2.1 Abortion


Spontaneous or induced interruption of pregnancy before 22 weeks LMP.

In countries where voluntary termination of pregnancy is legally restricted, induced abortions are often performed under poor conditions (inappropriate substances, nonsterile equipment, without qualified health care personnel, etc.). Complications from such abortions (trauma, bleeding and severe infection) are common and may be lifethreatening.
For safe abortion care, see Chapter 12.

2.1.1 Diagnosis

Signs and symptoms

– Threatened abortion or missed abortion: light bleeding, abdominal pain, closed cervix.
– Incomplete abortion: more or less severe bleeding, abdominal pain, uterine contractions, expulsion of products of conception, open cervix.
– Trauma to the vagina or cervix or the presence of a foreign body are strongly suggestive of unsafe abortion. Look for complications, especially infection.

Additional tests

– A pregnancy test is useful if the history and clinical examination are inconclusive.
– Ultrasound is useful for confirming pregnancy termination or the presence of retained products of conception after incomplete abortion.

2.1.2 Differential diagnosis

The main differential diagnoses are: ectopic pregnancy, cervicitis, cervical ectropion (eversion of the cervical mucosa, which is more fragile and may bleed easily on contact, especially after a vaginal examination or sexual relations), cervical polyp, and functional uterine bleeding.

2.1.3 Management

Threatened abortion

– Advise the patient to reduce activity. Either the threat of abortion recedes, or abortion is inevitable.
– Look for a possible infectious cause (malaria or sexually transmitted infections) and treat it.
– Treat pain according to severity.

Ongoing or incomplete abortion

– Measure pulse, blood pressure, temperature; assess severity of bleeding.
– Treat pain according to severity.
– Remove any visible products of conception from the vagina and cervix.
– Remove foreign bodies, if present, clean the wound, and check and/or update tetanus immunisation (Table 2.1).

Table 2.1 - Tetanus prophylaxis

Immunisation status

Spontaneous abortion

Unsafe abortion,
with wound or foreign body

Not immunised
or
Immunisation status unknown

Begin immunisation against tetanus

Begin immunisation against tetanus
+
Human tetanus immunoglobulin

Incompletely immunised

Tetanus booster

Tetanus booster
+
Human tetanus immunoglobulin

Fully immunised
Last booster dose:



< 5 years

No prophylaxis No prophylaxis

5 to 10 years

No prophylaxis Tetanus booster

> 10 years

Tetanus booster Tetanus booster
+
Human tetanus immunoglobulin


– For septic abortion (fever, abdominal pain, tender uterus, foul-smelling discharge), add:
amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 3 g/day in 3 divided doses administered 8 hours apart + gentamicin IM: 3 to 5 mg/kg once daily
or
ampicillin IV: 6 g/day in 3 divided doses administered 8 hours apart + metronidazole IV: 1.5 g/day in 3 divided doses administered 8 hours apart + gentamicin IM: 3 to 5 mg/kg once daily

Continue until the fever disappears (at least for 48 hours), then change to:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) to complete 5 days of treatment
Using the 8:1 ratio: 3000 mg daily, i.e. 2 tablets of 500/62.5 mg 3 times daily

Using the 7:1 ratio: 2625 mg daily, i.e. 1 tablet of 875/125 mg 3 times daily
or
amoxicillin PO: 3 g/day in 3 divided doses + metronidazole PO: 1.5 g/day in 3 divided doses to complete 5 days of treatment
For very severe infection (infected perforated uterus or peritonitis), treat for 10 days.

– If bleeding is heavy:
• Insert an IV line (16-18G catheter) and administer Ringer lactate;
• Closely monitor pulse, blood pressure, bleeding;
• To prepare for a possible transfusion, determine the patient’s blood type and select potential donors or make sure that blood is available. If transfusion is necessary, only use blood that has been screened (HIV-1, HIV-2, hepatitis B, hepatitis C and syphilis).

– Uterine evacuation:

Before 10 weeks LMP:
Expulsion is often complete; uterine evacuation is usually not necessary.
Monitor blood loss; do not evacuate the uterus unless bleeding is heavy.

Between 10 and 12 to 14 weeks LMP1 :
Uterine evacuation is usually required due to retained products of conception, which can cause bleeding and infection. If uterine evacuation is necessary, there are three options:
• Instrumental methods:
  - manual vacuum aspiration (Chapter 9, Section 9.5)
  or
  - instrumental curettage (Chapter 9, Section 9.6).
Aspiration under local anaesthesia is the method of choice1. It is technically easier to perform, less traumatic and less painful than curettage.
• Medical method:
The use of misoprostol as a single dose (400 micrograms sublingually or 600 micrograms PO)2,3 may avoid surgical intervention.
There is, however, a risk of failure that increases as the pregnancy progresses.
Treatment success (that is, an empty uterus) must be verified in the days after the drug is taken. If the medical method fails, the use of an instrumental method is unavoidable.

Beyond 12 to 14 weeks LMP:
Be patient; leave the amniotic sac intact and allow labour to take its course. The placenta is usually expelled with the foetus. Part of the placenta may be retained. If examination of the placenta leaves any doubt, or in the event of haemorrhage, rapidly perform digital curettage after the expulsion. If delayed, this procedure becomes impossible due to retraction of the cervix. At that point, instrumental curettage –with its significant risk of uterine perforation– may become necessary (Chapter 9, Section 9.6).

– Afterward, provide iron + folic acid supplementation or, in case of severe anaemia, a blood transfusion.

– Look for a possible infectious cause (malaria or sexually transmitted infections) and treat it.



Footnotes
Ref Notes
1

The gestational  age is based on the date of last menstrual period and uterine size. Uterine evacuation, using aspiration or misoprostol are usually recommended up to 12 weeks. The estimation of gestational age is often approximative. Thus, these methods can be used up to an estimated gestational age of 14 weeks.