Covers the basic information about abortions that you need to know with in depth discussion of the different types of abortions and their characteristics
2. Introduction
• Abortion is defined as the spontaneous or induced termination of
pregnancy before 20 weeks’ gestation or with the fetus weighing <
500 g
• The term miscarriage is usually used by the lay public to describe the
spontaneous loss.
• Elective or therapeutic abortions are terms used to describe induced
pregnancy termination.
• Approximately 50% of the miscarriages or abortions are anembryonic;
that is with no identifiable embryonic elements and the other 50%
are embryonic miscarriages or abortions which commonly display
developmental abnormality of zygote, fetus or at times the placenta.
3. Legal status in Fiji
- Abortion is illegal is in Fiji except under certain conditions.
- Abortion is legally permitted when:
• there is a risk to life and health of the mother.
• the pregnancy is a result of a criminal act.
• when the fetus is seriously malformed
5. 1. Spontaneous abortion
• spontaneous abortion or miscarriage is the natural death of an
embryo or fetus before it is able to survive independently. The cut of
used is 20 weeks of gestation, after which fetal death is known as still
birth.
Fetal death < 20 weeks = abortion.
Fetal death > 20 weeks = stillbirth.
6. Pathogenesis of spontaneous abortion
• More than 80 percent of the spontaneous abortions occur within the
first 12 weeks’ of gestation.
• Death of an embryo or fetus is always accompanied by hemorrhage
into the decidua basalis, this is followed by adjacent tissue necrosis
that stimulates uterine contractions and expulsion.
• In later pregnancy losses, the fetus usually does not die before
expulsion.
7. Etiology/Risk factors
Fetal factors Maternal factors
• Genetic
- Chromosomal abnormalities
• Multiple pregnancies
• Male fetus.
• degeneration of villi
• Unexplained or idiopathic.
• Infections e.g. bacterial vaginosis
• Maternal Medical illness
- Celiac disease.
• Immunological factors
- alloimmune disease
- autoimmune diseases (antiphospholipid
antibody syndrome).
• Anatomical abnormalities
- Cervical insufficiency
• Endocrine and metabolic factors
- Diabetes mellitus
- thyroid disease
• Social and behavioral factors e.g.
consumption of alcohol and smoking.
• maternal age > 35
• Previous abortion or miscarriage.
10. 1. Threatened abortion
• is a term used for vaginal bleeding and symptoms that suggest that a
woman is at an increased risk of miscarriage during the first 20 weeks of
pregnancy.
Clinical features
• Vaginal bleeding.
• Pain: usually painless however, lower abdominal pain sometimes
accompanies bleeding.
• Vaginal examination at this stage usually reveals a closed cervix.
11. Management
• It is best managed by an ultrasonic examination to determine
whether the fetus is present and if so, whether it is alive.
• Other part of management essentially consists of reassurance,
however, mother of the fetus should be encouraged to undergo first
trimester screening for chromosome abnormalities.
• Rho(D) immunoglobulin should be given to prevent alloimmunization
if the mother is Rh (D) negative.
• There is no need for admission to hospital nor is there any evidence
that bed rest improves the prognosis.
12. 2. Inevitable Abortion
• Inevitable abortion can come without warning or after a threatened
abortion where changes have progressed to a state from where
continuation of pregnancy is impossible.
Clinical features
• Pronounced vaginal bleeding.
• Cramp-like lower abdominal pain.
• Vaginal examination at this stage usually reveals dilation of cervical
os.
• Gross rupture of membranes occur followed by a gush of vaginal fluid.
13. Management
Management is aimed to:
- To accelerate the process of expulsion.
- To maintain strict asepsis.
• If pregnancy <12 weeks, suction evacuation is done.
• If pregnancy > 12 weeks, expulsion by misoprostol 200μg pv every 6
hours
14. 3. Incomplete abortion
• The process of abortion has already taken place, but entire products
of conception are not expelled and a part of it is left inside the
uterine cavity.
• Bleeding results from partial or complete placental separation.
Clinical features
• vaginal bleeding
• Cramp-like lower abdominal pain
• cervical os dilatation is revealed by vaginal examination.
• incomplete passage of the products of conception.
15. Management
• Until bleeding has stopped or is minimal, it is best to insert an
intravenous line and take blood for grouping and crossmatching
because shock may occur from hemorrhage or sepsis.
• Once the patient’s condition is stable, the remaining products of
conception should be evacuated from the uterus using either:
- Expectant – waiting for the remaining products of conception to come
out naturally.
- Medical- misoprostol 400–800μg pv q.d
- Surgical – dilation and evacuation or manual vacuum aspiration
16.
17. 4. Complete abortion
• When the products of conception are completely expelled from the
uterus.
Clinical features
History of expulsion of a fleshy mass per vaginam followed by:
• Abatement of the vaginal bleeding and cramp-like abdominal pain.
vaginal examination reveals
• Closing of the cervical os.
• Uterus is smaller than the period of amenorrhea.
• Immunological test for pregnancy becomes negative.
19. 5. Missed abortion
• The fetus is dead and retained passively inside the uterus usually for a
variable period.
Clinical features
The patient presents with features of threatened abortion followed by:
• Subsidence of pregnancy symptoms.
• Uterus becomes smaller in size.
• Cervix feels firm with closed internal os.
• Non audibility of the fetal heart sound even with doppler ultrasound.
• Immunological test for pregnancy becomes negative.
20. Management
• Suspected missed abortion should be confirmed by ultrasound.
• Once the diagnosis has been made, it is appropriate to evacuate the
retained products of conception surgically to minimize the risk for
sepsis and DIC and to reduce the extent of hemorrhage and the
degree of pain that accompanies the spontaneous expulsive process.
21. 6. Septic abortion
• Any abortion associated with clinical evidences of infection of the
uterus or its contents.
• Most commonly caused by attempts at induced abortion by an
untrained person without the use of aseptic technique.
Clinical features
• Fever
• Abdominal pain
• Nausea
• Diarrhea
- Vaginal examination reveals
• Purulent vaginal discharge
22. Management
Mild cases
• Broad spectrum antibiotics plus evacuation of the retained products
of conception.
Severe cases
- Intensive supportive care.
• Fluid therapy (IV infusion with crystalloid)
• Oxygen therapy
• Broad spectrum antibiotics and evacuation of retained products
when patient stabilizes.
• If purulent discharge is present, take a swab and send it for culture
and sensitivity for identification of causative agent to initiate
appropriate antibiotic therapy.
24. Recurrent abortion
• Is defined as sequence of three or more consecutive pregnancy losses at ≤
20 weeks or with a fetal weight of < 500g.
Recurrent abortion is divided into two:
• First trimester abortions are most commonly due to genetic or
chromosomal problems of the embryo, with 50-80% of spontaneous losses
having abnormal chromosomal number. Structural problems of the uterus
can also play a role in early abortion.
• Second trimester can be the result of uterine abnormalities, autoimmune
problems, an incompetent cervix or premature labor
26. General management for spontaneous
abortion
• The management option chosen for each patient depends on the type
of abortion/miscarriage, the size of uterus, medical comorbidities,
availability of equipment and supplies, and a woman’s preference.
• Options include surgical management, medical
management, or expectant management.
• Informed consent should be obtained for whatever treatment option
is desired.
27. 1. Conservative or Expectant management
- Is defined as an approach in which time is allowed to pass before medical or
surgical intervention is used.
- patient should be aware that complete resolution may take several weeks
and the overall efficacy rates are lower.
- Expectant management should only be offered when the patient is stable and
can access 24 hour telephone advice and emergency admission if required.
28. 2. Medical management
- Non-invasive
Drugs used are:
• Misoprostol*
• Mifepristone
• Methotrexate
• Oxytocin
30. 2. Induced abortion
• Is defined as medical or surgical termination of pregnancy before the
time of fetal viability.
Classification
Therapeutic Elective
- Refers to an abortion recommended
when mother’s health is at risk.
- Includes cases of rape, incest and when
the fetus is serious malformed.
- Interruption of pregnancy before the
fetal viability at the request of the
mother but not for medical reasons
(illegal in Fiji)
32. Medical
Misoprostol (prostaglandin E1 analogue)
• Mode of action - Soften and dilate the cervix and induce uterine
contractions via their actions on smooth muscle causing expulsion of the
products of conception.
Dosage:
- 800 μg sl or pv q3h <13 weeks gestation
- 400 μg sl or pv q3h 13-26 weeks gestation
- 200 μg sl or pv q4h >26 weeks gestation
Others that can be used
• Mifepristone
• Methotrexate
33. Surgical:
• dilation and curettage. *
• Manual vacuum aspiration.*
Others
• Salt poisoning
• Hysterotomy
34. Factor Expectant Medical Surgical
• Invasive
• Pain
• Vaginal bleeding
• Incomplete abortion
• Failure rates
• Infection rate
• Anesthesia
• Time involved
No
More
Prolonged,
unpredictable
More common
50%
Low
None
Multiple visit plus
follow up exam
No
More
Prolonged,
unpredictable
More common
5-40 percent
Low
None
Multiple visit plus
follow up exam
Yes
Less
Light, predictable
Uncommon
1 percent
High when proper
aseptic technique not
used.
Yes
Usually one visit, no
follow up exam.
36. Definition
Post-abortion care (PAC) is defined as care given to woman who presents at a
health center or hospital with complications due to an incomplete abortion or
miscarriage.
Goals
• The ultimate goal of PAC is to reduce maternal morbidity and mortality and to
improve women’s sexual and reproductive health.
Components of PAC
The original concept for post abortion care was first articulated by Ipas in 1991 and
published by the PAC Consortium in 1994 and it included:
• emergency treatment for complications of spontaneous or induced abortion.
• post abortion family planning counseling and services
• linkages between emergency care and other reproductive health
services.
37. The PAC Consortium in 2002 expanded the three elements of PAC to fiv
e essential elements. These are:
• Treatment: Medical management of complications, including surgical
evacuations of products
• Provision of family planning services.
• Provision of emotional support and counselling.
• Provision of other reproductive health services.
• Community and service provider partnerships.
38. Conclusion
• It can be concluded that abortion or miscarriage are either naturally
occurring (spontaneous) or intended (induced).
• The management option chosen for each patient depends on the typ
e of abortion/miscarriage, the size of uterus, medical comorbidities,
availability of equipment and supplies, and a woman’s preference.
• High quality post abortion services can help in saving many lives.
39. Reference
Cunningham F, Leveno K, bloom S, Sponge C. Williams obstetrics. 24th
ed. 2010.pp 350-371.
Hacker N, Gambone J, Hobel C. Hacker & Moore's essentials of
obstetrics and gynecology. 5th ed. 2009. pp 71-74
What is Stillbirth? | CDC [Internet]. Centers for Disease Control and
Prevention. 2019 [cited 24 June 2019]. Available from:
https://www.cdc.gov/ncbddd/stillbirth/facts.html
40. • Ministry of Health and Medical Services, Goverenment of Fiji. (2015.)
Obstetrics and Gynaecology:Clinical Practic Guidelines. Version 2.1. June,
pp 103-119
• [Internet]. Figo.org. 2019 [cited 24 June 2019]. Available
from:https://www.figo.org/sites/default/files/uploads/project-
publications/Miso/FIGO_Dosage_Chart%20EN_0.pdf
• Moise Jr K, Lockwood C. Overview of Rh(D) alloimmunization in pregnancy
[Internet]. Uptodate.com. 2019 [cited 23 June 2019]. Available from:
https://www.uptodate.com/contents/overview-of-rh-d-alloimmunization-
inpregnancy?search=Erythroblastosis%20fetalis&source=search_result&sel
ectedTitle=3~150&usage_type=default&display_rank=3
41. • Sinan M. Abortion [Internet]. 2019 [cited 23 June 2019]. Available
from: https://www.slideshare.net/msinan94/abortion-54257120
