Abstract
Termination is ending of a pregnancy by removing a fetus or embryo before it can survive outside the uterus.
The legality of abortion/termination of pregnancy varies worldwide.
When allowed by law, it is considered as one of the safest procedures in medicine.
The World Health Organization recommends safe and legal abortions be available to all women.
In 95 per cent of cases, no complications develop; however, there is always a risk of infection. The risk is higher in surgical than medical terminations due to uterine instrumentation.
Today, about 50 million abortions are performed every year. The worldwide rate of abortion is 28 per 1000 women. With proper equipment and qualified medical personnel, legal abortion is one of the safest procedures.
Rates of upper genital tract infection in the setting of legal induced abortion in the United States are generally less than 1 per cent.
Introduction
Termination is ending of a pregnancy by removing a fetus or embryo before it can survive outside the uterus.
The legality of abortion/termination of pregnancy varies worldwide.
When allowed by law, it is considered as one of the safest procedures in medicine.1, 2
The World Health Organization recommends safe and legal abortions be available to all women.3
In 95 per cent of cases, no complications develop; however, there is always a risk of infection. The risk is higher in surgical than medical terminations due to uterine instrumentation.
Today, about 50 million abortions are performed every year. The worldwide rate of abortion is 28 per 1000 women. With proper equipment and qualified medical personnel, legal abortion is one of the safest procedures.
Rates of upper genital tract infection in the setting of legal induced abortion in the United States are generally less than 1 per cent.
A) Infectious Complications
Risk Factors
The risk of infection has been estimated at up to 10 per cent.
Pre-existing sexually transmitted diseases like gonorrhoea or Chlamydia are the highest risk factor. Use of tampons, intercourse, vaginal douches, tub baths, bubble baths and swimming in the first two weeks after termination are also contributing risk factors.4
Clinical Picture
The commonest symptoms include
Severe lower abdominal pain
Heavy bleeding
Fever > 38°C
Tachycardia >90 bpm
Tachypnea relative risk (RR) >20
Systemic signs of sepsis as organ dysfunction (in cases of severe infection)
Septic shock (tachycardia (>110), respiratory distress, oliguria, altered mental status and hypotension)
Diagnosis
Clinical Diagnosis
It is clinical diagnosis based on the clinical picture.
Laboratory Diagnosis
1. Blood culture.
2. Urine culture.
3. Cervical cultures.
4. Endometrial biopsy specimen or tissue obtained at uterine aspiration provides a better specimen for culture than does cervical discharge. Examination of the Gram-stained material can guide early management.
5. Raised white blood cell count >12 000 or <4000, or >10 per cent immature forms.
Prevention
Primary Prevention
Prevention of unintended pregnancy is considered the primary method of preventing terminations and thus post-termination infections.
Secondary Prevention
There are two main strategies for the prevention of infection after termination of pregnancy:
1. Routine prophylaxis by giving antibiotics around the time of surgery for all women.
Randomised controlled trials support the use of prophylactic antibiotics for surgical abortion in the first trimester.
The current evidence supports pre-procedure but not post-procedure antibiotics for the purpose of prophylaxis.
A Cochrane review concluded that ‘Antibiotic prophylaxis at the time of first trimester surgical abortion is effective in preventing post-abortal upper genital tract infection.’5 [EL 1]
Perioperative oral doxycycline given up to 12 hours before a surgical abortion appears to effectively reduce infectious risk.
A perioperative single-dose regime of nitroimidazole or tetracyclines seems to be safe and effective.6
Azithromycin can be used for presumptive treatment of Chlamydia at the time of surgical abortion.
2. ‘Screen-and-treat’, in which all women presenting for termination are screened for genital infections and those with positive results are treated.
In a study involving 1672 abortion cases, women managed by the screen-and-treat strategy had slightly higher rates of infective morbidity in the eight weeks after abortion than those managed by ‘prophylaxis’. Prophylaxis appears to be more cost-effective than screen-and-treat policy.7
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