ABORTION

ABORTIONMRS B.M.N. KAPETABSC/RM/RN(2014)

GENERAL OBJECTIVETo equip students with skill and knowledge to identify types of abortions and enable them to provide comprehensive services that will meet the clients needs.

SPECIFIC OBJECTIVES

Define abortionState the different causes of abortionState the classification of abortionsMention the signs and symptoms of specific types of abortionDiscuss immediate management of specific types of abortionINTRODUCTION

Globally, of all maternal deaths approximately 15% are related to unsafe abortion. Uterine abortion is the commonest cause of vaginal bleeding in early pregnancy. It accounts for 95% of cases of bleeding in early pregnancy. In Zambia 30% of maternal deaths are as a result of abortions.. ContPregnancy is not a disease but still, its a major killer among young women in the world today. However bleeding in early pregnancy can be caused by other pregnancy complications such as ectopic pregnancy, and molar pregnancy being the most serious. ContAbortion is important not only because of the loss of the wanted pregnancy, but because its an important cause of maternal death from the haemorrhage and sepsis which may follow a mismanaged abortionIntrod cont,Its also vital to note that in abortal services, certain human rights should be respected, such as right to life, right to privacy, right to information and education, right to decide whether or when to have children.

DEFINITIONS

Abortion is an expulsion of products of conception before the 28th week of gestation and before viability of the fetus (Hossan 1982)Abortion is loss of pregnancy before the 28th week or loss of fetus weighing less than 500g (WHO)

TYPES OF ABORTIONSSpontaneous abortion also known as miscarriage is the unintentional expulsion of an embryo or fetus before the 24th week of gestation. or an involuntary loss of the products of conception prior to 24 weeks gestationInduced abortions- Its an intentional or voluntary disruption of the products of conception before the 24th week of gestation

Definitions cont,

Therapeutic Abortion: A medically performed abortion to save the life of the pregnant woman; prevent harm to the woman's physical or mental health; terminate a pregnancy where indications are that the child will have a significantly increased chance of premature morbidity or mortality or be otherwise disabled; Contor to selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy.

Elective (Voluntary) Abortion: Is performed at the request of the woman for non-medical reasons.

CAUSES OF ABORTION

In many cases, no definite cause can be found, however the following are regarded as causesa). FOETAL CAUSESMal-development of the conceptus- due to chromosomal abnormalities which accounts for 50% of the cases.Genetic and Structural abnormalities Causes contb). MATERNAL CAUSESThese include the following maternal influences:Maternal infections this is brought about by the effects of fever on the fetus, from acute illnesses like influenza or rubella, the toxins are able to cross over to the fetus, toxoplasmosis, cytomegalovirus, syphilis, Chlamydia, etc.

Cont Uterine abnormalities This includes retroversion of the uterus, bicornuate uterus, unicornuate uterus and fibroids, Infantile uterusMedical disorders conditions such as anaemia lead to reduced fetal perfusion as in renal disease, diabetes, thyroid disease, and hypertensive and renal disorders.

Cont Cervical incompetence due to Congenital weakness - owing to the weight of the growing fetus, the weakened cervix starts to dilate and hence not maintain the pregnancy.Trauma - resulting from previous D&C or child birthMaternal Age and Gravidity data reveals an increased risk with advancing maternal age (over 30 yrs) and increasing gravidity (Oats & Abraham, 2005).

Causes of abortions contEndocrine abnormalities Poor development of the corpus luteum, inadequate secretory endothelium and low serum progesterone levels.Psychological factor Such as severe emotional stress/ anxiety affects the function of the hypothalamus leading to the release of stress hormones which cause vaso-constriction hence reducing blood supply to the fetusCauses contTraumaDirect trauma to the uterusCriminal interferenceDrugs:Large doses of all drugsCytotoxic drugsAnaesthetic drugsCauses contEnvironmental/ social factors excessive consumption of alcohol leads to malnutrition;coffee due to caffeine causes vaso constriction of blood vessels; smoking ( nicotine causes vaso-constriction of blood vessels) women who smoke 10 cigarettes per day double their riskCauses contincluding passive exposure to cigarette smoke, have been found to increase the risk of abortions. Exposure to organic solvents such as lead and radiation increases the likelihood of fetal malformation and miscarriagec). PATERNAL CAUSESPoor sperm quality may be a factor which may lead to fetal malformation.

CLINICAL TYPES OF ABORTION

SPONTANEOUS ABORTIONThe stages of spontaneous abortion may include: Threatened Abortion (occurs in the early weeks of pregnancy; pregnancy may continue); Inevitable Abortion (this pregnancy will not continue and will proceed to incomplete/complete abortion);

CLINICAL TYPES.. contIncomplete Abortion (products of conception are partially expelled); usually happens in the 2nd trimesterComplete Abortion (products of conception are completely expelled).Clinical types cont,INDUCED ABORTIONSepticTherapeutic CompleteIncomplete

INVESTIGATIONS

HistoryDate of last menstrual period (LMP), duration and amount of bleeding severity of cramping type of contraceptive used before such as implants and injectables Passage of products of conception unexplained fevers and chills.

Investigations contLaboratory testsGravindex test confirms pregnancy by presence of HCG and decreased levels suggest abortionBlood for culture and sensitivity will confirm the septic abortion, the causative organism and its sensitivity.

Investigations contUltra sound examinationA confirmatory test that will reveal:Gestational sacPresence or absence of fetal heart sounds or an empty amniotic sac.

SPONTANEOUS ABORTIONS

THREATENED ABORTIONIn this type of abortion, there is slight painless vaginal bleeding during the first three months of pregnancy. It may be associated with slight lower abdominal pain or backache but there is no cervical dilatation.

Signs and symptoms

History of amenorrheaSigns of pregnancy presentHeight of fundus corresponds with datesUterus softWith or without backache and lower abdominal painsPresence of scanty vaginal bleedingCervical OS closed

Management of threatened abortion

Obtain history and do physical examination and vital sign observations .Bed rest is the most important form of treatment. The patient should remain in bed for 5-7days or for as long as blood is bright red. Bed rest increases blood flow to the placenta and reduces pain.Abstinence from sexual activitiesManagement of threatened abortion cont,If uterine contractions become stronger, analgesics such as pethidine100mg intramuscularly or morphine 15mg may be needed. Pads should be saved in order to help assess the amount of blood loss. Report any increase in bleeding or pain to the doctor for further management.

AN INEVITABLE ABORTION

A condition in which the cervix has already dilated, but the fetus is yet to be expelled, this usually progresses to a complete abortion or incomplete abortion.Signs and symptomsHistory of amenorrheaSigns and symptoms of pregnancy presentHeight of fundus may not correspond with the gestational age Signs and symptoms cont,Cramping Lower abdominal pains and backacheFairly heavy Vaginal bleedingCervical os is openProducts of conception maybe seen at the vaginal introitusMay progress to either complete or incomplete abortion

COMPLETE ABORTION

This is when all the products of conception, which is the embryo and the placenta with intact membranes, are expelled from the uterus.Signs and symptomsHistory of amenorrheaSigns and Symptoms of pregnancy presentSome backache and lower abdominal pains

Complete abortion contUterus firm and well contractedHistory of passage of the products of conceptionDiminishing or Minimal bleeding per vaginaCervical os closed

IMMEDIATE MANAGEMENT OF COMPLETE ABORTIONRest in bed, if possible with sedationEvacuate uterus as soon as possible to ensure completeness.Check Hb after 24hours in case of severe anemia due to severe bleeding.Curettage only needed if bleeding persists

AN INCOMPLETE ABORTION

This is one in which part of the products of conception, usually the fetus is delivered while the placenta and membranes are retained. The cervix is usually open. Incomplete abortion when unattended to causes fatal complications. Signs and symptomsHistory of amenorrheaSevere and Cramping lower abdominal pains and backacheAbdomen soft, height of fundus may correspond Incomplete abortion cont,

Abdomen softHeavy and profuse vaginal bleedingPassage of some products of conception, usually the fetus and the placenta and membranes are retainedSigns of shockIncomplete abortion contImmediate management of incomplete abortionEvacuate uterus under anesthesia or strong analgesiaReplace blood if necessary or if the hemoglobin level is below 5 grams.Antibiotics only if febrileSet up oxytocin drip to aid in expelling retained products of conception by uterine contraction.

Management contIf patient is in shock start a plasma expander for example dextran 50%, heamacil, drip after taking blood for grouping and cross-matching.Do a sterile vaginal examination and remove any placental tissue distending the cervix with a finger or sponge forcepsGive ergometrine 0.5mg intramuscularly. Once these steps have been taken the condition usually improves and the patient can safely be transferred to hospital.

Incomplete abortion cont,If bleeding is light to moderate and pregnancy is less than 16 weeks, use fingers or ring (or sponge) forceps to remove products of conception protruding through the cervix. If bleeding is heavy and pregnancy is less than 16 weeks, evacuate the uterus: Manual vacuum aspiration is the preferred method of evacuation. Evacuation by sharp curettage should only be done if manual vacuum aspiration is not available;

ContIf evacuation is not immediately possible, give ergometrine 0.2 mg IM (repeated after 15 minutes if necessary) OR misoprostol 400 mcg orally (repeated once after 4 hours ifnecessary).ContIf pregnancy is greater than 16 weeks: Infuse oxytocin 40 units in 1 L IV fluids (normal saline or Ringers lactate) at 40 drops per minute until expulsion of products of conception occurs; If necessary, give misoprostol 200 mcg vaginally every 4 hours until expulsion, but do not administer more than 800 mcg; Evacuate any remaining products of conception from the uterus. Ensure follow-up of the woman after treatment

MISSED/DELAYED/SILENT ABORTION

This occurs when the fetus dies and is retained in utero, together with the placenta and membranes. Signs and symptomsHistory of amenorrheaSigns of pregnancy regressHeight of fundus less than expectedSome spotting per vagina or brownish vaginal discharge

Missed abortion contCervical os closedThere is no pain.Fetal heart cannot be heard by either fetoscope or DopplerUltra sound may confirm the abscence of fetal heart beatPregnancy test usually is negativeMissed abortion contMissed abortion is usually not tempered with until after one month because it eventually spontaneously initiates its expulsion. The main complication of missed abortion is disseminated intravascular coagulation (DIC) which is profuse bleeding due to hypofibrinogenemia . There is evidence of poor response to oxytocin/pitocin. Refer cases of missed abortion to hospital for surgical evacuation to prevent any further complications.ContManagementConfirm the diagnosisSpontaneous expulsion may occur on its own later but the waiting period may be distressing to the mother knowing she is carrying a dead fetus.If the pregnancy is below12 weeks-16 weeks, evacuation of retained products of conception (ERPC) is doneIf above 12/16 weeks induction with prostaglandin E2 and oxytocin.(prostaglandin brings about contractions of uterine muscles)

BLOOD MOLE AND CARNEOUS MOLE

Blood mole may arise in case of a missed abortion where the zygote is surrounded by a layer of blood (blood mole). The mole usually forms after 2 weeks and is retained for months. All the fluid is then absorbed from the bloody mole leaving a fleshy firm hard mass known as the carneous mole. On examination, the mole will resemble the placenta. A tiny embryo may be seen at the centre of the mass.

SEPTIC ABORTIONInfection can easily set in or can complicate any type of abortion. Therefore if infection is disseminated into the systemic circulation it is called septic abortion. The commonest type of abortion that leads to sepsis is illegal or criminal abortion.Signs and symptomsHistory of amenorrheaHistory of abortion usually unsafe abortion

Septic contGeneral discomfortPyrexia usually >38C,Chills and sweatingHeadachesTachycardiaUterus bulky and very tender on palpationFoul smelling vaginal dischargeCervical OS openChills and fever signifies serious infectionGeneralized abdominal tenderness with rebound tenderness, rigidity or distension

Septic abortion contImmediate management of septic abortionTreatment of these patients with septic abortion is an emergency as delay may result in severe complications or death.Patients should be managed in the hospital if possibleResuscitate with intravenous fluids in order to replace lost fluids.

Septic abortion contGive parenteral broad spectrum antibiotics to combat infection.Take a cervical swab for culture and sensitivity before starting antibiotic treatmentBlood transfusion can be given in cases of low hemoglobin (5g/dl)

Complications of septic abortionSepticaemia BacteremiaRenal failureDisseminated Intravascular Coagulation (DIC)- inappropriate coagulation within the blood vessels leading to the consumption of clotting factors. Secondary infertilitySheehans syndrome (Pituitary Necrosis)

HABITUAL ABORTION

Also called recurrent abortion or recurrent pregnancy loss (RPL) this is when the patient has experienced 3 or more consecutive spontaneous abortions, usually after 14weeks of gestation. There is usually no obvious cause but the commonest cause is cervical incompetence. However some of the known causes are chronic illness, such as diabetes mellitus, and abnormalities such as a septate uterus. ContCauses Often the cause is unknownIncompetence of the internal os of the cervix resulting from previous trauma Infections of low grade feverLocal lesions such as cervical erosionDiseases like diabetes mellitus, nephritisContSigns and symptomsThe abortion occurs late in the second trimester usually between the 22-24th weekThere is no previous warning such as vaginal bleedingThe membranes may rapture suddenly followed by expulsion of the conceptusThe abortus looks fresh

ContManagement Investigations to R/O systemic diseases like diabetes, syphilis, cervical erosion(RPR, FBC, blood sugar, Ultra sound scan, cervical smear, full history)Advise the mother to improve general health by taking foods rich in proteins, vitamins, minerals and to start a new pregnancy as soon as possibleContThe woman should report to the hospital as soon as they are pregnantTreat her as a case of threatened abortion ( bed rest)Admit client if she cant rest at homeIt must be emphasised/stressed to the couple that coitus should not take place for the rest of the pregnancy

ContIf the cervix is incompetent a shirodkar suture of any non absorbable suture material is tied around the cervix at the level of the internal os at about 14th-16th weekThis operation should be recorded clearly and boldly in the clients antenatal recordsContThe suture must be removed at about the 38th week or as soon as the client goes into labour otherwise there are dangers of uterine rapture if not removed in time.Offer psychological care to the couple and counselling them as treatment may not always be effectiveMild sedatives may be required to promote rest

ContINDUCED ABORTIONThis is an intentional emptying of the uterus. It can either be therapeutic or criminalTherapeutic abortionThis is evacuation of the uterus done by a qualified medical practitioner. It is provided for under the legal framework; The Abortion Act of 1972.

ContSubject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if he and two other registered medical practitioners,

Contone of whom has specialised in the branch of medicine in which the patient is specifically required to be examined before a conclusion could be reached that the abortion should be recommended, are of the opinion, formed in good faithContThe Act states that pregnancy is terminated if the pregnancy:Involves risk to the life of the pregnant woman e.g. a woman who has a condition that is complicated by pregnancyInvolves risk of injury to the physical or mental health of the womanInvolves risk to the existing children of the family, greater than if the pregnancy were terminated

ContCarries substantial risk that if the child were to be born, it would suffer from such physical and mental abnormalities as to be seriously handicapped e.g. German measles/rubellaThe Act further state that it is done if two registered medical practitioners are of the opinion that the pregnancy should not continue. The spouse should signCont A therapeutic abortion should be done in the hospital where:-i. Haemorrhage can be controlled, Ii. Resuscitative measures are available and Iii. Aseptic measures are always taken.Staffs are however allowed to refuse to advocate for or take part in abortions on moral grounds. The moral issue is profound and each one either the Dr or the nurse should act according to their conscience

METHODS USED FOR TERMINATION OF PREGNANCY

1). Prostaglandin preparationInduction is done after 12 weeks. Prostaglandin E2 and E12. Prostaglandin in misoprostol (cytotec) is commonly used where it is inserted in the cervix to induce labour. Rapture of membranes should not be done to reduce infection.Cont2). Vacuum aspirationVacuum aspiration is used for pregnancies between seven and 12 weeks. A tube is inserted into your womb through the cervix and suction is applied to remove the womb contents. This procedure takes 10 to 15 minutes and recovery time is one to two hours.

Cont3). Dilatation and Curettage (D&C)D&C is used for pregnancies between 12 and 19 weeks. A speculum is inserted into the vagina to view the cervix and a slender rod (called laminaria) is used to gently open the cervix. The pregnancy may be removed using forceps and a curved instrument (a curette) is used to scrape the lining of the womb. Suction is applied to remove the tissue. ContThis procedure takes about 30 minutes and is usually done under general anaesthesia.The removed tissue is examined to make sure the termination is complete and disposed of sensitively.

UNSAFE ABORTION/CRIMINAL

This is an abortion that is performed in controversy or violation of the Abortion Act of 1972 by unauthorized persons and is punishable by law. It may be done by the woman herself or any other person.

UNSAFE .contMethods usedDrugs intoxication, Herbs, dettol, chloroquine overdoseInsertion of sharp objects, instruments, catheter, herbal sticks. Successful or not the action is illegal

Risks of criminal abortion

InfectionUterine perforationCervical lacerationAir embolusHaemorrhageShock and deathinfertility

CONCLUSION

We have discussed abortion and we said that abortion is the expulsion of products of conception before the 28th week of gestation. An abortion can either be induced or can start spontaneously. Causes of abortion can either be maternal or fetal, but there are cases where the cause is not known. We also looked at various clinical types of abortion such as incomplete, complete and others. ContAll cases of abortion should be considered incomplete until a thorough investigation is done. They should be treated as an emergency because of the severe complications that may arise if mismanaged such as maternal death and severe bacterial infection.

REFERENCESFraser D.M. et al (2003) Myles Textbook for Midwives, 14th Edition, Elsevier Limited Winkler J. et al, (1995) Post Abortion Care, A reference manual for improving quality of care, Post Abortion Care Consortium, United States of America.Sellers P.M, (2008) Sellers Midwifery Volume 11,Complications in Childbirth, Juta and Co, LtdOats J and Abraham S (2005) Fundamentals of Obstetrics and Gynaecology, 8th Edition, Philadelphia; Elsevier Limited

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