ABORTION AND ITS ABORTION AND ITS COMPLICATIONSCOMPLICATIONSPRESENTED BY PRESENTED BY

DR T.K NYENGIDIKIDR T.K NYENGIDIKI

• INTRODUCTION

• BURDEN OF THE PROBLEM

• PREDISPOSING FACTORS TO COMPLICATIONS

• COMPLICATIONS

• PREVENTION OF COMPLICATIONS

INTRODUCTIONINTRODUCTION• Ancient as mankind-prevention of unwanted birth• Most hazardous procedure –unsafe abortion• Unsafe Abortion- procedure of termination of

pregnancy either by a person lacking in the necessary skilled or in an environment lacking the minimal medical standards or both (WHO 1992)

• Clinically recognizable abortion -15-17% of pregnancies- spontaneous or induced.

• Associated with complications• Induced abortion on its own is a result of failure of

the complex often tricky balance act engaged in human to reconcile 2 aspects their life-Sexual intercourse & wish/reluctance to make babies.

Burden of the problemBurden of the problem

• 26-53 million induced abortion annually

• 40% in countries with restrictive laws

• In Nigeria,

.Abortion rates 25 per 1000 women ,

.610,000 abortion per year.

. 40 % of maternal deaths

• Netherlands – 5 per 1000 women.

PREDISPOSING FACTORS TO PREDISPOSING FACTORS TO UNSAFE ABORTIONUNSAFE ABORTION

• Lack of adequate legislature and policies to regulate the procedure.• Financial constraints on the part of the affected persons:

-to raise children-to seek adequate contraception-Acquire appropriate education-Seek procedure under safe conditions-medical care for treatment of complications.

• Low illiteracy levels• Unstable family set up• Societal outlook and taboos• Single parenthood• Student pregnancies• Religious condemnation of pregnancies etc• Lack of information about complication of procedure, preventive

measures prevalence of unsafe abortions.

ComplicationsComplications• EARLY-Incomplete abortion-septic abortion-septic shock-Injury

-vagina, cervix, uterus -perforation of large /small

bowels-Acute renal failure-Dissseminated intravascular

coagulation-Haemorrhage-pelvic abscesses-septic pelvic thrombophlebitis-Septic arthritis-TetanusAdult respiratory distress syndrome

• LATE• -Chronic pelvic inflammatory

disease• -pelvic adhesions• -chronic tubo-ovarian masses• -chronic pelvic pain• -tubal occlusion• Ectopic Gestation• Infertility• Asherman’s syndrome

-infertility-oligomenorrhoea /amenorrhoea-intrauterine adhensions

• Psychological factors-grief-regrets-dejection

•

• INCOMPLETE ABORTION• history-Attempted criminal termination-Passage of fetal parts-Abdominal pains • Exam• Pale,tachycardia,hypotension

–severe blood loss.• Uterine size < gestation• Abdominal tenderness• Cervical os open with products• Investigation• Full blood count- Hb• Grouping and cross matching

of compatible blood• Ultrasound scan

• TREATMENT• Resuscitation: Normal saline,

Ringers lactate,blood transfusion• Use of oxytocics• -intravenous bolus of

ergometrime-0.5mg stat• -intravenous oxytocins 40 units in

one litre of normal saline at a rate of 30-60 drops per minute.

• Arrangement for evacuation of retained products-Surgical -manual vacuum aspiration (98% )-Medically- Oral misoprostol 400mg alone .-Intramuscular sulprostone 0.5mgstat(95% )

. Adminstration of Anti D immunoglobulin-250units.

.Counseling and psychological support

Prophylactic antibiotics

Septic abortionSeptic abortion• Presence of intrauterine infection after an

abortion-organisms:pneumococci, streptococci, staph, E.coli,Stspp,klebsiella, proteus pseudomonas spp.Predisposing factorsCriminal abortionsRetained productsClinical features.Hx of criminal termination-may not be

volunteered.Fever, pallor, jaundiced, furred tongue tachycardia with sometimes evidence of hypotension-toxic shock.Evidence of peritonitis:- Abdominal -tenderness/rebound tenderness distension.-Reduction of bowel sounds-Malodorous blood stained discharge from

cervix-Cervix may be opened or closed-Positive C.E.T

• Investigations• HVS, intracervical, intrauterine

microscopy• FBC+ESR• Blood grouping and typing• Midstream urine• Electrolyte, urea and creatinine• Coagulation studies• Erect abdominal X ray• Ultrasound sound

• Treatment• Resuscitation• Blood transfusion• Strict input and output chart• Antibiotics- triple regiment• Tetanus prophylaxis- T.Toxiod-

0.5mg Stat, H.I.T Globulin 250-500mgStat.

SEPTIC SHOCKSEPTIC SHOCK

• _Caused by release of toxins by organisms such as E.Coli,Klebsiella ,Proteus ,Bacteriods Etc

• -affects small vessels- cvs collapse.

• Clinical features• Warm extremities,

Hypotension-in the face of adequate fluid replacement. Other evidence of sepsis.

• Treatment• Adequate infusion of crystalloids

colloids, blood transfusion• Refractory shock

-+vasopressors –Dopamine (renal dose)->6g/kg/hr

.HA-1A- Human monoclonal IgM antibodies (centroxin)-100mg in 3.5g of Albumin

.Oxygen by face mask

.Monitoring of vital signs.

.Severe cases-Endotracheal intubation/O2-Respirator care-ECG monitoring-Pulse oximeter CVP monitoring

INJURIES INJURIES

• Genital tract laceration-vaginal cervix ,uterine perforation

• Clinical features • Bleeding, abdominal

pains ,marked suprapubic tenderness, signs of intraperitoneal hemorrhage.

• Treatment Options• Prompt resuscitation,• Repair of vaginal/cervical

lacerations

• Perforation• Stop the procedure, observe

closely,-cardiovascular compromise.

• Not present- antibiotics • Present – laparotomy• Laparotomy –Extent of injury

and effect repairs-hysterectomy

-extensive damage-clostridium infection

-gangrene/necrosis-drainage and

peritoneal lavage did not produce an improvement in condition

Abscesses and intestinal injuriesAbscesses and intestinal injuries

• Massive pelvic and abdominal abscesses-pouch of douglas, paracolic gutters,general abdomen

Clinical features -unrelenting fever, abdominal

distensions, absent or reduced bowel sounds

InvestigationsFBC,U/S scan, Erect plain

abdominal X ray

MGT• Co-management with the

surgeons- antibiotics, laparotomy –

midline incision- N/B No place for culdotomy- -bowel resection and

anastomosis, colostomy-Drainage of abscesses-irrigation of abdomen with normal

saline-Fascia closed with non

absorbables-Massive Antibiotics

Acute renal failureAcute renal failure

• Urinary output < 30mls per hour despite adequate hydration and blood transfusion

• Deranged electrolyte urea and creatinine

• Diagnosis made• -refer to renal unit

• Treatment• Initial

-adequate hydration-Fluid challenge with 200-250 mls of mannitol or iv frusemide 100-200mg

If established-Restrict fluid, institute renal

failure regiment- high CHO, low protein and low potassium

Dialysis-Hemodialysis or Peritoneal

Disseminated intravascular Disseminated intravascular coagulationcoagulation

• -inappropriate activation of the coagulation and fibrinolytic system

• Causes-saline induced abortion-septic abortion-septicaemia-massive blood transfusion

MxRelease of tissue thromboplastins and

bacteria endotoxinsClinical featuresGeneralized bleeding, localized purpura ,petechia and thromboembolic phenomenon, fever, hypotension ,proteinuria frank gangrene

Investigations-Low platelets <100,000/ml-Increased prothrombin time-low fibrinogen <150mg/dl-clotting time elevated-bleeding time elevated-fibrin degradation products elevatedTreatment-Correction of underlying dx-supportive treament

-correction of shock,acidiosis-cardiopulmonary support-fresh whole blood transfusion –massive haemorrhage

-platelet transfusion-platelet count < 50,000/ml-subcutanous low dose heparin-intravascular

clotting process-contraindicated in fulminant D .I.C and liver failure.

PrognosisGood when treatment is started early

Prevention of unsafe abortionPrevention of unsafe abortion

• Preventable cause of maternal mortality and morbidity

• This involves:

- prevention of unwanted pregnancies

- increasing access to safe abortion practices

- effective management of abortion complications through post abortal care

LEVELS OF PREVENTIONLEVELS OF PREVENTION

Primary-provision of reproductive health information and choices-prevention of unplanned and unwanted pregnancies-provision of quality sexuality education to all ages.-Provision of sustainable contraceptive delivery service.

- National policies on adolescent reproductive health should be formulated.

• Secondary-programmes /activities aimed at providing

information and counseling to women experiencing unwanted pregnancy

N/B: Not available b/c of restrictive laws Tertiary care

-Provision of services for treatment of complications of unsafe abortion in 10,20

and 30 health facilities.

TERTIARY PREVENTION CONTTERTIARY PREVENTION CONT

• Provision of equipments for manual vacuum aspiration and supplies of contraceptives.

• Pre-service training of staff on all aspects of abortion, post abortion care contraceptive delivery and quality care framework.