Safe Abortion & PAC

Tutorial for C-I Students

1
By:Adane S.(MD) 2/1/2018
 Outline
 Introduction and definition
 Discuss Classifications of abortion
 Discuss spontaneous abortion
 Discuss etiologies of spontaneous abortion.
 Discuss Diagnosis of abortion
 Investigation modalities of abortion
 Clinical stages of abortion with their management
 Highlight safe and unsafe abortion
 Medical and surgical abortion
 PAC
 Abortion law in Ethiopia
2 2/1/2018
 Definition
 Abortion is spontaneous or induced termination of
pregnancy before fetal viability(28wks in Ethiopia).
 WHO considers a gestational age of 20 weeks as the cut
off for fetal viability and thus for the definition of
abortion versus delivery
 Unsafe abortion globally accounts for 13% of maternal
deaths and over 30% of maternal deaths in Ethiopia.
 The majority of deaths from abortion result from
hemorrhagic shock and sepsis

3 2/1/2018
 Brief epidemiology of abortion
 Spontaneous abortion complicates 10-20% of
pregnancies
 Incidence of induced abortion varies from country to
country based on the availability and accessibility of
contraception
 WHO estimates that there are 80 million abortions
annually of which 40% are unsafely induced
 Nearly 80,000 maternal deaths (20% of total annual
global maternal mortality) is due to unsafe abortions

4 2/1/2018
 Classification of Abortion
Based on Occurrence
Spontaneous Vs Induced abortion
Based on gestational age
EarlyVs Late abortion
Based on site of termination in
induced abortions
Safe Vs unsafe abortion

5 2/1/2018
 Based on clinical presentations.
Threatened abortion
Inevitable abortion
Incomplete abortion
complete abortion
Missed abortion
Septic abortion
Habitual abortion

6 2/1/2018
 Spontaneous abortion
 Abortion occurring without medical or
mechanical means to empty the uterus, with no
intervention.
 Occurring in about 15% of pregnancies.
 Most commonly due to fetal chromosomal abnormality
in 50 to 60% of cases.
 80% of spontaneous abortions occur prior to 12
weeks' gestation.

7 2/1/2018
 Etiologies of spontaneous abortion
 Fetal causes
 Fetal chromosomal abnormalities
 Is the commonest cause of abortion
 50– 60% of the first trimester(early) abortions are due to
chromosomal abnormalities.
o The majority of these are numerical abnormalities like
trisomy.
o Chromosomal structural abnormalities infrequently cause
abortion.
Autosomal trisomy
o The most frequently identified chromosomal anomaly
associated with first-trimester abortions.

8 2/1/2018
 Maternal cause
 Infections
 genital tract infection
 systemic infection with pyrexia & TORCH syndrome
 Mycoplasma hominis ,Ureaplasma urealyticum,
 Malaria

 Uterine factors
Uterine myomata
Mullerian abnormalities or defects – septate, bicornuate uterus etc
Cervical insufficiency
Previous uterine scarring
 D&C
 Myomectomy,C/S,Infection,TB
 Asherman’s syndrome

9 2/1/2018
 Etiology cont…
Endocrine abnormalities
Hypo\hyperthyroidism
Uncontrolled diabetes mellitus
Progestrone deficiency
Immunological factors
Antiphospholipid syndrome
Blood group incompatibility b/n the mother &
fetus
Abdominal trauma

10 2/1/2018
  Drug use and environmental factor
Tobacco
 Heavy smoking ↑ Risk for abortion
Alcohol
 Spontaneous abortion & fetal anomalies → result from frequent alcohol
use during the first 8 weeks of pregnancy
Radiation
 In sufficient doses → abortifacient
Contraceptives
 When IUD fail to prevent pregnancy → abortion↑
Environmental toxins
 Arsenic, lead, formaldehyde, benzene, ethylene oxide → abortifacient

11 2/1/2018
 Diagnosis of abortion
Clinical
Vaginal bleeding
Cramping and/or lower abdominal pain
A possible history of amenorrhea
Ultrasound
gestational sac,
embryo status,
fetal heart tones,
 fetal movement

12 2/1/2018
 Investigations
Pregnancy test
CBC,Hct / Hgb
BG & Rh
U/A
Coagulation profile
U/S
OFT
 +/- Screening for STI ….etc

13 2/1/2018
 Clinical stages of abortion
Threatened abortion
 History
 Usually mild Vaginal bleeding
 Mild or no Abdominal cramp
 No passage of tissue

 Physical examination
 Good general condition
 PV-closed cervix
 Uterus : consistent with GA

 Ultrasound
 reveal a normal gestational sac and viable embryo

14 2/1/2018
 Management of threatened abortion
 Reassurance
 Advice-avoid heavy activity, avoid intercourse & douching
 Analgesia
 Anti-D( for Rh –ve mother)
 ANC as high risk patients
 Monitor progress by subsequent assessment.
 Ultrasonography-for viability
 after death of conceptus uterus should be emptied.
 If signs of established pelvic infection – evacuate the
uterus after antibiotic coverage

15 2/1/2018
 Inevitable abortion
 History
Profuse vaginal bleeding.
 no passage of products of conception
Severe lower abdominal pain which follows the bleeding.
There is rupture of membrane with gush of fluid.
 Physical examination
Poor general condition.
The cervix is dilated
The uterus may be the correct size for date
 Ultrasound
+\-Fetal heart activity

16 2/1/2018
 Management of Inevitable abortion
Less than 14 wks of gestation
 Evacuation of the uterus is the mainline of treatment
MVA
E & C
 Mandatory indications for evacuation
 Considerable bleeding
 Bleeding which continues for more than 24 hours.
 Patients in whom the retained products of conception are
obviously still present on vaginal examination.

17 2/1/2018
 Mgt cont…
More than 14 wks of gestation
 In the absence of heavy bleeding evacuation of the uterus is not
advised before the expulsion of the fetus
 Management includes
 Monitoring the vital signs and the amount of bleeding
After expulsion check for completeness & if incomplete or
the bleeding continues evacuate the uterus
Ergometrine or oxytocin as drip should be given for
continued bleeding.

18 2/1/2018
 Incomplete abortion
History
Heavy vaginal bleeding.
passage of products of conception partially
Severe lower abdominal pain
Examinations
Poor general condition.
The cervix is dilated and products of conception is
passing through the os
The uterus is small for date
U/S
19  retained products of conception 2/1/2018
 RPOC

20 2/1/2018
 Management of incomplete abortion
 Uterine evacuation should be done preferably by MVA.
 Methods of Ux evacuation determined by Ux size.
 If uterine size < 14 weeks
 MVA/EVA
 E & C if cervix is open
 D&C if cervix is closed
 If uterine size > 14 week
 Oxytocin infusion
 E&C
 D&C 2/1/2018
21
 Analgesics/anaesthetics for E&C and MVA
Paracervical block with local
anaesthesia
Pethidine
NSAIDs
ibuprophen,paracetamol,diclofenac

22 2/1/2018
 Complete abortion
History
 Heavy vaginal bleeding and lower
abdominal pain which has been stopped
Physical examination
 The cervix is closed
U/S
 showed empty uterine cavity.

23 2/1/2018
 Management of complete abortion
Ways of confirming completeness
Examine conceptus carefully for completeness
Ultrasound to see retained tissue
Documented completeness on referral paper
If any doubt of completeness evacuate the uterus
Administer ergometrine

24 2/1/2018
 Missed abortion
 The fetus dies in utero and is retained for a prolonged period of
time.
 Serious coagulation defect(DIC) occasionally develop after
prolonged retention of fetus.
History
 Pregnancy symptoms disappear
 Stop of fetal movements after 20 weeks gestation
 Episodes of mild vaginal bleeding
 Physical examination: small for gestational age
uterus.
 U\S:show no evidence of fetal heart activity .

25 2/1/2018
 No fetal cardiac activity

26 2/1/2018
 Management of Missed abortion
 Expectant management up to 4 weeks
95% women with missed abortion will abort spontaneously in
3-4 weeks time,despite GA
 Surgical evacuation of the uterus
 D & C and MVA for GA less than 12wks
 Medical termination of pregnancy
 prostaglandin vaginal ( is the best) or oral tab.
Subsequent surgical evacuation is needed in cases of RPOC
High dose oxytocin infusion +/- prostaglandins

27 2/1/2018
 Anembryonic pregnancy
(Blighted ovum)
 Blighted Ovum or an embryonic pregnancy
represents a failed development of the embryo
so that only a gestational sac, with or without a
yolk sac, is present.
 An alternative hypothesis proposes that the fetal
pole has been resorbed prior to ultrasound
diagnosis.
 It is due to an early death and resorption of the
embryo with the persistence of the placental
tissue.

28 2/1/2018
  It is diagnosed if two ultrasound ( T/V or T/A) at
least 7 days apart showed after 7 weeks of gestation
i.e. gestational sac > 20mm , an empty gestational
sac with no fetal echoes seen .
 It is treated in a similar way to missed abortion .

29 2/1/2018
 Septic abortion
 Abortion complicated by infection, majority follow unsafe
induced abortion.
 infection starts in the uterus and spread to
pelvic,peritonium
 can result in death causing sepsis and multiorgan failure.
Patients present with
 Offensive vaginal discharge
 Fever ≥ 380C
 lower abdominal pain/tenderness
accompany any of abortion
30 2/1/2018
 Management of septic abortion
Antibiotics
 Cephalosporin I.V + Metronidazole I.V
Surgical evacuation of uterus
 usually 12 hrs after antibiotic therapy.

31 2/1/2018
 Induced abortion
An abortion is said to be induced if it
results from medical or surgical
intervention that can cause abortion.
It could be Safe or Unsafe abortion
Unsafe abortion:
the termination of unwanted pregnancy
either by a person who doesn’t have the
skills or in an environment lacking the
minimal medical standards or both
32 2/1/2018
 Safe abortion
 is termination of unwanted

pregnancy by a qualified person,

with proper equipment, correct
technique & under sanitary
standards.
It could be therapeutic or Elective

33 2/1/2018
 Safe abortion cont…
Therapeutic abortion- Subset of safe abortion
aimed to interrupt pregnancy to:
save the life of the pregnant woman
preserve the woman's physical or mental health
terminate pregnancy with fatal congenital malformation
Selectively reduce the number of fetuses in multiple
pregnancy
Elective(voluntary) abortion- termination of
unwanted Pregnancy at the request of the woman, but not
for medical reasons. 2/1/2018
34
 Features of Medical Vs Surgical abortion
Medical abortion
 Avoids invasive procedure
 Usually avoids anesthesia
 Days to weeks to complete
 High success rate (95%)
 Bleeding moderate to heavy
for a short period
 Requires patient participation
throughout a multi step
process
35
Surgical abortion
 Invasive procedure
 Sedation is used
 Complete in a predictable
period
 High success rate (99%)
 Bleeding commonly
perceived as light
 Patient participation in a
single step process
2/1/2018
 Choice of methods of termination
1.SURGICAL
 The primary factors in choosing a particular
surgical technique are:
 volume & content of intrauterine tissue and
 the experience of the surgeon.
2. NON SURGICAL
 Employed in very early (<7 to 9 weeks) and late pregnancy
terminations (≥ 15 weeks).
 Surgical methods are recommended for pregnancies between
these gestational ages.

36 2/1/2018
 Surgical termination of 1st trimester
pregnancy
1. ManualVacuum Aspiration(MVA)
 safe& effective for GA < 12 weeks
as safe & effective as EVA for GA < 10wks
 Advantages of MVA over EVA:
less pain and blood loss
quieter/ no noise
more portable, inexpensive, and
does not require electricity
 a choice for low-resource settings

37 2/1/2018
 Cont…
2. Electric vacuum aspiration( EVA)
 Used for terminations at all GAs.
 A rigid curved suction curette/ cannula is used
 A metal curette may be used to verify completeness
3. Sharp curettage/ Dilatation and Curettage
 used in the absence of suction curettage equipments
 Vacuum aspiration is preferable to sharp curettage
because:
 less pain and blood loss
 Shorter duration of procedure & less skill
38  less risk of uterine perforation or Asherman’s syndrome 2/1/2018
 Cont…
4.Menstrual Aspiration
 Is aspiration of the endometrial cavity within 1 to 3 weeks
after a missed menstrual period.
 Also called menstrual extraction, menstrual induction,
instant period, traumatic abortion, or mini-abortion

39 2/1/2018
 Medical abortion
Three medications for early medical abortion have been
widely studied and used:
1. the antiprogestin mifepristone
2. the antimetabolite methotrexate, and
3. the prostaglandin misoprostol

 These agents cause abortion by increasing Ux contractility either by:

 Reversing the progesterone-induced inhibition of contractions (mifepristone

and methotrexate), or

 Stimulating the myometrium directly (misoprostol).

 In addition, mifepristone causes cervical ripening

40 2/1/2018
 Regimens for Medical Termination of
Early Pregnancy
Mifepristone/misoprostol
 Mifepristone(200 mg )orally, followed 36 to 48 hours later by
Misoprostol, 200–600mcg orally or 800 mcg vaginally.
Methotrexate/misoprostol
 Methotrexate, 50 mg IM or PO followed by:
Misoprostol, 800 mcg vaginally in 3–7 days; repeat if needed 01
week after methotrexate initially given.
Misoprostol alone
 800 mcg vaginally, repeated for up to three doses

41 2/1/2018
 Complications of abortion
1. Hemorrhage .
2. Complication related to surgical evacuation ie E&C and D&C.
 Uterine perforation- which may lead to rupture uterus in the
subsequent pregnancy.
 Cervical tear & excessive cervical dilatation – which may lead to
cervical incompetence.
 Infection – which may lead to infertility & Asher man's syndrome.
 Excessive curettage – which may lead to Adenomyosis

3. Rh- iso immunization  if the anti –D is not given or if the

dose is inadequate .
4. Psychological trauma

42 2/1/2018
 PAC(Post abortion care)
 Intervention to manage complications of abortion
 5 components
1. Emergency treatment of incomplete abortion and its
complications
2. Counseling- about procedure, post procedure cxn
prevention, when to seek care etc.
3. FP services
4. Linkage with other Reproductive health services
5. Community-service provider partnership (community
awareness creation)

43 2/1/2018
 PAC cont…
 Emergency treatment of incomplete abortion and
its complications
 Support: from the husband, family & obstetric
staff
 Anti D – to all Rh –ve, nonimmunised patients,
whose husbands are Rh+ve
 Counseling & explanation:
 Contraception (Hormonal, IUCD, Barrier) Should
start immediately after abortion if the patient choose to wait , because
ovulation can occur 14 days after abortion and so pregnancy can occur before
the expected next period

44 2/1/2018
 PAC cont…
 When can try again:
 Best to wait for 3 months before trying again . This time allow to
regulate cycles and to know the LMP, to give folic acid, and to allow
the patient to be in the best shape (physically and emotionally) for the
next pregnancy

 Why has it happened

 Majority of cases there is no obvious cause
 In the first trimester abortion , the most common cause is fetal
chromosomal abnormality

45 2/1/2018
 PAC cont…
 Can it happen again
As the commonest cause is the fetal
chromosomal abnormality which is not a
recurrent cause , so the chance of successful
pregnancy next time in the absence of obvious
cause is very high even after 2 or 3 abortion
 Not to feel guilty  as it is extremely unlikely that
anything the patient did can cause abortion
 No evidence that intercourse in early pregnancy is
harmful
 No evidence that bed rest will prevent it ..

46 2/1/2018
 PAC cont…
 Contraceptives & post abortion FP services
Ovulation may resume as early 2 weeks after an abortion.
Therefore, if pregnancy is to be prevented,
effective contraception should be initiated soon after abortion
 To prevent unwanted Px
 To practice child spacing
 Linkage with other RH services
 Rx of STI,infertility and screening of cervical cancer
 Community-service provider partnership
(community awareness creation)
 To prevent unwanted Px & unsafe abortion

47 2/1/2018
 Abortion law in Ethiopia
 The 1957 penal code allowed abortions only to save the life or
health of the woman.
 In 2004, the Ethiopian Parliament passed one of Africa’s most
progressive abortion laws.
 Article 551 of the Penal Code of the FDRE allows termination
of pregnancy under the following conditions:
1.Termination of pregnancy by a recognized medical institution
with in the period permitted by the profession is not punishable
where:

48 2/1/2018
  The pregnancy is a result of rape or incest; or
 The continuation of the pregnancy endangers the life of the
mother or the child or the health of the mother or where the birth
of the child is a risk to the life or health of the mother; or
 The fetus has an incurable and serious deformity; or
 The pregnant woman, owing to a physical or mental deficiency she
suffers from or her minority, is physically as well as mentally unfit
to bring up the child.

2.In the case of grave and imminent danger which can be averted
only by an immediate intervention, an act of terminating
pregnancy in accordance with the provisions of Article 75 of
this Code is not punishable.

49 2/1/2018
 References
Current gyn\obs 2007
Williams' Gynecology 23rd edition
Uptodate 21.6v
Guidelines for Safe Abortion in
Ethiopia 2006

50 2/1/2018
 !

51 2/1/2018