This document provides an overview of abortion and its complications in developing countries. It discusses the definition, incidence, causes, types, management, and complications of abortion. Some key points include: - Abortion contributes to 30% of maternal deaths in Tanzania. Complications include hemorrhage, uterine perforation, hematometra, infection, and maternal mortality. - Types of abortion include threatened, inevitable, incomplete, complete, missed, and septic abortion. Management depends on gestational age and type. - Causes include infection, psychological stress, nutrition deficiencies, trauma, drugs, uterine abnormalities, and fetal abnormalities. - Complications in developing countries are made worse by lack of access to health facilities

1. DEPARTMENTOFOBGY|MUHAS
ABORTION AND ITS
COMPLICATIONS
IN DEVELOPING
COUNTRIES
PRESENTERS:
JOSEPH PAUL
JUSTIN MPWAGA
FACILITATORS:
PROF. MUGANYIZI
DR. GEORGE

2. INTRODUCTION
CAUSES
ASSESSMENT AND COUNSELING
TYPES OF ABORTION & MANAGEMENT
COMPLICATIONS IN DEVELOPING COUNTRIES
POST-ABORTAL CARE
Presentation
Outline
TUESDAY • JULY 22. 2019

3. Introduction

4. DEFINITION
Spontaneous or induced termination of pregnancy before 28wks
of pregnancy i.e before fetal viability
Current WHO definition- before 22wks GA or less than 500g
Abortion contributes 50% of maternal death!
TUESDAY • JULY 22. 2019

5. INCIDENCE
Approximately 26 million legal and 20 million illegal abortions
were performed worldwide in 2002, resulting in a worldwide
abortion rate of 35 per 1,000 women aged 15–44. Among the sub
regions of the world, Eastern Europe had the highest abortion rate
(90 per 1,000) and Western Europe the lowest rate (11 per 1,000).
TUESDAY • JULY 22. 2019

6. INCIDENCE
In Africa, about one-quarter of the unsafe abortions are among
teenagers (ages 15 to 19), a higher proportion than in any other
world region
Worldwide, one in five pregnancies (22 percent) ends in abortion,
and one in 10 pregnancies ends in unsafe abortion.
TUESDAY • JULY 22. 2019

7. INCIDENCE
It is estimated that 30% of Tanzania's annual 21,000 maternal
deaths are a result of abortion-related complications.
60% of incomplete abortions is a result of unsafe abortions. More
often this occurs in younger, singles and in students.
TUESDAY • JULY 22. 2019

8. ABORTION LAW
Person Act of 1961 and the Infant Life (Preservation) Act of 1929. Under the Revised Penal Code of Tanzania
(chapter 16, sections 150-152) the performance of abortions is generally prohibited. Any person who, with
intent to procure the miscarriage of a woman, whether she is pregnant or not, unlawfully uses any means
upon her is subject to 14 years’ imprisonment. A pregnant woman who undertakes the same act with
respect to her own pregnancy or permits it to be undertaken is subject to seven years’ imprisonment. Any
person who supplies anything whatsoever knowing that it is intended to be unlawfully used to procure the
miscarriage of a woman is subject to three years’ imprisonment.

9. Causes of
Abortion

10. GENERAL
CAUSES
Infection
Are responsible especially in 2nd trimester.
This is because infection with syphillis
occurs 16-24 Wks GA
Psychological
Severe emotional stress eg loss of
close relative.
Nutrition
Severe vitamin deficiency eg. folic
acid
General Hyperpyrexia
Temperature > 39 C due to general acute
illness increases uterine contactions
Metabolic Diseases
DM is associated with congenital
malformation hence expelled by uterus

11. GENERAL
CAUSES
Endocrine
Hypothyroid or Hyperthyroid states
Renal Disease
Chronic renal disease e.g
glomerulonephritis reduces blood
volume and causes fetal hypoxia
Severe Trauma
Severe trauma can expel the fetus
Drugs
Cause congenital malformation (6th to
8th wk) or fetal hypoxia.
Other Drugs interfere with fetal nutrition
E.g Quinine, Chloroquine, PGs,
Methotrexate

12. LOCAL
CAUSES
Uterine Causes
Malformations- bicornuate, septate
Tumors- fibromyoma etc occupy cavity and
reduce blood supply.
Cervical incompitence
Ovarian Causes
Regression of the corpus luteum
prematurely before the placenta takes
over
Corpus luteum fails to produce
progesterone. It usually occurs during
12th to 14th wk.
Fetal Causes
Congenital malformations ( XO, trisomy,
anencephaly, molar pregnancy)
Commonest cause of 1st trimester fetal loss
(70-80%)

13. Uterine
malformations
types
Uterine fibroids can occupy cavity
Causes of cervical
incompetence

14. Types of
Abortion

15. TYPES OF ABORTION
Threatened abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Missed abortion
Septic abortion (any type of abortion
complicated with infection)
Recurrent abortion ( 2 or more consecutive
abortions)

16. Management
Give simple analgesics, avoid
strenuous activities + sexual
intercourse and encourage bed
rest.
Mild sedation to decrease anxiety
DO NOT give tocolytics or
hormones as they will not
prevent miscarriage
Threatened
Abortion
Pt presents with Hx of ammenorhoea
Vaginal Bleeding - Fresh & Mild
Lower Abdominal Pain - Almost absent
Cervix is closed
Uterine size corresponds with GA
Abortion process is started but not
completed. (can continue or be arrested)

17. Management
If pregnancy <12 wk GA
Pt presents with Hx of ammenorhoea
Vaginal Bleeding - Heavy bright red
with clots
Severe Lower Abdominal Pain, colicky
with strong uterine contractions
Cervix is open and Products of
conception can be palpated from OS
Uterine size corresponds with GA
Innevitable
Abortion
Abortion process has started and will
proceed to complete or incomplete
abortion. It is an inevitable process.
Plan for evacuation OR
Give Misoprosol 400ug @ 4hrly
If pregnancy >12 wk GA
Await for spontenous evacuation of
POC and evacuate if remaining
Infuse oxytocin 40IU in 1L of NS/RL
at 40drops/min
Depending on severity give IV fluids, blood
transfusion, Oxygen and analgesics e.g
pethidine

18. Management
If pregnancy <12 wk GA
Pt presents with Hx of ammenorhoea
Vaginal Bleeding - Scanty to Moderate
brownish
Lower Abdominal Pain of varying
degrees
Cervix is partially open with partial
expulsion of POC
Uterine size is smaller than expected GA
Incomplete
Abortion
Abortion process has started but some
parts of POC are still in the uterine cavity
Evacuate the uterus via MVA,
Curretage OR
misoprostol 400ug orally
If pregnancy >12 wk GA
Infuse oxytocin 40IU in 1L of NS/RL
at 40drops/min
If necessary give misoprostol 200ug
vaginally @4hrs until expulsion of
POC occurs

19. Management
Evacuation of Uterus is not
necessary
Observe of heavy bleeding
Pt presents with Hx of ammenorhoea
Vaginal Bleeding - None, but has hx of
placenta, fetus & membranes coming
out.
Lower Abdominal Pain - absent
Cervix is closed
Uterine size is smaller than expected
GA
Complete
Abortion
Abortion process is completed with no
POC in uterus. Common after >20 Wk GA
Follow up patient after treatment
Confirm diagnosis with USS, for fetal
heart activity

20. Management
If pregnancy <12 wk GA
Pt presents with Hx of ammenorhoea
Vaginal Bleeding - None
Lower Abdominal Pain - absent
Cervix is closed
Fundal height is very small to dates
Missed Abortion
Fetus dies in utero and is retained (has
not been expelled.
D&C
If pregnancy >12 wk GA
Induce labour
Confirm diagnosis with USS, for fetal
heart activity

21. Clinical Features
Agents include: E.coli, Streptococcus
Haemolyticus, S. aureus, C.welchii.
Septic Abortion
An abortion complicated by infection.
Results from unsafe abortion, prolonged
retention of POC, incomplete or unsterile
evacuation of the uterus.
Hx of amenorrhoea
Pregnancy symptoms
Vaginal bleeding
Fever
Low abdominal pain
Vaginal Discharge (smelling,
profuse, dirty)
Routes:
Droplet infection from attendants
Unsterile instruments
Enviromental unhygiene
Patients own cloths and hands
Signs:
Increased body temperature
Increased pulse rate
Low or normal BP
Abdominal Tenderness
Offensive per vaginal discharge

22. ManagementInvestigation of
Septic Abortion
HB
FBP : WBC
Mid Stream Urine : microscopy, culture
& sensitivity
Blood for group & cross matching
Vaginal Swab for microscopy, culture &
sensitivity
Resuscitate the patient and manage
the shock
Antibiotics (intravenous);
ampicillin 500mg+ metronidazole
500mg + genta 80mg) 8hrly or
ceftriaxone 1g od if symptoms
persist within 3days
Give FeSO4 and folic acid for 6wks
Surgically:
Empty the uterus with evacuation
Drainage of pelvic abscess
Laparotomy for peritonitis
Routes:
Droplet infection from attendants
Unsterile instruments
Enviromental unhygiene
Patients own cloths and hands

23. 1ST TRIMESTER CAUSES
Genetic
Endocrine (PCOS,DM,
Hypothyroidism)
Infection
Thrombophilia
Immune (antiphospolipid
syndrome, alloimunity)
2ND TRIMESTER CAUSES
Anatomic abnormalities
Acquired anomalies such as
intrauterine adhesions, uterine
fibroids and endometriosis and
cervical incompetence.
Infections
Chronic maternal illness
Recurrent
Abortion
Is defined as a sequence of three or
more consecutive spontaneous abortion
before 28 weeks. Some, however,
consider two or more as a standard.

24. Complications
of Abortion

25. The total abortion-related complication rate including all sources of care including
emergency departments and the original abortion facility is estimated to be about 2%.
The incidence of abortion-related emergency department visits within six weeks of initial
abortion procedure is about 40%.
Epidemiology

26. Post-abortion
complication
Incomplete evacuation of the
products of conception
Infection
Injury from the surgical
procedure itself

27. HEMORHAGE
Early complication
Postabortal hemorrhage may result from cervical or vaginal
lacerations, uterine perforation, retained tissue, or uterine atony.
Other causes of hemorrhage include infection, uterine arteriovenous
malformation, placenta accreta, and coagulopathy (secondary to
release of tissue thromboplastin into the maternal venous system).

28. UTERINE PERFORATION
Lack of skillful or inexperienced clinicians who perform the procedure
Nature of the instruments used for abortion in developing country
together with sociocultural and religious perspectives.
Bowel and bladder injuries

29. HEMATOMETRA
Immediate postoperative pain without overt bleeding from the vagina
may indicate development of hematometra. Hematometra (also
known as uterine distension syndrome or postabortal syndrome)
usually presents with complaints of dull, aching lower abdominal
pain, sometimes accompanied by tachycardia, diaphoresis, or
nausea. The onset is usually within the first hour after completion of
the procedure.

30. HEMATOMETRA
Pelvic examination reveals a large midline globular uterus that is
tense and tender. Treatment requires immediate uterine evacuation,
permitting the uterus to contract to a normal post procedure size.
Administration of intramuscular methylergonovine maleate (0.2 mg) is
then given to ensure continued contraction of the uterus

31. MATERNAL MORTALITY
Second trimester is worse, mortality is lowest before 8 weeks of
gestation and increase after 18 weeks
In developing countries where abortion is illegal, ≥25 percent of all
maternal deaths are abortion-related
Factors associated with increased maternal mortality from unsafe
abortion in developing countries include inadequate delivery
systems for contraception needed to prevent unwanted pregnancies,
restrictive abortion laws, pervading negative cultural and religious
attitudes towards induced abortion, and poor health infrastructures
for the management of abortion complications.

32. INFECTION
Delayed complication occurring more than 72 hours after the
procedure
Postabortal infection due retained products of conception. Also can
ascend from cervicitis and endometriosis
Lack of prophylactic antibiotics
Leads to pelvic infection, and peritonitis

33. BREAST CANCER
Some studies support that induced abortion is associated with
significant increase in the risk of breast cancer

34. RISK FOR FUTURE
PREGNANCIES
A meta-analysis of 37 studies reported that women with versus
without a history of pregnancy termination had a significantly
increased risk of low birth weight infants (OR 1.4, 95% CI 1.2-1.5) and
preterm delivery (OR 1.4, 95% CI 1.2-1.5).

35. References
DC Dutta’s Textbook of Obstetrics, 8E (2016)
UpToDate
Medscape
https://www.sciencedirect.com/science/article/pii/00207292
89900994
https://www.ncbi.nlm.nih.gov/books/NBK430793/
https://apps.who.int/iris/bitstream/handle/10665/40349/924
1544694.pdf;jsessionid=09F9750B252A8951978506CFBBF0
E9C8?sequence=1
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