abortion

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UNSAFE ABORTION AND THE CHALLENGES OF THE GYNAECOLOGIST

Before I go into the subject of what constitute an unsafe abortion, lets know what abortion itself is and if it is different from a miscarriage. Abortion is the termination or loss of pregnancy before the age of viability (the age at which the baby is capable of surviving outside the womb with or without life support) or the loss of an embryo or fetus that weigh less than 500g. The term abortion is often used interchangeably with miscarriage. However, women advocacy groups have faulted the use of both terms to mean the same. The term miscarriage is preferred as it is considered non-judgemental and not criminal as compared to the term abortion.  Abortion is now use to define induce abortion whether legal or criminal. While miscarriage is use to describe spontaneous termination of the pregnancy without any intervention.

Abortion is said to be unsafe when it is carried out by a person lacking the necessary skills, or in an environment lacking the minimum requirement to carry out the procedure. Abortion is legal when done within the confines of the law of the country, and criminal when done outside the stipulation of the law of the country. The law regulating abortion may vary between states in the same country; in Australia and the United States of America, abortion is legal in some states. Some countries have no restrictions like Canada and South Africa. Other countries like Nigeria and Egypt have the same restrictive laws in all states, only therapeutic abortion is allowed to save the mother.

THE CHALLENGES OF THE GYNAECOLOGIST IN A RESOURCE LIMITED SETTING

The annual unintended pregnancies globally were 121million between 2015 and 2019, which corresponds to 64 unintended pregnancies per 1000 women aged 15 to 49 years. 61% of unintended pregnancy ends in abortion, 73.3million abortions take place each year corresponding to 34 to 44 per 1000 women age 15-49years in the world [1]. 25million unsafe abortion occurred worldwide each year between 2010-2014 according to the World Health Organization (WHO). Abortion rates are higher in areas with unmet need for contraception. The WHO estimated that 47,000 women die from unsafe abortion each year.

The gynaecologists in resource poor settings face many challenges relating to abortion. Apart from the limited resources, another challenge is the restrictive abortion laws. A few patients have consulted me at the clinic because they want an abortion for reasons other than a threat to their lives by the pregnancy. The patients I have encountered were all married, they were at the right place but the law does not permit that. These patients do not have the opportunity to travel to other state as abortion laws in all the states in Nigeria are the same.

Whenever a woman walks out of my consulting room after a request for an abortion had been turned down, I get really worried. My fear is that she might not change her mind after counselling and might procure an abortion. I worry because it is likely to be an unsafe abortion because of the restrictive abortion laws. My experience with the outcome of patients at the emergency room with complications of unsafe abortion and low financial status is worrisome. They present late to us, often after 72hours and septic. While at surgery, their womb or womb with one or both ovaries will often appear gangrenous(decaying). Out of the four cases I have been directly involved in managing, only one of them survive. She went home after several weeks of battling infection and wound breakdown. She survived with only one ovary, the womb and the other ovary were gone.

The restrictive abortion laws never stop the abortions from happening, it only stopped many women from surviving to take care of their families. Most won’t make it because of their poor financial status. These I will say are avoidable deaths, they died from poor healthcare financing and the law.

REASONS FOR ABORTION

The reasons why women have abortion other than for therapeutic purpose include;

  • Unwanted pregnancy
  • Incest
  • Pregnancy from rape
  • Career decision
  • Pregnancy with malformed babies

COMPLICATION OF UNSAFE ABORTION

  • Injury to the genitals
  • Perforation of the womb
  • Injury to the intestines
  • Infertility
  • Infection
  • Kidney failure from the overwhelming infection or massive blood loss necessitating dialysis
  • Bleeding; necessitating blood transfusion and it attendant complications
  • Gangrene (decomposition) of the womb and ovaries
  • Premature menopause from the removal of the decaying ovaries
  • Death

PREVENTION OF UNSAFE ABORTION

In a country with restrictive abortion laws, prevention of unsafe abortion and it complication starts with prevention of unwanted pregnancies. Though abstinence is the best prevention strategy, it is the most likely strategy to fail in this age of increased sexual awareness. To prevent unwanted pregnancies, women of reproductive age (15 to 49years) need to be enlightened on contraception. Though one can argue that even the most effective contraception does not provide hundred percent pregnancy prevention cover. So, what happen in that situation? I will say relax the restrictive laws. Improve health financing by government at all levels will go a long way. Making contraception available, accessible and affordable to women of reproductive age should be a must.

In my opinion, which is based on my experience in the field, relaxing the restrictive laws will save more women. They will have the opportunity to seek atonement for those who belief in the existence of God, many never had the chance, their deaths were avoidable.

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MISCARRIAGE

The terms miscarriage and abortion are often used interchangeably but what is the most appropriate term for a spontaneous pregnancy loss? If your answer is miscarriage, then you are right. The term miscarriage is considered to be non judgemental while the term abortion is often associated with criminal abortion. Spontaneous miscarriage is a considerable cause of emotional and psychological trauma for patients including symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD) that can last for months. It is defined as the spontaneous loss of a pregnancy prior to viability.

The incidence of early pregnancy loss is as high as 3 in 10 chemical pregnancies (urine or blood test confirmed pregnancies), though the incidence decreases to approximately 1 in 10 pregnancies when considering only losses occurring in clinically recognized pregnancies (ultrasound scan confirmed pregnancies).

TYPES OF MISCARRIAGE

Incomplete miscarriage is a pregnancy that is associated with vaginal bleeding, opening of the cervix or mouth of the womb, and passage of product of conception. Usually, the cramps are intense, and the vaginal bleeding is heavy. Patients may describe passage of tissue, or the examiner may observe evidence of tissue passage within the vagina. Ultrasound will show that some of the product of conception are still present in the womb.

Complete miscarriage; there is complete passage of the product of conception, the pain resolves, bleeding reduce, the cervix is closed and scan demonstrate empty womb.

Threatened miscarriage; usually mild bleeding from the womb with mild pain, the cervix is closed with scan demonstrating a viable pregnancy.

Inevitable miscarriage; there is bleeding and pain, the cervix is open with no tissue passed, scan may show a viable or non-viable pregnancy

Missed miscarriage; this is a non-viable pregnancy that is retained in the womb. It might be an incidental finding on scan or the patient might notice her pregnancy is not growing well.

Septic miscarriage; constitutes any of the above miscarriages with infection.

CAUSES OF MISCARRIAGE

Causes of miscarriage includes;

  • Chromosomal abnormalities
  • Maternal disease; antiphospholipid syndrome, polycystic ovarian disease, obesity, diabetes, thyroid disease
  • Medication and substance use; methotrexate, some antiepileptic drugs, cocaine, smoking, caffeine, alcohol
  • Abnormalities of the womb; cervical incompetence (inability of the cervix to retain the fetus due to some defect resulting in a painless cervical opening and subsequent pregnancy loss), fibroid
  • Infection; varicella, rubella, parvovirus B19, Syphilis, cytomegalovirus
  • Environmental factors and exposure; ionizing radiation, Lead, arsenic
  • Placenta causes; Abruptio placenta, placenta previa
  • Maternal stress
  • Advanced maternal age > 35years and advanced paternal age
  • The cause of miscarriage could be unexplained in about 4 to 6 in 10 cases.

SYMPTOMS AND SIGNS OF MISCARRIAGE

Bleeding and lower abdominal cramping are the most common presenting complaints of pregnancy loss. Others are fever, foul-smelly vaginal discharge in cases of septic miscarriage. If ultrasound is available, serum human chorionic gonadotrophin and progesterone have limited utility in the diagnostic evaluation of pregnant women with early pregnancy loss.

COMPLICATIONS OF MISCARRIAGE

The most common complications associated with pregnancy loss are retained product, bleeding and infection. Others are renal failure, pelvic abscess, uterine or gut perforation from surgical treatment and death. These complications can be prevented when help is sort on time and in a health facility with the requisite man power to manage miscarriage.

TREATMENT OF MISCARRIAGE

The treatment of miscarriage depends on the type of miscarriage but also include post abortal care for all types. For complete miscarriage treatment constitute what is known as the post abortal care; treating anaemia or any complications if present, providing contraceptive counselling and services when needed and other reproductive services like pap smear or screening for sexually transmitted diseases.

If a diagnosis of missed or incomplete miscarriage is made, the options of management include surgical, medical or expectant management. Surgery was the standard of care in the past because of the concern of retained product associated with medical and expectant management. For missed, incomplete, or inevitable abortion presenting before 13 weeks’ gestation, treatment may include misoprostol as an alternative to surgery or performing suction dilation and curettage.

Surgical management is achieved using electric or manual vacuum aspiration trans-vaginally through an appropriately dilated cervix at a gestational age <15 weeks. Surgical treatment will shorten treatment duration, associated with less pain and blood loss. However, in less experience hand, surgical treatment might result in perforation of the womb or adhesion formation in the womb due to excessive curettage of the womb. Unless a patient present with incomplete or inevitable miscarriage, pre-operative cervical softening and dilatation is common prior to surgical evacuation.

Medical treatment eliminate the risk associated with surgical treatmen.t However, it is associated with prolonged duration of treatment, increase pain and blood loss with subsequent blood transfusion and it attendant risk. Patient with recurrent miscarriage (≥ 2 consecutive pregnancy losses) requires proper evaluation to identify the possible cause before another attempt at conception should be made. Miscarriage due to cervical incompetence will require insertion of a cervical cerclage to help retain the pregnancy.

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