ABORTION AND POST ABORTION CARE

INTRODUCTION

Abortion in pregnancy is a cause of maternal mortality worldwide.  It  is  the  number  one  cause  of  maternal  death  in  Nigeria  as  it  carries  23%  out of  the  other  direct  cause.  Complication of abortion is preventable with an improved maternal  health  care e.g. post abortion care;   this could  save  many  lives.

DEFINITION ;  -

•       This is termination of pregnancy before 24weeks of gestation or before the foetus is viable.

PATHOLOGY

•      Haemorrhage into the decidua basalis.

•      Necrotic changes in the tissue adjacent to the bleeding.

Detachment of the conceptus. The above will stimulate uterine contraction resulting in expulsion

CAUSES OF ABORTION

•        FETAL-  1) Chromosome abnormalities e.g.    Trisomy 21( Down syndrome),

•      Trisomy 18 (Edward syndrome)  Monosomy →     Turner syndrome(x0)

MATERNAL CAUSES

1) Uterine abnormality; Bi-cornuate uterus → recurrent abortion. - fibroids (submucus): → (a) disruption of implantation and development of the fetal blood supply, (b) inadequate space for  the fetus to grow.

(2) Maternal disease;  Diabetes, Thyroid dysfunction                  

(3) Infections ; Rubella, Chlamydia and Malaria.

(4) Environmental factors; alcoholism, Fall, cigarette smoking/exposure to smoke )      

 (5)Immunological: - autoimmune response: failure of a normal immune response in the mother to accept the fetus for duration of a normal pregnancy. –Autoimmune disease: antiphospholipid antibodies especially  lupus anticoagulant (LA) and the anticardiolipin antibodies (ACL) .

TYPES OF ABORTION

TYPES OF ABORTION

A spontaneous miscarriage

This is characterized with history of  bleeding with or without lower abdominal pain and  presents in different number of ways.   

Clinical features/management

•      Threatened abortion

•       Short period of amenorrhea. - Mild bleeding (spotting). - Mild pain. - P.V.: closed cervical os. - Pregnancy test (hCG): + ve. - US: viable intra uterine fetus. 

•       Management - reassurance. - Rest. - Repeated U/S.

•      Inevitable abortion  

•      Clinical feature: - Short period of amenorrhea. - heavy bleeding accompanied with clots (may lead to shock). - Severe lower abdominal pain. - P.V.: opened cervical os. - Pregnancy test (hCG): + ve. - US: non-viable fetus and blood inside the uterus. Products of conception may pass into the vagina

•      Management –fluids…..blood -evacuation of the uterus(medical/surgical).

•      If some of the products be retained, it is called an INCOMPLETE miscarriage.

•      However remaining products may be passed spontaneously to become a COMPLETE miscarriage –Cessation of active bleeding and abdominal pain. –P.V. closed cervix. –US: empty uterus.

•      Incomplete  abortion has a high risk of infection with the following signs and symptoms; uterine tenderness, pyrexia and offensive vaginal discharge. If left untreated may lead to overwhelming sepsis. SEPTIC abortion may lead to renal failure and disseminated intravascular coagulation(DIC)

•      Missed or silent miscarriage; Initially may have abdominal pain and bleeding. Gradual disappearance of pregnancy symptom and signs. –Brownish vaginal discharge/

•      Pregnancy test: negative but it may be positive for 3-4 weeks after the death of the fetus.-US: absent fetal heart pulsations.

•      Complications –Infection, DIC, Treatment –Wait 4weeks for spontaneous expulsion(expectant management) –Evacuate if: Spontaneous expulsion does not occur after 4weeks in missed abortion.

Management: Manage according to size of uterus –Uterus < 12weeks: Misoprostol 600-800mcg x2times in vaginal fornix OR 600mcg x2times sublingual. Give space of 24hours from first dose. Leave to work up to 2weeks(unless heavy bleeding and infection). MVA/ -Uterus > 12weeks: oxytocin.

Miscarriage can be managed surgically, expectantly and medically.

   Surgically;  evacuation before 12wks gestation.  Dilate and a        suction curettage. Use of prostaglandins(400mcg 3hrs)  before       surgery is done to ripen the cervix.

•      Expectantly; This is to wait for the product of conception to be passed spontaneously. Explain that it may take weeks, patient may be on admission or not, contact information, education on when to seek medical aid.

•      Medically; Include a variety of treatment options to prevent unsafe abortion. Incomplete abortion;  0-12wks

•      Administer 600 orally (buccal) or 400mg sublingually at a time. Leave to work for up to 2wks, unless heavy bleeding or infection.

•      NOTE: Sublingual (under the tongue) starts working in 10mins and is faster than Buccal (under the cheek).

UNSAFE ABORTION

•      Definition- This is an abortion performed by persons lacking necessary skills or in an environment lacking minimal medical standards or both.

INCIDENCE  OF  UNSAFE  ABORTION  WORLDWIDE

•        >70,000  women  die  yearly,  23,000  of  which  occur  in  sub-sahara Africa.

•      1  out  of  8  deaths  related  to  pregnancy  is  caused  by  unsafe  abortion.

Unsafe  abortion  account  for  about  62%  of  maternal  mortality  worldwide.

•      Each year1.25million Nigerian women have an abortion.

•      40% of them experience complications serious enough to require treatment.

GROUPS   COMMONLY  AFFECTED  INCLUDE:

-Students, Divorcees, Married women, Single girls, Unemployed.   Widows, Commercial sex workers.

CAUSES  OF  UNSAFE  ABORTION

•      Unwanted  pregnancy.

•      Lack  of  access  to contraceptives.

•      Financial  difficulties.

•      Fear of Parent’s  reaction  to a teenager in school.

•      Willingness  to continue  educational  pursuit.

•      Too  many  children.

METHOD  USED.

•      Drugs  e.g.  ergometrine,  misoprostol,  quinine, codeine.

•       Substances e.g. Blue  or  potash.

•      Vaginal interference such as inserting knitting pin or bicycle  spoke to evacuate the uterus .

•      Alcohol e.g. ogogoro

•      Sponge with a spring

COMPLICATIONS OF UNSAFE   ABORTION

•      Severe  vaginal  bleeding.  Perforation of  the pouch of douglas  & or laceration of uterus.

•      Shock.- Sepsis - Intra-abdominal  injury- Uterine  perforation.

•      Peritonitis.

TREATMENT  OF  UNSAFE  ABORTION.

•      Examine  for  signs  of  uterine  or  vagina  infection  and  bowel  injury.

•      If  infection  is  present,  start  antibiotics.

•      Give  Ceftriazone 1g  I.V. 12 hourly.

•      Gentamycin  5mg/kg  body  weight   I.V.  24 hourly  (daily).

•      Metronidazole  500mg. I.V. 8hourly  for  48 hours.

•      Perform  manual  vacuum  aspiration (MVA)  if  available  if  not,  refer  the  client.

POST  ABORTION  CARE.

This  is  defined  as  an  approach  for  reducing  morbidity  and  mortality  from  incomplete  and  unsafe  abortion  and  it’s complications  and for  improving  women’s  sexual  and  reproductive health lives.

ELEMENT OF POST ABORTION CARE

- 5 elements:

1. Treatment of incomplete and unsafe abortion and abortion related complications.

2. Counseling to identify and respond to women's emotional and physical health needs and other concerns.

3. Contraceptive and family planning services to prevent unwanted pregnancy.

4. Reproductive and other health services that are provided on-site and via referrals to other facilities in providers network e.g. STI/HIV.

5. Community and service providers’ partnership to;

•      Prevent unwanted pregnancy and unsafe abortion.

•      Mobilize resources for timely care of complication of abortion.

•      Ensure health services reflect and meet community  expectations and needs.

POTENTIAL DIFFILCULTIES IN PROVIDING PAC

•      Lack of adequate staff

•      Inadequate physical conditions

•      Lack of necessary equipment and medicine

•      Lack of training in PAC

•      Problems communicating with patients

•      Lack of political decision making

•      Lack of support from leaders

•      Inadequate infection prevention programmes

•      Inadequate referral systems 

•      Inadequate monitoring and follow up of training process

•      Administrative separation of emergency and contraceptive processes

•      Resistance to using MVA 

RIGHTS OF CLIENT SEEKING PAC

•      Information

•      Accessible services, safe services

•      Choices, Opinions

•      Privacy, Comfort

•      Confidentiality

•      Dignity

•      Follow-up care

PRINCIPLES  THAT SUPPORT PATIENTS RIGHT IN  PAC

•      Having  empathy  and  respect  for  patient.

•      Maintaining  positive  interaction  and  communication  with  patients.

•      Respecting  privacy  and  confidentiality.

•      Adhering  to  the  voluntary  informed  consent  process.

MANUAL  VACUUM   ASPIRATION (MVA).

•      This  is  a  procedure  performed  to  evacuate  uterine  contents  in  the  management  of  abortion.

     

  INDICATION  FOR  MVA.

•      Inevitable  abortion. Incomplete  abortion.

•      Missed  abortion. Molar  pregnancy/  hydatidiform  mole.

•      Endometriosis. Retained  product  of  conception.

ROLES OF THE MIDWIFE

-         The midwife has the responsibility of ensuring that the facilities and the necessary equipment are always available at the MVA room. Portable water should be made available

-         All sterile items for procedure should be always available

-         The general cleanliness of the room must not be assumed

-         She should ensure proper cleaning and setting up of the trolley. She must ensure completeness of the items on both shelves of the trolley

-         She is to ensure availability of the stock for the procedure. There should be no out of stock syndrome

Pre and post procedure care of the patient is an important responsibility of the midwife.

•      Her role in the actual MVA procedure depends on whether she is permitted to carry out the procedure or to assist the doctor during a procedure.

•      In which ever situation she must have a good grip of the procedure

•      She must possess a proper understanding of cleaning and sterilization /or disinfecting of equipment used during the procedure and disposal of waste, aspirate and sharp instrument

•      She is responsible for keeping records of details of the procedure 

INSTRUMENTS/ MATERIALS  NEEDED  FOR  MVA

•      Vaginal  speculum.

•      Tenaculum(marie stopes).

•      Sponge  holding  forcep.

•      Cervical  dilators (plastic).

•      Povidone-iodine usp 10%

•      Sterile  gloves.

•      Sterile  fields.

SELECTING CANNULA AND ADAPTERS

CANNULA	APPROXIMATE UTERINE SIZE  IN (WEEKS LMP)	SYRINGE	ADAPTER
4 , 5 and 6mm	5 – 7 weeks	double	Yellow
7mm	8 – 9 weeks	Double	Brown
8mm	8 – 9 weeks	Double	Beige
9mm	10 – 12weeks	Double	Dark brown
10mm	10 – 12 week	Double	Dark green
12mm	10 – 12 week	Double	Blue

      PREPARING THE CERVIX

•      Place  the  speculum (cuscos vaginal speculum)

•      Clean the  cervix

•      Stabilize  the  cervix  with  the  tenaculum/marie stopes UTERINE SOUND: use plastic uterine sound.   Push  the  cannula  slowly  inside  the  uterine  cavity  until  it  touches  the  fundus.

  

  INSERTING   THE  CANNULAR

•      Apply  traction  to  the  tenaculum  gently.

•      Insert  the  selected  cannula  gently  through  the  cervix  with   a  rotation  movement.

•      Do  not  touch  the  end  that  will  be  inserted  into  the  uterus.

                                                                          

    CREATING  A  VACUUM

•      Open the valve, pull the plunger. When  the  safety  valve  is  released, the vaccum is transferred to the  uterus through the cannula.

•      The passage  of blood and tissue through the cannula to the syringe  begins.

     

EVACUATING  UTERINE  CONTENT.

•      Hold the cannula with the  thumb  and  index  finger  and  the  syringe  with the ring and little fingers.

•      Moves the cannula side to side, back and forth gently , up and down slowly,   cannula and the syringe at the same  time.

•      do not withdraw and aperture of the cannula beyond the external   cervical  os.

•      Do not grasp the syringe by plunger arms.

     

IF  THE   SYRINGE  BECOMES  FULL.

•      1.Close the valve. 2.Disconnect the syringe, leaving the tip of the cannula inside the  uterus. 3.Empty  the  content  of  the  syringe  in  a  container. 4.Open  the  valve. 5.Re-establish  the  vacuum,  reconnect  and  continue

 IF  TISSUE  CLOGS   THE  CANNULAR  APERTURE.

•      Withdraw  the  cannula  slowly  up  the  external  os. The  release  of   air  will  cause  the  tissue  to  pass  through  to  the  syringe.

•      Reinsert  the  cannula  in  the  uterus,  detach  the  syringe,  empty   the   contents,  re-establish  the  vacuum  and  continue  the  procedure.

•      Never  try  to  unclog  the  cannula  by  pushing  back  into  the  barrel.

  

SIGNS  OF  COMPLETION  OF  THE  PROCEDURE.

•      There  is  pinkish  foam  on  the  cannula.

•      No  more  tissue  is  seen  passing  through  the  cannula.

•      A  gritty  sensation  is  felt.

•      The  uterus  grips  the  cannula  and  it  is  difficult  to move  it.

 

AFTER  THE  PROCEDURE.

•      Disconnect the  syringe.

•      Withdraw cannula   and   tenaculum.

•      Check for  active  bleeding  in  the  uterus  or  cervix.

•      Place all instruments  in  0.5%  chlorine  solution or bleach 1:6 (Decontaminant).

•      Perform bimanual examination.

•      Inspect the tissue.

PATIENT RECOVERY/ DISCHARGE.

•        IN RECOVERY:.

•      Take  patients vital  signs.

•      Allow  the  patient  to  rest  comfortably  where  she  can  be  monitored  closely.

•      check   bleeding  and  cramping.

•         NB: When  MVA  is  performed  with  a  low  level  of  medications   for  pain  management,  recovery  is  fast.

•            DISCHARGE  WHEN:

•      Vital  signs  of  the  patient  are  normal.

•      She  can  walk  without  assistance.

•      She  has  received  information  about  follow  up  care  and  recovery.

•      She  has  been  counseled  and  informed  about  her   return  to  fertility  and  contraception.

 NOTE  THAT:

•      1.In  1^st   trimester  abortion,  a  woman  usually  recovers  her  fertility  during  the  first   weeks  after  abortion.

•      2.In  2^nd  trimester  abortion,  a  woman  usually  recovers  her  fertility  during  the  first  four  weeks  after  abortion.

WHAT  PATIENT  NEED  TO  KNOW

•      She  should  expect  some  uterine  cramping  and  bleeding.

•      Her  normal  menstrual  period  should  begin  within  4-8  weeks.

•      She  should  take  medications  as  prescribed.

•      She  should  not  have  sex  or  put  anything  into  her  vagina  until  a  few  days  after  bleeding  has  stopped.

•      She  could  be  pregnant  before  her next  period  is  expected.

•      Contraception  can  prevent  or  delay  pregnancy,  if  she  so  desires.

•      She  should  schedule  a  follow  up  visit.

•      Where  to  seek  medical  attention  if  she  experiences  prolonged  cramping,  excessive  bleeding,  severe  pain,  fever,  chills, malaise  and  fainting.

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