On this page
Referral and warning signs
When to refer
Urgent Referral to Hospital (HC4/H): Shock/severe bleeding, Septic abortion, Molar pregnancy, Suspected ectopic, Incomplete/Inevitable requiring evacuation beyond capacity, Missed abortion, Significant anaemia.
Red flags
- Heavy vaginal bleeding
- Signs of shock
- Signs of sepsis
- Severe abdominal pain
- Passage of grape-like vesicles
Signs and symptoms
- Threatened Abortion: Slight bleeding +/- mild pain, cervix CLOSED.
- Inevitable Abortion: Moderate/heavy bleeding, pain, cervix OPEN, POC not passed.
- Incomplete Abortion: Heavy bleeding/clots, pain, cervix OPEN, some POC passed.
- Complete Abortion: Bleeding/pain subsided, cervix CLOSED, uterus empty.
- Septic Abortion: Signs of incomplete abortion + infection (fever, foul discharge, tenderness, shock).
- Missed Abortion: Fetal demise, POC retained, uterus small, cervix CLOSED.
- Molar Abortion: Bleeding, grape-like vesicles, large uterus, severe N/V.
Risk factors
- Advanced maternal age.
- Previous miscarriage.
- Chromosomal abnormalities.
- Uterine abnormalities.
- Infections.
- Uncontrolled chronic diseases.
- Smoking/alcohol/drugs.
- Trauma.
- Unsafe induced abortion.
Diagnosis
Clinical assessment
History (LMP, bleeding, pain, tissue passage). Vitals. Abdo exam (size, tenderness). Speculum exam (bleeding, cervix open/closed, POC). Bimanual exam (cervical motion tenderness, size, adnexa - rule out ectopic).
Investigations
- Urine Pregnancy Test (hCG).
- Ultrasound Scan (Confirm IUP vs ectopic, viability, retained POC, molar).
- FBC (assess blood loss).
- Blood Group & Cross-match (if bleeding/surgery).
- Swabs for C&S (if septic).
Diagnostic criteria
Clinical presentation + cervical status + ultrasound findings (if available) to classify type.
Management
Non-pharmacological management
- General: Assess ABC, resuscitate if shocked. Emotional support.
- Threatened Abortion: Bed rest (limited evidence), pelvic rest. Follow up ANC.
- Inevitable/Incomplete (pre-evacuation): Remove visible POC at os.
- Septic Abortion: Stabilize first.
- Molar Abortion: Resuscitate, urgent referral.
- Post-Abortion Care: Contraception, hygiene, danger signs, follow-up.
Pharmacological treatment
- Analgesia: Paracetamol, NSAIDs (cautious if heavy bleed), Opioids.
- Inevitable/Incomplete Abortion: Medical (Misoprostol 600mcg PO/SL) OR Surgical (MVA preferred <16wks OR D&C). Antibiotic prophylaxis (Doxycycline/Azithromycin).
- Septic Abortion: Broad Spectrum IV Antibiotics (Ceftriaxone + Metronidazole) IMMEDIATELY, then evacuate uterus.
- Missed Abortion: Medical (Misoprostol +/- Mifepristone) or Surgical evacuation. Refer.
- Molar Abortion: Evacuation (suction preferred) in hospital. Follow hCG.
- Iron supplementation if anaemic.
- Anti-D Immunoglobulin for Rh-negative women.
Monitoring
Monitor vitals, bleeding, uterine tone. Assess evacuation completion. Monitor for infection. Follow hCG (molar).
Complications
- Haemorrhage, Shock.
- Infection, Sepsis.
- Uterine perforation.
- Incomplete evacuation.
- Asherman's syndrome.
- Psychological distress.
- Persistent trophoblastic disease (molar).
Prevention
- Family planning.
- Early ANC.
- Manage risk factors.
- Safe abortion services.
- Prompt management.
Patient education
- Explanation of type and cause.
- Management options.
- What to expect.
- Signs of complications.
- Follow-up need.
- Contraception.
- Emotional support.
Uganda-specific notes
Unsafe abortion major issue. MVA preferred evacuation method. Misoprostol increasingly used. Ultrasound access varies. High suspicion for ectopic needed.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.3.2