UNSAFE ABORTION Dr.Nooshin-Eshraghi - PowerPoint Presentation

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UNSAFE ABORTION

Dr.Nooshin-Eshraghi

perinatologist

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Safe

abortion

WHO :abortion

in countries

where

abortion law is not restrictive (abortion is legally permitted for social or economic

reasons

or

without

specification as to

reason

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unsafe

abortion

performed

by people

lacking

the necessary

skills

using

hazardous

technique

 

in

an environment that does not meet minimum medical standards.

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PREVALENCE AND EPIDEMIOLOGY OF UNSAFE ABORTION

It is estimated that 25 million unsafe abortions occur worldwide, and 97 percent of these abortions occur in the

developing world

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women

themselves induce

,classified into four broad categories:

oral and

injectable

treatments

;

preparations placed in the cervix,

vagina, or rectum

intrauterine instrumentation

;

trauma

to the abdomen

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Oral and

injectable

:

metal

salts, phosphorus, lead, kerosene, turpentine, detergent

solutions

uterinestimulants

(

misoprostol

 or 

oxytocin

)

 

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Preparations placed in the cervix, vagina, or rectum include

:

potassium permanganate tablets,

herbal,

 

misoprostol

, enemas.

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Instrumentation

:

catheter

insertion followed by infusion of alcohol,

saline…..

insertion of foreign bodies such as coat hanger, knitting needle, stick crochet

hook.

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Trauma to the abdomen

:

self-inflicted blows

abdominal

massage

jumping from a

height

lifting heavy weights.

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Misoprostol

in

successful

abortion

causes

uterine bleeding by initiating the abortion process without the risks of instrumentation

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side effects:

high

fever, shaking chills, abdominal cramping, vomiting, diarrhea, tremor, agitation, confusion,

rhabdomyolysis

, hypoxemia, and hypotension

.

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toxicity

have been

reported

Mild to moderate toxicity symptoms have been reported with doses of 3 mg to 8.5 mg

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Reported:

stomach

necrosis, distal esophagus, upper gastrointestinal bleeding, sepsis,

multiorgan

failure, and ultimately death after ingesting 12 mg of

misoprostol

These

doses are much higher than the recommended guidelines for safe abortion

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Factors that increase morbidity and mortality at the time of unsafe abortion include

Lack of provider skill

●Poor technique

●Unsanitary

conditions

●Lack of appropriate equipment

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●Use of toxic substances

●Poor maternal health

●Increasing gestational age

●Lack of access to

postabortion

care

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Death 

One in eight pregnancy-related deaths worldwide is the result of unsafe abortion

and

an estimated 47,000 women die every year from unsafe abortion

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Hemorrhage

Hemorrhage is the most common complication of unsafe abortion, and may result in

hypovolemic

shock,

coagulopathy

, and death

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Infection

 

Infection related to unsafe abortion is caused by retained products of conception, trauma, and

nonsterile

techniques

.

 sepsis, septic shock, organ failure, disseminated intravascular coagulation, and future sterility

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Incomplete abortion

 

more

common

:

self-induced abortion

,abortion

by an untrained provider, at later gestational ages, in the presence of uterine anomalies, or with distorting uterine pathology (

eg

, uterine

leiomyomas

).

Patients generally present with bleeding or infection

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Trauma

Vaginal and cervical lacerations generally present with overt vaginal bleeding; however, internal bleeding can mask the total estimated blood loss.

Lacerations

to the cervix and lateral uterus are particularly dangerous due to the risk of lacerating one of the vessels in the

parametrial

space

.

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MANAGEMENT OF COMPLICATIONS

 Initial

evaluation:

assessment

of vital signs, gestational age, vaginal bleeding and total blood loss, vaginal discharge, and examination for signs of uterine infection

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.

Stabilization

airway

and respiratory

stabilization

fluid

resuscitation

management of pain,

control

of bleeding with uterine massage,

uterotonic

agents (

eg

, 

misoprostol

 800

mcg)

or

 

methylergonovine

 

0.2mgintramuscularly)

 placement of a vaginal/intrauterine pack  an intrauterine balloon

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Signs of potential surgical emergency include:

●Heavy bleeding

●Abdominal pain

●

Shock

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Laparotomy

is needed to repair lacerations extending into the peritoneal cavity and trauma to

intraabdominal

organs and blood vessels

.

In stable patients, initial laparoscopy may be appropriate to assess

intraabdominal

trauma if

bleeding is controlled and bowel and blood vessels are intact.

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retained

products

are suspected:

the patient should first undergo surgical evacuation of the uterus using suction evacuation or dilatation and evacuation

.

Antibiotics

should be given prior to instrumentation.

use

broad spectrum antibiotics that have anaerobic coverage

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septic

abortion

:

fever, chills, malaise, abdominal pain, vaginal bleeding,

anddischarge

Physical

examination

:tachycardia

,

tachypnea

, lower abdominal

tenderness,

tender uterus with dilated cervix.

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Infection

:

Staphylococcus

aureus

, Gram negative bacilli, or some Gram positive

cocci

. Mixed infections, anaerobic

organisms

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Antibiotic therapy and evacuation of the uterus are the mainstays of management.

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The route of

antibiotic,

depends on degree of infection.

Postabortal

infections are typically

polymicrobial

and thus a broad-spectrum antibiotic is needed

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oral

regimen

:

the

patient is clinically stable, not

immunocompromised

, does not have signs of a pelvic

abscess

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option

for patients with mild to moderate pelvic inflammatory disease (PID) is one dose of 

cefoxitin

 2 grams intramuscularly plus one dose of 

probenecid

 1 gram orally, followed by 

doxycycline

 100 mg twice daily orally for 14 days

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DIC

:

is a rare but life-threatening complication of abortion

.

It is associated

with,

excessive blood loss, and amniotic fluid embolism.

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DIC can be diagnosed by drawing a 10 cc tube of whole blood and assessing whether it forms a stable clot after 10 minutes without movement of the tube

.

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