Unsafe Abortion Post Abortion Care and Ectopic Pregnancy

Definition of Unsafe Abortion • A procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards - or both.

Magnitude of the problem • 25% of all pregnancies worldwide end in an induced abortion, approximately 50 million each year. • Of these abortions 20 million are performed unsafely. • In Africa unsafe illegal abortions are 700 times more likely to lead to death than safe legal abortions in developed countries • Unsafe abortions are responsible for 65. 000 maternal deaths each year (13%) • Due to religious, cultural and political barriers, abortion remain illegal in many developing countries

Unsafe Abortion Typical complications from unsafe abortions (840 cases from Ibadan, Nigeria, 1989): Sepsis 86% Hemorrhage 35% Uterine perforations 16% Genital tract injury 10% Renal failure 0. 4% Coma 0. 4% Embolism 0. 2% 59 (7%) died because of complications

Unsafe Abortion Long-term consequences: • Pelvic inflammatory disease • Tubal occlusion • Ectopic pregnancy • Infertility • Chronic pelvic plain

Abortion Laws Denmark Every woman aged 18 and over has a right to pregnancy interruption in a public hospital at no cost to her without stating any reasons, providing she is resident in Denmark and the interruption is performed before the end of the 12 th week of gestation.

Abortion Laws Tanzania When Tanzania gained independence in 1961 it inherited a law based on the British legislation of 1861. Illegal abortion carries a sentence up to 14 years for the abortionist, seven years for the woman herself and three years for any person supplying drugs or instruments. Although the law is very strict, prosecutions are rare

Effects of the introduction in Romania in November 1966 of an anti abortion law, and legalization of abortion in December 1989

• In Tanzania it is estimated that more than half of the patients admitted at gynecolological ward attend because of complications to unsafe abortion. Therefore. . . • All women in reproductive age (14 -50 y) attending a health facility should have a pregnancy urine dipstick performed on admittance!! • If the pregnancy test is positive: vital signs, abdominal and vaginal examinations are the absolute minimum examinations on admittance. • If signs of infection, excessive bleeding or in a critical condition: MVA or D&C should be carried out immediately!!

Post Abortion Care 1. Emergency treatment 2. Contraceptive counseling, STI and HIV evaluation and treatment. 3. Community involvement

Emergency Treatment • At sepsis or significant bleeding surgical abortion must be performed immediately! • Surgical abortion is part of basic emergency obstetric care and should be available at all health facilities • At sepsis antibiotics should be started during or after surgery: ampicillin is only in therapeutic levels for 15 -30 minutes and does not penetrate to the infected, dead pregnancy product.

Post Abortion Care Surgical abortion Vacuum Aspiration: The cervix is dilated with a series of instruments. A tube is inserted into the uterus and connected to a strong vacuum. The embryo is removed by suction. Dilatation and Curettage (D & C): The cervix is dilated. An instrument with a blunt loop at the end is inserted into the uterus. The inside wall of the uterus is scraped. Can be done in local analgesia only

Manual Vacuum Aspiration

Ectopic Pregnancy Occurs in more than 1 in 100 pregancies Risk Factors: • Prior tubal infection • Prior Ectopic Pregnancy • Contraceptive intrauterine device

Ectopic Pregnancy

Ectopic Pregnancy - Treatment • Expectant: 50% will end in tubal abortion. Can be considered if no clinical symptoms. • Medical treatment: Metotrexate (cytostatic) or Mifegyne (ant-progesterone). Can be considered if only minor clinical symptoms and S-h. CG < 2000 • Surgical treatment: symptomatic extrauterine pregnancy. In developing countries women diagnosed with ectopic pregnancies will have symptoms and will need surgery.