UNSAFE ABORTION Dr NooshinEshraghi perinatologist Safe abortion WHO
UNSAFE ABORTION Dr. Nooshin-Eshraghi perinatologist
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
unsafe abortion �performed by people lacking the necessary skills �using hazardous technique �in an environment that does not meet minimum medical standards.
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
�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
�Oral and injectable : �metal salts, phosphorus, lead, kerosene, turpentine, detergent solutions �uterinestimulants(misoprostol or oxytocin)
� Preparations placed in the cervix, vagina, or rectum include: � potassium permanganate tablets, herbal, misoprostol, enemas.
�Instrumentation : �catheter insertion followed by infusion of alcohol, saline…. . � insertion of foreign bodies such as coat hanger, knitting needle, stick crochet hook.
�Trauma to the abdomen : �self-inflicted blows � abdominal massage � jumping from a height � lifting heavy weights.
Misoprostol �in successful abortion �causes uterine bleeding by initiating the abortion process without the risks of instrumentation
� side effects: �high fever, shaking chills, abdominal cramping, vomiting, diarrhea, tremor, agitation, confusion, rhabdomyolysis, hypoxemia, and hypotension.
� toxicity have been reported � Mild to moderate toxicity symptoms have been reported with doses of 3 mg to 8. 5 mg
�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
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
�●Use of toxic substances �●Poor maternal health �●Increasing gestational age �●Lack of access to postabortion care
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
Hemorrhage �Hemorrhage is the most common complication of unsafe abortion, and may result in hypovolemic shock, coagulopathy, and death
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
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
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.
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
�. 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. 2 mgintramuscularly) � placement of a vaginal/intrauterine pack an intrauterine balloon
�Signs of potential surgical emergency include: �●Heavy bleeding �●Abdominal pain �●Shock
�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.
�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
�septic abortion : � fever, chills, malaise, abdominal pain, vaginal bleeding, anddischarge �Physical examination : tachycardia, tachypnea, lower abdominal tenderness, tender uterus with dilated cervix.
�Infection : �Staphylococcus aureus, Gram negative bacilli, or some Gram positive cocci. Mixed infections, anaerobic organisms
�Antibiotic therapy and evacuation of the uterus are the mainstays of management.
�The route of antibiotic, depends on degree of infection. Postabortal infections are typically polymicrobial and thus a broad-spectrum antibiotic is needed
�oral regimen : �the patient is clinically stable, not immunocompromised, does not have signs of a pelvic abscess
�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
�DIC: is a rare but life-threatening complication of abortion. � It is associated with, excessive blood loss, and amniotic fluid embolism.
�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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