Abortion And Its Complications 2

ABORTION AND ITS COMPLICATIONS PRESENTED BY DR T.K NYENGIDIKI

• INTRODUCTION • BURDEN OF THE PROBLEM • PREDISPOSING FACTORS TO COMPLICATIONS • COMPLICATIONS • PREVENTION OF COMPLICATIONS

INTRODUCTION • 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 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 UNSAFE ABORTION • •

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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.

Complications • 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 -Tetanus Adult respiratory distress syndrome

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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

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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 abortion •

Presence of intrauterine infection after an abortion -organisms: pneumococci, streptococci, staph, E.coli,Stspp, klebsiella, proteus pseudomonas spp. Predisposing factors Criminal abortions Retained products Clinical 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

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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.Toxiod0.5mg Stat, H.I.T Globulin 250500mgStat.

SEPTIC SHOCK • _Caused by release of toxins by organisms such as E.Coli,Klebsiella ,Proteus ,Bacteriods Etc • -affects small vesselscvs collapse. • Clinical features • Warm extremities, Hypotension-in the face of adequate fluid replacement. Other evidence of sepsis.

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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 • Genital tract lacerationvaginal cervix ,uterine perforation • Clinical features • Bleeding, abdominal pains ,marked suprapubic tenderness, signs of intraperitoneal hemorrhage. • Treatment Options • Prompt resuscitation, • Repair of vaginal/cervical lacerations

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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 injuries •

Massive pelvic and abdominal abscesses -pouch of douglas, paracolic gutters,general abdomen Clinical features -unrelenting fever, abdominal distensions, absent or reduced bowel sounds Investigations FBC,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 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 200250 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 coagulation • •

-inappropriate activation of the coagulation and fibrinolytic system Causes -saline induced abortion -septic abortion -septicaemia -massive blood transfusion

Mx Release of tissue thromboplastins and bacteria endotoxins Clinical features Generalized bleeding, localized purpura ,petechia and thromboembolic phenomenon, fever, hypotension ,proteinuria frank gangrene

nvestigations -Low platelets <100,000/ml -Increased prothrombin time -low fibrinogen <150mg/dl -clotting time elevated -bleeding time elevated -fibrin degradation products elevated Treatment -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 heparinintravascular clotting process -contraindicated in fulminant D .I.C and liver failure. Prognosis Good when treatment is started early I

Prevention 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 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 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.