ABORTION: ABORTION By Dr. Ngarina Matilda Gynecologist Contents.: Contents. Definition Types of abortion Causes Management Complications Post abortal care Definition.: Definition. Abortion can defined as termination of pregnancy before 28 weeks of gestation or viability. The current WHO defn is termination of preg before 22 wks or when the fetus weigh 500 g or less. This may be spontaneous or induced. Abortion is important as it contributes to approximately 50% of maternal death ! Types of abortion. (spontaneous): Types of abortion. (spontaneous) Threatened abortion Inevitable abortion Incomplete abortion Complete abortion Missed abortion Threatened abortion: Threatened abortion Presents with: -cramping/lower abdominal pain -light PV bleeding O/E -soft uterus that corresponds with dates -closed cervix Inevitable abortion: Inevitable abortion Presents with: -Cramping/ lower abdominal pain -heavy PV bleeding O/E -tender uterus c corresponds to dates -dilated cervix -POC often felt thru the cervical os Incomplete abortion: Incomplete abortion Presents with: -painful uterine contractions -heavy bleeding O/E -uterus smaller than dates -dilated cervix -partial expulsion of POC Complete abortion: Complete abortion Presents with: -Hx of heavy PV bleeding followed by expulsion of POC then light bleeding. O/E -uterus smaller than dates -closed cervix. Missed abortion: Missed abortion The embryo/fetus dies but doesn’t get expelled from the uterus. Pt presents with slow progressive bleeding followed by caesation of pregnancy symptoms. Examination reveals a firm uterus smaller than GA and a closed cervix. Induced abortion: Induced abortion Interfered pregnancy – usually done when the preg is unwanted/unplanned or when it endangers the life of the woman. Can be done surgically or medically depending on the GA, skills and availability of appropriate equipment. Unsafe abortion is performed either by persons lacking necessary skills or in an environment lacking minimal medical standards or both usually ending in septic abortion. Induced abortion is ILLEGAL in Tanzania. Causes of abortion: Causes of abortion Genetical/x’somal malformation of the zygote (eg molar preg) Immunological factors (eg antiphospholipid ab, antinuclear ab) Infections (TORCHES, malaria, HIV, genital tract infections) Uterine anomalies (septate uterus, bicornuate uterus, unicornuate uterus, cervical incompetance) General dxs of the mother (diabetes, HT, cardiac dxs) Endocrine disorders (eg luteal phase insufficiency) Others; trauma, drugs, emotional disturbance, etc. In the majority cause is unknown. Management of abortion: Management of abortion Depends on type of abortion and GA. It becomes an emergency when it is incomplete, septic, or c severe h’rrage. Threatened abortion -take proper hx -do proper PE and make diagnosis -give simple analgesics, avoid strenuous activities + sexual intercourse and encourage bed rest. Mgt of inevitable abortion: Mgt of inevitable abortion Take proper hx and PE to confirm dx. If GA is less than 12 wks do manual vacuum aspiration of the uterus (MVA) If GA is > 12 wks await spontaneous expulsion of POC the MVA. S’times augmentation with oxytocin is necessary to speed up the process. Counseling before and after the procedure is very important. Mgt of incomplete abortion: Mgt of incomplete abortion Hx and proper PE are mandatory. Some of these pts come in shock 2° severe bleeding. Act fast, put iv line & give NS or Ringers lactate, take blood for grpg and x-matching & prepare blood for BT. Do MVA if GA is < 12 wks, simple curettage if GA is > 12. Counseling and reassurance – very important. Mgt of complete abortion: Mgt of complete abortion Take proper hx & PE to confirm dx. Evacuation of the uterus is usually not necessary. Observe for heavy bleeding or LAP Counseling and follow-up. Mgt of missed abortion: Mgt of missed abortion Eventually they are all expelled spontaneously. Once the dx has been made evacuation of the uterus must be done by dilation & curettage. Its important to check bleeding indices as this condition may complicate to DIC Septic abortion: Septic abortion Results from unsafe abortion, prolonged retention of POC, incomplete or unsterile evacuation of the uterus. Symptoms include; fever, abdominal pain, foul smelling PV discharge & PV bleeding. Signs; high temp, high PR, abdominal tenderness, foul smelling PV discharge, shock, confusion, hypothermia, jaundiced or oliguric. Mgt of septic abortion cont’d: Mgt of septic abortion cont’d Suspect bowel, uterine or vaginal injury if the pt presents with the following; -Cramping/abdominal pain. -rebound tenderness. -abdominal distension -rigid (tense and hard) abdomen. -shoulder pain -nausea and vomiting. Mgt of septic abortion cont’d: Mgt of septic abortion cont’d Act fast, take hx & do PE. Give IVF depending on the degree of shock. Take blood for grpg & x-matching, Hb, WBC, platelet count, serum urea & creatinine, endocervical swab for c/s Give IV broad spectrum antibiotics e.g cephalosporins and metronidazole. Evacuate the uterus under GA after initiating antibiotics and resuscitation. Do a laparatomy if injury to internal organs is suspected. Complications of abortion.: Complications of abortion. Severe bleeding-anemia-shock-renal failure Sepsis-septicaemia-PID-infertility-ectopic preg. Depression-marital disharmony BT may predispose pt to HIV, hepatitis Perforation of pelvic organs-peritonitis. POSTABORTAL CARE:: POSTABORTAL CARE: Importance…………15% of preg are aborted Counseling before discharge on what happened, signs of recovery/complications, resume of menses and intercourse etc Counsel and provide contraception; couple counseling encouraged. Follow up visits – assess recovery, feedback on FP. Discuss on histology results ECTOPIC PREGNANCY: ECTOPIC PREGNANCY Preg implanted outside the uterine cavity, usually in the fallopian tubes (90%). Internal bleeding occurs when the site of implantation ruptures or tubal abortion occurs. Pts easily die of h’rrge. Clinical presentation: Clinical presentation Short period of amenorrhea (6-8wks). Some may have no hx of amenorrhea. LAP, fainting attacks, dizziness, palpitation, scanty PV bleeding, shoulder tip pain. O/E pt presents c moderate to severe palor, low BP, high PR, cold sweats, tender distended abdomen with guarding and rebound tenderness, +ve fluid thrill and shifting dullness Mgt of ectopic preg.: Mgt of ectopic preg. IVF – NS or Ringers lactate should be given fast. Take blood for grouping and x-matching Urgent laparatomy to arrest bleeding. Salpingectomy. Auto transfusion or give cross matched blood as necessary. Correct anaemia, give postabortal care. Slow leaking ruptured ectopic preg: Slow leaking ruptured ectopic preg May be difficult to diagnose as it may resemble threatened abortion, PID, UTI, twisted ovarian cyst or appendicitis Symptoms & signs of shock may not be there. Confirm dx by ultrasound and perform laparatomy urgently. ADVANCED ABDOMINAL PREG: ADVANCED ABDOMINAL PREG RARE BUT IT HAPPENS REFFER CASE REPORT ALL THE BEST DEAR COLLEGUES.: ALL THE BEST DEAR COLLEGUES.