Author's details
Reviewer's details
Abortion
Miscarriage is the discontinuation of pregnancy before the age of viability. In Nigeria, the age of viability is 28 weeks. However, for the World Health Organization, it is 24 weeks. About 15-20% of clinically recognized pregnancies will end in miscarriage.
Causes
- Chromosomal abnormalities (commonest)
- Infections e.g. urinary tract infections U.T.I, malaria
- Maternal diseases e.g. diabetes mellitus, hypothyroidism, renal disease
- Uterine defects e.g. septate uterus, submucous myomas
- Immunological disorders e.g. antiphospholipid syndrome
- Drugs e.g. neoplastic agents
Types
- Threatened miscarriage: Refers to the presence of bleeding per vagina with a closed cervical os or without expulsion of products of conception and pregnancy is viable on ultrasound
- Inevitable miscarriage: Refers to the presence of cervical changes without expulsion of products of conception. There may be associated abdominal pains and some bleeding per vagina. The pregnancy is not viable.
- Incomplete miscarriage: Refers to the expulsion of some but not all the products of conception. It may be associated with heavy bleeding with the passage of fleshy parts and is usually associated with abdominal pains. The retained products of conception are confirmed on an ultrasound scan.
- Complete miscarriage: Refers to the complete expulsion of all products of conception. The bleeding per vagina and abdominal pain which were present will subside. The cervix will be closed, and the uterus will be empty on an ultrasound scan.
- Missed miscarriage: When the embryo or fetus dies but products of conception remain in utero. The woman may complain of the disappearance of pregnancy symptoms. There will be an empty gestational sac or the embryo/fetus will have no cardiac activity on ultrasound.
- Septic miscarriage: Presence of features suggestive of sepsis in the background of miscarriage
NICE miscarriage diagnosis criteria
| Mode of scanning | Ultrasound markers | Second opinion | Diagnosis confirmed | Follow up scan required |
| Transvaginal ultrasound | CRL (crown–rump length) is 7 mm or more and no visible heartbeatOR
Mean gestational sac diameter 25 mm or more and no visible fetal pole |
Yes, to confirm non-viable pregnancy | Yes – early embryonic demise | Optional if no second opinion or diagnosis uncertain then re-scan in 1 week before confirming diagnos |
| Transvaginal ultrasound | CRL (crown–rump length) is less than 7 mm and no visible heartbeat OR Mean gestational sac diameter less than 25 mm and no visible fetal pole |
Not needed as requires a follow up scan | No – needs follow up scan | Rescan in 1 week (minimum interval) Further scans may be required before confirming a diagnosis |
| Transabdominal ultrasound | CRL (crown–rump length) is 7 mm or more and no visible heartbeat OR Mean gestational sac diameter 25 mm or more and no visible fetal pole |
Not needed as requires a follow up scan | No – needs follow up scan | Rescan in 2 weeks to confirm the diagnosis
|
N/B: Don’t use gestation age from Last Menstrual Period (LMP) alone to determine whether fetal heartbeat should be visible (this is because of variability in LMP).
This includes ectopic pregnancy, pregnancy of unknown location, urinary tract infection, ovarian torsion, dysmenorrhea and appendicitis.
This includes qualitative serum beta human chorionic gonadotrophin, transvaginal ultrasound scan, full blood count, midstream urine for microscopy, culture and sensitivity, blood grouping and crossmatching.
This is dependent on the type of miscarriage.
Threatened miscarriage is managed by evaluation of patient and treatment of underlying cause when possible. In incomplete miscarriage, management can be expectant, medical or surgical. Expectant management can be considered in cases where the product of conception remaining within the uterus is minimal. Medical treatment involves use of misoprostol and mifepristone. Surgical management for miscarriage in the first trimester involves use of manual vacuum aspiration (MVA). Surgical management for miscarriage in second trimester may be used if there are retained product of conception. For septic miscarriage, management involves a septic work up of the patient, administration of antibiotics to treat sepsis and subsequent evacuation of products of conception. Products of conception are sent for histopathology to exclude conditions like gestational trophoblastic disease. Anti D immunoglobulin prophylaxis can be given in non-sensitized rhesus negative women.
.
Post abortion care (PAC) consists of emergency treatment for complications related to spontaneous or induced abortions, family planning and birth spacing counseling, and provision of family planning methods for the prevention of further mistimed or unplanned pregnancies that may result in repeat induced abortions with the aim of reducing morbidity and mortality and safeguarding the reproductive health of the woman. PAC also includes services such as evaluation for sexually transmitted infections, including HIV/ AIDS. There are 5 components of post abortion care. 1) Treatment of miscarriage and complications. 2) Counseling. 3) Family planning. 4) Other reproductive healthcare services. 5) Health care provider and community partnership
With complete resolution, qualitative serum beta HCG test should be negative after 21 days. However, if persistent, may require further evaluation
Abortion in sub-Saharan Africa remains a critical public health issue, with many women seeking unsafe procedures due to restrictive laws, stigma, and limited access to safe services. Unsafe abortions contribute significantly to maternal morbidity and mortality in the region. Expanding access to comprehensive reproductive health services, including family planning, safe abortion care where legal, and post-abortion services, is essential to reducing preventable maternal deaths and improving women's health outcomes.
A 27-year-old woman from a rural village in Northern Nigeria presented to a local clinic with severe abdominal pain, fever, and heavy vaginal bleeding after attempting an unsafe abortion. Due to financial constraints and fear of social repercussions, she sought help from a traditional healer who provided an herbal concoction to terminate her pregnancy. The attempt led to a septic abortion with uterine perforation, severe anaemia, and sepsis. She was referred to a regional hospital where she received life-saving treatment, including surgery, antibiotics, and a blood transfusion. This case highlights the dangers of unsafe abortions and the need for better access to safe reproductive healthcare in sub-Saharan Africa.
1. WHO: human reproductive program: www.who.int/reproductivehealth
2. Human Rights Committee; Committee Against Torture; Committee on the Elimination of Discrimination Against Women.
3. NICE Guideline [NG140]: Abortion Care. 2019.
Author's details
Reviewer's details
Abortion
Miscarriage is the discontinuation of pregnancy before the age of viability. In Nigeria, the age of viability is 28 weeks. However, for the World Health Organization, it is 24 weeks. About 15-20% of clinically recognized pregnancies will end in miscarriage.
Causes
- Chromosomal abnormalities (commonest)
- Infections e.g. urinary tract infections U.T.I, malaria
- Maternal diseases e.g. diabetes mellitus, hypothyroidism, renal disease
- Uterine defects e.g. septate uterus, submucous myomas
- Immunological disorders e.g. antiphospholipid syndrome
- Drugs e.g. neoplastic agents
Types
- Threatened miscarriage: Refers to the presence of bleeding per vagina with a closed cervical os or without expulsion of products of conception and pregnancy is viable on ultrasound
- Inevitable miscarriage: Refers to the presence of cervical changes without expulsion of products of conception. There may be associated abdominal pains and some bleeding per vagina. The pregnancy is not viable.
- Incomplete miscarriage: Refers to the expulsion of some but not all the products of conception. It may be associated with heavy bleeding with the passage of fleshy parts and is usually associated with abdominal pains. The retained products of conception are confirmed on an ultrasound scan.
- Complete miscarriage: Refers to the complete expulsion of all products of conception. The bleeding per vagina and abdominal pain which were present will subside. The cervix will be closed, and the uterus will be empty on an ultrasound scan.
- Missed miscarriage: When the embryo or fetus dies but products of conception remain in utero. The woman may complain of the disappearance of pregnancy symptoms. There will be an empty gestational sac or the embryo/fetus will have no cardiac activity on ultrasound.
- Septic miscarriage: Presence of features suggestive of sepsis in the background of miscarriage
NICE miscarriage diagnosis criteria
| Mode of scanning | Ultrasound markers | Second opinion | Diagnosis confirmed | Follow up scan required |
| Transvaginal ultrasound | CRL (crown–rump length) is 7 mm or more and no visible heartbeatOR
Mean gestational sac diameter 25 mm or more and no visible fetal pole |
Yes, to confirm non-viable pregnancy | Yes – early embryonic demise | Optional if no second opinion or diagnosis uncertain then re-scan in 1 week before confirming diagnos |
| Transvaginal ultrasound | CRL (crown–rump length) is less than 7 mm and no visible heartbeat OR Mean gestational sac diameter less than 25 mm and no visible fetal pole |
Not needed as requires a follow up scan | No – needs follow up scan | Rescan in 1 week (minimum interval) Further scans may be required before confirming a diagnosis |
| Transabdominal ultrasound | CRL (crown–rump length) is 7 mm or more and no visible heartbeat OR Mean gestational sac diameter 25 mm or more and no visible fetal pole |
Not needed as requires a follow up scan | No – needs follow up scan | Rescan in 2 weeks to confirm the diagnosis
|
N/B: Don’t use gestation age from Last Menstrual Period (LMP) alone to determine whether fetal heartbeat should be visible (this is because of variability in LMP).
This includes ectopic pregnancy, pregnancy of unknown location, urinary tract infection, ovarian torsion, dysmenorrhea and appendicitis
This includes qualitative serum beta-human chorionic gonadotrophin, transvaginal ultrasound scan, full blood count, midstream urine for microscopy, culture and sensitivity, blood grouping and crossmatching.
This is dependent on the type of miscarriage.
Threatened miscarriage is managed by evaluation of the patient and treatment of underlying cause when possible. In incomplete miscarriage, management can be expectant, medical or surgical. Expectant management can be considered in cases where the product of conception remaining within the uterus is minimal. Medical treatment involves the use of misoprostol and mifepristone. Surgical management for miscarriage in the first trimester requires the use of manual vacuum aspiration (MVA). Surgical management for miscarriage in the second trimester may be used if there are retained products of conception. For septic miscarriage, management involves a septic workup of the patient, administration of antibiotics to treat sepsis and subsequent evacuation of products of conception. Products of conception are sent for histopathology to exclude conditions like gestational trophoblastic disease. Anti-D immunoglobulin prophylaxis can be given in non-sensitized rhesus-negative women.
Post-abortion Care
Post-abortion care (PAC) consists of emergency treatment for complications related to spontaneous or induced abortions, family planning and birth spacing counselling, and provision of family planning methods for the prevention of further mistimed or unplanned pregnancies that may result in repeat induced abortions with the aim of reducing morbidity and mortality and safeguarding the reproductive health of the woman. PAC also includes services such as evaluation for sexually transmitted infections, including HIV/ AIDS.
There are 5 components of post-abortion care.
1) Treatment of miscarriage and complications.
2) Counseling.
3) Family planning.
4) Other reproductive healthcare services.
5) Healthcare provider and community partnership
With complete resolution, the qualitative serum beta HCG test should be negative after 21 days. However, if persistent, it may require further evaluation.
1. WHO: human reproductive program: www.who.int/reproductivehealth
2. Human Rights Committee; Committee Against Torture; Committee on the Elimination of Discrimination Against Women.
3. NICE Guideline [NG140]: Abortion Care. 2019.
Content
Author's details
Reviewer's details
Abortion
Background
Miscarriage is the discontinuation of pregnancy before the age of viability. In Nigeria, the age of viability is 28 weeks. However, for the World Health Organization, it is 24 weeks. About 15-20% of clinically recognized pregnancies will end in miscarriage.
Causes
- Chromosomal abnormalities (commonest)
- Infections e.g. urinary tract infections U.T.I, malaria
- Maternal diseases e.g. diabetes mellitus, hypothyroidism, renal disease
- Uterine defects e.g. septate uterus, submucous myomas
- Immunological disorders e.g. antiphospholipid syndrome
- Drugs e.g. neoplastic agents
Types
- Threatened miscarriage: Refers to the presence of bleeding per vagina with a closed cervical os or without expulsion of products of conception and pregnancy is viable on ultrasound
- Inevitable miscarriage: Refers to the presence of cervical changes without expulsion of products of conception. There may be associated abdominal pains and some bleeding per vagina. The pregnancy is not viable.
- Incomplete miscarriage: Refers to the expulsion of some but not all the products of conception. It may be associated with heavy bleeding with the passage of fleshy parts and is usually associated with abdominal pains. The retained products of conception are confirmed on an ultrasound scan.
- Complete miscarriage: Refers to the complete expulsion of all products of conception. The bleeding per vagina and abdominal pain which were present will subside. The cervix will be closed, and the uterus will be empty on an ultrasound scan.
- Missed miscarriage: When the embryo or fetus dies but products of conception remain in utero. The woman may complain of the disappearance of pregnancy symptoms. There will be an empty gestational sac or the embryo/fetus will have no cardiac activity on ultrasound.
- Septic miscarriage: Presence of features suggestive of sepsis in the background of miscarriage
NICE miscarriage diagnosis criteria
| Mode of scanning | Ultrasound markers | Second opinion | Diagnosis confirmed | Follow up scan required |
| Transvaginal ultrasound | CRL (crown–rump length) is 7 mm or more and no visible heartbeatOR
Mean gestational sac diameter 25 mm or more and no visible fetal pole |
Yes, to confirm non-viable pregnancy | Yes – early embryonic demise | Optional if no second opinion or diagnosis uncertain then re-scan in 1 week before confirming diagnos |
| Transvaginal ultrasound | CRL (crown–rump length) is less than 7 mm and no visible heartbeat OR Mean gestational sac diameter less than 25 mm and no visible fetal pole |
Not needed as requires a follow up scan | No – needs follow up scan | Rescan in 1 week (minimum interval) Further scans may be required before confirming a diagnosis |
| Transabdominal ultrasound | CRL (crown–rump length) is 7 mm or more and no visible heartbeat OR Mean gestational sac diameter 25 mm or more and no visible fetal pole |
Not needed as requires a follow up scan | No – needs follow up scan | Rescan in 2 weeks to confirm the diagnosis
|
N/B: Don’t use gestation age from Last Menstrual Period (LMP) alone to determine whether fetal heartbeat should be visible (this is because of variability in LMP).
Differential diagnoses
This includes ectopic pregnancy, pregnancy of unknown location, urinary tract infection, ovarian torsion, dysmenorrhea and appendicitis
Investigations
This includes qualitative serum beta-human chorionic gonadotrophin, transvaginal ultrasound scan, full blood count, midstream urine for microscopy, culture and sensitivity, blood grouping and crossmatching.
Treatment
This is dependent on the type of miscarriage.
Threatened miscarriage is managed by evaluation of the patient and treatment of underlying cause when possible. In incomplete miscarriage, management can be expectant, medical or surgical. Expectant management can be considered in cases where the product of conception remaining within the uterus is minimal. Medical treatment involves the use of misoprostol and mifepristone. Surgical management for miscarriage in the first trimester requires the use of manual vacuum aspiration (MVA). Surgical management for miscarriage in the second trimester may be used if there are retained products of conception. For septic miscarriage, management involves a septic workup of the patient, administration of antibiotics to treat sepsis and subsequent evacuation of products of conception. Products of conception are sent for histopathology to exclude conditions like gestational trophoblastic disease. Anti-D immunoglobulin prophylaxis can be given in non-sensitized rhesus-negative women.
Post-abortion Care
Post-abortion care (PAC) consists of emergency treatment for complications related to spontaneous or induced abortions, family planning and birth spacing counselling, and provision of family planning methods for the prevention of further mistimed or unplanned pregnancies that may result in repeat induced abortions with the aim of reducing morbidity and mortality and safeguarding the reproductive health of the woman. PAC also includes services such as evaluation for sexually transmitted infections, including HIV/ AIDS.
There are 5 components of post-abortion care.
1) Treatment of miscarriage and complications.
2) Counseling.
3) Family planning.
4) Other reproductive healthcare services.
5) Healthcare provider and community partnership
Follow up
With complete resolution, the qualitative serum beta HCG test should be negative after 21 days. However, if persistent, it may require further evaluation.
Further readings
1. WHO: human reproductive program: www.who.int/reproductivehealth
2. Human Rights Committee; Committee Against Torture; Committee on the Elimination of Discrimination Against Women.
3. NICE Guideline [NG140]: Abortion Care. 2019.
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