ABORTIONS

GROUP WORK
Def. The expulsion of products of conception
from the uterus through the birth canal
before 24 weeks gestation.
Classifications
 Sponteneous abortions: occur on their
own examples;
 Threatened abortion,
 Inevitable abortions
 missed abortion
2. Induced abortions: examples
 Theraputic abortion
 Criminal abortion
 Septic abortion
 Types of sponteneous abortion
1. Threatened abortion:- Onset of vaginal bleeding
before 20 weeks gestation with or without uterine pain
with closed cervix.
2. Inevitable abortion:- Onset of vaginal bleeding and
abdominal pain in early pregnancy accompanied by
cervical dilatation
3. Incomplete abortion:- Vaginal bleeding and pain with
dilatation of the cervix and some of the products of
conception having come out while others are retained
4. Missed abortion:- The fetus dies in the uterus while
cervix remains clossed. The fundal height is usually
smaller than the actual dates. It may follow threatened
abortion
5. septic abortion:- Abortion complicated by infections
6. Harbitual abortions:- Where there are three or more
consecutive sponteneous abortions
Theraputic abortions: deliberate induction of
abortion before 20 weeks gestation especially when
the pregnancy is threatening the life of the mother
 Onset of abortions
 The onset may either be
1. Spontaneous or
2. Induced
There is therefore need for proper assessment
through history taking, physical examination
and ultra sound scanning where possible for
proper diagnosis and subsequent
management
 Causes of sponteneous abortion
 Divided into 3 causes
1. Maternal causes
2. Fetal causes
3. Paternal causes
Maternal causes
May be general or local
4. General maternal causes
 Acute febrile illness especially in septicaemia with
infection of the fetus and placenta
 Untreated syphilis particularly after 20 weeks.
 Severe high BP, renal disease, diabetes,
hypothyroidism, trauma, emotional stress
 Local causes of sponteneous
abortions
Tumors of pelvic organs eg fibroids
Congenital malformations of the uterus eg
displacement or retroversion
Incompetence of the internal Os: the
commonest cause of habitual abortion
This may be congenital, acquired or as
result of birth injury or operations such as
D/C
Inadequate amount of progesterone
Folic acid deficiency leading to anaemia
Infections and diseases of the
endometrium
 Fetal causes
Congenital malformations of the fetus
Faulty implantation
Multiple pregnancy
Paternal causes
Abnormal form of sperms
This may also be associated with congenital
malformations of the fetus
 Threatened abortion
When a woman who has missed her period for
some months and she passes dark PV
discharge and bright red bleeding
Signs and symptoms
History of amenorrhea and early signs of
pregnancy eg active breasts
Slight lower abdominal pains and backache
Scanty vaginal bleeding which is bright red
On examination uterus is enlarged and
corresponds with history of amenorrhea
Cervix is closed
 Management of threatened abortion
Put patient on bed rest until bleeding has
stopped and several days later
Give sedatives e.g. phenobarbitone 30mg tds
to help the patient relax and rest
Inspect any vaginal discharge
Monitor vaginal bleeding by means of sanitary
pads
After bleeding has stoped patient should avoid
any for of exertion eg travelling, lifting,
bending and coitus until after about 12 weeks.
 Prognosis (outcome)
Pregnancy may proceed to full term or
Fetus may die in uterus- missed abortion or
Bleeding may continue to become inevitable
abortion
 Inevitable abortion
This is when the bleeding is accompanied by
severe abdominal pains, back ache and
dilatation of the cervix
Signs
Severe abdominal crums
Increased vaginal bleeding
Patient may start passing parts of the
products of conception
O/E internal os is dilated and products of
conception felt at the external cervical os
 Management
Patient is taken for evacuation either under GA or
under local anaesthesia
If pregnancy within the first trimester manual
vacuum aspiration (MVA) is recommended as it is
easier, faster and has less complications
For pregnancies beyond 12 weeks if bleeding is not
severe an oxytocin drip may be started and
products of conception allowed to come out
sponteneously
If abortion is incomplete do evacuation either by
mva or dilatation and curratage
Complete abortion is when all the products of
conception have come out and there is less bleeding
Allow bed rest for some time
 Missed abortion
It occurs when the embryo dies in uterus and
sponteneous abortion fails to occur
Signs
Pregnancy signs disappear
Brownish PV discharge seen
O/E cervical os is clossed
Pregnancy test is negative if done 7-8 days after
Treatment: Evacuation of the uterine contents is
done if pregnancy is within first trimester by
MVA or D&C
After 12 weeks sponteneous abortion can be
induced by oxytocin drip
 Septic abortion
Commonly occurs as a result of criminal
abortion or as a result of retained products of
conception
Signs
Fever, tarchycardia, general malaise and
headache
O/E the uterus is tender
PV bleeding increases which becomes
offensive
 Management of septic abortion
Patient requires isolation
Broad spectrum antibiotics which may be give
iv/im if she is unable to take orally
Iv fluids and Iv metronidazole
Antipyretic analgesics
Good vulval hygiene
Patient may require blood transfusion
If patient improves and there are still signs of
retained POCs evacuation can be done
 Criminal abortion
An attempt to procure an abortion by
unauthorized persons
Can be procured by taking drugs, instruments
and insertion of foreign bodies to the uterus
through the vagina
Effects
Infections such as salphingitis, infertility ,
Uterine perforation
Drug poisoning, and
Death due to haemorrhage, air embolism and
septicaemia
 Therapeutic Abortions
Carried out by an authorized person (medical expert) to
safeguard the health of the mother
Can also be considered in cases of severe fetal
malformations
Habitual abortions
Occurs when a woman has 3 consecutive sponteneous
abortions. Causes include:-
Commonest cause is cervical incompetence
Can also occur due to systemic maternal conditions such
as brucellosis and syphilis
Can also arise from localized tumors of the uterus eg
uterine fibroids
Maternal hormonal imbalance
 Management of habitual abortions
Proper assessment and investigations to establish the
cause so that the underlying cause is treated
Manage the patient according to her clinical presentation
ie the nature of the abortion eg threatened, inevitable,
complete, incomplete or septic.
After stabilizing the patient investigate and treat the
underlying cause to prevent similar occurrences in future.
 For cervical incompetence, clinic follow up should start
the earliest time possible after confirming any future
pregnancy
A cervical stitch called McDonald’s stitch may be put in
situ early in pregnancy to strengthen/reinforce the
cervical sphincter muscles to bear the weight of the
growing uterus. The mother is booked for theatre
 Post abortion care (PAC)
This is medical and nursing care provided to patients
who come to the health facility with abortion related
symptoms where conservative management to
preserve the pregnancy is not possible
The abortion is usually inevitable, incomplete,
complete or septic
The objectives include:-
prevent shock by controlling haemorrhage through fast
evacuation of the products of conception
Prevent other complications such as infections
Treat any infections which may have set in
Counseling the woman on prevention of unwanted
pregnancies through use of contraceptives
The commonest and most cost effective procedure is
MVA which can be done in OPD, special room in the
ward or in minor theater. Can also be done by specially
trained nurses and clinical officers
For pregnancies above 12 wks gestation dilation &
curettage is done