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Hesperian Health Guides

Emergency care for problems after miscarriage or abortion

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HealthWiki > A Book for Midwives > Chapter 22: Helping a woman after a pregnancy ends early > Emergency care for problems after miscarriage or abortion


The 2 most dangerous problems that women can have after miscarriage or abortion are bleeding too much and infection.

Infection can happen when:

See more about infection.

Bleeding too much can happen when:

  • tissue from the pregnancy is still inside the woman’s womb after the miscarriage or abortion.

WARNING!   If a woman has heavy bleeding or a serious infection, she can go into shock or even die. Get medical help fast.

If you have been trained to help a woman after an unsafe abortion or
miscarriage, you can help her yourself.

Contents

Incomplete abortion (tissue left inside the womb)

Incomplete abortion is a common cause of bleeding or infection. The bleeding or infection will not stop until all the tissue has been removed from the womb.

tissue on the cervix, seen through a speculum.
Tissue or blood may come from the cervix.
  • Tissue coming out of the womb. If you do a pelvic exam you might see pieces of tissue coming out of the cervix or you might feel that the womb is still enlarged because of tissue inside it.
  • Infection. The woman might have a fever, a bad smell coming from her vagina, or pain in her belly.
  • Heavy bleeding from the vagina.

Treating incomplete abortion

There are several ways to empty the womb after an incomplete abortion. In this book, we explain how to use:

  • MVA
  • medicines
  • forceps or other ways to remove tissue from the cervix, if you cannot use the first 2 methods.

MVA

syringe and cannula for
manual vacuum aspiration

The best treatment for incomplete abortion is to empty the womb using manual vacuum aspiration. Even though MVA is usually only safe in the first 3 months of pregnancy, it is worth trying after 3 months for a woman who has an incomplete abortion.

Treating incomplete abortion with medicines

Two medicines can help empty the womb after an incomplete abortion — misoprostol and ergometrine. Misoprostol can be given by mouth or inserted in the rectum — it makes the womb contract and pushes out any tissue. It is best to use this medicine when you have access to emergency care, including MVA, because it can cause heavy bleeding and does not always empty the womb completely. Ergometrine is another medicine that causes contractions and can be given by mouth or injection.


To empty the womb after an incomplete abortion
  • give 400 mcg (micrograms) misoprostol
by mouth
The woman should dissolve tablets against her cheek or under her tongue and then swallow any remaining parts.
or
  • give 600 mcg (micrograms) misoprostol
by mouth, 1 time only
or
  • give 0.2 mg ergometrine
by mouth, 1 time only
or
  • inject 0.2 mg ergometrine
in the muscle, 1 time only

When misoprostol is used to end a pregnancy
Misoprostol can be used, usually with another medicine called mifepristone, to end a pregnancy in the first 3 months. Because misoprostol is available at pharmacies and is not expensive, some women use it by itself to end their pregnancies.

Access to emergency care is very important when ending a pregnancy with misoprostol because it can cause heavy bleeding, incomplete abortion, or other dangerous problems. Emptying the womb using misoprostol alone may take several hours or several days to finish. If it does not empty the womb completely, the woman must find someone to empty her womb in another way.

WARNING!   Do not use misoprostol after 12 weeks of pregnancy. The womb becomes more sensitive and can split open.

Removing tissue from the cervix If you cannot do MVA, cannot give medicines, and you cannot find someone else to empty the womb, do a speculum exam and look for tissue or clots of blood coming out of the cervix. Use a sterilized forceps or long tweezers to remove the tissue or clots. This does not always work, but it is better than doing nothing.

2 fingers being wrapped together in gauze.

If you do not have a speculum but you do know how to do a bimanual exam, wash yourhands well and put on sterile plastic gloves. Put 2 fingers into the woman’s vagina to feel her womb. Move your fingers across the opening of the cervix. If you feel tissue coming from inside the cervix, gently try to remove it. If it is too slippery to hold, wrap two fingers with sterile gauze or a thin piece of sterilized cloth and try again to remove the tissue. This might be painful for the woman, so be very gentle. This method is rarely helpful, but it is better than doing nothing.

WARNING!   If you are not able to remove the tissue from an incomplete abortion, you must get medical help immediately so the tissue can be removed. On the way to the medical center, treat the woman for infection, and watch for shock.

After you remove the tissue:

Infection

A woman with an infection in the womb is in serious danger. The infection can cause injury to the womb, and can spread into the blood (sepsis). Sepsis is very dangerous and can cause shock or death. Women mainly get infections after abortions when unsterile tools were used, or after miscarriages and abortions that were not complete, but even an abortion that was done safely can sometimes cause an infection.

  • High temperature, above 38°C (100.4°F).
  • Fast pulse, over 100 beats a minute.
  • Feeling chills and shivering.
  • Swollen, hard, or painful belly.
  • Bad-smelling fluid coming from the vagina.
  • Feeling ill or weak.

To help a woman with an infection

  • Help the woman drink lots of fluids. This will help the body fight infection. If she has a hard time drinking, give her rehydration drink, rectal fluids, or an IV.
  • Help the woman eat nutritious food. Some fresh fruits like oranges, guava, papaya, mangos, and breadfruit have vitamin C, which helps fight infections.


To treat infection
Get medical help. On the way, give these medicines. For complete information on these medicines, see the green medicine pages.
  • inject 2 g ampicillin
in the muscle, then reduce the dose to 1g, 4 times a day
and
  • inject 300 mg gentamicin
    (or 5 mg gentamicin for
    each kg the woman weighs)
in the muscle, 1 time a day
and
  • give 400 to 500 mg metronidazole
by mouth, 3 times a day
Stop giving these antibiotics when the signs of infection have been gone for 48 hours. Then start giving doxycycline tablets.
When signs have been gone for 48 hours
  • give 100 mg doxycycline
by mouth, 2 times a day for 10 days
If you cannot inject medicines or you do not have the above medicines
You can give medicines by mouth instead.
  • give 3.5 g ampicillin
by mouth, 1 time only
and
  • give 100 mg doxycycline
by mouth, 2 times a day for 10 days

Tetanus (Lockjaw)

Tetanus is a type of infection that can be caused by unsafe abortion.

Women who have not been vaccinated against tetanus face a high risk of becoming sick or even dying from tetanus if anything that was not sterilized was put into their womb during an abortion.

If a woman had an unsafe abortion and she may not have been vaccinated against tetanus in the last 10 years, give her tetanus antitoxin immediately.


To protect against a tetanus infection
  • inject 1500 Units tetanus antitoxin
in the muscle
and 4 weeks later
  • inject 0.5 ml tetanus toxoid vaccination
in the muscle
Signs of tetanus
  • headache
  • difficulty swallowing
  • stiff neck
  • jaw spasms
  • tense or rigid body
  • painful muscle contractions or spasms
  • convulsions

Signs of a tetanus infection might start weeks after the infection happened.

If a woman is sick with tetanus, get medical help right away. On the way, help her lie down on her side, keep her calm, and protect her from light.

All women should receive vaccinations to prevent them from getting tetanus.

Bleeding

It is normal to bleed about the same amount as regular monthly bleeding for a few days after a miscarriage or abortion. Some women keep bleeding a small amount for up to 2 weeks. After a couple of days, the blood should be dark, not bright red. More bleeding than this is not normal and could be dangerous. If a woman is bleeding a lot after an abortion, especially if the blood is bright red and has few clots, it means the blood is fresh and flowing. She is in danger and the bleeding must be stopped. If she keeps bleeding she could go into shock or even die.

Women bleed too much after an abortion or miscarriage when:

A woman can help herself if she is bleeding heavily

If a woman is bleeding and she is by herself with no one to help her, she can try to stop the bleeding herself. This method is probably not enough to stop the bleeding, but it may slow it down.

Help the womb contract by rubbing the lower belly very hard while lying down or squatting. If there is tissue in the womb, a woman may be able to push it out by bearing down as if she is having a bowel movement or pushing a baby out.

To help a woman who is bleeding

  1. Help stop the bleeding by emptying the womb.
    a health worker speaking to a woman who lies on an exam table.
    I need to empty your womb to make the bleeding stop. It will not take long.
  2. Rub her womb every few hours until it is hard to help it push out the blood and tissue inside of it.
  3. Check the woman for infection.
  4. Watch the woman for signs of shock.

Internal injury (injury inside the body)

An internal injury from an abortion is most often caused by a sharp tool making a hole in the womb. The object may also cause harm to other organs inside the body such as the ovaries, intestines, or bladder.

When a woman has internal injuries she may have bleeding inside her belly that you cannot see. Or she may have bleeding from her vagina that you can see.

  • Belly feels stiff and hard with no sounds or gurgles inside.
  • Very bad pain or cramps in the belly.
  • Fever with chills or shivering.
  • Nausea and vomiting.
  • Pain in one or both shoulders.
  • Shock.

WARNING!   Immediately take any woman with an internal injury to a hospital or medical center to have surgery. Without surgery she could die.

On the way to a medical center, treat the woman as you would for shock, but do not give her any food or drink by mouth. (It is OK to give medicines by mouth and a little water so the woman can swallow the medicine.)

Shock

If a woman has a serious infection or bleeds heavily, she may go into shock.

  • She feels faint, dizzy, weak, or confused.
  • She is pale and has a cold sweat.
  • Fast pulse, over 100 beats a minute.
  • Fast breathing.
  • Dropping blood pressure.
  • Sometimes loss of consciousness.

Get medical help fast. You must treat the shock first to save her life. Then follow the directions earlier in this chapter to stop her bleeding or infection.

On the way to a medical center:

  • Have the woman lie with her feet higher than her head, and her head turned to one side.
  • Give her fluids. If she is conscious, she can drink water or rehydration drink. If she is not conscious, you can give her rectal fluids, or an IV if you know how.
  • If she is unconscious, do not give her anything by mouth — no medicines, drink, or food.


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