Abortion and Its Complications
- 1. DEPARTMENTOFOBGY|MUHAS ABORTION AND ITS COMPLICATIONS IN DEVELOPING COUNTRIES PRESENTERS: JOSEPH PAUL JUSTIN MPWAGA FACILITATORS: PROF. MUGANYIZI DR. GEORGE
- 2. INTRODUCTION CAUSES ASSESSMENT AND COUNSELING TYPES OF ABORTION & MANAGEMENT COMPLICATIONS IN DEVELOPING COUNTRIES POST-ABORTAL CARE Presentation Outline TUESDAY • JULY 22. 2019
- 3. Introduction
- 4. DEFINITION Spontaneous or induced termination of pregnancy before 28wks of pregnancy i.e before fetal viability Current WHO definition- before 22wks GA or less than 500g Abortion contributes 50% of maternal death! TUESDAY • JULY 22. 2019
- 5. INCIDENCE Approximately 26 million legal and 20 million illegal abortions were performed worldwide in 2002, resulting in a worldwide abortion rate of 35 per 1,000 women aged 15–44. Among the sub regions of the world, Eastern Europe had the highest abortion rate (90 per 1,000) and Western Europe the lowest rate (11 per 1,000). TUESDAY • JULY 22. 2019
- 6. INCIDENCE In Africa, about one-quarter of the unsafe abortions are among teenagers (ages 15 to 19), a higher proportion than in any other world region Worldwide, one in five pregnancies (22 percent) ends in abortion, and one in 10 pregnancies ends in unsafe abortion. TUESDAY • JULY 22. 2019
- 7. INCIDENCE It is estimated that 30% of Tanzania's annual 21,000 maternal deaths are a result of abortion-related complications. 60% of incomplete abortions is a result of unsafe abortions. More often this occurs in younger, singles and in students. TUESDAY • JULY 22. 2019
- 8. ABORTION LAW Person Act of 1961 and the Infant Life (Preservation) Act of 1929. Under the Revised Penal Code of Tanzania (chapter 16, sections 150-152) the performance of abortions is generally prohibited. Any person who, with intent to procure the miscarriage of a woman, whether she is pregnant or not, unlawfully uses any means upon her is subject to 14 years’ imprisonment. A pregnant woman who undertakes the same act with respect to her own pregnancy or permits it to be undertaken is subject to seven years’ imprisonment. Any person who supplies anything whatsoever knowing that it is intended to be unlawfully used to procure the miscarriage of a woman is subject to three years’ imprisonment.
- 10. GENERAL CAUSES Infection Are responsible especially in 2nd trimester. This is because infection with syphillis occurs 16-24 Wks GA Psychological Severe emotional stress eg loss of close relative. Nutrition Severe vitamin deficiency eg. folic acid General Hyperpyrexia Temperature > 39 C due to general acute illness increases uterine contactions Metabolic Diseases DM is associated with congenital malformation hence expelled by uterus
- 11. GENERAL CAUSES Endocrine Hypothyroid or Hyperthyroid states Renal Disease Chronic renal disease e.g glomerulonephritis reduces blood volume and causes fetal hypoxia Severe Trauma Severe trauma can expel the fetus Drugs Cause congenital malformation (6th to 8th wk) or fetal hypoxia. Other Drugs interfere with fetal nutrition E.g Quinine, Chloroquine, PGs, Methotrexate
- 12. LOCAL CAUSES Uterine Causes Malformations- bicornuate, septate Tumors- fibromyoma etc occupy cavity and reduce blood supply. Cervical incompitence Ovarian Causes Regression of the corpus luteum prematurely before the placenta takes over Corpus luteum fails to produce progesterone. It usually occurs during 12th to 14th wk. Fetal Causes Congenital malformations ( XO, trisomy, anencephaly, molar pregnancy) Commonest cause of 1st trimester fetal loss (70-80%)
- 13. Uterine malformations types Uterine fibroids can occupy cavity Causes of cervical incompetence
- 15. TYPES OF ABORTION Threatened abortion Inevitable abortion Incomplete abortion Complete abortion Missed abortion Septic abortion (any type of abortion complicated with infection) Recurrent abortion ( 2 or more consecutive abortions)
- 16. Management Give simple analgesics, avoid strenuous activities + sexual intercourse and encourage bed rest. Mild sedation to decrease anxiety DO NOT give tocolytics or hormones as they will not prevent miscarriage Threatened Abortion Pt presents with Hx of ammenorhoea Vaginal Bleeding - Fresh & Mild Lower Abdominal Pain - Almost absent Cervix is closed Uterine size corresponds with GA Abortion process is started but not completed. (can continue or be arrested)
- 17. Management If pregnancy <12 wk GA Pt presents with Hx of ammenorhoea Vaginal Bleeding - Heavy bright red with clots Severe Lower Abdominal Pain, colicky with strong uterine contractions Cervix is open and Products of conception can be palpated from OS Uterine size corresponds with GA Innevitable Abortion Abortion process has started and will proceed to complete or incomplete abortion. It is an inevitable process. Plan for evacuation OR Give Misoprosol 400ug @ 4hrly If pregnancy >12 wk GA Await for spontenous evacuation of POC and evacuate if remaining Infuse oxytocin 40IU in 1L of NS/RL at 40drops/min Depending on severity give IV fluids, blood transfusion, Oxygen and analgesics e.g pethidine
- 18. Management If pregnancy <12 wk GA Pt presents with Hx of ammenorhoea Vaginal Bleeding - Scanty to Moderate brownish Lower Abdominal Pain of varying degrees Cervix is partially open with partial expulsion of POC Uterine size is smaller than expected GA Incomplete Abortion Abortion process has started but some parts of POC are still in the uterine cavity Evacuate the uterus via MVA, Curretage OR misoprostol 400ug orally If pregnancy >12 wk GA Infuse oxytocin 40IU in 1L of NS/RL at 40drops/min If necessary give misoprostol 200ug vaginally @4hrs until expulsion of POC occurs
- 19. Management Evacuation of Uterus is not necessary Observe of heavy bleeding Pt presents with Hx of ammenorhoea Vaginal Bleeding - None, but has hx of placenta, fetus & membranes coming out. Lower Abdominal Pain - absent Cervix is closed Uterine size is smaller than expected GA Complete Abortion Abortion process is completed with no POC in uterus. Common after >20 Wk GA Follow up patient after treatment Confirm diagnosis with USS, for fetal heart activity
- 20. Management If pregnancy <12 wk GA Pt presents with Hx of ammenorhoea Vaginal Bleeding - None Lower Abdominal Pain - absent Cervix is closed Fundal height is very small to dates Missed Abortion Fetus dies in utero and is retained (has not been expelled. D&C If pregnancy >12 wk GA Induce labour Confirm diagnosis with USS, for fetal heart activity
- 21. Clinical Features Agents include: E.coli, Streptococcus Haemolyticus, S. aureus, C.welchii. Septic Abortion An abortion complicated by infection. Results from unsafe abortion, prolonged retention of POC, incomplete or unsterile evacuation of the uterus. Hx of amenorrhoea Pregnancy symptoms Vaginal bleeding Fever Low abdominal pain Vaginal Discharge (smelling, profuse, dirty) Routes: Droplet infection from attendants Unsterile instruments Enviromental unhygiene Patients own cloths and hands Signs: Increased body temperature Increased pulse rate Low or normal BP Abdominal Tenderness Offensive per vaginal discharge
- 22. ManagementInvestigation of Septic Abortion HB FBP : WBC Mid Stream Urine : microscopy, culture & sensitivity Blood for group & cross matching Vaginal Swab for microscopy, culture & sensitivity Resuscitate the patient and manage the shock Antibiotics (intravenous); ampicillin 500mg+ metronidazole 500mg + genta 80mg) 8hrly or ceftriaxone 1g od if symptoms persist within 3days Give FeSO4 and folic acid for 6wks Surgically: Empty the uterus with evacuation Drainage of pelvic abscess Laparotomy for peritonitis Routes: Droplet infection from attendants Unsterile instruments Enviromental unhygiene Patients own cloths and hands
- 23. 1ST TRIMESTER CAUSES Genetic Endocrine (PCOS,DM, Hypothyroidism) Infection Thrombophilia Immune (antiphospolipid syndrome, alloimunity) 2ND TRIMESTER CAUSES Anatomic abnormalities Acquired anomalies such as intrauterine adhesions, uterine fibroids and endometriosis and cervical incompetence. Infections Chronic maternal illness Recurrent Abortion Is defined as a sequence of three or more consecutive spontaneous abortion before 28 weeks. Some, however, consider two or more as a standard.
- 25. The total abortion-related complication rate including all sources of care including emergency departments and the original abortion facility is estimated to be about 2%. The incidence of abortion-related emergency department visits within six weeks of initial abortion procedure is about 40%. Epidemiology
- 26. Post-abortion complication Incomplete evacuation of the products of conception Infection Injury from the surgical procedure itself
- 27. HEMORHAGE Early complication Postabortal hemorrhage may result from cervical or vaginal lacerations, uterine perforation, retained tissue, or uterine atony. Other causes of hemorrhage include infection, uterine arteriovenous malformation, placenta accreta, and coagulopathy (secondary to release of tissue thromboplastin into the maternal venous system).
- 28. UTERINE PERFORATION Lack of skillful or inexperienced clinicians who perform the procedure Nature of the instruments used for abortion in developing country together with sociocultural and religious perspectives. Bowel and bladder injuries
- 29. HEMATOMETRA Immediate postoperative pain without overt bleeding from the vagina may indicate development of hematometra. Hematometra (also known as uterine distension syndrome or postabortal syndrome) usually presents with complaints of dull, aching lower abdominal pain, sometimes accompanied by tachycardia, diaphoresis, or nausea. The onset is usually within the first hour after completion of the procedure.
- 30. HEMATOMETRA Pelvic examination reveals a large midline globular uterus that is tense and tender. Treatment requires immediate uterine evacuation, permitting the uterus to contract to a normal post procedure size. Administration of intramuscular methylergonovine maleate (0.2 mg) is then given to ensure continued contraction of the uterus
- 31. MATERNAL MORTALITY Second trimester is worse, mortality is lowest before 8 weeks of gestation and increase after 18 weeks In developing countries where abortion is illegal, ≥25 percent of all maternal deaths are abortion-related Factors associated with increased maternal mortality from unsafe abortion in developing countries include inadequate delivery systems for contraception needed to prevent unwanted pregnancies, restrictive abortion laws, pervading negative cultural and religious attitudes towards induced abortion, and poor health infrastructures for the management of abortion complications.
- 32. INFECTION Delayed complication occurring more than 72 hours after the procedure Postabortal infection due retained products of conception. Also can ascend from cervicitis and endometriosis Lack of prophylactic antibiotics Leads to pelvic infection, and peritonitis
- 33. BREAST CANCER Some studies support that induced abortion is associated with significant increase in the risk of breast cancer
- 34. RISK FOR FUTURE PREGNANCIES A meta-analysis of 37 studies reported that women with versus without a history of pregnancy termination had a significantly increased risk of low birth weight infants (OR 1.4, 95% CI 1.2-1.5) and preterm delivery (OR 1.4, 95% CI 1.2-1.5).
- 35. References DC Dutta’s Textbook of Obstetrics, 8E (2016) UpToDate Medscape https://www.sciencedirect.com/science/article/pii/00207292 89900994 https://www.ncbi.nlm.nih.gov/books/NBK430793/ https://apps.who.int/iris/bitstream/handle/10665/40349/924 1544694.pdf;jsessionid=09F9750B252A8951978506CFBBF0 E9C8?sequence=1 1. 2. 3. 4. 5. 6.
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