ABORTION

August 2014
A.c
 Outline
 Definition, type, clinical features, causes, legal aspect and
client respect [1 Hr]
 CA & NG[8 Hrs.]
 Revise anatomy of uterus and pharmacology for abortion
 (Misoprostol, mifepristone, analgesics & antibiotics) (1hr)
 Choice [Medical abortion (1hr) Manual vacuum aspiration
(1hr)]
 Post abortion family planning counseling care (1hr)
 Abortion complications types & its management (1hr)
 Ectopic pregnancy (1hr)
 Gestational trophoblastic diseases (1 hr)
Definitions
 Abortion :- Spontaneous or induced
termination of pregnancy before fetal
viability(GA or weight)
 Spontaneous abortion . . .

 Induced abortion …

 Recurrent abortion ≥3 consecutive losses of

clinically recognized pregnancies prior to viability

 Primary and secondary recurrent abortion
Cont’d…
 Unsafe abortion(illegal persons lacking the
necessary skills or in an environment that does
not conform to minimal medical standards, or
both
 1st trimester abortion
 2nd trimester abortion
 Selective reduction
Etiology

Genetic,
Endocrine and metabolic ,
Immunological,
Anatomic,
Thrombophilias, Infection ,
Environmental,
unexplained and other
 Genetic factors:

50 ～ 60% of the early abortions/ miscarriages are due to

chromosomal abnormality in the conceptus.
 Numeral abnormalities:
 Aneuploidy:-
• Autosomal trisomy(trisomy -16) is the commonest
(50%) cytogenetic abnormality
• Monosomy –Turner syndrome in 1–2% of all
conceptions, but about 99% of affected babies are
miscarried or stillborn(30%)
• Trisomy-Klinefelter syndrome and Down syndrome 
 Cont’d…
 Eupolidy:-polyploidy,
• triploidy, tetraploid
 Structural abnormalities: (2-4%)accounts
break, translocation, deletion
 ENDOCRINE AND METABOLIC
FACTORS (10–15%)
 Luteal Phase Defect (LPD) : results in early miscarriage
• Deficient progesterone secretion from corpus luteum
• or poor endometrial response to progesterone is the
cause. as implantation and placentation are not
supported adequately.
 Thyroid abnormalities:
• Overt hypothyroidism or hyperthyroidism is
associated with increased fetal loss.
• Thyroid auto-antibodies are often increased.
• Diabetes mellitus when poorly controlled causes
increased miscarriage.
IMMUNOLOGICAL DISORDERS

• is due to the presence of APAS. These are:

• lupus anticoagulant (LAC), anticardiolipin antibodies
(ACAs) and b-glycoprotein 1 antibodies (b-GP1).
 Mechanisms of pregnancy loss in women with APAS are:
• (a) inhibition of trophoblast function and
• differentiation,
• (b) activation of complement pathway,
• (c) release of local inflammatory mediators (cytokines,
• interleukins)
• (d) thrombosis of uteroplacental vascular bed. Ultimate
pathology is fetal hypoxia.
 Immune factors:
 Cytokines are immune molecules.
 Cytokine response may be either (Th1) type or (Th2) type.
 Th1 response is the production of proinflammatory
cytokines [interleukin-2, interferon and tumor necrosis
factor (TNF)].
 Th2 response is the production of anti-inflammatory
cytokines (interleukins -4, -6 and -10).
 Successful pregnancy is the result of predominantly Th2
cytokine response.
 Women with recurrent miscarriage have more Th 1
response.
 Maternal factors

 Age
 History of previous spontaneous abortion
 Disease(TORCH)- acquired during pregnancy such as
rubella or influenza, especially if they are
accompanied by acute fever, interfere with
transplacental oxygenation and may precipitate
abortion.
 Cont’d…
MATERNAL MEDICAL ILLNESS :.
- Chronic disorders, for example renal disease
accompanied by hypertension, may have a similar effect.

- Drugs - large doses of any drug are poisonous and

should
be avoided
- ABO incompatibility between mother and embryo may
result in abortion.
- Psychological factors
 Local causes

Reproductive organic
diseases(developmental defects ):
congenital uterine malformation, pelvic
tumor, cervical incompetence
Injuries
premature rupture of the membranes inevitably
leads to abortion
 Extrinsic factors

 Chemical:
 mercury, lead, cadmium, smoking, IUD
insitue, anesthetic gases, arsenic, aniline, lead,
formaldehyde increase the risk
 Physical:
 video display terminals, Exposure to
electromagnetic radiation from video display
terminals (VDTs) does not the risk of abortion
Clinical stages of abortion
 Cont’d…
 Threatened abortion :-
 vaginalbleeding in the first 28 weeks of
pregnancy, without the passage of tissue or
rupture of membranes.
Symptoms of pregnancy (Painless bleeding)
Speculum exam blood coming from the
cervical os
The internal cervical os is closed
uterus is soft and enlarged appropriate for
gestational age
 Cont’d…
 Differential diagnosis
 Benign and malignant lesions
 Disorders of pregnancy
 Hydatidiform mole
 passage of grape-like vesicles
 uterus that large for date
 No heart tones by Doppler after 12 weeks
 Hyperemesis, preeclampsia, hyperthyroidism
 Ultrasonography confirms the
 Cont’d…
 Ectopic pregnancy
 pelvic exam. cervical motion tenderness
 pain, Orthostatic light-headedness, syncope or
shoulder pain (from diaphragmatic irritation)
may occur
 Abdominal tenderness is noted
 Serum beta-HCG is positive
 Cont’d…
 Laboratory tests
 Complete blood count(hgb/htc, ABO and Rh

grouping.
 Quantitative serum beta-HCG
 Ultrasonography

 Treatment of threatened abortion

 Bed rest with sedation and abstinence from intercourse.
 Increased bleeding (>normal menses), cramping, passage
of tissue, or fever
 Passed tissue
 Cont’d…
 Inevitable abortion
 Threatened abortion + dilated cervical os.
 Menstrual-like cramps usually occur.

 Differential diagnosis
 Incomplete abortion
 tissue has passed.
 tissue visible in the vagina or endocervical canal.
 Threatened abortion

internal os is closed
 Incompetent cervix
 dilatation of the cervix without cramps.
 Cont’d…
 Treatment of inevitable abortion
 Surgical evacuation of the uterus is necessary.
 Anti D is administered
 Before 13 weeks gestation 50 mcg IM
 At 13 weeks gestation 300 mcg IM
 Cont’d…

 Incomplete abortion
 Cramping, bleeding, passage of tissue, and a dilated
internal os with tissue present in the vagina or
endocervical canal.
 Profuse bleeding, orthostatic dizziness, syncope, and
postural pulse and blood pressure changes may occur
 Cont’d…
 Laboratory evaluation
 CBC
 Blood group & Rh typing
 cross-matching

 Treatment
 Stabilization
 Removal of products of conception
 Anti D
 Methylergonovine (Methergine)
Cont’d…
 Complete abortion
 complete passage of products of conception
 uterus well contracted, & the cervical os may be
closed
 Differential diagnosis
 Incomplete abortion
 Ectopic pregnancy.
Cont’d…
 Management of complete abortion
 Between 8 and 14 weeks, curettage is necessary
 Anti D
 Beta-HCG levels are obtained weekly until zero.
 Cont’d…
 Missed abortion products of conception are
retained after the fetus has expired.
 uterus fails to grow as expected
 fetal heart tones disappear.
 Amenorrhea may persist
 intermittent vaginal bleeding
 spotting, or brown discharge may be noted.
 Ultrasonography confirms the diagnosis
 Cont’d…
 Management
 counsel the parents

 CBC with platelet count, PT, PTT

 Blood grouping & Rh

 Evacuation of the uterus

 Anti D

 Complications
 coagulation disorders
 Infection
 maternal case-fatality rate was estimated to be 4.5 deaths
per 100,000 fetal deaths
 Cont’d…

 Septic abortion :-
 Endometritis --- parametritis and peritonitis.
 Cl.f -- fever, abdominal tenderness, and uterine pain.
 Causatives --- E. coli and other aerobic, enteric, gram-
negative rods, group B-hemolytic streptococci, anaerobic
streptococci, Bacteroides species, staphylococci, and
microaerophilic bacteria.
 Management of septic abortion
 Thorough examination *pelvic examination
 Investigations *intrauterine and blood cultures
 Placement of indwelling Foley catheter
 Administration of intravenous fluids
 TAT
 Abdominal x-rays to detect free air or foreign bodies
Cont’d…
 Optimal therapy consists of evacuation of the
uterus and aggressive use of parenteral
antibiotics before*, during, and after removal of
necrotic tissue by curettage
 Classifications and
characteristics

conceptus Vaginal abdominal Cervix os Uterine

Subgroups expulsion bleeding pain dilation enlargement

Threatened no ＋ －＋ －
compatible
abortion
Inevitable no ＋ ＋ ＋ ＋ ＋
－ compatible or abortion
smaller

Incomplete part ＋ ＋ ＋ ＋ ＋
－ smaller
abortion
Complete all ＋ － －
－ normal
abortion
 RECURRENT ABORTION

 Terms used to describe repetitive early

spontaneous pregnancy
 Losses include recurrent miscarriage,
recurrent spontaneous abortion, and recurrent
pregnancy loss, with the last term gaining
popularity
 Etiology
 Approximately 1 to 2 percentile couples experience
recurrent miscarriage, which is
 Classically defined as 3 ≥ consecutive losses at < 20
weeks’ gestation or with a fetal weight < 500g.
 Most women with recurrent miscarriage have
embryonic or early fetal loss.
 Recurrent anembryonic miscarriage or those with
consecutive losses after 14 weeks are much less
common
 Cont’d…
 Of the many putative causes of early RPL, only
4 are widely accepted:
Antiphospho- lipid antibody syndrome
Parental chromosomal abnormalities,
acquired or congenital uterine abnormalities
Endocrinologic Factors- Luteal Phase De
fect
 Timing clue
 The timing of the recurrent losses may provide a
clue to their etiology.
 For a given individual with RPL, each

miscarriage tends to occur near the same

gestational age (Heuser, 2010).
Genetic factors most frequently result in
early embryonic losses,
autoimmune or anatomic abnormalities more
likely lead to second-trimester losses.
Induced Abortion
 Medical or surgical termination of pregnancy before the
time of fetal viability
 In 2014, an estimated 620,300 abortions were performed in
Ethiopia
 The abortion rate is highest in urban areas: 92/1,000 women
in Addis Ababa, the country’s largest city, and 78 per 1,000
in the smaller urban regions of Dire-Dawa and Harari.
 13 % unintended pregnancies ending in abortion .
 25% unintended pregnancies ending in
miscarriage ,mistimed birth or unwanted birth
 62% Intended pregnancy ending in miscarriage or birth
Cont’d…
 Teenagers have the highest proportion of
abortions per live births
 abortion rate among women living below the
federal poverty level > 4× that of women above
300 percent of the poverty level
 Repeat pregnancy terminations account for
approximately 44 percent
Cont’d…
 62 percent ≤ 8 weeks
 88 percent <13 weeks of gestation
 96 percent by 16 weeks
 81% of terminations were via curettage
 9.9 % were medication-only procedures
 0.6 % used intrauterine instillation
Cont’d…
 20-30 million legal abortions are performed
annually, with another 10-20 million abortions
performed illegally
 48% of all induced abortions are unsafe
 More than 95% of abortions in Africa and Latin
America are unsafe
 worldwide, 80,000 women die each year because
of abortions
Cont’d…
 one-third of the approximately 205 million
pregnancies that occur worldwide annually are
unintended
 about 20% of all pregnancies end in induced
abortion
 Of the 182 million pregnancies that occur in
developing countries, more than one-third are
unintended, and 19% end in induced abortion
(8% are safe procedures and 11% are unsafe)
Consequences of unsafe abortion
 5 million hospitalized each year for abortion-
related complications
 13% of maternal deaths worldwide, or 67,000
per year
 Africa 650 deaths/100,000 unsafe abortions
 10 per 100,000 in developed regions
 220,000 children worldwide lose their mothers
every year from abortion-related deaths
Cont’d…
 loss of productivity
 economic burden on public health systems,
 stigma
 long-term health problems, such as infertility
 Cont’d…
 Samples of Unsafe Abortion Methods Used
 Drinking turpentine, bleach or tea made with livestock
manure
 Inserting herbal preparations into the vagina or cervix

 Placing foreign bodies, such as a stick, coat hanger or

chicken bone, into the uterus
 Jumping from the top of stairs or a roof
 Classification of Induced Abortion

 Therapeutic Abortion
 persistent cardiac decompensation

 severe diabetes

 advanced hypertensive vascular disease

 invasive carcinoma of the cervix

 rape

 Incest

 fetus with a significant anatomic or mental deformity

 IUFD
Cont’d…
 Fetal indications for abortion
 fetal cardiac anomalies
 trisomy 21,13, 18,
 open and closed neural tube defects
 anencephaly, some hydrocephalic cases
 esophageal or duodenal atresia
 chest and abdominal wall defects
 cystic kidneys , hydronephrosis, renal agenesis
 intracranial calcifications suggestive of viral disease
 diaphragmatic defects.
Cont’d…
 Elective (Voluntary) Abortion
 at the request of the woman, but not for medical
reasons
 one pregnancy is electively terminated for every
four live births in the US
Cont’d…
 common reasons for choosing abortion
 having a baby would interfere with work, school, or
other responsibilities
 inability to afford a child

 not wanting to be a single parent

 having problems with a husband or partner

Preoperative considerations
 Counseling before elective abortion
 continued pregnancy with its risks and parental
responsibilities
 continued pregnancy with its risks and
responsibilities of arranged adoption
 the choice of abortion with its risks
 Cont’d…
 INFORMED CONSENT
 EVALUATION
 pregnancy dx
 GA estimation
 LMP
 bimanual pelvic examination
 Ultrasound* Preoperative intraoperative
 Identify all pre-existing conditions
 malignant hyperthermia
 coagulation disorder
 Cardiorespiratory disease.
 Cont’d…
 Investigations
 hemoglobin and Rh factor
 cervical cytology (if necessary)
 screen for sexually transmitted pathogens
 Cont’d…
 Antibiotic prophylaxis for surgical abortion (5 to 20
percent)
 Doxycycline (100 mg PO BID on the day of the
procedure)
 Ofloxacin (400 mg PO BID on the day of the procedure)
 Ceftriaxone (1 g IV 30 min prior to the procedure)
 Cervical preparation 
  Dilation of the cervix to allow insertion of
instruments and removal of the products of
conception
 gradual, safe dilatation of the cervix

 facilitates vacuum aspiration

 decreases the incidence of cervical lacerations

and uterine perforation by up to 80%.

 Cont’d…
 Chemical Dilators
 Administer the following combination of drugs
in the specified dosage:
 Up to 9 completed weeks since LNMP
o Mifeprestone PO 200 mg followed 48
hours later by
o Misoprostol 800 µg vaginally, Insert
misoprostol deep into the vagina or
 instruct the woman to do so by herself.
After 12 till 24 weeks completed weeks since
LMP
• Mifeprestone PO 200 mg followed 48
hours later by
• Misoprostol 400µg of oral misoprostol
every 3 hours up to a maximum of 5
doses if abortion does not occur.
.
 After 24 till 28 weeks completed weeks since LMP
• Mifeprestone PO 200 mg followed 48 hours
later by
• Misoprostol 100µg of oral misoprostol every
3 hours up to a maximum of 5 doses if
abortion does not occur.
NB :-Depending on the need for pain control,
non-narcotic analgesics should be
prescribed during and after medical abortion
 Advantages
 Convenience: the patient can insert the tablets at
home
 Minimal pain on application

 Highly cost effective

 Potential Disadvantages
 Cramping
 Bleeding

 Incomplete abortion before the surgical procedure

 Contraindications:
 Mifepristone and Misoprostol
o Suspected ectopic pregnancy or undiagnosed adnexal
mass
o IUCD in place (remove before administering medication)
o Chronic adrenal failure
o Concurrent long term corticosteriod therapy
o History of allergy to mifepristone
o Hemorrhagic disorders or concurrent anticoagulant
therapy
o Inherited porphyrias
o History of allergy to prostaglandins including
misoprostol
Cont’d…
 Rigid dilators
 instrument sets with progressively increasing
diameters.
 more traumatic to the cervix than other methods

 Pratt, Tapered Pratt or Denniston

Cont’d…
 Osmotic dilators
 laminaria osmotic dilators & Dilapan
 absorb cervical moisture,
 release of endogenous prostaglandin
 potential disadvantage a false passage may be dilated
 hypersensitivity or anaphylactic reaction to laminaria
 must be placed several hours prior to the procedure
(6-8hrs , 4hrs)
Insertion of Osmotic Dilators
 Visualize the cervix using a speculum and wash
with antiseptic solution.
 Grasp the anterior lip of the cervix with a single
toothed tenaculum or other appropriate
instrument.
 Straighten the cervical canal with tenaculum,
followed by the use of a uterine sound to probe
the canal to determine the position, length, and
diameter of the internal os.
 Cont’d…
 Determine the size and number of laminaria osmotic
dilators needed.
 Grasp the osmotic dilator longitudinally at its distal
end and insert it into the cervical canal just through
the internal os counter traction to the cervix, the
internal and external os should be traversed.
 held it in place for several seconds to reduce expulsion.
 Place gauze (4 x 4) sponges against the cervix and
leave in place until removal of the osmotic dilator
Choice of technique
 Factors in choosing a particular abortion
technique
 volume and content of intrauterine tissue
 experience of the surgeon

 availability of equipment and drugs

 the preference of the woman

 Surgical methods of abortion
 MVA --- 4-10 wks' 99.2% effective.
 Suction curettage --- 6-14 Wks' .
 Sharp curettage --- 4-14 Wks' increased bl. loss and
retained product of conception compared with suction.
 D&E--- 14-24 wks' .
 D&X ≥ 18 wks' , as a partial-birth abortion
 Hysterotomy/Hysterectomy 12-24 wks
 all other methods of abortion have failed or are contraindicated.
 stenotic cervical os, placenta accreta, leiomyoma obstructing
cervical os).
 List of medical methods
 A combination of methotrexate and misoprostol
 misoprostol-alone
 Prostaglandin E2 & PGF2
 Misoprostol with mifepristone
 Carboprost tromethamine
 High-dose oxytocin 
 Prostaglandin F2 (PGF2) Amnio-Infusion
 Hyperosmolar Urea Amnio-Infusion
References
 ACOG Treatment Guidelines 2004 Ed.
 SOGC CLINICAL PRACTICE GUIDELINES

No 184, November 2006

 Danforth's Obstetrics and Gynecology, 10th

Edition
 UpToDate 17.3

 Essentials of obstetrics and gynecology 4th Ed.

 Te Linde's Operative Gynecology, 10th Edition

 Williams Gynecology 22 nd Ed.(2005)

Thank You