Miscarriage 2016 hashem

Hashem Yaseen MD 4th year OG resident

Before we start??Bleeding in early Bleeding in early

pregnancy may pregnancy may be associated be associated with:with:

1.1. MiscarriageMiscarriage2.2. Ectopic pregnancyEctopic pregnancy3.3. Gestational Gestational

trophoblastic disease trophoblastic disease 4.4. Rarely gynecological Rarely gynecological

lower tract pathology lower tract pathology ((e.g. chlamydia, cervical e.g. chlamydia, cervical cancer. Or a polyp)cancer. Or a polyp)


The TerminologyThe Terminology1- Termination

1- Termination of pregnancy, of pregnancy, either either spontaneously spontaneously or intentionally or intentionally = = AbortionAbortion2- Abortion 2- Abortion occurring occurring without medical without medical or mechanical or mechanical means to empty means to empty the uterus is the uterus is referred to as referred to as spontaneousspontaneousAnother widely Another widely used term is used term is miscarriagemiscarriage

- - The medical or The medical or surgical termination

surgical termination of pregnancy before of pregnancy before the time of fetal the time of fetal viability = viability = Induced Induced abortion “TOP”abortion “TOP”Pregnancy termination Pregnancy termination prior to 20 weeks’ prior to 20 weeks’ gestation or less than gestation or less than 500-g birthweight500-g birthweight Therapeutic abortionTherapeutic abortionTermination of Termination of pregnancy before of pregnancy before of fetal viability for the fetal viability for the purpose of saving purpose of saving the life of the motherthe life of the mother

Before we start??


Abortion


OutlinesOutlines

Spontaneous abortionSpontaneous abortion Induced abortionInduced abortion Postabortion carePostabortion care

Rhesus prophylaxis

Information after the abortionpatient's FAQspatient's FAQs

Follow-up after the abortion

Contraception after the abortion

Jordanian Lowاألردنية التشريعات في األردنية اإلجهاض التشريعات في PathologyPathologyاإلجهاض

EtiologyEtiology

Risk Factors (maternal , paternalFactors (maternal , paternal , ,and fetaland fetal))

CategoriesCategories

Medical management

Spotlight on mifepristone

Medical inductionMedical induction

Surgical techniquesSurgical techniques

Spotlight on management of late IUFD


HemorrhageHemorrhage into the decidua basinalis, followed by into the decidua basinalis, followed by necrosisnecrosis of tissues of tissues adjacent to the bleedingadjacent to the bleedingIf early, the ovum detaches, stimulating uterine contractions that result in If early, the ovum detaches, stimulating uterine contractions that result in its ovulationits ovulationGestational sac is opened , fluid surrounding a small macerated fetus or Gestational sac is opened , fluid surrounding a small macerated fetus or alternatively no fetus is visible → alternatively no fetus is visible → blighted ovumblighted ovumIn In laterlater abortion, the retained fetus may undergo abortion, the retained fetus may undergo macerationmaceration The skull bones collapse, the abdomen distends with blood-stained fluid, The skull bones collapse, the abdomen distends with blood-stained fluid, and the internal organs degenerateand the internal organs degenerateThe skin softens and peels off in utero or at the slightest toughThe skin softens and peels off in utero or at the slightest toughWhen amnionic fluid is absorbed, the fetus may become When amnionic fluid is absorbed, the fetus may become compressedcompressed and desiccated → fetal and desiccated → fetal compressuscompressusThe fetus become so The fetus become so drydry and compressed that it resembles and compressed that it resembles parchment - a fetus parchment - a fetus papyraceouspapyraceous

PathologyPathology


Abortion


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Rhesus prophylaxis





EtiologyEtiology

Risk Factors (maternal , paternalFactors (maternal , paternal , ,and fetaland fetal))


Medical management






EtiologyEtiology More than 80 percent of More than 80 percent of abortions occur in the first abortions occur in the first 12 weeks of pregnancy12 weeks of pregnancy

At least half result from At least half result from chromosomal anomalieschromosomal anomalies

After the first trimester, After the first trimester, both the abortion rate & the both the abortion rate & the incidence of chromosomal incidence of chromosomal anomalies decreaseanomalies decrease


The risk of spontaneous The risk of spontaneous abortion increases with abortion increases with parity as well as with parity as well as with maternal and paternal agematernal and paternal age

The frequency of abortion The frequency of abortion increases from 12 percent in increases from 12 percent in women younger than 20 women younger than 20 years to 26 percent in those years to 26 percent in those older than 40 yearsolder than 40 years

If a woman conceives within If a woman conceives within 3 months following a term 3 months following a term birthbirth → → incidence of abortion ↑

incidence of abortion ↑

EtiologyEtiology


Abortion


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Rhesus prophylaxis





EtiologyEtiology

Risk Factors (maternal , paternalRisk Factors (maternal , paternal , ,and fetaland fetal))


Medical management






EtiologyEtiology

• Abnormal zygotic development

– Early spontaneous abortion commonly display a developmental abnormality of the zygote, embryo, early fetus, or placenta

– 1000 spontaneous abortions analyzed by Hertig and Sheldon

•Half demonstrated degenerated or absent embryos, that is, blighted ova

The exact mechanism responsible for abortion are not apparent

In the first 3 months of pregnancy

* Death of the embryo or fetus nearly always precedes spontaneous expulsion of the ovum

* Finding of the cause of early abortion involves ascertaining the cause of fetal death

In subsequent months * The fetus frequently

does not die before expulsion

Other explanations for its expulsion should be sought

• Aneuploid abortion

Approximately 50 to 60 percent of embryos and early fetuses that are spontaneously aborted contain chromosomal abnormalities accounting for most of early pregnancy wastage

Jacobs and Hassold (1980)

95 percent of chromosomal abnormalities d/t maternal gametogenesis error, 5 percent → d/t paternal error


Aneuploid abortion - Autosomal trisomyThe most frequently identified The most frequently identified

chromosomal anomaly associated chromosomal anomaly associated with first-trimester abortionswith first-trimester abortions

Most trisomies result from Most trisomies result from isolated isolated nondisjunctionnondisjunction , , balanced balanced structural chromosomal structural chromosomal rearrangements are present in one rearrangements are present in one partner in 2 to 4 percent of couples partner in 2 to 4 percent of couples with a history of recurrent with a history of recurrent abortionsabortions

Autosomes 13, 16, 18, 21, and 22 Autosomes 13, 16, 18, 21, and 22 – most common– most common


Monosomy XThe second frequent chromosomal abnormalityUsually results in abortionMuch less frequently in liveborn female infant (Turner syndrome)

TriploidyAssociated with hydropic placental (molar) degenerationIncomplete (partial) hydatidiform moles may contain triploidy or

trisomy for only chromosome 16Tetraploid abortuses

Rarely are liveborn and most often are aborted early in gestation

Chromosomal structural abnormalitiesIdentified only since the development of banding techniques, infrequently cause abortion

Euploid abortion

Abort later in gestational than aneuploid Three fourths of aneuploid abortions occurred before8 weeksEuploid abortions peak at about 13 weeksThe incidence of euploid abortions increased dramatically after maternal age exceeded 35 years


Etiology – maternal Etiology – maternal factorsfactors

InfectionsInfections Uncommon causes of abortion in humanUncommon causes of abortion in human

Listeria monocytogenes Listeria monocytogenes Clamydia trachomatisClamydia trachomatisMycoplasma hominis Mycoplasma hominis Ureaplasma urealyticumUreaplasma urealyticumToxoplasma gondiiToxoplasma gondii

Chronic debilitating diseasesChronic debilitating diseasesIn early pregnancy, fetuses seldom In early pregnancy, fetuses seldom

abort secondary to chronic wasting abort secondary to chronic wasting disease such as tuberculosis or disease such as tuberculosis or carcinomatosiscarcinomatosis

Celiac sprue Celiac sprue Cause both male and female infertility Cause both male and female infertility

and recurrent abortionsand recurrent abortions

Endocrine abnormalitiesEndocrine abnormalities

Hypothyroidism Hypothyroidism Iodine deficiency associated with excessive miscarriagesIodine deficiency associated with excessive miscarriagesThyroid autoantibodies → incidence of abortion↑Thyroid autoantibodies → incidence of abortion↑

Diabetes mellitusDiabetes mellitusThe rates of spontaneous abortion & major congenital The rates of spontaneous abortion & major congenital

malformationsmalformationsPoor glucose control → incidence of abortion↑Poor glucose control → incidence of abortion↑

Progesterone deficiencyProgesterone deficiencyLuteal phase defectLuteal phase defectInsufficient progesterone secretion by the corpus luteum or Insufficient progesterone secretion by the corpus luteum or

placentaplacentaPoor glucose control → incidence of abortion↑Poor glucose control → incidence of abortion↑

NutritionNutritionDietary deficiency of any one nutrients → Dietary deficiency of any one nutrients →

not important causenot important cause

Drug use and environmental factorDrug use and environmental factorTobaccoTobacco

↑ ↑ Risk for euploid abortionRisk for euploid abortion More than 14 cigarettes a day → the risk More than 14 cigarettes a day → the risk

twofold greater ↑twofold greater ↑AlcoholAlcohol

Spontaneous abortion & fetal anomalies Spontaneous abortion & fetal anomalies → result from frequent alcohol use → result from frequent alcohol use during the first 8 weeks of pregnancyduring the first 8 weeks of pregnancy

Drinking twice a week → abortion rates Drinking twice a week → abortion rates doubled ↑doubled ↑

Drinking daily → abortion rates tripled ↑Drinking daily → abortion rates tripled ↑CaffeineCaffeine

At least 5 cups of coffee per day → slightly At least 5 cups of coffee per day → slightly increased risk of abortion increased risk of abortion


Etiology – maternal Etiology – maternal factorsfactorsDrug use and environmental factorDrug use and environmental factor

RadiationRadiationIn sufficient doses → In sufficient doses →

abortifacientabortifacient

ContraceptivesContraceptivesWhen intrauterine devices fail When intrauterine devices fail

to prevent pregnancy → to prevent pregnancy → abortion↑abortion↑

Environmental toxinsEnvironmental toxinsAnesthetic gases : exact fetal Anesthetic gases : exact fetal

risk of chronic maternal risk of chronic maternal exposure is unknownexposure is unknown

Arsenic, lead, formaldehyde, Arsenic, lead, formaldehyde, benzene, ethylene oxide → benzene, ethylene oxide → abortifacientabortifacient

Video display terminal & Video display terminal & accompanying accompanying electromagnetic fieldselectromagnetic fields

short waves & ultrasound do short waves & ultrasound do not increase the risk of not increase the risk of abortionabortion

Immunological factors – autoimmune Immunological factors – autoimmune factorsfactors

Recurrent pregnancy loss patients : 15%Recurrent pregnancy loss patients : 15%Antiphospholipid antibody : most Antiphospholipid antibody : most

significantsignificant LCA (lupus anticoagulant), ACA LCA (lupus anticoagulant), ACA

(anticardiolipin Ab)(anticardiolipin Ab)Reduce prostacyclin productionReduce prostacyclin production → → facilitating thromboxane dominant facilitating thromboxane dominant

milieu → thrombosismilieu → thrombosisProstacyclin : produced by vascular Prostacyclin : produced by vascular

endothelial cellendothelial cell → → potent vasodilator & inhibit platelet potent vasodilator & inhibit platelet

aggregationaggregationThromboxane A2 : produced by plateletsThromboxane A2 : produced by platelets → → vasoconstrictor & platelet aggregatorvasoconstrictor & platelet aggregatorStrong association withStrong association with

Decidual vasculopathy , placental Decidual vasculopathy , placental infarction, fetal growth restrictioninfarction, fetal growth restriction

Early-onset preeclampsia, recurrent Early-onset preeclampsia, recurrent abortion, fetal deathabortion, fetal death

Immunological factors – Immunological factors – alloimmune factorsalloimmune factors

Allogeneity Allogeneity Genetic dissimilarities Genetic dissimilarities

between animals of the between animals of the same speciessame species

Human fetus is allogenic Human fetus is allogenic transplant tolerated by transplant tolerated by mothermother

Several test for diagnosis of Several test for diagnosis of alloimmune factorsalloimmune factors

Maternal & paternal HLA Maternal & paternal HLA comparisoncomparison

Maternal serum test for Maternal serum test for blocking antibodies blocking antibodies

: blocking antibodies to : blocking antibodies to paternal antigens paternal antigens

: ig G origin: ig G originMaternal serum test for Maternal serum test for

antipaternal antibodiesantipaternal antibodies : cytotoxic antibodies to : cytotoxic antibodies to

paternal leukocytepaternal leukocyte


Abortion


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Rhesus prophylaxis





EtiologyEtiology



Medical management






Abortion


OutlinesOutlines


Rhesus prophylaxis





EtiologyEtiology



Medical managementMedical management






Medical management Medical management of miscarriageof miscarriage•Traditionally, surgical curettage was the gold

Traditionally, surgical curettage was the gold standard for the management of miscarriage.standard for the management of miscarriage.•The chief pharmacological agents include

The chief pharmacological agents include prostaglandins (misoprostol, gemeprost) used prostaglandins (misoprostol, gemeprost) used alone or in combination with the anti-alone or in combination with the anti-progestogen mifepristone.progestogen mifepristone.•MifepristoneMifepristone: increases the sensitivity of

: increases the sensitivity of the myometrium to prostaglandins by 5 times the myometrium to prostaglandins by 5 times with maximal effect on uterine contractility with maximal effect on uterine contractility and cervical ripening at 36–48 hours following and cervical ripening at 36–48 hours following treatmenttreatment

* Choice of prostaglandin analogue: gemeprost or misoprostol;Choice of prostaglandin analogue: gemeprost or misoprostol;1.1. are more potent and have a longer half-life than natural Prostaglandinsare more potent and have a longer half-life than natural Prostaglandins2.2. Unlike the gemeprost pessary, misoprostol is Unlike the gemeprost pessary, misoprostol is stable at room temperaturestable at room temperature and therefore and therefore

does not require stringent storage conditions and is also considerably does not require stringent storage conditions and is also considerably cheapercheaper, thus , thus providing a cost-effective alternative to gemeprost.providing a cost-effective alternative to gemeprost.


Medical management Medical management of miscarriageof miscarriage1.1. Route of misoprostol administration:Route of misoprostol administration:There is no clinically significant difference

There is no clinically significant difference between vaginal misoprostol that is between vaginal misoprostol that is administered dry and vaginal misoprostol administered dry and vaginal misoprostol moistened with water, saline, or acetic acidmoistened with water, saline, or acetic acid

2. Mode of action and adverse effects with 2. Mode of action and adverse effects with misoprostol:misoprostol:cervical ripening. On the connective tissue cervical ripening. On the connective tissue stroma with evidence of disintegration and

stroma with evidence of disintegration and dissolution of collagen.dissolution of collagen.While a single dose increases uterine tonus,

While a single dose increases uterine tonus, repeated doses are required to maintain repeated doses are required to maintain sustained contractions.sustained contractions.Side effects are generally limited to the

Side effects are generally limited to the gastrointestinal tract, including gastrointestinal tract, including nausea, nausea, diarrhoea, vomiting, dizziness, fever and diarrhoea, vomiting, dizziness, fever and chills.chills. Regardless of the administered

Regardless of the administered route, side-effects are dose-relatedroute, side-effects are dose-related


Medical management Medical management of miscarriageof miscarriagePain management:Pain management:• In routine clinical practice, analgesia should be offered

In routine clinical practice, analgesia should be offered to all women. to all women. • analgesic requirements and the perception of pain are

analgesic requirements and the perception of pain are significantly higher in women of significantly higher in women of youngeryounger age and age and those at a those at a higher gestationalhigher gestational age, with a age, with a longer longer induction-to-expulsion of productsinduction-to-expulsion of products interval and with a interval and with a greater greater number ofnumber of misoprostol doses misoprostol doses..• Non-steroidal anti-inflammatory drugsNon-steroidal anti-inflammatory drugs (NSAIDs) are a (NSAIDs) are a potential first-line treatment. It should be noted that

potential first-line treatment. It should be noted that NSAIDs do not appear to mitigate the action of NSAIDs do not appear to mitigate the action of misoprostol or mifepristone in clinical trials, despite

misoprostol or mifepristone in clinical trials, despite theoretical concerns and may decrease narcotic theoretical concerns and may decrease narcotic requirementsrequirements..• Prophylactic NSAIDsProphylactic NSAIDs may reduce the need for narcotic

may reduce the need for narcotic analgesia during MVA.analgesia during MVA.• Prophylactic paracetamolProphylactic paracetamol (oral or rectal) is ineffective

(oral or rectal) is ineffective in reducing pain during both surgical and medical in reducing pain during both surgical and medical abortion.abortion.

• Local anaesthesia, such as Local anaesthesia, such as lidocainelidocaine, will alleviate , will alleviate discomfort from mechanical cervical dilatation and discomfort from mechanical cervical dilatation and uterine evacuation during surgical abortion and uterine evacuation during surgical abortion and should be routinely offered if available.should be routinely offered if available.• General anaesthesiaGeneral anaesthesia is not recommended for routine

is not recommended for routine abortion procedures, as it has been associated with abortion procedures, as it has been associated with higher rates of complications than analgesia and local

higher rates of complications than analgesia and local anaesthesia.anaesthesia.


Medical management Medical management of miscarriageof miscarriage1.1. If there is no suspicion of infection and

If there is no suspicion of infection and uterine size is less than 14 weeksuterine size is less than 14 weeks• misoprostol 600 micrograms orally or 400 misoprostol 600 micrograms orally or 400 micrograms sublingually.micrograms sublingually.2. 2. If there is no suspicion of infection and

If there is no suspicion of infection and uterine size is 14 weeks or largeruterine size is 14 weeks or largerA. A. 14–28 weeks14–28 weeks: 200 micrograms : 200 micrograms administered vaginally, sublingually or administered vaginally, sublingually or buccally at least 6-hourly (maximum four buccally at least 6-hourly (maximum four doses)doses)

B. B. 28+ weeks28+ weeks: 25 micrograms vaginally 6-: 25 micrograms vaginally 6-hourly or 25 micrograms orally 2-hourly

hourly or 25 micrograms orally 2-hourlyC. C. 14+ weeks if the woman has had a previous 14+ weeks if the woman has had a previous caesarean sectioncaesarean section: 25 micrograms : 25 micrograms vaginally 6-hourly or 25 micrograms orally vaginally 6-hourly or 25 micrograms orally 2-hourly2-hourly

~ RCOG 2016~ RCOG 2016

•If infection is present the If infection is present the uterus should be evacuated uterus should be evacuated urgentlyurgently

•start broad-spectrum start broad-spectrum antibiotics orally immediately antibiotics orally immediately if infection is mild but if infection is mild but intravenously if infection is intravenously if infection is moderate or severemoderate or severe

•if the woman is in septic if the woman is in septic shock, start IV fluids (normal shock, start IV fluids (normal saline or Hartmann’s). Transfer saline or Hartmann’s). Transfer to a specialist unit for surgical to a specialist unit for surgical uterine evacuation. Administer uterine evacuation. Administer broad-spectrum antibiotics broad-spectrum antibiotics (such as a combination of (such as a combination of ampicillinampicillin 0.5–1 g 6-hourly, 0.5–1 g 6-hourly, metronidazolemetronidazole 500 mg 8- 500 mg 8-hourly and hourly and gentamicingentamicin 120 mg 120 mg dailydaily) intravenously prior to ) intravenously prior to transfer if available.transfer if available.

~ RCOG 2016~ RCOG 2016


•Wagaarachchi et al.Wagaarachchi et al. proposed that although incomplete miscarriages may be managed with proposed that although incomplete miscarriages may be managed with misoprostol alone, in the presence of an intact sac and a closed cervix (early fetal demise), priming with misoprostol alone, in the presence of an intact sac and a closed cervix (early fetal demise), priming with the antiprogesterone mifepristone makes the regimen more effective with success rate of above 80%.the antiprogesterone mifepristone makes the regimen more effective with success rate of above 80%.

•A Cochrane review by A Cochrane review by Neilson et alNeilson et al. suggested that non-viable pregnancies may contain viable . suggested that non-viable pregnancies may contain viable trophoblast (placental) tissue, which produces hormones, which may in theory make these pregnancies trophoblast (placental) tissue, which produces hormones, which may in theory make these pregnancies more susceptible to anti-hormone therapy and more resistant to uterotonic (stimulating uterine more susceptible to anti-hormone therapy and more resistant to uterotonic (stimulating uterine contractions) therapy than pregnancies in which (incomplete) miscarriages have already taken place.contractions) therapy than pregnancies in which (incomplete) miscarriages have already taken place.

•A recent randomised trial by A recent randomised trial by Gronlund et al.Gronlund et al. showed that the addition of mifepristone did not improve showed that the addition of mifepristone did not improve the overall success rate compared with regimens using misoprostol alone and these results were the overall success rate compared with regimens using misoprostol alone and these results were subsequently confirmed by Stockhein.subsequently confirmed by Stockhein.

•A recent meta-analysis of 13 randomised controlled trials A recent meta-analysis of 13 randomised controlled trials by Graziosi et alby Graziosi et al. in 2004 confirms the findings . in 2004 confirms the findings with complete evacuation rates ranging between 60% and 83% for missed miscarriage and 99% for with complete evacuation rates ranging between 60% and 83% for missed miscarriage and 99% for incomplete miscarriage.incomplete miscarriage.

•In a study In a study by Chung et alby Chung et al. 225 women with spontaneous miscarriage and ultrasound diagnosis of . 225 women with spontaneous miscarriage and ultrasound diagnosis of retained products of conception (POC) were treated with up to 1200 micrograms of oral misoprostol in retained products of conception (POC) were treated with up to 1200 micrograms of oral misoprostol in three divided doses followed by a repeat course the second day. The success rate with the first course of three divided doses followed by a repeat course the second day. The success rate with the first course of misoprostol was about 48% but increased to 70% after a repeat course of treatment the next day.misoprostol was about 48% but increased to 70% after a repeat course of treatment the next day.

•Vaginal and oral misoprostol are equally effective although the oral regimen has higher gastrointestinal Vaginal and oral misoprostol are equally effective although the oral regimen has higher gastrointestinal side-effects. side-effects. Nynde et al.Nynde et al. compared oral and vaginal administration of 200 micrograms of misoprostol compared oral and vaginal administration of 200 micrograms of misoprostol given 6 hourly for up to four doses. The induction to delivery time was significantly shorter in the vaginal given 6 hourly for up to four doses. The induction to delivery time was significantly shorter in the vaginal group by nearly 8 hours.group by nearly 8 hours.

Efficacy studies, dosing regimens and adverse effectsEfficacy studies, dosing regimens and adverse effectsEvidence basedEvidence based \ 1 \ 1stst trimester trimester


Abortion


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Rhesus prophylaxis





EtiologyEtiology




Spotlight on mifepristoneSpotlight on mifepristone





Spotlight on MifepristoneSpotlight on Mifepristone1.1. Mifepristone (RU486), an anti-progestogen,

Mifepristone (RU486), an anti-progestogen, was discovered in 1980 by chemists at was discovered in 1980 by chemists at Roussel-Uclaf, France.Roussel-Uclaf, France.2.2. The pharmacokinetics of oral administration The pharmacokinetics of oral administration are characterized by rapid absorption and a are characterized by rapid absorption and a long half life of 25 – 30 hourslong half life of 25 – 30 hours3.3. It competitively blocks both progesterone It competitively blocks both progesterone and glucocorticoid receptorsand glucocorticoid receptors4.4. increases the sensitivity of the myometrium increases the sensitivity of the myometrium to prostaglandins by 5 times with maximal to prostaglandins by 5 times with maximal effect on uterine contractility and cervical effect on uterine contractility and cervical ripening at 36–48 hours following treatmentripening at 36–48 hours following treatment

•For pregnancies of less than For pregnancies of less than 14 weeks of gestation, in 14 weeks of gestation, in medically indicated abortion: medically indicated abortion: If mifepristone is available, it If mifepristone is available, it is best practice to use it in is best practice to use it in combination with misoprostol combination with misoprostol as it shortens as it shortens the induction–the induction–abortion interval, reduces side abortion interval, reduces side effects and decreases the rate effects and decreases the rate of ongoing pregnancyof ongoing pregnancy; ; mifepristone 200 mg should be mifepristone 200 mg should be administered orally 24–48 administered orally 24–48 hours before misoprostolhours before misoprostol

~ RCOG ~ RCOG


Abortion


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Rhesus prophylaxis




Jordanian LowJordanian Lowاألردنية التشريعات في األردنية اإلجهاض التشريعات في PathologyPathologyاإلجهاض

EtiologyEtiology





PrePre--abortion managementabortion managementAssessment and counselingAssessment and counseling



Spotlight on managementSpotlight on management of late IUFDof late IUFD


12لمادة ا لسنة رقم العامة الصحة قانون 2008منالمباح باإلجهاض المتعلقة

بقصد - شيء أي وصف طبيب أي على يحظر أ ، لها اجهاض عمليه اجراء او حامل امرأة اجهاض

لحمايتها ضرورية االجهاض عملية كانت اذا االوعلى للموت يعرضها او صحتها يهدد خطر من

ما توافر شريطة مستشفى في ذلك يتم انيلي :-

العملية 1. باجراء الحامل من مسبقة خطية موافقةعجزها او الكتابة على مقدرتها عدم حالة وفي

او زوجها من الموافقة هذه تؤخذ النطق عنامرها ولي

ذوي 2. ومن مرخصين طبيبين من شهادةالعملية اجراء وجوب تؤكد والخبرة االختصاص

صحتها . او الحامل حياة على للمحافظةوتاريخ 3. الحامل اسم المستشفى قيود تضمين

بالموافقة واالحتفاظ ونوعها العملية اجراءسنوات عشر لمدة الطبيبين وبشهادة الخطية

مدير من مصدقة بشهادة الحامل تزود ان علىلها . العملية هذه باجراء المستشفى

- ال ، العقوبات قانون في ورد مما الرغم على بالذين االشخاص او والشخص الحامل تالحق

لها االجهاض عملية اجراء في اشتركوا او اجروا ) بتهمة ) المادة هذه من أ الفقرة الحكام وفقاً

االجهاض . جريمة اقتراف

األردنية التشريعات في اإلجهاض



الصادة 21المادة األردني الطبي الدستور مناألردنية األطباء نقابة قانون بموجب

الطبيب- على يحظر المرعية القوانين مراعاة مع أاال كانت وسيلة بأية االختياري اإلجهاض إجراء

الحامل حياة على خطرا الحمل استمرار كان اذا: حينئذ ويشترط

وبموافقة( 1 مختص طبيب قبل من اإلجهاض يتم أن. مرخص مستشفى في آخر مختص طبيب

لإلجهاض( 2 الملحة الحاجة بتقرير محضر يحرر أن. العملية إجراء قبل

اللزوم( 3 حسب أكثر أو نسخ أربع منه تنظم أنوليها أو وزوجها والمريضة األطباء يوقعها

. المريضة إضبارة في نسخة وتحفظتوضيح- رغم العملية اجراء الحامل رفضت إذا ب

االمتثال فعليه وضعها، خطورة لها الطبيبمعارضتها تثبيت بعد الرادتها



رقم األردني العقوبات قانون االجهاض 2014لسنة 16مواد في 321المادة

بأن رضيت او الوسائل من استعملته بما نفسها اجهضت امرأة كلثالث الى أشهر ستة من بالحبس تعاقب ، الوسائل هذه غيرها لها يستعمل

سنوات.322المادة

من بالحبس عوقب ، برضاها امرأة إجهاض على كانت وسيلة بأية أقدم من. سنوات ثالث الى سنة


األسباب تنحصر السابقة التشريعات على بناء: يلي فيما األردن في اإلجهاض ألجراء المبيحة

دموي( 1 ) نزف مثل الحامل، حياة عن الخطر درء. الحمل مكونات مصدره

الصحة( 2 ) ويشمل الحامل، صحة على المحافظة. الجسدية والصحة النفسية

: فإن أيضا تقدم ما على وبناء

اإلجهاض .1 إلجراء سبب تعد ال االخالقية األسباب. االغتصاب عن الناتج الحمل مثل العالجي،

اإلجهاض .2 إلجراء سبب تعد ال االقتصادية األسباب. الفقر مثل العالجي،

دواعي .3 من يعد ال لإلجهاض مبرراً النسل تحديداإلجهاض.

من .4 التخوف أو تشخيص بسبب اإلجهاض إجراءاألش¤عة ) بسبب خلقية بتشوهات الحميل إصابة

لإلجهاض( قانونيا سببا يشكل ال مثالال .5 الجنين حياة على حفاظا المبكرة الوالدة إجراء

الفن أصول على يجرى النه إجهاضا يعتبروالصنعة.

أو .6 طبيب عيادة في قانونا المباح اإلجهاض إجراءيجرى أن يجب حيث للقانون، مخالف هو منزل

. مرخصة للتوليد دار أو مستشفى في




Abortion


OutlinesOutlines


Rhesus prophylaxis





EtiologyEtiology










Pre-abortion Pre-abortion managementmanagement1.1. Blood tests: Blood tests: Rhesus blood status, haemoglobinRhesus blood status, haemoglobinconcentrationconcentration2. Determining gestational age:2. Determining gestational age:It is not necessary to determine the exact gestational age but

It is not necessary to determine the exact gestational age but rather to make sure that the gestation falls within the

rather to make sure that the gestation falls within the range of eligibility for a particular method of inducing

range of eligibility for a particular method of inducing abortion. The date of onset of the last menstrual period,

abortion. The date of onset of the last menstrual period, bimanual pelvic examination, abdominal examination

bimanual pelvic examination, abdominal examination and recognition of symptoms of pregnancy are usually

and recognition of symptoms of pregnancy are usually adequate after a positive pregnancy test. Routine pre-

adequate after a positive pregnancy test. Routine pre-abortion ultrasound scanning is unnecessary but, if abortion ultrasound scanning is unnecessary but, if available, may be useful if there are concerns about available, may be useful if there are concerns about complications, e.g. ectopic pregnancy.complications, e.g. ectopic pregnancy.3. STI screening: 3. STI screening:

It is best practice to undertake a risk assessment for STIs for

It is best practice to undertake a risk assessment for STIs for all women (e.g. HIV, chlamydia, gonorrhoea, syphilis),

all women (e.g. HIV, chlamydia, gonorrhoea, syphilis), and to screen for them if appropriate and available but

and to screen for them if appropriate and available but this should be done without delaying the abortion.this should be done without delaying the abortion.4. Prevention of infective complications:

4. Prevention of infective complications:

•The following regimens are The following regimens are recommended for perisurgical recommended for perisurgical abortion antibiotic abortion antibiotic prophylaxisprophylaxis::

1. 200 mg doxycycline within 2 1. 200 mg doxycycline within 2 hours before the procedurehours before the procedure

OROR

2. 500 mg azithromycin within 2 2. 500 mg azithromycin within 2 hours before the procedure.hours before the procedure.


1.1. That abortion is a safe procedure for which major complications and mortality are rare at all That abortion is a safe procedure for which major complications and mortality are rare at all gestations.gestations.

2.2. For women in whom abortion is medically indicated, the earlier in pregnancy an abortion is For women in whom abortion is medically indicated, the earlier in pregnancy an abortion is undertaken, the safer it is likely to be.undertaken, the safer it is likely to be.

3.3. That surgical and medical methods of abortion carry a small risk of failure to end the pregnancy (1 That surgical and medical methods of abortion carry a small risk of failure to end the pregnancy (1 or 2 per 100 procedures). or 2 per 100 procedures).

4.4. That there is a small risk (less than 2 in 100 for surgical abortion, and 5 in 100 for medical abortion That there is a small risk (less than 2 in 100 for surgical abortion, and 5 in 100 for medical abortion using mifepristone and misoprostol and around 15 in 100 using misoprostol alone) of the need for using mifepristone and misoprostol and around 15 in 100 using misoprostol alone) of the need for further intervention to complete the procedure, i.e. surgical intervention following medical abortion further intervention to complete the procedure, i.e. surgical intervention following medical abortion or re-evacuation following surgical or re-evacuation following surgical

5.5. That the following complications may occur:That the following complications may occur:• severe bleeding requiring transfusion – the risk is lower for first-trimester abortions (less than 1 in severe bleeding requiring transfusion – the risk is lower for first-trimester abortions (less than 1 in

1000), rising to around 4 in 1000 at gestations beyond 20 weeks1000), rising to around 4 in 1000 at gestations beyond 20 weeks• uterine rupture in association with second-trimester medical abortion at late gestations – the risk is uterine rupture in association with second-trimester medical abortion at late gestations – the risk is

less than 1 in 1000.less than 1 in 1000.For surgical abortions only:For surgical abortions only:• cervical trauma – the risk of damage is no greater than 1 in 100 and is lower for first-trimester cervical trauma – the risk of damage is no greater than 1 in 100 and is lower for first-trimester

abortions; trauma is less likely if cervical preparation is undertaken in line with best practiceabortions; trauma is less likely if cervical preparation is undertaken in line with best practice• uterine perforation – the risk is in the order of 1–4 in 1000 and is lower for first-trimester abortions.uterine perforation – the risk is in the order of 1–4 in 1000 and is lower for first-trimester abortions.6. That should one of these complications occur, further treatment (e.g. blood transfusion, 6. That should one of these complications occur, further treatment (e.g. blood transfusion,

laparoscopy, laparotomy or hysterectomy) may be required.laparoscopy, laparotomy or hysterectomy) may be required.7. That infection of varying degrees of severity is unlikely, but may occur after medical or surgical 7. That infection of varying degrees of severity is unlikely, but may occur after medical or surgical

abortion and is usually caused by pre-existing infectionabortion and is usually caused by pre-existing infection

The counseling The counseling

There are a number of myths about the consequences of abortion. If she expresses concern, the woman can be reassured that there are no proven associations between induced abortion and subsequent ectopic pregnancy, placenta praevia, infertility, risk of breast cancer or psychological problems.


The counseling The counseling


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Medical abortionMedical abortionFor pregnancies of less than 14 weeks of For pregnancies of less than 14 weeks of gestationgestation• If mifepristone is available, it is best

If mifepristone is available, it is best practice to use it in combination with practice to use it in combination with misoprostol as it shortens the misoprostol as it shortens the induction–abortion interval, reduces induction–abortion interval, reduces side effects and decreases the rate of side effects and decreases the rate of ongoing pregnancy; mifepristone 200 ongoing pregnancy; mifepristone 200 mg should be administered orally 24–mg should be administered orally 24–48 hours before misoprostol.48 hours before misoprostol.• Misoprostol 800 micrograms given by Misoprostol 800 micrograms given by the vaginal, buccal or sublingual route, the vaginal, buccal or sublingual route, followed by misoprostol 400 followed by misoprostol 400 micrograms every 3 hours until micrograms every 3 hours until abortion occurs.abortion occurs.

For pregnancies of 14 weeks of For pregnancies of 14 weeks of gestation or moregestation or more

misoprostol 800 micrograms misoprostol 800 micrograms followed by misoprostol 400 followed by misoprostol 400 micrograms every 3 hours until micrograms every 3 hours until abortion occurs.abortion occurs.


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Surgical abortionSurgical abortionFor pregnancies of less than 14 weeks of For pregnancies of less than 14 weeks of gestationgestation

Either manual or electric vacuum aspiration:Either manual or electric vacuum aspiration:• There is no lower limit of gestation for There is no lower limit of gestation for

surgical abortion. surgical abortion. • It is best practice to inspect aspirated It is best practice to inspect aspirated

tissue at all gestations to confirm tissue at all gestations to confirm complete evacuation; this is essential complete evacuation; this is essential following vacuum aspiration before 7 following vacuum aspiration before 7 weeks of gestation.weeks of gestation.

• During vacuum aspiration, the uterus During vacuum aspiration, the uterus should be emptied using the suction should be emptied using the suction cannula and forceps (if required) only. cannula and forceps (if required) only. The procedure should not be routinely The procedure should not be routinely completed by sharp curettage.completed by sharp curettage.

• Use of medications containing either Use of medications containing either oxytocin or ergometrine are not oxytocin or ergometrine are not recommended for prophylaxis to prevent recommended for prophylaxis to prevent excessive bleeding either at the time of excessive bleeding either at the time of vacuum aspiration or afterwards.vacuum aspiration or afterwards.

• Sharp curettage should not be Sharp curettage should not be performed.performed.


surgical abortionsurgical abortionFor pregnancies of 14 weeks of gestation or moreFor pregnancies of 14 weeks of gestation or more

Either manual or electric vacuum aspiration:Either manual or electric vacuum aspiration:Surgical abortion can be performed by trained providers using:Surgical abortion can be performed by trained providers using:• vacuum aspiration using large bore cannulaevacuum aspiration using large bore cannulae• dilatation and evacuation (D&E).dilatation and evacuation (D&E).

Cervical preparation before surgical abortionCervical preparation before surgical abortionCervical preparation should be used for all women with a pregnancy over 14 weeks. Cervical preparation should be used for all women with a pregnancy over 14 weeks.

Suitable preparations include:Suitable preparations include:osmotic dilators 12–24 hours before the procedureosmotic dilators 12–24 hours before the procedureORORmisoprostol 400 micrograms vaginally, sublingually or buccally 3 hours before the misoprostol 400 micrograms vaginally, sublingually or buccally 3 hours before the

procedure.procedure.Cervical preparation may be considered for women before 14 weeks if there is a high Cervical preparation may be considered for women before 14 weeks if there is a high

risk for cervical injury or uterine perforation. The following regimen is risk for cervical injury or uterine perforation. The following regimen is recommended:recommended:

misoprostol 400 micrograms administered vaginally or buccally 3 hours before the misoprostol 400 micrograms administered vaginally or buccally 3 hours before the procedure or sublingually 2 hours before the procedureprocedure or sublingually 2 hours before the procedure


surgical abortionsurgical abortion


surgical abortionsurgical abortionComplications Complications : : uterine perforationuterine perforation

With hysteroscopic surgery the incidence of uterine perforation has been reported at With hysteroscopic surgery the incidence of uterine perforation has been reported at 1.6%. ~ )RCOG(1.6%. ~ )RCOG(

Most perforations are Most perforations are in the bodyin the body of the uterus and are often small, tending to cause of the uterus and are often small, tending to cause relatively little haemorrhage.relatively little haemorrhage.

internal cervical os and lower part of the uterus -> branches of the uterine vessels -> internal cervical os and lower part of the uterus -> branches of the uterine vessels -> haematoma formation in the broad ligament or serious intra-peritoneal haemorrhage.haematoma formation in the broad ligament or serious intra-peritoneal haemorrhage.

Up to 15% of uterine perforations caused by the fitting of an intrauterine device will Up to 15% of uterine perforations caused by the fitting of an intrauterine device will involve abdominal or pelvic viscera )the intestines, ureter, urinary bladder or a major involve abdominal or pelvic viscera )the intestines, ureter, urinary bladder or a major blood vessel.( ~)Zakin D, Obstet Gynecol Surv 1981(blood vessel.( ~)Zakin D, Obstet Gynecol Surv 1981(



an injury can be suspected if:an injury can be suspected if:

1.1.extension of the instrument goes beyond the limitation of the uterus.extension of the instrument goes beyond the limitation of the uterus.

2.2.loss of resistance with further instrumentationloss of resistance with further instrumentation

3.3.Sudden loss of vision during hysteroscopic procedures due to collapse of the uterusSudden loss of vision during hysteroscopic procedures due to collapse of the uterus

4.4.bleeding together with a large deficit of the distension mediumbleeding together with a large deficit of the distension medium

5.5.Direct visualisation of the perforation site, omentum or bowel is diagnostic.Direct visualisation of the perforation site, omentum or bowel is diagnostic.


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Spotlight on management Spotlight on management of late IUFDof late IUFD

International guidelinesInternational guidelines• The World Health Organization adopted the

The World Health Organization adopted the recommendations of an expert group on recommendations of an expert group on misoprostol in its guideline on induction of misoprostol in its guideline on induction of labour which was published in 2011.labour which was published in 2011.• These were ratified by the International These were ratified by the International Federation of Gynecology and Obstetrics Federation of Gynecology and Obstetrics (FIGO) and incorporated into its misoprostol (FIGO) and incorporated into its misoprostol dosage guideline published in 2012.dosage guideline published in 2012.• The RCOG Green-top Guideline recommends The RCOG Green-top Guideline recommends adjustment of misoprostol dose according to adjustment of misoprostol dose according to gestational age (100 μg 6-hourly before a gestational age (100 μg 6-hourly before a gestational age of 26 weeks and 25–50 μg 4-gestational age of 26 weeks and 25–50 μg 4-hourly for a gestational age of 27 weeks or hourly for a gestational age of 27 weeks or moremore

• This is similar to the recommendation This is similar to the recommendation endorsed by the National Institute for Health endorsed by the National Institute for Health and Care Excellence in 2008. The use of and Care Excellence in 2008. The use of misoprostol at the recommended doses is misoprostol at the recommended doses is considered safe in women with one previous considered safe in women with one previous caesarean section.caesarean section.

•The updated guideline recommends The updated guideline recommends 100 μg misoprostol vaginally 6-hourly 100 μg misoprostol vaginally 6-hourly (maximum of four doses) for a (maximum of four doses) for a gestational age of 18–26 weeks and 25 gestational age of 18–26 weeks and 25 μg vaginally 6-hourly or 25 μg orally 2-μg vaginally 6-hourly or 25 μg orally 2-hourly (maximum not specified for both hourly (maximum not specified for both routes) for late intrauterine fetal death.routes) for late intrauterine fetal death.

•Caution is advised in women with a Caution is advised in women with a previous scar for a gestational age of 18–previous scar for a gestational age of 18–26 weeks, whereas the use of 26 weeks, whereas the use of misoprostol is contraindicated in women misoprostol is contraindicated in women with late intrauterine fetal deathwith late intrauterine fetal death


•The optimal dose, schedule, and route of administration have not been determined. The optimal dose, schedule, and route of administration have not been determined. G’omez G’omez Ponce de Le’on and WingPonce de Le’on and Wing performed a review of 14 studies on the use of misoprostol for performed a review of 14 studies on the use of misoprostol for termination of pregnancy with intrauterine fetal demise in second and third trimesters. They termination of pregnancy with intrauterine fetal demise in second and third trimesters. They concluded that misoprostol is highly effective in inducing delivery after to 48 hours of concluded that misoprostol is highly effective in inducing delivery after to 48 hours of administration.administration.

•Yapar et alYapar et al. compared five different methods for second trimester pregnancy termination . compared five different methods for second trimester pregnancy termination including fetal deaths. They compared the use of extra-amniotic instillation of ethacridine including fetal deaths. They compared the use of extra-amniotic instillation of ethacridine lactate, intracervical PGE2 gel, intravenous infusion of concentrated oxytocin, intracervical lactate, intracervical PGE2 gel, intravenous infusion of concentrated oxytocin, intracervical balloon insertion and vaginal misoprostol in 340 patients. They reported both misoprostol and balloon insertion and vaginal misoprostol in 340 patients. They reported both misoprostol and PGE2 were less effective than the other three methods in achieving successful expulsion of PGE2 were less effective than the other three methods in achieving successful expulsion of products within 24-48 hours.products within 24-48 hours.

•Jain et alJain et al. compared use of misoprostol with PGE2 for second trimester pregnancy loss or . compared use of misoprostol with PGE2 for second trimester pregnancy loss or termination for medical reasons. They concluded that misoprostol is at least as effective as termination for medical reasons. They concluded that misoprostol is at least as effective as PGE2 but it is less costly, easier to administer and associated with fewer adverse effects.PGE2 but it is less costly, easier to administer and associated with fewer adverse effects.

•Jain et alJain et al. concluded that laminaria tents inserted concurrently with the first dose of . concluded that laminaria tents inserted concurrently with the first dose of misoprostol do not significantly improve the efficacy of vaginal misoprostol in the second misoprostol do not significantly improve the efficacy of vaginal misoprostol in the second trimester of pregnancy.trimester of pregnancy.

Efficacy studies, dosing regimens and adverse effectsEfficacy studies, dosing regimens and adverse effectsEvidence basedEvidence based \ 2 \ 2ndnd trimester trimester


Use of mechanical (non-pharmacological) methodsUse of mechanical (non-pharmacological) methods of induction in women with a previous uterine scarof induction in women with a previous uterine scar

•A standard Foley catheter or a proprietary Cook cervical ripening balloon are the most A standard Foley catheter or a proprietary Cook cervical ripening balloon are the most commonly used mechanical methods of cervical ripening for the induction of labour.commonly used mechanical methods of cervical ripening for the induction of labour.

•A 2012 Cochrane review that analysed 71 published randomised controlled trials A 2012 Cochrane review that analysed 71 published randomised controlled trials (n=9722 women) reported similar vaginal delivery rates with lower risk of (n=9722 women) reported similar vaginal delivery rates with lower risk of hyperstimulation with the use of mechanical methods than with other pharmacological hyperstimulation with the use of mechanical methods than with other pharmacological methods for induction of labour.methods for induction of labour.

•An observational trial of induction of labour in 1083 women (term induction of labour, An observational trial of induction of labour in 1083 women (term induction of labour, n=969) with a Bishop score of less than 6, using a 26F Foley catheter combined with extra-n=969) with a Bishop score of less than 6, using a 26F Foley catheter combined with extra-amniotic saline infusion, reported an overall vaginal delivery rate of 73.9% and a amniotic saline infusion, reported an overall vaginal delivery rate of 73.9% and a complication rate of less than 10%. The complications included acute transient febrile complication rate of less than 10%. The complications included acute transient febrile reaction (3%), non-reassuring cardiotocograph (2%), vaginal bleeding (1.8%) and reaction (3%), non-reassuring cardiotocograph (2%), vaginal bleeding (1.8%) and unbearable pain which necessitated removal of the catheter (1.7%). The vaginal birth rate unbearable pain which necessitated removal of the catheter (1.7%). The vaginal birth rate for the 97 women with one previous caesarean section was 80.4%.for the 97 women with one previous caesarean section was 80.4%.

•A retrospective chart review of outcomes for 2479 women undergoing vaginal birth after A retrospective chart review of outcomes for 2479 women undergoing vaginal birth after caesarean reported very high vaginal birth rates for women undergoing spontaneous caesarean reported very high vaginal birth rates for women undergoing spontaneous labour (78%, n=1807) and amniotomy with or without oxytocin (77.9%, n=417) compared labour (78%, n=1807) and amniotomy with or without oxytocin (77.9%, n=417) compared with those following the use of a Foley catheter (55.7%, P<0.001, n=255).The rates of with those following the use of a Foley catheter (55.7%, P<0.001, n=255).The rates of uterine rupture were comparable in the three groups (1.1 versus 1.2 versus 1.6%, uterine rupture were comparable in the three groups (1.1 versus 1.2 versus 1.6%, respectively).respectively).


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Postabortion carePostabortion careRhesus prophylaxisRhesus prophylaxisAnti-D IgGAnti-D IgG

If available, anti-D IgG should be If available, anti-D IgG should be given by injection into the

given by injection into the deltoid muscle to all RhD-deltoid muscle to all RhD-negative women within 72 negative women within 72 hours following abortion for hours following abortion for gestations longer than 12 gestations longer than 12 weeks.weeks.


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Rhesus prophylaxis

Information after the abortionInformation after the abortionpatient's FAQspatient's FAQs




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Postabortion carePostabortion careInformation after the abortionInformation after the abortion• On discharge, all women should be given a letter providing

On discharge, all women should be given a letter providing sufficient information about the procedure to allow another

sufficient information about the procedure to allow another practitioner elsewhere to manage any complications.

practitioner elsewhere to manage any complications.• Following abortion, women should be provided with verbal and

Following abortion, women should be provided with verbal and written information about:written information about:1. symptoms they may experience, emphasising those which would

1. symptoms they may experience, emphasising those which would necessitate an urgent medical consultationnecessitate an urgent medical consultation2. symptoms suggestive of continuing pregnancy.

2. symptoms suggestive of continuing pregnancy.• Before leaving the facility, women should receive instructions

Before leaving the facility, women should receive instructions about how to care for themselves after they go home, including:

about how to care for themselves after they go home, including:1.1. how much bleeding to expect in the next few days and weeks

how much bleeding to expect in the next few days and weeks2.2. how to recognise potential complications, including signs of

how to recognise potential complications, including signs of ongoing pregnancyongoing pregnancy3.3. when to resume normal activities (including sexual intercourse)

when to resume normal activities (including sexual intercourse)4.4. how and where to seek help if required

how and where to seek help if required5.5. whether or not they can get pregnant again and when to start

whether or not they can get pregnant again and when to start trying.trying.


Postabortion carePostabortion carepatient's FAQspatient's FAQsWhat did I do to cause it?What did I do to cause it?Nothing. It was not stress at work, carrying heavy shopping, having sex,Nothing. It was not stress at work, carrying heavy shopping, having sex,or any other reason women commonly worry about. Sadly, miscarriagesor any other reason women commonly worry about. Sadly, miscarriageshappen in up to about 40% of pregnancies.happen in up to about 40% of pregnancies.If I had had a scan earlier could you have stopped it happening?If I had had a scan earlier could you have stopped it happening?No, we might have found out it was happening sooner, but we couldNo, we might have found out it was happening sooner, but we couldnot have stopped it. There is no effective treatment available to stop anot have stopped it. There is no effective treatment available to stop a1st-trimester miscarriage.1st-trimester miscarriage.How bad will the pain be if I opt for expectant management?How bad will the pain be if I opt for expectant management?It will be like severe period pain, which comes to a peak when tissue isIt will be like severe period pain, which comes to a peak when tissue isbeing passed, then settles down shortly afterwards. Ibuprofen, paracetamol,being passed, then settles down shortly afterwards. Ibuprofen, paracetamol,or codeine should help and may be taken. If pain is very bad contactor codeine should help and may be taken. If pain is very bad contacthospital for advice.hospital for advice.What is heavy bleeding?What is heavy bleeding?Soaking more than 3 heavy sanitary pads in under 1h or passing a clotSoaking more than 3 heavy sanitary pads in under 1h or passing a clotlarger than the palm of your hand. If you bleed heavily you should seeklarger than the palm of your hand. If you bleed heavily you should seekmedical attention urgently.medical attention urgently.How long will I bleed for?How long will I bleed for?It should gradually get less and less but may be up to 3wks after theIt should gradually get less and less but may be up to 3wks after themiscarriage before the bleeding stops completely.miscarriage before the bleeding stops completely.


Do I need bed rest afterwards?Do I need bed rest afterwards?No, not necessarily, but obviously it can be physically and emotionallyNo, not necessarily, but obviously it can be physically and emotionallydraining so a few days off work may help. You can return to normaldraining so a few days off work may help. You can return to normalactivities as soon as you feel ready.activities as soon as you feel ready.How long will the pregnancy test remain positive?How long will the pregnancy test remain positive?hCG is excreted by the kidneys and it can take up to 3wks after a hCG is excreted by the kidneys and it can take up to 3wks after a miscarriage for it all to be removed from the bloodstream and a pregnancy miscarriage for it all to be removed from the bloodstream and a pregnancy test to record as –ve.test to record as –ve.How long before we can try again?How long before we can try again?There is no good evidence that the outcome of a subsequent pregnancyThere is no good evidence that the outcome of a subsequent pregnancyis affected by how soon you conceive after a miscarriage. As long as youis affected by how soon you conceive after a miscarriage. As long as youhave had either a period or a –ve pregnancy test since you miscarried,have had either a period or a –ve pregnancy test since you miscarried,you can try again as soon as you feel physically and emotionally ready.you can try again as soon as you feel physically and emotionally ready.Does this make me more likely to have another miscarriage?Does this make me more likely to have another miscarriage?There are a very small number of women who will have recurrent There are a very small number of women who will have recurrent miscarriages, but for the vast majority, next time they get pregnant they miscarriages, but for the vast majority, next time they get pregnant they will face the same odds; 40% risk of miscarriage and 60% chance of a baby.will face the same odds; 40% risk of miscarriage and 60% chance of a baby.

Postabortion carePostabortion carepatient's FAQs patient's FAQs contcont’’


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Follow-up after the abortionFollow-up after the abortion



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Postabortion carePostabortion careFollow-up after the abortionFollow-up after the abortion• There is no medical need for routine follow-up after surgical

There is no medical need for routine follow-up after surgical abortion or after medic al abortion if successful abortion has been

abortion or after medic al abortion if successful abortion has been confirmed at the time of the procedure.confirmed at the time of the procedure.• Women having a medical abortion in whom successful abortion has

Women having a medical abortion in whom successful abortion has not been confirmed at the time of the procedure should be offered

not been confirmed at the time of the procedure should be offered follow-up to exclude continuing pregnancy.follow-up to exclude continuing pregnancy.• All women having an abortion should be able to choose to return for

All women having an abortion should be able to choose to return for routine follow-up if they so wish.routine follow-up if they so wish.• Referral should be available for any woman who may require

Referral should be available for any woman who may require additional emotional support or whose mental health is perceived to

additional emotional support or whose mental health is perceived to be at risk.be at risk.

• UltrasoundUltrasound examination should not be used routinely to screen examination should not be used routinely to screen

women for incomplete abortion.women for incomplete abortion.• The decision to evacuate the uterus following incomplete abortion

The decision to evacuate the uterus following incomplete abortion should be based on clinical signs and symptoms and not on

should be based on clinical signs and symptoms and not on ultrasound appearances.ultrasound appearances.


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Contraception after the abortionContraception after the abortion


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Postabortion carePostabortion careContraception after the abortionContraception after the abortion• Women should be advised of the greater effectiveness and

Women should be advised of the greater effectiveness and duration of duration of LARC methodsLARC methods (implants and IUDs) and (implants and IUDs) and encouraged to choose them unless they have a clear

encouraged to choose them unless they have a clear preference for another effective method.preference for another effective method.

• SterilisationSterilisation can be safely performed at the time of induced can be safely performed at the time of induced abortion although it can be more likely than interval

abortion although it can be more likely than interval sterilisation to be associated with regret.sterilisation to be associated with regret.

• Failure ratesFailure rates for sterilisation are slightly higher if it is for sterilisation are slightly higher if it is performed at the same time as the abortion.

performed at the same time as the abortion.

Women for whom abortion is medically indicated may wish to get pregnant again as soon as Women for whom abortion is medically indicated may wish to get pregnant again as soon as possible. They are usually advised to wait until after possible. They are usually advised to wait until after at least one normal menstrual periodat least one normal menstrual period but women with chronic medical conditions that but women with chronic medical conditions that require treatmentrequire treatment (e.g. anaemia) or (e.g. anaemia) or women who undergo induced abortion at late gestation should wait longer. There may be women who undergo induced abortion at late gestation should wait longer. There may be some women for whom another pregnancy would be an unacceptable risk to healthsome women for whom another pregnancy would be an unacceptable risk to health..


The references The references 1.1. Chapter 18 of Chapter 18 of Williams Obstetrics textbook

Williams Obstetrics textbook, 24e F. Gary , 24e F. Gary Cunningham, MD, Kenneth J. Leveno, MD, Steven L. Bloom, MD,

Cunningham, MD, Kenneth J. Leveno, MD, Steven L. Bloom, MD, Catherine Y. Spong, MD, Jodi S. Dashe, MD, Barbara L. Hoffman,

Catherine Y. Spong, MD, Jodi S. Dashe, MD, Barbara L. Hoffman, MD, Brian M. Casey, MD, Jeanne S. Sheffield, MDMD, Brian M. Casey, MD, Jeanne S. Sheffield, MD2.2. The Care of Women Requesting Induced AbortionThe Care of Women Requesting Induced Abortion, Evidence-based , Evidence-based Clinical Guideline Number 7, RCOG 2011Clinical Guideline Number 7, RCOG 20113.3. Best practice in comprehensive postabortionBest practice in comprehensive postabortion care Best Practice care Best Practice Paper No. 3 , March 2016 RCOGPaper No. 3 , March 2016 RCOG4.4. Saraswat L, Ashok PW, Mathur M. Saraswat L, Ashok PW, Mathur M. Medical management of

Medical management of miscarriage.miscarriage. The Obstetrician & Gynaecologist 2014;16:79–85. The Obstetrician & Gynaecologist 2014;16:79–85.

5.5. World Health Organization. Safe AbortionWorld Health Organization. Safe Abortion: Technical and Policy

: Technical and Policy Guidance for Health Systems. 2nd ed. Geneva: WHO; 2012 [

Guidance for Health Systems. 2nd ed. Geneva: WHO; 2012 [6.6. Shakir F, Diab Y. Shakir F, Diab Y. The perforated uterus

The perforated uterus The Obstetrician & The Obstetrician & Gynaecologist 2013;15:256–61.Gynaecologist 2013;15:256–61.7.7. Review: Review: The use of mifepristone and misoprostol in the

The use of mifepristone and misoprostol in the management of late intrauterine fetal deathmanagement of late intrauterine fetal death, Volume 16, Issue 4

, Volume 16, Issue 4 October 2014 Pages 233–238 , The Obstetrician & Gynaecologist

October 2014 Pages 233–238 , The Obstetrician & Gynaecologist 8.8. Sagili H, Divers M. Sagili H, Divers M. Modern management of miscarriage

Modern management of miscarriage. The . The Obstetrician & Gynaecologist2007;9:102–108.Obstetrician & Gynaecologist2007;9:102–108.9.9. Wagaarachchi PT, Ashok PW, Narvekar N, Smith NC, Templeton A.

Wagaarachchi PT, Ashok PW, Narvekar N, Smith NC, Templeton A. Medical management of early fetal demise using a combination of

Medical management of early fetal demise using a combination of mifepristone and misoprostol. Hum Reprod 2001;16:1849–53.

mifepristone and misoprostol. Hum Reprod 2001;16:1849–53.10.10. National Institute for Health and Care Excellence. Ectopic

National Institute for Health and Care Excellence. Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management in

Pregnancy and Miscarriage: Diagnosis and Initial Management in Early Pregnancy of Ectopic Pregnancy and Miscarriage (CG154).

Early Pregnancy of Ectopic Pregnancy and Miscarriage (CG154). London: NICE; 2012.London: NICE; 2012.11.11. The RCOG's Green-top Guideline Late Intrauterine Fetal

The RCOG's Green-top Guideline Late Intrauterine Fetal Death and Stillbirth[Death and Stillbirth[


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