Abortion is defined as the termination of pregnancy before the age of viability (varies from country to country; 20 weeks in the US, 28weeks in Nigeria) or loss of a foetus weighing 500 grams or less. Abortion can be spontaneous or induced. Some gynecologists often prefer to use the word “miscarriage” for a spontaneous abortion.
It is estimated that up to 50% of all confirmed and unconfirmed human pregnancies will result in an abortion. However, by the 8th week of a viable gestation, the chances of a spontaneous abortion occurring drops to only 2-3%.
Bleeding from the vagina is the commonest symptom of abortion. 30% of pregnant women experience some form of bleeding in the first trimester. About 50% of them will end up with a spontaneous miscarriage. Therefore, it is important to understand that, apart from impending abortion, bleeding during pregnancy could be due to other causes such as:
*lower genital tract infections
*unprovoked or post-coital bleeding due to increased friability of the cervix
*ectopic pregnancy (implantation of the embryo in any location outside the uterus)
What are the causes of miscarriage?
*Genetic causes – foetal genetic anomalies account for 70% of 1st trimester miscarriages
*Uterine causes – abnormal anatomy, growths or adhesions
*Cervical causes – incompetent cervix
*Infections of the genital tract and other systemic infections
*Endocrine causes – such as diabetes
*Immunologic causes – such as antiphospholipid syndrome
*Toxins – such as alcohol, caffeine, high energy radiations, some drugs, etc
What are the symptoms of abortion?
*Vaginal bleeding – from mild spotting to heavy bleeding, can be life-threatening if not treated promptly.
*Lower abdominal pain – can be mild to moderate to severe, sometimes no pain
*Passage of fetal tissues – clotted blood, fleshy materials, (take note of “vesicles” in case of molar pregnancy)
*Gush of fluid from the vagina – ie. amniotic fluid, in second trimester miscarriages
*Reduced or NO fetal movement – if the fetal movement has been perceived earlier
*Cessation of the usual early pregnancy symptoms
*Fever, malaise, vomiting etc – in septic abortion
-Full history and thorough examination
-Complete blood count
-Blood group – especially Rhesus
-BHCG levels – to rule out ectopic pregnancy
-Other investigations to determine the cause, especially in recurrent (>/= 3) pregnancy losses
Types of Abortion and their management.
*COMPLETE ABORTION – spontaneous expulsion of the foetus and placenta, bleeding stopped and cervix closed. No further management is required except ultrasound to confirm completeness.
*INCOMPLETE ABORTION – passage of some fetal tissues but not all, cervix is open and bleeding continues. Management – group and prepare blood, IV fluids, medical or surgical evacuation of the remaining uterine contents, +/- blood replacement
*THREATENED ABORTION – bleeding but closed cervix. Management – rest and avoid intercourse
*INEVITABLE ABORTION – bleeding/rupture of membranes with cervical dilatation but no expulsion of foetus or placenta. Management – expectant, medical or surgical
*MISSED ABORTION – foetal demise without expulsion, +/- bleeding, cervix closed. Management – medical or surgical.
*SEPTIC ABORTION – any abortion associated with uterine infection. Management – IV fluids, antibiotics, followed by surgical evacuation.
What are the complications of unsafe abortion or uterine evacuation?
If the evacuation is handled by a qualified personnel, using aseptic techniques, the complications are infinitesimally low.
Short term complications of unsafe abortion include:
*severe blood loss – which can require blood transfusion and may lead to death if not treated promptly.
*infection – septic abortion
*damage to adjacent internal organs such as the bladder and bowels
Long term complications include:
-Pregnancy losses more than 3 consecutive times should be thoroughly investigated. A cause can be identified in 50-60% of cases and measures can be taken to prevent subsequent losses.
-Patients should be reassured that conception can be achieved within one cycle after complete abortion. The chances of a live birth after 2 or more consecutive miscarriages is up to 50 – 70%
-A miscarriage can be physically and mentally traumatic. Women should be supported and reassured throughout this trying period.