Inevitable Abortion

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Introduction

Abortion is when a pregnancy is ended so that it doesn’t result in the birth of a child. It is also called termination of pregnancy.

We have different types of abortion which include complete abortion, septic abortion, safe abortion, missed abortion, inevitable abortion, incomplete abortion, threatened abortion etc.

Symptoms of an inevitable abortion

  1. Lower abdominal pain
  2. Heavy vaginal bleeding
  3. No foetus or products of conception passed per vagina
  4. Painless loss of liquor per vaginam

Signs of an inevitable abortion

Signs of an inevitable abortion include the following

  1. The cervix is dilated with the membranes bulging
  2. There may be loss of liquor
  3. The uterine size is compatible with the gestational age
  4. There may be signs of shock pallor, collapsed peripheral vessels, rising pulse with reducing volume, falling BP and cold clammy skin

Investigations

  • FBC and sickling
  • Blood grouping and cross matching
  • Ultrasound scan (shows the foetus dead or alive)
  • Cervix may be dilated with membranes bulging through it
  • In instances associated with loss of liquor, there may be oligohydraminios
  • Ultrasound is necessary only if the diagnosis is in doubt

Treatment for an inevitable abortion

Treatment objectives

The treatment objectives of an inevitable abortion include the following:

  1. To resuscitate patient and/or prevent shock
  2. To relieve pain
  3. To allow the patient to abort (assist uterine contractions if weak)
  4. To evacuate the retained products of conception from the uterus
  5. To determine cause of abortion if recurrent
  6. To prevent infection with antibiotic prophylaxis
  7. To prevent risk of Rhesus incompatibility in future pregnancies

Non-pharmacological treatment

Evacuation of the uterus is done by either of the following techniques after the expulsion of the foetus or before the expulsion of the foetus if it is less than 12-14 weeks size

  • Manual Vacuum Aspiration (MVA) with or without paracervical block anaesthesia

 Or

  • Uterine curettage under paracervical block or general anaesthesia (Gestations 12 weeks or less
  • Uterine evacuation under anaesthesia especially when the uterine size is larger than 12 weeks size

Pharmacological treatment

A. If patient is in shock or bleeding is severe

  • IV fluids and blood transfusion as necessary

B. To relieve severe pain

Evidence Rating: [C]

Morphine, IV,

  • 2.5-5 mg 4 hourly as required

And

Metoclopramide, IV,

  • 5-10 mg 8 hourly as required for vomiting

Or

Pethidine, IM,

  • 75-100 mg stat. then 50-100 mg 6-8 hourly if required

And

Promethazine, IV/IM,

  • 25 mg as required (max. 25 mg 6 hourly) as required to reduce the chances of vomiting and to potentiate the analgesic effect of Pethidine

C. Evacuate uterus

If uterine size > 12-14 weeks

Evidence Rating: [A]

Oxytocin, IV,
10-20 units per litre of Normal saline

 Or

Uterine size <12 weeks

Evidence Rating: [C]

Misoprostol, oral/SL,

  • 600 microgram stat.

D. To Prevent Infection

Amoxicillin, oral,

  • 500 mg 8 hourly for 5-7days

And

Metronidazole, oral,

  • 400 mg 8 hourly for 5-7days

E. To prevent Rhesus Isommunization in Rhesus negative women

Evidence Rating: [A]

Anti D Rh Immune Globulin, IM,

  • 300 microgram (1,500 Units), stat. within 72 hours of abortion

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