COMPREHENSIVE ABORTION CARE

Dr. Diomede NTASUMBUMUYANGE

Senior Lecturer
UR/CMHS
 Session Objectives
• Define abortion
• Explain magnitude of abortion
• Discuss legality of abortion for safe abortion in Rwanda
• Identify causes/risk factor
• Classify abortion
• Identify differential diagnosis of abortion
• Manage abortion based on its classification
• Identify uterine evacuation methods
• Provide post abortal care
 Definitions

• Abortion (Miscarriage) is termination of pregnancy before viability

• In USA, abortion sometimes defined as termination of pregnancy at GA

of less than 20 weeks or a birth weight of less than 500gm

• In most Developing Countries abortion is defined as termination of

pregnancy before GA 28 weeks or birth weight of less than1000gm

• In Rwanda?
 WHO Definition

• Abortion is referred as termination of pregnancy before or at GA of 22 weeks or

weight less than 500gm (WHO, 2003)

• Viability depends on various factors in each country (WHO, 2012)

 Magnitude

• Globally, 213 million pregnancy annually (>40% unplanned:

85 Million)

• Currently, an estimated 55.9 million abortions occur each year

—49.3 million in developing regions and 6.6 million in
developed regions ( Singh, Remez, Sedgh Kwok &Onda, 2017)
Abortion rate
Abortion rate
Abortion rate
 Legality of Abortion in Rwanda

• Abortion in Rwanda is governed by organic Law 01/2012/OL of

02/05/2012

• Exemptions from criminal liability for abortion were specified in

articles 162 through 167 of the Penal Code:
Rape
Incest
Forced marriage
Risk to the health of the woman or the fetus
 Classification of Abortion

WHO classification
• Safe abortion
• Unsafe abortion
• “Less safe”
• “Least safe”

Based on gestational age

• First trimester abortion
• Second trimester abortion
 Classification (con’d)

Based on occurrence
• Spontaneous
• Induced
Based on clinical stages
• Threatened
• Inevitable
• Incomplete
• Complete
• Missed
• Anembryonic pregnancy
• Septic
• Recurrent
 Spontaneous Abortion

• Definition: Abortion occurring without any medical or surgical means to empty

the uterus
• Incidence:
At least 15% of clinically evident pregnancies end up in spontaneous abortion
80% of spontaneous abortion occur before 12 weeks
 Etiology/Risk factor of spontaneous abortion

Fetal factors:
Chromosomal
abnormalities (60%)  Accidental injuries to the fetus
Aneuploidy(Monosomy X )  Aging of the gametes
Autosomal Trisomies (T-16 )  Failure of hormonal
Polyploidy mechanisms
 Exposure of the embryo to
Defective implantation
various viruses, chemicals or
Defects in the placenta or irradiation
embryo
 Etiologies (con’d)

Maternal factors:
Infections (Bacterial, Viral, protozoal )
Endocrine disorders (Hypothyroidism, DM)
Cardiovascular disorders (HTN, Renal disease)
Malnutrition
 Etiologies (con’d)

Drugs Environmental toxins

Tobacco Immunologic factors
Alcohol Thrombophilias
Caffeine Maternal surgery
Radiation
Trauma
Uterine defects
• Paternal factors?
 Mechanism of Abortion

Hemorrhage The POC, partly or Expulsion

occurs in the wholly detached, acts complete. The
decidua basalis as a foreign body and decidua is shed
initiates uterine during the next
leading to local contractions. The few days in the
necrosis and cervix begins to
lochial flow.
inflammation. dilate.
 Differential Diagnosis

• Ectopic pregnancy
• Molar pregnancy
• Local lesions
• Polyps
 Management

Threatened abortion

• Medical treatment usually not necessary.

• Advise woman to avoid strenuous activity and sexual intercourse; bed rest not necessary.

• If bleeding stops, follow up in antenatal clinic.

• Reassess if bleeding recurs.

• If bleeding persists, assess for fetal viability (pregnancy test/ultrasound) or ectopic pregnancy (ultrasound).

• Persistent bleeding, esp. in the presence of uterus larger than expected may indicate twins or molar
pregnancy.

• Treat if anaemia or in hypovolemic shock.

 Management of Inevitable Abortion

• Mild to sever vaginal bleeding with no expulsion of products of conception

• Crampy abdominal pain
• Effacement & dilatation of cx
• Rupture of membrane
 Management of Inevitable Abortion

• If pregnancy is less than 12 weeks, plan for evacuation of uterine

contents. If evacuation not immediately possible:
misoprostol 400 mcg by mouth (repeated once after 4 hours if necessary);
Arrange for evacuation as soon as possible.

• Ensure follow-up after treatment.

 Management of Inevitable Abortion

• If pregnancy is greater than 12 weeks:

• Await spontaneous expulsion of products of conception and then
evacuate uterus to remove any remaining products of conception
• If necessary, infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min to
help expulsion of products of conception
 Incomplete Abortion

The expulsion of some but not all of the products of conception.

• Symptoms & sign

Placental tissue is in uterine cavity
Cervix is open & visible or palpable RPC
Pain with profuse vaginal bleeding
 Management of Incomplete Abortion

Less than 12 weeks:

• If bleeding light to moderate, use fingers or ring (or sponge)
forceps to remove products of conception protruding through
cervix.

• If bleeding heavy, evacuate uterus:

Manual vacuum aspiration (MVA) is preferred method.
EVA should only be done if MVA not available
Ensure follow-up of the woman after treatment.
 Management of Incomplete Abortion

Greater than 12 weeks:

• Infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min. until expulsion of
POC occurs
• Evacuate any remaining products of conception from uterus by evacuation
and curettage
• If necessary, give misoprostol 200 mcg vaginally every 4 hours until
expulsion, but do not administer more than 800 mcg.
• Antibiotic therapy.
• Ensure follow-up of the woman after treatment.
 Mifepristone Misoprostol Protocol
FDA regimen 2016 Alternative: Vaginal Msoprostol
Buccal Misoprostol

Maximum GA 70 days from LMP 70 days from LMP

Mifepristone dose/location 200 mg orally. Dispensed in office 200 mg orally

Misoprostol dose/route 800 mcg buccally (4 tablets) 800 mcg buccally (4 tablets)

Misoprostol timing 24-48 hours after Mifepristone 6-72 hours after mifepristone

Misoprostol Home Home

 Complete Abortion

• Definition: The whole products of conception is expelled.

• Symptoms & Sign:
The uterus is small and well contracted,
 Closed cervix,
Scant vaginal bleeding,
and only mild cramping
 Management of Complete Abortion

• Evacuation of the uterus usually not necessary

• Observe for heavy bleeding
• Ensure follow-up of woman after treatment
 Missed Abortion

• Definition: Retention of dead products of conception in utero for several weeks

• Signs and symptoms:

Regression of symptoms and signs of pregnancy
Persistent amenorrhea, brownish vaginal discharge
Uterine size regress & cervix is closed

• Management:
Counseling for uterine evacuation
Clotting profile
Post abortion care
 Septic Abortion

• Definition: any of the types of abortion complicated by pelvic infection.

• Etiology: Polymicrobial

Symptoms & Sign

Fever, shivering
Restlessness
Abdominal pain
Malodorous vaginal discharge
Low BP
Tachypnea & tachycardia
Guarding & rebound tenderness
Cervical motion tenderness
Peritonitis
 Management of Septic Abortion

• Fluid resuscitation
• Broad spectrum Antibiotics
• Consider uterine evacuation
• Follow up of treatment
 Which Method Is Best?

Use of a certain method depends on:

• Safety, efficacy and cost

• Staff skills
• Equipment, supplies, drugs available
• Woman’s clinical condition
• Woman’s personal preference
 Methods of uterine evacuation
 

Medication
methods Foot pump

Electric vacuum
aspiration MVA 34
Distribution of abortion safety categories worldwide
and by region
Unsafe Abortion consequences
• Every year, 68 000 women die ,about eight per hour
• Unsafe abortions when performed under least safe conditions can lead
to:
• Incomplete abortion
• Heavy bleeding
• Infection
• uterine perforation
• Damage to the genital tract and internal organs.
• Death
 Effective CAC Counselling

• Explores feelings, coping, decisions

• Identifies special needs
• Improves woman-provider relationships
• Facilitates less painful procedure
• Creates greater satisfaction
 Decision to Terminate

• Confidentiality of care
• Length of pregnancy
• Abortion methods available
• Pain medications available
• Any other tests that may be done
• If applicable, fetal anomalies or other medical indications detected
• Permission to treat a complication if necessary
 Procedure Choice

• Explain differences between methods

• What will be done during and after the procedure
• What she is likely to experience
• How long it will take
• Side-effects, risks and potential complications
• Aftercare and follow-up
 SUMMARY: Post Abortion Care

Treatment of incomplete abortion • Use safe and effective treatment methods

Counseling • Identify and respond to women’s emotional and physical health needs

Family planning services • Help women prevent an unwanted pregnancy or practice birth spacing

Reproductive and other health

• Preferably provided on site or via referrals to other accessible facilities
services

• To prevent unwanted pregnancies and unsafe abortion, mobilize women to

Community and service provider
help receive care for complications from unsafe abortion, and ensure health
partnerships
services meet needs
Summary (cont’d)
Thank You