ABORTION AND POST ABORTION CARE

Question 1

Definition of abortion

Answer 1

the expulsion or extraction of product of conception (fetus) weighing <500g. – WHO
•Expulsion or extraction of a fetus <28weeks GA (in Nigeria)

Question 2

AETIOLOGY

Answer 2

Chromosomal abnormalities: responsible for at least 50% of abortions.
Defects like Trisomy( trisomy 16 most common) , Polyploidy, Monosomy.
Structural defects like Translocation, Deletion, Inversion
Maternal infections:
Viral: Rubella, Cytomegalovirus
Parasitic: Toxoplasmosis, Malaria
Acute fever for whatever the cause can induce abortion
Trauma: External trauma to the abdomen or during abdominal or pelvic operations

Endocrine and metabolic factors:
Progesterone deficiency (causes abortion between 8-12weeks)
Diabetes mellitus
Hypothyroidism
Uterine defects:
Congenital/ Uterine anomalies: arcuate uterus, uterine didelphys, bicornuate uterus unicornuate uterus
Acquired: Asherman’s syndrome/ Uterine synechie (intrauterine adhesions)

Drugs and Environmental causes: mifepristone, tobacco, alcohol, arsenic, lead, formaldehyde, bezene and radiation
Immunological causes: Antiphospholipid syndrome, Systemic lupus erythematous,
Cervical incompetence

Idiopathic

Question 3

Risk factors

Answer 3

Increasing maternal Age, risk increases after 35yrs
Previous miscarriage(s)
Obesity
Chronic (uncontrolled) medical condition – DM, HTN, CKD etc
Social drug use
High impact exercise.

Question 4

Classification

Answer 4

SPONTANEOUS
INDUCED
- Therapeutic
- Criminal

Question 5

Spontaneous abortion subtypes?

Answer 5

CoMSIT

COMPLETE MISCARRIAGE
MISSED MISCARRIAGE
SEPTIC MISCARRIAGE
INEVITABLE MISCARRIAGE
INCOMPLETE MISCARRIAGE
THREATENED MISCARRIAGE

RECURRENT MISCARRIAGE
BLIGHTED OVUM/ ANAEMBRYONIC PREGNANCY
UNSAFE ABORTION

Question 6

Threatened abortion ..diagnosis

Answer 6

Vaginal bleeding is slight or mild, “spotting”.
Pain is typically absent (or slight)
Cervical os is closed
Pregnancy test is positive
USS shows a living fetus.

Question 7

Inevitable abortion diagnosis

Answer 7

Vaginal bleeding is significant and may be accompanied with clots.
Pain is typically colicky
Cervical os is dilated and the products of conception my be felt through it.
Rupture of membrane prior to the age of viability is also inevitability of abortion

USS shows a living fetus

Question 8

Incomplete abortion diagnosis

Answer 8

Passage of part of the conception product (fleshy materials, fetus) with some products retained
Bleeding is continuous
Pain is colicky
Uterine size may be less than gestational age
Cervix is opened and retained contents may be felt through it. (It may be plugging the os)

Ultrasonography shows retained contents.

Question 9

Complete abortion diagnosis

Answer 9

All products of conception have been expelled from the uterus.
Bleeding subsides and gradually diminishes
Pain ceases
Cervical os is closed

Ultrasonography shows empty uterine cavity.

Question 10

Missed abortion diagnosis

Answer 10

It is defined as “a gestational sac containing a dead embryo or foetus before the age of viability without clinical symptoms of expulsion”.
Bleeding is absent/ spotting
No pain
Cervical os is closed

USS shows either a collapsed gestational sac or absent foetal heart movement.

Question 11

Septic abortion diagnosis

Answer 11

When any type of abortion complicated by infection.
A common feature of unsafe abortion.
In addition to the clinical picture of the type of miscarriage, there are presence of infecrions – fever, tachycardia, +/- abd pain/ tenderness, foul smelling vaginal discharge etc

Question 12

Recurrent abortion diagnosis

Answer 12

Recurrent/Habitual Abortion- 3 or more consecutive spontaneous pregnancy losses before the age of viability,
1- 2% of all pregnancies.
If it occurs >20weeks, cervical weakness (cervical incompetence)
Distressing and frustrating condition for both the patient and Dr.

Residive: 2 consecutive spontaneous abortion

Question 13

Blighted ovum diagnosis

Answer 13

Anaembryonic pregnancy
The embryo stopped or never developed.
Presence of gestational sac without an embryo. mean GSD =/>25mm
A radiological diagnosis (1st trimester)
Vaginal bleeding is absent/ spotting
No Pain
Cervix is closed

Question 14

Unsafe abortion

Answer 14

Termination of an unintended pregnancy by a person lacking the necessary

Question 15

Methods of unsafe abortion

Answer 15

Methods for TOP in unsafe abortion
Ingestion - Quinine, blue dye, concoction, postinor2, ampiclox
Injection – quinine, oxytocin, ergot
Insertion – potash, herbs, coat hanger, bicycle spoke, sticks, misoprostol etc
Trauma – blunt abdominal trauma, uterine massage, fall from height

Question 16

Early complications of unsafe abortion

Answer 16

Severe haemorrhage - Shock
Acute kidney injury
Uterine perforation
Bowel injury
Gas gangrene
Sepsis/ septicaemia

Question 17

Late compilation of unsafe abortion

Answer 17

Chronic pelvic pain
Uterine synechiae/Asherman syndrome
Infertility
Ectopic pregnancy
Chronic renal disease
Marital disharmony

Question 18

Clinical features

Answer 18

HISTORY – variable amenorrhea, vaginal bleeding, abdominal pain, passage of products,
EXAMINATION – anxious, pallor, +/- fever, dehydration, vital signs, +/-tenderness, uterine size,
V.E: blood smeared vulva/ active bleeding,
Speculum examination- cervical os maybe closed/ open, active bleeding, product of conception plugging the cervical os (remove with sponge holding forceps immediately to prevent neurogenic shock)
Digital exam-bulky uterus/ size, os dilatation, gloved fingers stained with blood (+/- odour)

Question 19

Investigation

Answer 19

Full blood count – urgent PCV
Pregnancy test
Serum B HCG
Blood grouping & crossmatching
Ultrasonography
Serology – HBsAg, HCV, RVS
Electrolyte, urea and creatinine
Blood film for malaria parasite
Urine MCS, urinalysis
Abdominal Xray-suspicion of uterine perforation
Other investigations to confirm etiology-fetal karyotype etc

Question 20

Treatment

Answer 20

Treatment depends on type of miscarriage
Resuscitation- IVF, +/- oxygen by face mask, blood transfusion,
Antibiotics
Rhogam injection,500IU if pt is Rh negative
Tetanus prophylaxis – ATS, T.T
Evacuation of products of conception ERPOC
- Medical evacuation - Prostaglandin E1 analogue(Misoprostol 600µg)
- Surgical evacuation – MVA
Surgery - exploratory laparotomy for uterine, viscus perforation, drainage of abscess etc

Question 21

Post abortal care

Answer 21

A composite care given to a woman after an abortion process and the partner where appropriate in order to prevent future risk of unwanted pregnancy and its complications

Question 22

Post abortal care

Answer 22

A composite care given to a woman after an abortion process and the partner where appropriate in order to prevent future risk of unwanted pregnancy and its complications

Question 23

Components of PAC

Answer 23

•Management of emergencies and complications
•Counseling to identify and respond to woman’s emotional and physical needs – counselling, religious & grieve support,
•Post abortion family planning/ contraception services to prevent future unintended pregnancies and abortion – counsel and informed decision on any method of contraception
•Linkage with other reproductive health services
•Community and service provider partnership

Question 24

Abortion law in Nigeria.

Answer 24

Nigeria operates a restrictive abortion law. Ignorance of the law is not an excuse!!!

Criminal code in the South and penal code in the North.

Criminal code section 228, 229, 230, 297 (Southern Nigeria) – punishment from 3 – 14 years

Penal code 232, 233, 234 (Northern Nigeria) 3 – 14 years

Question 25

PRIMARY PREVENTION of abortion mortality

Answer 25

Promotion of effective contraception for women at risk of unwanted pregnancy
Removal of barriers which deny access to contraception to women
Provision of postnatal family planning services
Education of the girl child, the community and its leaders
Adolescent / young adult friendly hospitals

Question 26

SECONDARY PREVENTION of abortion mortality

Answer 26

Liberalization of abortion laws
Provision of safe abortion services as permitted within the limits of the law
Training of service providers to decentralize care and increase access for women
Provision of MVA and medical abortion, rather than D&C or other harmful methods

Question 27

TERTIARY PREVENTION of abortion mortality

Answer 27

Promotion of post-abortion care for the treatment of incomplete abortion and unsafe abortion
Organization of services for the management of severe complications of abortion
Support groups for patient