ABORTION

Prof. K.Punithalakshmi

Principal

JIETCON

OBJECTIVES

At the end of this session the students will be able to:

1. Define various types of abortions.
2. Outline the causes and management approach for various types of abortions.
3. Describe the relation between complications of abortions and maternal mortality
4. Explain the Abortion and Post abortion care.

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STATISTICS OF ABORTIONS

• 50 - 60% of all pregnancies end in spontaneous abortion (SAB) since 2-4 wk pregnancies will often go unnoticed.

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• 15% of all recognized pregnancies 4-20 wks

end in SAB.

• 30% lost between implantation and the 6^th wk.
• 70% of first trimester losses are due to chromosomal abnormalities

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Abortion Law

In May 2005, Ethiopia's new Criminal Code came into effect. ... In addition, the revised code stipulates that the woman's word is all that is needed to justify pregnancy termination in cases of rape and incest.

• In 2005, the Ethiopian Parliament amended the penal code to allow abortion in cases of rape/incest, if the woman has physical or mental disabilities; it is needed to preserve the woman’s life or physical health; she is a minor who is physically or mentally unprepared for childbirth.

• In 2014, it was found that an estimated 620,296 induced abortions occurred in Ethiopia, resulting in a rate of 28 abortions per 1,000 women 15‐49 annually as compared to a rate of 22 in 2008. The abortion rate remains highest in Addis Ababa and the densely populated urban regions of Dire‐Dawa and Harari.  

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• The proportion of abortions occurring in health facilities increased from 27% in 2008 to 53% in 2014, while an estimated 294,127 abortions (47% of all abortions) occurred outside of health facilities in Ethiopia in 2014. The number of women receiving treatment for complications from induced abortion increased by 97% between 2008 and 2014 from 52,607 to 103,648.

Definition

• Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing 500 g or less when it is not capable of independent survival (WHO).
• This 500 g of fetal development is attained approximately at 22 weeks (154 days) of gestation.

Classification of Abortion

I. SPONTANEOUS ABORTION

• Threatened
• Inevitable
• Complete
• Incomplete
• Septic
• Missed
• Recurrent

II. INDUCED ABORTION

1. Legal

2. Illegal

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• Spontaneous abortion is the most common complication of pregnancy and is defined as the passing of a pregnancy prior to completion of the 20th gestational week. It implies delivery of all or any part of the products of conception, with or without a fetus weighing less than 500 gm.
• When the abortion occurs spontaneously, the term " miscarriage" is often used.

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• Threatened abortion is bleeding of intrauterine origin occurring before the 20th completed week, with or without uterine contractions, without dilatation of the cervix, and without expulsion of the products of conception.
• Inevitable abortion refers to bleeding of intrauterine origin before the 20th completed week, with dilatation of the cervix without expulsion of the products of conception.

• Complete abortion is the expulsion of all of the products of conception before the 20th completed week of gestation.
• Incomplete abortion is the expulsion of some, but not all, of the products of conception.
• Missed abortion - the embryo or fetus dies, but the products of conception are retained in utero.
• Septic abortion - infection of the uterus and sometimes surrounding structures occur.

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�Aetiology�

1) Chromosomal abnormalities: It is a genetic factor which cause at least 50% of early abortions e.g. trisomy, monosomy X (XO) and triploidy.

2) Blighted ovum (anembryonic gestational sac): where there is no visible foetal tissues in the sac.

3) Maternal infections :

Bacterial : Ureaplasma urealyticum,

Viral :Cytomegalovirus

Parasitic: toxoplasma gondii which causes abortion if there is acute infection early in pregnancy.

4) Trauma: External to the abdomen or during abdominal or pelvic operations.

5) Endocrine causes:

a. Progesterone deficiency ( causes abortion between 8-12 weeks).

b. Diabetes mellitus.

c. Hyperthyroidism.

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6) Drugs and environmental causes:

e.g. severe purgatives, tobacco, alcohol, arsenic, lead, formaldehyde, benzene and radiation.

7) Maternal anoxia and malnutrition.

8) Over distension of the uterus: e.g. acute hydramnios.

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9) Immunological causes:

a. Systemic lupus erythematosus

b. Anti phospholipid antibodies that are directed against platelets and vascular endothelium leading to thrombosis, placental destruction and abortion. Spiral artery and placental intervillous thrombosis, placental infarction and fetal hypoxia is the ultimate pathology to cause abortion.

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c. Histocompatibility between the mother and father and in turn the fetus. It is assumed that histo incompatibility particularly in human leucocyte antigen (HLA- DR locus) is essential for stimulation of the immune system to produce blocking factors which prevent rejection of the fetus.

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d) Antifetal antibodies are deleterious to cause fetal loss as found in cases with Rh-negative women with anti-D antibodies.

Blood Group Incompatibility: Incompatible ABO group matings may be responsible for early pregnancy wastage and often recurrent. Couple with group ‘A’ husband and group ‘O’ wife have got higher incidence of abortion.

10) Ageing sperm or ovum.

11) Premature Rupture Of The Membranes inevitably leads to abortion.

12) Uterine defects

e.g. Septum , Asherman's syndrome (intrauterine adhesions) and submucous myomas.

13) Nervous, psychological conditions and over fatigue.

14) Idiopathic.

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�Mechanism of Abortion�

a. Up to 8 weeks: The gestational sac tends to be expelled complete and the decidua is shed thereafter.

b. From 8-12 weeks: The decidua capsularis ruptures and the embryo is expelled either entire or after rupture of the amnion.

c. After 12 weeks: The placenta is completely formed and the process of abortion is like a miniature labour. It is more common for the fetus to be expelled but for the placenta to be retained due to firmer attachment to the uterine wall.

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Pathologic change

• Most commonly, necrotic changes occur in the decidual tissue about the placentation site and result in hemorrhage into this area. As bleeding continues, the sac and the placenta become detached from the uterine wall and are expelled by uterine contractions.
• Early pregnancy: abortion is complete
• 8 - 12wks: abortion is incomplete

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�(A) Threatened Abortion�

Definition: It is a clinical entity where the process of miscarriage has started but has not progressed to a state from which recovery is impossible .

Clinical picture

1. Symptoms and signs of pregnancy coincide with its duration.

2. Vaginal bleeding slight or mild, bright red in colour originating from the chorio decidual interface.

3. Pain is absent or slight.

4. Cervix is closed.

5. Pregnancy test is positive.

6. Ultra sonography shows a living fetus.

Prognosis:

• If the blood loss is less than a normal menstrual flow and is not accompanied by pain of uterine contraction there is a reasonable chance for continuing pregnancy. This occurs in 50% of cases while other half will proceed to inevitable or missed abortion.

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• Treatment
• Rest in bed until one week after stoppage of bleeding.
• No intercourse as it may disturb pregnancy by the mechanical effect and the effect of semen prostaglandins on the uterus.
• Sedatives: if the patient is anxious.

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�(B) Inevitable Abortion�

• Definition: It is the clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible.
• Clinical picture:
• Symptoms and signs of pregnancy coincide with its duration.
• Vaginal bleeding is excessive and may accompanied with clots.
• Pain is colicky felt in the suprapubic region radiating to the back.

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• The internal os of the cervix is dilated and products of conception may be felt through it.
• Rupture of membranes between 12-28 weeks is a sign of the inevitability of abortion.
• Treatment:

- Any attempt to maintain pregnancy is useless.

- Resuscitation and ergometrine 0.5 mg is given by IM or IV route to induce tetanic uterine contraction and stop bleeding.

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(I) If pregnancy is less than 12 weeks: Termination is done by vaginal evacuation and curettage or suction evacuation under general anaesthesia.

(II) If pregnancy is more than 12 weeks:

- Oxytocin is given by intravenous drip to expel the uterine contents.

- If the placenta is retained it is removed under general anaesthesia.

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�(C) Incomplete Abortion�

• Definition: When the entire products of conception are not expelled, instead a part of it is left inside the uterine cavity, it is called incomplete miscarriage.
• Clinical picture:
• The patient usually noticed the passage of a part of the conception products.
• Bleeding is continuous.

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• On examination, the uterus is less than the period of amenorrhoea but still large in size. The cervix is opened and retained contents may be felt through it.
• Ultrasonography: shows the retained contents.
• Complications: The retained products may cause: (a) profuse bleeding (b) sepsis (c) placental polyp.

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• Management: In recent cases—Evacuation of the retained products of conception (ERCP) is done.

• Early abortion: Dilatation and evacuation under analgesia or general anesthesia is to be done.

• Late abortion: The uterus is evacuated under general anesthesia and the products are removed by ovum forceps or by blunt curette. In late cases, dilatation and curettage operation is to be done to remove the bits of tissues left behind.

�(D) Complete Abortion�

Definition: When the products of conception are expelled, it is called complete miscarriage.

Clinical picture:

• The bleeding is slight and gradually diminishes.
• The pain ceases.
• The cervix is closed.
• The uterus is slightly larger than normal.
• Ultrasound : shows empty cavity

• Management: Evacuation and Curettage.
• Rh-negative Women: A Rh—negative patient without antibody in her system should be protected by Anti-D gamma globulin 50 -100 microgram intramuscularly in cases of early miscarriage or late miscarriage respectively within 72 hours. However, Anti-D may not be required in a case with complete miscarriage before 12 weeks gestation where no instrumentation has been done.

�(E) Missed Abortion�

• Definition: When the fetus is dead and retained inside the uterus for a variable period, it is called missed miscarriage or early fetal demise.
• Pathology: The causes of prolonged retention of the dead fetus in the uterus is not clear.
• Beyond 12 weeks, the retained fetus becomes macerated or mummified. The liquor amnii gets absorbed and the placenta becomes pale, thin and may be adherent.

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• Before 12 weeks, the pathological process differs when the ovum is more or less completely surrounded by the chorionic villi. a special variety of missed abortion in which the dead ovum in early pregnancy is surrounded by clotted blood.

Clinical picture:

(A) Symptoms:

• Symptoms of threatened abortion may or may not be developed.
• Regression of pregnancy symptoms as nausea, vomiting and breast symptoms.

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• The abdomen does not increase and may even decrease in size.
• The fetal movements are not felt or ceases if previously present.
• A dark brown vaginal discharge may occur

(B) Signs:

• The uterus fails to grow or even decreases in size and becomes firmer.
• The cervix is closed.
• The fetal heart sounds cannot be heard by the doppler.

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• Investigations:
• Pregnancy test becomes negative within two weeks from the ovum death, but it may remain positive for a longer period due to persistent living chorionic villi.
• Ultrasound shows either a collapsed gestational sac, absent fetal heart movement or fetal movement.

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Complications:

• Disseminated intravascular coagulation (DIC) may occur if the dead conceptus is retained for more than 4 weeks.
• Superadded infection.

Treatment:

• The dead conceptus is expelled spontaneously in the majority of cases.

Evacuation of the uterus is indicated in the following conditions:

• spontaneous expulsion does not occur within four weeks,
• there is bleeding,
• infection or DIC developed or
• If the patient is anxious.

a. Prostaglandins: given intravaginally (PGE2), intravenously, intra-or extra- amniotic (PGF2 )Prostacyclin

b. Oxytocin infusion – 10-20 units in 500 ml of NS at 30 drops/min

c. Combination: starting with prostaglandin and completed with oxytocin.

d. Dilatation and Evacuation

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�(F) Septic Abortion�

• Definition: Any abortion associated with clinical evidences of infection of the uterus and its contents, is called septic abortion.
• Microbiology:
• E.Coli, bacteroids, anaerobic streptococci, clostridia, streptococci and staphylococci are among the most causative organisms.

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Clinical Grading:

Grade–I: The infection is localized in the uterus.

Grade–II: The infection spreads beyond the uterus to the parametrium, tubes and ovaries or pelvic peritoneum.

Grade–III: Generalized peritonitis and/or endotoxic shock or jaundice or acute renal failure.

General examination:

- Pyrexia and tachycardia.

- Rigors suggest bacteraemia.

• A subnormal temperature with tachycardia is ominous and mostly seen with gas forming organisms.
• Malaise, sweating , headache, and joint pain.

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• Jaundice and /or haematuria is an ominous sign, indicating haemolysis due to chemicals used in criminal abortion or haemolytic infection as clostridium welchii.
• Abdominal examination:

- Suprapubic pain and tenderness.

- Abdominal rigidity and distension indicates peritonitis.

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• Local examination:
• Offensive vaginal discharge. Minimal inoffensive vaginal discharge is often associated with severe cases.

- Uterus is tender.

- Products of conception may be felt.

- Local trauma may be detected.

- Fullness and tenderness of Douglas pouch indicates pelvic abscess which will be associated with diarrhoea.

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• COMPLICATIONS:
• • Hemorrhage related due to abortion process and also due to the injury inflicted during the interference.
• •Injury may occur to the uterus and also to the adjacent structures particularly gut.
• •Spread of infection leads to: (a) Generalized Peritonitis
• (b) Endotoxic
• (c) Acute renal failure
• (d) Thrombophlebitis.

• Remote: The remote complications include:
• (a) Chronic debility
• (b) Chronic pelvic pain and backache
• (c) Dyspareunia
• (d) Ectopic pregnancy
• (e) Secondary infertility due to tubal blockage and
• (f) Emotional depression.
• Treatment:

- Isolate the patient . Bed rest in semi-sitting position.

- An intravenous line is established for therapy. In case of shock a central venous pressure (CVP) line to aid in the control of fluid and blood transfusion is added

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- Observation for vital signs: pulse, temperature and blood pressure as well as fluid intake and urinary output.

- Fluid therapy: e.g. glucose 5% normal saline and/or lactated ringer solutions can be given as long as there is no manifestations of acute renal failure particularly the urinary output is more than 30 ml/hour.

- Blood transfusion : is given if CVP is low (normal: 8-12 cm water). It is of importance also to correct anaemia coagulation defects and infection.

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• A cervico-vaginal swab is taken for culture (aerobic and anaerobic) and sensitivity,
• Antibiotic therapy: Ampicillin or cephalosporin ( as a broad spectrum) +gentamycin (for gram -ve organisms) + metronidazole (for anaerobic infection)are given by intravenous route while awaiting the results of the bacteriological culture. Another regimen to cover the different causative organism is clindamycin + gentamycin.

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• Oxytocin infusion: to control bleeding and enhances expulsion of the retained products.
• Surgical evacuation of the uterus can be done after 6 hours of commencing IV therapy but may be earlier in case of severe bleeding or deteriorating condition in spite of the previous therapy.
• Hysterectomy may be needed in endotoxic shock not responding to treatment particularly due to gas gangrene (Cl. welchii).

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G. Recurrent (Habitual) Abortion

• Definition :

Three consecutive pregnancies ending in spontaneous abortion therefore constitute the criterion for the diagnosis of ‘recurrent abortion’.

• Investigation

1.  Occurrence of previous abortions

2.  Periods of amenorrhoea

3.  subsequent bleeding painful

4.  Curettings contain chorionic villi on histological examination

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• Special tests

Between pregnancies

(1)  Blood count and urinalysis.

(2)  Serological tests for syphilis in wife and husband.

(3)  Determination of the blood groups of wife and husband, with tests for antibodies in the wife.

(4)  Glucose tolerance test.

(6)  Tests of thyroid function.

(7)  Hysterography to determine the shape of the fundus and the competence of the internal os is essential in all cases. Cervical sphincteric action is best studied during the luteal phase.

(8)  A formiminoglutamic acid (FIGLU) excretion test and blood folate assays.

(9)  Study of the chromosome patterns of wife and husband.

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• During pregnancy

(1) All the above tests except those involving the use of radioactive isotopes and hysterography. Re-assessment of the folate and vitamin B12 status in early pregnancy is particularly important since a defect is commonly found even though it is not demonstrable before conception.

(2) Careful vaginal examination to determine the position of the uterus and the competence of the cervix.

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(3) Assays of the urinary excretion of HCG, pregnanediol and oestriol, and of plasma levels of HCS (HPL) and progesterone, the choice depending on the duration of the pregnancy, can give a guide to placental function.

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• Treatment of the cause

1. Uterine retroversion can be corrected

2. Uterine fibroids can be removed

3. Torn cervix repaired

4. Utriculoplasty

5. Shirodkar operation : It is generally best to perform this operation between the twelfth and sixteenth weeks of pregnancy removing the ligature 2 weeks before term or at the onset of abortion or labour.

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• Empirical remedies
• 1.  General measures before pregnancy
• a.  Wait 3 months
• b.  Improve her physical and mental health
• c.  Dietetic errors
• d.  Folic acid 5 mg t. d. s.
• 2.  General treatment during pregnancy
• a.  Rest
• b.  Psychological support
• c.  Sedatives
• d.  Diet

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• 3.  Special treatment during pregnancy

a.  Progestogens - a natural or synthetic steroid hormone, such as progesterone, that maintains pregnancy and prevents further ovulation during pregnancy

i)     Improving placentation

ii)    Rendering uterine contractions non-expulsive

iii)   Raising the tone of the cervical sphincter

• Results

Whatever treatment they receive, or if they have none at all, 70 per cent women who have lost 3 consecutive pregnancies by way of abortion will have a live child next time

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Induced abortion

• Induced abortion is the intentional termination of a pregnancy before the fetus can live independently. An abortion may be elective (based on a woman's personal choice) or therapeutic (to preserve the health or save the life of a pregnant woman)

• MEDICAL TERMINATION OF PREGNANCY (MTP)
• Since legalization of abortion in Ethiopia, deliberate induction of abortion by a registered medical practitioner in the interest of mother’s health and life is protected under the MTP Act.
• The following provisions are laid down:

•The continuation of pregnancy would involve serious risk of life or grave injury to the physical and mental health of the pregnant woman.

•There is a substantial risk of the child being born with serious physical and mental abnormalities so as to be handicapped in life.

•When the pregnancy is caused by rape, both in cases of major and minor girl and in mentally imbalanced women.

• Pregnancy caused as a result of failure of a contraceptive.

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METHODS OF TERMINATION OF PREGNANCY

Medical

• Mifepristone

• Misoprostol

• Methotrexate

• Tamoxifen

Surgical

• Vacuum Aspiration (MVA)

• Suction evacuation and/or curettage

• Dilatation and evacuation

• Hysterotomy (abdominal)

• Mifepristone an analog of progestin (norethindrone) acts as an antagonist, blocking the effect of natural progesterone.
• In a Methotrexate (MTX) Abortion, it stops embryonic cells from dividing and multiplying and is a non-surgical method of ending pregnancy in its early stages
• Tamoxifen works by competing with the hormone estrogen for attachment to the estrogen receptors on certain tissues.

Misoprostol:

-Misoprostol (Cytotec) is a synthetic PGE1 analog that has been found to be a safe and inexpensive agent for cervical ripening.

Pharmacokinetics:

• Route of administration: Oral, vaginal and sublingual route for induction. Rectal route is used to prevent and treat postpartum hemorrhage.

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Surgical

• Vacuum Aspiration (MVA) - is done upto 12 weeks with minimal cervical dilatation. It is performed as an outpatient procedure using a plastic disposable cannula (up to 12 mm size) and a 60 mL plastic (double valve) syringe. It is quicker (15 minutes), effective (98–100%), less traumatic and safer than dilatation, evacuation and curettage.

• Suction Evacuation And/Or Curettage: This improvised method consists of a suction machine fitted with a cannula either plastic (Karman) or metal available in various sizes.
• Advantages:
• It is done as an outdoor procedure

(2) Hazards of general anesthesia are absent as it is done, at best, under paracervical block anesthesia

(3) Ideal for termination for therapeutic indications

(4) Blood loss is minimal

(5) Chance of uterine perforation is much less specially with the plastic cannula.

• Drawbacks
• The method is not suitable with bigger size uterus of more than 10 weeks as chance of retained products is more

(2) Requires electricity to operate and the machine is costly.

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• Dilatation And Evacuation:

• Rapid method: This can be done as an outdoor procedure with diazepam sedation and paracervical block anesthesia.

Advantages:

1. As it can be done as an outdoor procedure, the patient can go home after the sedative effect is over.

(2) Chance of sepsis is minimal.

Drawbacks:

1. Chance of cervical injury is more

(2) Uterus should not be more than 6–8 weeks of pregnancy.

(3) All the drawbacks of D and E

• Slow Method:

Slow dilatation of the cervix is achieved by inserting laminaria tents (hygroscopic osmotic dilators) into the cervical canal (synthetic dilators like Dilapan, Lamicel are also used). This is followed by evacuation of the uterus after 12 hours. Vaginal Misoprostol (PGE1) 400 µg 3 hours before surgery is equally effective for cervical ripening.

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• Advantages:
• Chance of cervical injury is minimal

(2) Suitable in cases of therapeutic indications.

Drawbacks:

1. Hospitalization is required at least for one day

(2) Chance of introducing sepsis

(3) All the complications of D and E.