest

Anxiolytics

USS to confirm viability

Clinical surveillance

Abstinence from coitus

Prognosis is good when bleeding/cramping resolves

Inevitable Miscarriage

Other features

Mgt(inevitable and incomplete)

1. Open cervix/rupture of membrane

2. Non viable pregnancy( No FHR)

Mgt

Admit the pt

2. ABCs of resuscitation

3. Analgesics for pain

4. IV access, samples for gxm

5. Remove poc manually or with forceps during sterile speculum exam if within cervical canal

6. Profuse bleeding give 0.5mg ergometrine IM

7. Give 5-10U oxytocin to control bleeding

8. Transfuse if necessary

9. Rhesus negative pt should be given rhogam

10. MVA if less than 12 weeks

Give antibiotics

Send POC to histology

Mgt of complete abortion

Reassure the patient

If in doubt or if pregnancy is less than 12 weeks, manage as incomplete

Define CoMSIIT

Threatened abortion no dilation of the cervix or expulsion of POCs

MISSED MISCARRIAGE

•Retention of a failed intra-uterine pregnancy for an extended period usually defined as more than two menstrual cycles.

Specifics for missed abortion

• hx of Regression of symptoms and signs of pregnancy.

•±brownish vaginal discharge.

•No FH activity

•May be complicated by hypofibrinogenemia due to thromboplastin produced by the dead fetus. leads to DIC

• low HCG for GA

• empty gestational sac on USS

Mgt of missed abortion

1. Reassure the pt

2. Intervene immediately because of possible DIC

3. Counsel on need for medical induction or surgical evacuation depending on GA

4. MVA less than 12wks

5. >12wks, use misoprostol/Mifepristone then MVA

6. Do coagulation studies

7. Gxm

8. FFP, fibrinogen concentrate in case of bleeding diathesis

Septic miscarriage definition an clinical Features

When any of the clinical types becomes infected.

•Fever, lower abd, pain, foul-smelling vaginal discharge, ± vaginal bleeding.

Others: tachycardia, hypotension, uterine tenderness, malodorous vaginal discharge, pelvic and abdominal pain, cervical motion tenderness

Mgt of septic abortion

Admit

Resuscitate

Broad spectrum antiobiotics

Analgesics

Transfuse if necessary

Monitor fluids and electrolytes

Laparotomy may be necessary if there is peritonitis or pelvic abscess.

•Peritoneal toileting, lavage and repair of intestinal injury where necessary.

Define recurrent abortion

Likely causes in early pregnancy

Later

3 or more consecutive spontaneous pregnancy losses under 28 weeks of GA from the LMP by the same partner or two late fetal losses

Chromosomal Abdonormalities

Cervical incompetence

Treatment

Define unsafe abortion

Termination of an unintended pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal standards or both

Complications

Early and late

Early

1. Infections(sepsis)

2. Hemorrhage

3. Trauma to the genital tract

4. intestinal perforation and fistula

5. Vaginal laceration

6. Uterine perforation

7. DVT

Long Term

1. Chronic pelvic pain

2. Pelvic adhesions

3. Residual abscesses

4. Dyspareunia

5. Chronic vaginal discharge

6. Asherman’s syndrome

7. Secondary infertility

8. Rhesus isoimmuinization

9. Depression/guilt

10. Ectopic pregnancy

11. Death

What is post abortal care and its aim?

A composite care given to a woman and her partner after an abortion process in order to prevent future risk of unwanted pregnancies and reduce death and injuries that may complicate abortion.

AIM: to reduce maternal Mortality and morbidity resulting from unsafe abortion

Components of Post abortal care

Methods of inducing abortion

Medical: dinoprostone(PGE2)

Hyperosmolar urea, PG F2A