Maternity lessons

1. Gynecology part
BSc Nurse
By Alemu Guta (Ass.t prof)
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2. Early pregnancy bleeding
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3. Cause of Early pregnancy bleeding
 Abortion
 Ectopic pregnancy
 GTD
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4. Abortion
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5. Outline
 Overview of maternal mortality
 Define abortion
 Discuss different classification of abortion
 Discuss etiologies of abortion
 Discuss clinical types of spontaneous abortion
 Outline the management of abortion
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6. MATERNAL MORTALITY-
MORBIDITY,
UNWANTED PREGNANCY AND
UNSAFE ABORTION:
CAUSE, MAGNITUDE,
PREVENTION
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7. Brainstorming
• Q1. Define maternal mortality?
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8. Maternal mortality: definition
 The death of a woman while pregnant or
within 42 days of termination of
pregnancy, irrespective of duration and site
of pregnancy, from any cause related to or
aggravated by pregnancy or its
management but not from accidental or
incidental causes.
(ICD-10, Tenth Revision,1992, WHO. ICD-MM, 2012)
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9. Causes of Maternal Death
1. Direct obstetric deaths:
Hemorrhage
Sepsis
Eclampsia/HPN
Unsafe abortion
Obstructed Labor
2. Indirect obstetric deaths:
 Cardiac/renal diseases (existing)
 Adolescent pregnancy
 HIV among pregnant women
 Malaria
 Malnutrition
 Harmful traditional practices
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10. Causes of Maternal Death in 2013: Global
Abortion,
15%
Haemorrhage,
15%
Gestational
HPN, 10%
Obstructed
Labor, 6%
Sepsis,
8%
Late, 15%
Other Direct,
19%
Indirect,
11%
HIV, 0.7%
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11. Unwanted Pregnancy
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12. Unwanted Pregnancy
Unwanted pregnancy is a pregnancy that a woman is not
actively trying to have (@ the time of conception).
It could be:-
Unintended
Unplanned
A mistake or
Not at the right time
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13. Why unwanted pregnancy happened?
Main reasons include
o Failure of family planning (contraceptive) delivery systems:
Lack of information
Lack of access
o Social/cultural/religious barriers
o Sexual violence: rape/incest
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14. Why unwanted pregnancy happened…
Main reasons include
o The method they were using failed
o Stigmatization/discrimination of unmarried women using
contraceptives
o Lack of knowledge on sexuality and reproduction
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15. Who is at Risk of Unwanted
Pregnancy?
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16. Who is at risk of Unwanted pregnancy?
 Married women
 Single women
 Adolescents and school girls
 Rich and poor
 From Urban/Rural
All women are at risk!!!
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17. Fate of women with unwanted
pregnancies
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18. Why women resort to unsafe abortion?
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19. Why women resort to unsafe abortion?
o Restrictive laws
o Unavailability of the service (despite liberal law)
o Lack of awareness
o Privacy (lack of facility)
o Providers attitude towards safe abortion
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20. What are the factors contributing
for maternal death?
The three delays
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21.  Lack of information and inadequate
knowledge about danger signals
during pregnancy and labor,
 Cultural/ traditional practices that
restrict women from seeking health
care, and
 Lack of money
The 1st delay: Delay in deciding to seek care at
household
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22.  Out of reach of health facilities,
 Poor roads and communication
network, and
 Poor community support
mechanisms.
 Most important barrier to seek
service (DHS 2011)
The 2nd delay: inability to access health facilities
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23.  Inadequate skilled attendants,
 Poorly motivated staff,
 Inadequate equipment and
supplies, and
 Weak referral system.
The 3rd delay: Delay between arriving and receiving
care at the health facility
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24. • Access to Comprehensive FP
• Access to legal Safe Abortion/CAC
• Skilled birth attendance
• Improvement in access & quality of Emergency
Obstetric Care (EmOc)
• Gender equality, Women’s empowerment
• Improvement in legal & policy framework.
What is the Magic/Secret?
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25. Thank You!!!
NO MORE…
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26. Define Abortion ?
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27. DEFINITION OF ABORTION
• Abortion is the termination of pregnancy before fetal viability,
Conventionally -less than 28 weeks from LNMP
If LNMP is not known, a birth weight of less than 1000gm
• WHO: define abortion as pregnancy termination or loss before 20 weeks’
gestation or with a fetus delivered weighing <500 g.
• It may occur either spontaneously or induced.
• Induced abortion can be safe or unsafe.
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28. Magnitude Abortion
 It is the most common complication of pregnancy
 About 15% of clinically recognized pregnancies end in abortion.
 More than 80% of spontaneous abortions occur within the first 12 weeks
of gestation.
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29. Magnitude of abortion in Ethiopian
 In 2014, an estimated 620,300 abortions were performed
every year in Ethiopia.
 Prevalence of induced abortion in
Wachamo University was 5.9% (Shimelis M, et al, 2015)
Hawassa University was 68.7% (አስደንጋጭ)
(Addisu Tadesse, et al, 2019)፣
https://doi.org/10.1155/2020/2856502.
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30. Classification of abortion
Classification of abortion based on:-
A. Method or onset:
 Spontaneous and Induced
B. Clinical staging of Abortion
1. Threatened
2. Inevitable
3. Incomplete
4. Complete
5. Missed
6. Septic
7. Recurrent
C. Legality:
 Legal and Illegal
D. Trimester:
 1st and 2nd
E. Service type
 Safe Abortion & Post abortion care
F. Safety
 Safe and unsafe
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31. Types of abortion
Based on onset:-
1. Spontaneous– happen on its own or without any deliberate
intervention.
2. Induced – caused by deliberate intervention
 Safe or unsafe
 Induced abortion is one of the mechanisms to deal with
unwanted pregnancy.
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32. Discuss -3Minute
Q. Abortion is legal or illegal in Ethiopia?
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33. Legality of abortion in Ethiopia
 Rape, (የተደፈረች)
 Incest or fetal impairment (እርግዝናዉ ከዜመድ ከሆነ)
 A woman can legally terminate a pregnancy if her life or her
child's life is in danger, or if continuing the pregnancy or giving
birth endangers her life.
 A woman may also terminate a pregnancy if she is unable to bring
up the child, owing to her status as a minor (aged under 18 years)
or to a physical or mental infirmity or illness.
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34. Based on service type: -
 Safe Abortion care: is a comprehensive termination of pregnancy that
is offered to clients as permitted by the law
 Post abortion care: is a comprehensive service to treat women that
present to a health care facility after abortion has occurred
spontaneously or after attempted termination.
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35. Etiology
A. First trimester abortion :(the first 12 wk) #1
1. Fetal chromosomal abnormalities –
 is commonest cause
 particularly Trisomy, Polyploidy.
50– 70 % of the first trimester abortions
the incidence increased with the increase in the maternal age.
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36. Etiology
2. Anembryonic pregnancy - Blighted ovum.
3. Infections: genital tract infection , systemic infection with pyrexia
& ToRCH syndrome.
4. Uterine disorders: Uterine anomalies, sub mucus fibroid & Asher
man's syndrome.
5. Psychological disorders.
6. Cigarette smoking ,alcohol, anesthetic agents & chemical agents .
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37. Etiology…
B. Second trimester abortion:
1. Multiple pregnancy
2. Cervical incompetence (congenital & acquired )
3. Uterine anomalies and sub mucous fibroid
4. Genital tract infection and PROM
5. Systemic infections: HIV, Malaria, syphilis, Rubella
6. Maternal health: Diabetes, Renal disease, Hypertension.
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39. Threatened abortion
 Painless vaginal bleeding
 Minimal/mild suprapubic discomfort, mild cramps, pelvic pressure, or
persistent low backache
 On examination:
Uterine size is appropriate for gestational age and
Cervix is long and closed.
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40. Threatened abortion..
 Fetal cardiac activity is detectable by ultrasound or Doppler.
 Even if miscarriage does not follow threatened abortion, rates of later
adverse pregnancy outcomes are increased.
 Of these, highest risks are for preterm delivery.
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41. Threatened abortion (Management)
1. Reassurance: If fetal heart activity is present
2. Advice the woman to avoid strenuous activity and sexual intercourse.
3. ANC as high risk patients
Because those patients are liable to late pregnancy complications such
as APH and preterm labour .
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42. Inevitable abortion
 Bleeding increases,
 Painful uterine cramps/contractions reach peak intensity,
 Membrane is ruptured
 The cervix is dilated to variable extent
 The gestational tissue can often be felt or visualized through the internal
cervical os.
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43. Incomplete abortion
 The membrane ruptured & often the fetus passed
 Part of the placenta may be retained
 On physical exam: cervix usually open, conceptus tissue in the
vagina/cervix
 Small for date uterus
 Amount of bleeding varies
 Often they have painful cramp
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44. Complete abortion
• Is complete expulsion of the entire pregnancy.
• A history of heavy bleeding, cramping, and passage of tissue is typical.
• The uterus is small for GA and well contracted
• Closed cervix,
• Scant vaginal bleeding
• US may indicate a minimally thickened endometrium without a gestational
sac.
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46. Missed abortion
 Is in-utero death of the embryo or fetus prior to the 28th week of
gestation with retention of the pregnancy for 1 wk and above.
 Regression of symptoms associated with early pregnancy and they don't
"feel pregnant" any more;
 Vaginal bleeding may occur.
 The cervix is usually closed
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47. Transvaginal sonography displays an anembryonic gestation
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48. Septic abortion
Definition: Any
of the stage of
abortion
complicated by
pelvic infection.
Etiology
Polymicrobial
• E.Coli
• Bacteroid
• Enterococi
• B-hemolytic
streptococci
• C.Perferenges &
tetani
• Klebsiella, proteus
Symptoms:
• Fever, chills,
malaise,
• abdominal pain,
• vaginal bleeding,
and
• foul smelling
vaginal
discharge.
Physical
examination
may reveal
• Tachycardia,
• Tachypnea,
• Lower abdominal
tenderness, and
• Boggy, tender uterus
with dilated cervix.
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50. Septic Abortion…
The infection may spread, leading to salpingitis, generalized
peritonitis, and septicemia.
Most spontaneous abortions are not septic.
Is, however, a common complication of illegally performed induced
abortion.
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51. Treatment of Septic Abortion
Antibiotics :
 Ampicillin 2gm IV QID,
 gentamicin 3-5mg/kg IV TID
 Metronidazole 500mg IV TID
Removal of infected tissue within an hour of antibiotics.
Administered until the patient has improved and been afebrile for 48
hours.
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52. Recurrent abortion
 Definition: Occurence of >3 consecutive spontaneous aboritions.
 Etiology
1. Immunologic
2. Anatomic
3. Endocrinology
4. Microbiology
5. Genetic
6. Thrombophilia
7. Vitamin deficiency
8. Unknown
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53. Management of abortion
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54. Management of Abortion
The choice of management approach depends on
 Gestational age
 Clinical diagnosis
 Availability of methods of uterine evacuation
 The skill of the providers
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55. Methods for evacuation of uterine content
Medical
methods:
• Mifepristone + misoprostol
• Misoprostol
• High dose oxytocin
Surgical
methods
• MVA- preferred method
• Suction dilation and curettage or suction curettage
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Expect
ant
Reassurance, Advice, Rest, ANC follow-up, counseling

56. 1. EXPECTANT MANAGEMENT
• In cases of threatened abortion, pregnancy can continue till
term and clients can be managed expectantly.
• Medical treatment is not usually required.
• Avoid strenuous activity and sexual intercourse.
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57. 2. MEDICAL ABORTION
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58. Definition and the drugs
• Medication abortion (MA) is termination of pregnancy using drugs
• There are different types of drugs used for abortion
• Currently, the commonly used MA agents are mifepristone and
misoprostole.
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60. Fig. Mifepristone + Misoprostol tablets
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61. The Drugs
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62. Mifepristone
Is a synthetic anti-progesterone
Is developed as RU-486- Roussel-Uclaf plus a serial number.
 Leads to
 detachment of the pregnancy from the uterine wall;
 it also dilates the cervix
It is teratogenic if pregnancy continues after use
It is given orally!
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63. Misoprostole
• Is a prostaglandin E analogue
• Originally manufactured for treatment of PUD
• Works by causing uterine contraction and cervical
dilatation
• Can be used for prevention and/or treatment of PPH
• Is given in different roots (oral, vaginal, buccal, sublingual).
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64. Mechanism of Action: Mifepristone + Misoprostol
Rhythmic
Uterine
Contractions
Progesterone Blockade
Decidual
Necrosis
Cervical
Ripening
Detachment Expulsion
Abortion
© Lisa Penalver
Source: NAF
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65. Effectiveness of MA
Combination of two drugs more effective than either used
alone.
Combined regimen is 92-98% effective in pregnancies ≤ 9
weeks since LMP (Von Hertzen et al., 2003).
Misoprostol alone = 85-90% effective
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66. Regimes for medication
abortion:
doses & route of administration
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67. MEDICALABORTION FOR FIRST TRIMESTER
SAFE ABORTION CARE
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68. Regimens
1. Mifepristone
200mg (1 tab) orally on day 1.
Most women will feel no change after taking mifepristone:
Some women will begin bleeding before taking the next pill
(misoprostol).
A few women will abort after the mifepristone alone.
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69. Regimens
2. Misoprostole
800 (4 tabs) microgram vaginal suppository after 36-48
hours.
There is a range of options in route, dosage and timing
After seven weeks LMP, vaginal doses are more
effective
Up to 90% of women will expel within six hours of
vaginal dose (WHO, 2003).
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71. What to expect after MA
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72. Side effects vs. Complications
Side effects:
• Effects of the treatment, other than the intended outcome,
that might include physiological or psychological
consequences.
 Most are minor, and require little or no intervention
Complications:
• Effects of treatment with potentially serious clinical
consequences
 Require medical intervention
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73. Expected side effects following MA
 Pain
 Bleeding
 Fever, chills, sweating
 Nausea, vomiting
 Dizziness
 Diarrhea
 Skin rashes
 Headache
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74. How much bleeding is too much?
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75. Heavy bleeding Management
Aspiration (MVA) to stop bleeding (0.4 - 2%)
Transfusion required in approximately 0.2% cases
For early surgical abortion ~ 0.1%
No reports of hysterectomy for hemostasis after MA reported
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76. Steps taken before administering MA
• Clinical assessment
History and physical examination
+ Investigations
• Counselling and informed consent
• Discussion of contraceptive needs
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77. Medical abortion for first trimester post abortion care
(Missed and incomplete abortion)
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78. MA for Post-abortion Care
• Evidences show that misoprostole is equally effective to treat incomplete
abortion in the first trimester as MVA.
• MA for PAC is included in the Ethiopian procedural guideline
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80. Misoprostol for Missed Abortion
 800 µgm vaginally
 Administered at home or in clinic
 Success rates: 80-90%
But diagnosis of “missed” abortion depends on access to
ultrasound
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81. MA for second trimester abortion
• MA can also be used for treatment of second trimester safe abortion
• The Ethiopian procedural guideline states
• Additionally trained personnel
• Should be done in hospital set-up having emergency back-up
• The risk of complication is higher than first trimester abortion
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82. 3. Uterine Evacuation using
Manual Vacuum Aspiration
(MVA)
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83. Manual Vacuum Aspiration [MVA]
The following equipment for MVA procedure:
 Pelvic model
 High-level disinfected or sterile surgical gloves
 Personal protective barriers
 MVA syringes and cannula
 Vaginal speculum
 Single-toothed tenaculum or vulsellum forceps
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84. Parts Assembled
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85. Steps of the MVA Procedure
1. Prepare instruments.
2. Prepare the woman.
3. Perform cervical antiseptic prep.
4. Dilate cervix.
5. Insert cannula.
6. Suction uterine contents.
7. Inspect tissue.
8. Perform any concurrent procedures.
9. Process instruments.

86. Step 1: Prepare Instruments
Prepare all necessary equipments and instruments for
doing UE using MVA
Check that the aspirator retains a vacuum.
Have more than one aspirator available.

87. Create a Vacuum

88. Step 2: Prepare the Woman
Ask for consent (when appropriate)
Ensure pain medication is given at the appropriate time.
Ask the woman to empty her bladder.
Help her onto the table.
Wash hands and put on barriers.
Perform a bimanual exam.

89. Signs of complete evacuation
• Red or pink foam without tissue passing through cannula
• Gritty sensation over surface of uterus
• Uterus contracting around cannula
• Increased uterine cramping
• Cervix tightly gripping the cannula

90. Post Abortion Family Planning Counseling &
Services (PAFP)
• PAFP is one of the key quality indicators for CAC
• Ovulation can occur within 10 days following abortion and
the woman may risk subsequent unintended pregnancy
• PAFP thus prevent further unintended pregnancy and
abortion
• Remember that some women may desire another
pregnancy.
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91. Post Abortion care (PAC)
 PAC- is a global initiative in response to the problem of maternal
mortality and morbidity resulting from unsafe abortion.
 Essential elements of PAC services
1. Treatment of incomplete and unsafe abortion
2. Counseling to respond to women's needs
3. Contraceptive services
4. Link to other Reproductive services
5. Community and provider partnerships
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92. GOOD LUCK
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