2.1 Abortion


Ending of pregnancy, either spontaneous (miscarriage) or induced (termination of pregnancy) before 22 weeks LMP. 

In countries where termination of pregnancy is legally restricted, induced abortions are often performed under poor conditions (non-sterile equipment, inappropriate equipment and/or substances, unqualified health care personnel, etc.). Complications (trauma, bleeding and severe infection) are common and may be life-threatening.

For termination of pregnancy, 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 bodies are strongly suggestive of unsafe abortion. Look for complications, especially infection.

Additional investigations

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

2.1.2 Differential diagnosis

The main differential diagnoses are: ectopic pregnancy, cervicitis, ectropion (eversion of the cervical mucosa, which is more fragile and may bleed easily on contact, especially after a vaginal examination or sexual intercourse), 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 infection) and treat it.
– Treat pain according to severity (Appendix 7).

Missed abortion 

If there are no signs of infection and/or no heavy bleeding, there is no urgency to perform uterine evacuation. 
– Before 13 weeks LMP
Uterine evacuation can be performed by:
• medication: misoprostol 600 micrograms sublingually or 800 micrograms vaginally (in the posterior fornix). Bleeding and cramping can be expected to start within 3 hours. If expulsion has not started within 3 hours, administer additional doses of misoprostol every 3 hours; max. 3 doses in total.1
or
• manual vacuum aspiration (Chapter 9, Section 9.5).
– Between 13 and 22 weeks LMP
mifepristone PO: 200 mg single dose, and 1 to 2 day later, misoprostol 400 micrograms sublingually or intravaginally (into the posterior fornix), every 4 to 6 hours until labour starts, to be repeated if necessary the following day
or 
misoprostol alone 400 micrograms sublingually or intravaginally (into the posterior fornix), every 4 to 6 hours until labour starts, to be repeated if necessary the following day
In case of 2 or more previous uterine scars or grand multiparity or overdistention of the uterus:
• Preferably use the combined regimen mifepristone + misoprostol, as fewer numbers of misoprostol doses are required.
• Reduce the dose of misoprostol to 200 micrograms every 6 hours.   
• Closely monitor the mother for possible signs of impending rupture (heart rate, blood pressure, uterine contractions, pain).

Ongoing or incomplete abortion without signs of infection

General measures
– Measure heart rate, blood pressure, temperature; assess severity of bleeding.
– In the event of heavy bleeding:
• insert an IV line (16-18G catheter) and administer Ringer lactate;
• closely monitor heart rate, blood pressure, bleeding;
• prepare for a possible transfusion: determine the patient’s blood type, select potential donors or ensure that blood is available. If transfusion is necessary, only use blood that has been screened (HIV-1, HIV-2, hepatitis B, hepatitis C, syphilis, and malaria in endemic areas).
– Treat pain according to severity (Appendix 7).
– Remove products of conception from the vagina and cervix, if present. 
– Look for a cause (e.g. malaria or sexually transmitted infections) and treat it.
– Afterwards, provide iron + folic acid supplementation or, in the event of severe anaemia, a blood transfusion.

Uterine evacuation
– Before 13 weeks LMP

Uterine evacuation is usually required due to retained products of conception, which can cause bleeding and infection. There are 2 options:
• Instrumental evacuation: manual vacuum aspiration (Chapter 9, Section 9.5) or, if not available, instrumental curettage (Chapter 9, Section 9.6). Aspiration under local anaesthesia is the method of choice2. It is technically easier to perform, less traumatic and less painful than curettage.
Medication: misoprostol 400 micrograms sublingually or 600 micrograms PO single dose3 
– Between 13 and 22 weeks LMP
• Instrumental evacuation in case of haemorrhage: manual vacuum aspiration (Chapter 9, Section 9.5) or instrumental curettage (Chapter 9, Section 9.6) or digital curettage (Chapter 9, Section 9.4). 
• Medication: misoprostol 400 micrograms sublingually every 3 hours until expulsion. In the absence of expulsion after 3 additional doses, consider instrumental evacuation. 
In case of 2 or more previous uterine scars or grand multiparity or overdistention of the uterus: same precautions as for missed abortion (see above).

Septic abortion

In the event of septic abortion (fever, abdominal pain, tender uterus, foul-smelling discharge), as above AND:
– Remove foreign bodies from the vagina and cervix, if present; clean wounds.
– Perform uterine evacuation as soon as possible, irrespective of gestational age.
– Administer antibiotherapy as soon as possible:
amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 1 g every 8 hours + gentamicin IM: 5 mg/kg once daily
or
ampicillin IV: 2 g every 8 hours + metronidazole IV: 500 mg every 8 hours + gentamicin 
IM: 5 mg/kg once daily

Continue until the fever disappears (at least 48 hours), then change to:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) to complete 5 days of treatment 
Ratio 8:1: 3000 mg daily (= 2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (= 1 tablet of 875/125 mg 3 times daily)
or
amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily, to complete 5 days of treatment
For very severe infection (infected perforated uterus or peritonitis), treat for 10 days.
– Check and/or update tetanus immunisation (Table 2.1).

Table 2.1 - Tetanus prophylaxis

Immunisation status

Spontaneous abortion

Unsafe abortion,
with wound or foreign bodies

Not immunised
or
Immunisation status unknown

Begin immunisation against tetanus

Begin immunisation against tetanus
+
Human tetanus immune globulin

Incompletely immunised

Tetanus booster

Tetanus booster
+
Human tetanus immune globulin

Fully immunised
Last booster dose:



< 5 years

No prophylaxisNo prophylaxis

5 to 10 years

No prophylaxisTetanus booster

> 10 years

Tetanus boosterTetanus booster
+
Human tetanus immune globulin