Abortion -Spontaneous, Induced, Abortion Laws and Post Abortion care

The incidence of Spontaneous miscarriage is approximately 15–20% of all pregnancies, when hospital records are considered.

The actual figure, from community- based assessment, may be up to 30%, as many cases remain unreported to the hospital.

The effect of a diagnosis of a miscarriage on the patient should not be underestimated.

The RCOG therefore recommends that ‘Early intrauterine death should be regarded as of equal importance to fetal death occurring at a later stage.’

The emergence of the Early Pregnancy Unit (EPU) in many hospitals has addressed the need for a dedicated clinical area for the diagnosis of miscarriage and patient support at a distressing time.

The same EPU caters for between 1 and 2% of fertile women who will experience recurring miscarriage (RM).

Definition of spontaneous Miscarriage:

The definition remains the loss/termination of a pregnancy before the age of viability which remains 28 weeks in this environment but 24 in the United Kingdom and perhaps 20 weeks in United State of America.

Other Terms:

Spontaneous abortion = Spontaneous miscarriage.

Early pregnancy loss = Pregnancy loss of <12 weeks gestation.

Recurrent abortion/ Habitual abortion = Recurrent miscarriage consisting of three early consecutive losses or two late pregnancy losses.

Medical abortion = Termination of pregnancy

Menstrual abortion/Preclinical abortion = Biochemical pregnancy loss

Early embryonic demise/Anembryonic pregnancy/Empty sac = Missed abortion Delayed pregnancy loss

Embryonic death = Fetal loss

Late abortion = Late pregnancy loss between 12- and 28-weeks’ gestation

Spontaneous Miscarriages – abortion process occurring rather naturally either due to maternal or fetal complications.

Threatened Miscarriages – the abortion process has started, but still with the chance of it resolving and the pregnancy continuing. This presents as vaginal bleeding in a pregnancy less than 28 weeks gestation without cervical dilatation.

Induced Miscarriages – the process initiated deliberately.

Inevitable Miscarriages – a pregnancy that is destined to be lost, but not yet lost. It is complicated by both vaginal bleeding and cramp-like lower abdominal pain. The cervix is frequently partially dilated, attesting to the inevitability of the process.

Incomplete Miscarriages – some parts of the product of conception has been lost or rather expelled from the womb, while some product of conception remains in the Uterus.

Missed Miscarriages – here the conceptus dies but is not yet expelled from the Uterus.

Septic Miscarriages – situation where there is primary or secondary infection of the genital tract as a result of the infection of the conceptus (products of conception).

Recurrent Miscarriages - consisting of three early consecutive losses or two late pregnancy losses.

Unsafe Miscarriages – usually induced and performed by quacks in unhygienic environment.

Most miscarriages happen when the unborn baby has fatal genetic problems. Usually, these problems are unrelated to the mother.

Other causes of miscarriage include:

• Infection
• Medical conditions in the mother, A woman has a higher risk of miscarriage if she:
• Is over age 35
• Has certain diseases, such as diabetes or thyroid problems
• Has had three or more miscarriages
• Hormone problems
• Immune system responses
• Physical problems in the mother
• Uterine abnormalities

Symptoms

• Bleeding which progresses from light to heavy
• Severe cramps
• Abdominal pain
• Weakness
• Worsening or severe back pain
• Fever with any of the symptoms listed above

Diagnosis

Clinically by performing a pelvic examination plus or minus an ultrasound test and blood work to confirm using the serum HCG or the urine HCG.

If the miscarriage is complete and the uterus is empty, then no further treatment is usually required.

Occasionally, the uterus is not completely emptied, so the remaining fetal or placental tissue is gently removed from the uterus. Occasionally there is the need to dilate the cervix and curette the Uterus.

As an alternative to a D&C, certain medications can be given to cause the Uterus to expel its contents. This option may be more ideal in women who want to avoid surgery and whose condition is otherwise stable.

If the blood type of the patient is Rh negative, Rh immune globulin (Rhogam) may be given.

Antibiotics may be necessary if there is evidence of infection, same for blood transfusion and general resuscitation in severe septic abortion cases.

Counselling against unwanted pregnancy and the use of contraception are equally important for unmarried Patients.

Pre-pregnancy screening is necessary if cause of miscarriage was found to be genetic in nature.

Expectant management is indicated in cases where there is still embryo viability (threatened miscarriages) with monitoring of HCG, USS for viability, and use of progesterone drugs, uterine relaxants and treatment of other medical conditions in the mother. If the miscarriage process progresses, then one of the treatment options are then instituted.

Medical Drugs in brief

Mifepristone blocks the progesterone receptors, reversing the influence of progesterone during pregnancy. As a result, there is an influx of leukocyte and red cells into the decidua followed by the release of prostaglandins and cytokines.

Addition of a synthetic prostaglandin E1 analogue results in powerful contractions, which supplement those induced by the withdrawal of progesterone. This process closely mimics events in a spontaneous miscarriage.

The two commonly used prostaglandin analogues are gemeprost and misoprostol. As misoprostol is cheaper, does not require refrigeration and can be given in different dosages by different routes, it is the most commonly used in recent published studies. Research seems to indicate that although oral or sublingual misoprostol is effective, the vaginal route of administration appears to give maximum efficacy with least side effects.

Mifepristone may be used to induce cervical change and is usually given orally, followed 36–48h later by one of the prostaglandin analogues. Mifepristone has been given in doses ranging from 200 mg to 600 mg.

The definition of unsafe abortion/miscarriage has already been given.

Maternal mortality due to abortion complications used to be among the three leading causes of maternal death in our UITH.

In countries with restrictive abortion laws, it has been reported that one in four pregnancies are unintended; some countries have an unmet need as high as 51% leading to unintended pregnancy which is a major risk for unsafe induced abortion.

In such countries unsafe induced abortion is under-estimated as only 4% of women of reproductive age reported the incident, because of criminalization and social stigma.

Complications of unsafe abortion include hemorrhagic shock and end organ damage, severe anaemia, septic abortion, septic shock, uterine perforation, peritonitis, pelvic abscess.

A miscarriage sometimes happens because there is a weakness of the sphincter of the cervix, called a cervical insufficiency/incompetency, which means the cervix cannot hold the pregnancy.

The cause is usually forceful dilatation of the cervix, sometimes cervical conisation, and congenital cause among others.

An untreated cervical incompetence is also a cause of recurrent abortions.

A miscarriage from a cervical insufficiency usually occurs in the second trimester.

There are usually few symptoms before a miscarriage caused by cervical insufficiency.

A woman may feel sudden pressure, her bulging amniotic membrane in the cervical canal may break, and tissue from the fetus and placenta may be expelled without much pain.

An insufficient cervix can usually be treated with a cerclage stitch in the cervix in the next pregnancy, usually around 12 weeks to 14 weeks.

The stitch holds the cervix closed until it is pulled out around the time of delivery, usually at 38 weeks. The stitch may also be placed even if there has not been a previous miscarriage if cervical insufficiency is discovered early enough, before a miscarriage does occur.

Abortion laws fall into one of four categories. Illegal, very restrictive, conditional and liberal.

Illegal – prohibited without exceptions.

Very restrictive – Permitted only to save the life of the pregnant woman.

Conditional – Permitted on several grounds to preserve the health of the woman i.e. in rape, impaired fetus. Some people use physical health while others use psychological health. In countries where this exists, there is usually the required consent of two physicians, or an abortion board is required.

Liberal – There are 2 categories:

1. On request with no restrictions.
2. For social reasons.

The 2 terms Liberal and legal are sometimes used interchangeably.

The Nigerian abortion law situation

The abortion law in the southern part of Nigeria is different from that for the northern part.

Northern – uses the penal code, which is very restrictive, only to save the mother’s life.

Southern – uses the criminal code which is directed at preserving the health of the mother. This is very similar to 1967 abortion law of the United Kingdom, which is still in operation there.

However, the socio-cultural cum political setting in the entire Nigeria has created gaps between the law and its application such that, most people, including Doctors tend to think that the southern part also has a restrictive law in place. The resultant effect is that all abortions for social reasons are also clandestinely done in both regions.

Manual uterine aspiration, a proven effective, expeditious, and simple technique for uterine evacuation, is a procedure that is routinely taught to obstetrics and gynecology residents and midlevel providers. It is commonly performed in non-operative settings.

Expeditious treatment of uterine hemorrhage from early pregnancy loss in the ED may ultimately decrease complications for patients, such as blood transfusions, disseminated intravascular coagulation, endometritis, or other complications of delayed treatment. The electric vacuum aspiration is usually left for the treatment of molar pregnancy nowadays.

Indication for MVA

Manual uterine aspiration is appropriate for treatment of early pregnancy loss or retained products of conception measuring up to 12 weeks gestational age.

Although expectant management and medical management with misoprostol have shown to be acceptable alternatives to vacuum aspiration for treatment of routine miscarriage, cases with brisk uterine hemorrhage may necessitate prompt aspiration to obtain hemodynamic stability of the mother.

The American College of Obstetricians and Gynaecologists recommend that women presenting with retained products of conception and hemorrhage or hemodynamic instability be treated with prompt surgical evacuation.

Procedural steps for MVA

1. Obtain informed consent from patient or proxy medical decision maker for intracervical or paracervical block, as well as the manual uterine aspiration procedure.
2. Perform bedside ultrasonography to evaluate intrauterine contents, gestational age of foetus if foetal pole observed, and presence of extrauterine pregnancy or free fluid from possible ruptured ectopic pregnancy. Manual uterine aspiration can be used for foetal pole or mean gestational sac diameter measuring 12 weeks’ gestation or less.
3. For afebrile patients, administer prophylactic antibiotics (azithromycin 500 to 1,000 mg orally once or doxycycline 200 mg orally once are reasonable regimens). For febrile patients or patients for whom endometritis is suspected, initiate empiric antibiotics to cover for Gram-positive, Gram-negative, and anaerobic organisms.
4. Misoprostol 400 to 800 μg orally or vaginally may also be necessary at the clinician’s discretion for cervical softening for functionally nulliparous patients (ie, no history of vaginal birth).
5. Place speculum (see picture of speculum in the attached picture slides).
6. Clean cervix with povidone-iodine.
7. Local cervical anaesthesia (choice of either intracervical or paracervical block):
1. Perform intracervical block using 20 mL of 1% lidocaine with epinephrine or 1% chloroprocaine. Using a 20-gauge spinal needle, inject 2 mL into the cervical stroma at 12 o’clock and then place a single-tooth tenaculum. Inject equal amounts of the remaining anaesthetic approximately 1 to 1.5 inches deep into the cervical stroma at 4 o’clock and 8 o’clock.
2. Perform paracervical block using 20 mL of 1% lidocaine with epinephrine or 1% chloroprocaine. Using a 22-gauge spinal needle, inject 2 mL into the cervical tissue at 12 o’clock and then place a single-tooth tenaculum. Inject equal amounts of the remaining anaesthetic approximately 0.5 inches into the cervicovaginal junction at 4 o’clock and 8 o’clock.
8. Oral or intravenous nonsteroidal anti-inflammatory drugs with or without benzodiazepines or opioids are commonly used for analgesia and anxiolysis. Procedural sedation can be used at provider’s discretion but is often unnecessary for outpatient procedures.
9. Many patients with incomplete or inevitable miscarriage will present with some degree of cervical dilation. Choose size of flexible cannula according to gestational age (i.e., cannula size in millimetres equal to the number of weeks gestational age of the foetus is appropriate, although for patient comfort you can first attempt to use a cannula 1 to 2 sizes down). If the cervix needs dilation, use graduated cervical dilators to dilate up to gestational size in millimetres. For example, for a pregnancy whose size correlates with 8 weeks gestational age, start with a cannula size 6 or 7 and dilate up to size 8, and use the size 8 cannula for the aspiration procedure.
10. Place gentle traction on tenaculum to straighten the cervix before dilation or cannula insertion, decreasing risk of uterine perforation.
11. Ensuring that the cannula remains sterile prior to touching the cervix, insert the cannula and advance it to the uterine fundus. Engage the vacuum by pulling out the plunger, attach the pre-set aspirator to the cannula, release the vacuum seal, and rotate the cannula several times at the fundus. Systematically move the cannula in and out, rotating 360 degrees. Aspiration should be complete when the uterine cavity feels uniformly “gritty” or mildly rough. One to 2 additional passes may be needed.
12. Send products of conception to pathology to confirm a failed intrauterine pregnancy, which in turn assists in excluding the diagnosis of ectopic pregnancy. This step can also exclude the possibility of molar pregnancy.
13. An option is to use real-time transabdominal ultrasonographic guidance to visualize the cannula entering the uterus and to guide the provider with respect to anatomy and confirm that the uterus is not being perforated. Post-procedural ultrasonography can confirm an empty uterus and successful procedure.
14. Administer Rh immunoglobulin if the patient is Rh negative.
15. Arrange to obtain a follow-up repeated β–human chorionic gonadotropin level if the patient never had ultrasonography confirming an intrauterine pregnancy.
16. Admit the patient to the hospital if her bleeding continues, endometritis is suspected, or she is otherwise unstable.
17. Depending on the analgesia or sedation used, observe the patient for at least 30 minutes after the procedure to ensure bleeding has stopped and haemostasis has been achieved before discharging her.

Complications

Manual uterine aspiration complications range from 0% to 1.0%.

The most common complication is uterine perforation. Other complications are anemia, pelvic pain, or endometritis on presentation. Asherman’s syndrome, or intrauterine scarring, is a rare complication of manual uterine aspiration and is more common with repeated procedures.

Conclusion

Manual uterine aspiration safety and time profiles are facilitated by lack of need for procedural sedation or general anaesthesia; manual uterine aspiration is commonly performed with a paracervical block only, using local injection of lidocaine, or in combination with systemic oral or intravenous analgesics or anxiolytics, which is a proven acceptable alternative analgesic for patients undergoing outpatient procedures.