Abortions and Post Abortion Care

INTRODUCTION/DEFINITION INCIDENCE CLASSIFICATION OF ABORTION AETIOLOGY OF SPONTANEOUS

ABORTION CLINICAL FEATURES/TYPES COMPLICATIONS UNSAFE ABORTION POST ABORTION CARE PREVENTION OF UNSAFE ABORTION CONCLUSION

Termination or loss of pregnancy before the age of viability( 28, 24 , 22 wks or <500 g)

WHO-24 wks or 500 g

In our environment- Officially still 28 wks

UK- 24 wks

USA-22 wks

Abortion is a significant public health problem and an important cause of maternal mortality in the developing world

An estimated 70,000 women die from complications of induced abortion annually in the world

A large number of these deaths (over 99%) are due to unsafe procedures carried out in developing countries

Preventing maternal deaths is an important Millennium Development Goal

-Varies 10-20%, or 15% of clinically recognized

pregnancies

Over half of all pregnancies lost spontaneously

women may abort before knowing they are pregnant

-delayed menses may be diagnosed as pregnancy

-spontaneous abortion may have been due to deliberate interference earlier

Spontaneous or induced

First trimester or second trimester

Induced abortion can be legal or criminal.

Most criminal abortions are unsafe.

Could be classified into fetal and maternal factors

A) Fetal anomalyChromosomalStructuralGeneticB) Maternal disease

- pyrexia- Diabetes mellitus- Thyroid disease

C) Endocrine disorder- early luteal phase defect

D) Uterine abnormalities- fibroids, especially sub mucous- congenital uterine anomalies- intrauterine adhesions- low implantation of the placenta

E) Infections- malaria- pyelonephritis

TORCHES- toxoplasmosis

-rubella- cytomegalovirus infection

-Herpes viruses -Ebsten Barr virus -Syphylis

F) Autoimmune disease- SLE

- Anticardiolipin antibodies

- Antiphospholipid antibodies

G) Immunological - Rhesus iso immunization

H) Trauma- Amniocentesis

-CVS- Pelvic surgery

Threatened

Inevitable

Incomplete

complete

Missed

Recurrent

*Septic

Threatened abortion- Bleeding from uterus before age of viability with cervix not dilated and fetus alive with or without slight lower abdominal pain- most common ( in 1/3 of pregnancies- USS – normal GS

FH activity presenthcg normal

- prognosis good- Bed rest- Hospitalization may not be necessary

Inevitable abortion- Vaginal bleeding with severe abdominal pain and dilatation of the cervix- Pregnancy cannot be redeemed and must be terminated- USS – GS irregular and may or may not be smaller than the EGA- GXM- Oxytocics- Evacuate- AntiD

Incomplete abortion- part of poc expelled but bleeding continues due to retained tissues- V/E- USS*- GXM- Evacuate- Tissue for histology

Missed abortion- Fetal demise (12-28wks) before expulsion- May be preceded by decreased pregnancy symptoms and signs- Uterus not enlarging- Blighted ovum* - absence of an embryo in the GS within the first 12wks of pregnancy as shown by an early USS- Evacuate- 25-30% develop DIC after 1mth if not evacuated

Recurrent/ Habitual abortion- Three or more abortions occurring consecutively or interspersed between term pregnancies- Clinical not pathological diagnosis- prognosis good when diagnosed ( >60% salvage rate)- Management aimed at conditions amenable to treatment

Cervical incompetence- Typical history- Serial V/E- USS/HSG- Cerclage

Myomas – especially submucous- USS- Myomectomy

Hormonal – mid follicular LH/FSH- TFT, FBS

Autoimmune – SLE (lupus anticoagulant- Anticardiolipin antibodies- Blood group

Karyotyping of parentsInfections – Infection screen/VDRL

Complications of abortion Early

- Haemorrhage- Sepsis- Failure to recognise ectopic

Long term- chronic PID- chronic pelvic pain-pelvic abcess- Ashermans syndrome- Ectopic pregnancy-Infertility

The World Health Organization has definedunsafe abortion as “the termination of an unintended pregnancy either by persons lacking

the necessary skills or in an environment lacking the minimal medical standards or both”

- WHO Report of a Technical Working Group, 1992 Unsafe abortion is a major cause of maternal

mortality in developing countries

Factors associated with high rates of abortion mortality in these countries include inadequate access to contraception, restrictive abortion laws, pervading negative attitudes to abortion and poor health infrastructures

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A frica South &South East

Asia

La tinAm erica

Developed

- Empathetic and compassionate pre-procedure counseling of women experiencing complications of abortion- Quality management with MVA

-use of antibiotics- Post procedure counseling to encourage the use of contraceptives to prevent repeat abortion.

-effective link up to FP and other RH servicesExpanded concept:

- Training of service providers, especially doctors, to handle both complicated as well as uncomplicated abortions.

-Provision of MVA Kits.

Primary - provision of RH information and services needed for women and (men) to make informed choices and prevent unwanted pregnancies- provision of quality sexuality education to all age groups- promotion of all form of FP methods (including abstinence)- Establishment of sustainable contraceptive delivery services that would ensure that sexually active people have access to effective methods of contraception

Secondary- programs and activities aimed at providing information and counseling to women experiencing an unwanted pregnancy. Restrictive abortion laws hinder this aspect.

Tertiary - Provision of services for the treatment of women suffering complication of unsafe abortion.

Tertiary contd- Pre-service training of health providers as well as in-service training of staff on all aspects of abortion and post abortion care, contraceptive delivery and quality of care frameworks- inclusion of all components of sexual and reproductive health and rights in the training curricula of all health care workers in Africa

-Abortion is an important public health problem in sub-Saharan Africa.

A public health approach based on primary, secondary and tertiary prevention can reduce the rate of mortality associated with induced abortion in developing countries.

Efforts to address abortion and abortion mortality can contribute to the attainment of the Millennium Development Goals in these countries.

-Obstetricians and Gynecologists in Africa have a leadership role to play in this direction- draw attention and mobilize policy makers and community leaders to find relevant and locally appropriate solutions.