Miscarriage and Induced Abortion

ultrasound of a baby

Abortion is the termination of pregnancy before the fetus has reached viability. Abortion refers to the 24th week of pregnancy or the 6th lunar month of pregnancy. After this time, we talk about premature birth.

Abortions can be spontaneous, i.e. not caused by medication or medical procedures or induced abortion. Induced abortion is made upon the patient’s insistence on the termination of pregnancy for personal reasons - social, domestic, financial, inappropriate period of life, etc. In addition to this type of abortion, there may be an abortion for medical reasons. The latter type occurs in the presence of severe anomalies of the fetus or endangering the life and health of the pregnant woman - severe preeclampsia (complication of the second half of pregnancy accompanied by high blood pressure, protein in urine, edema, impaired vision, heart, liver, kidney and brain disorders), severe hyperemesis (excessive vomiting during pregnancy), severe diabetes, and so on. These complications occur extremely rare in the present due to the adequate care of pregnant women and accessible health services in Bulgaria.

Abortions occur in several phases and the main reasons are from vaginal bleeding and low abdominal pain. Bleeding may be mild or abundant. It is important to know that there are a number of reasons that can cause vaginal bleeding without being a concern or endangering pregnancy. But even if bleeding is from the uterus, we are aware that about 20-30% of pregnant women may have this complaint at the beginning of pregnancy. The low abdominal pain is another symptom, but only if it is low in the abdomen and is in the middle above the pubic bone. Pain that is higher, on the side, and so on is not a cause for concern about abortion. Of course,  any bleeding and pain should be ‘investigated’ by your obstetrician and gynecologist on time, that is, not after a day or two, but within a few hours.

In my opinion, it is important to emphasize that about 10-15% of early pregnancies end up in abortions up to 12-13 WOP, then the risk falls to 2-3%. Why is that? One of the main causes of abortion in the first three months of pregnancy are severe chromosomal and genetic mutations that are incompatible with life. At this point, ‘mother nature’ takes precedence and causes abortion. That is why in the UK they do not provide substantial treatment to patients with a threatening abortion. They only provide painkillers like paracetamol. In Bulgaria, we are more aggressive and treat each woman with different medications to keep her pregnant. Hardly any of these models is perfect, but in both cases there are positives and negatives. In case of abortion, it is important that partners (spouses) not to blame because no one is responsible for abortion. A woman who is pregnant has a great chance of getting pregnant again.

Abortions after 12-13 week of pregnancy are less common, and the reasons for them are different. Among the most common causes are a cervical failure (birth canal) to keep the pregnancy. Causes can be both congenital and various medical interventions on the cervix - previous surgical abortions, conization (partial cervical cut due to cancer), cervical rupture from previous births, and so on. In such cases, it is important to give complete and accurate information to your attending physician so that appropriate preventive measures can be taken, or at least properly monitor the condition of the cervix. This is one of the reasons why examinations with placing the fingers inside the vagina or ulstrasound scans are performed. You should know that these examinations are safe for you and your pregnancy. The incorrect understanding and dissemination that vaginal examination is dangerous is absolutely unprofessional and unethical. Only a doctor with knowledge, skills and consistent thinking and action is aware of the importance of performing each procedure and the results of it. It is not ethical to deprive a person from the full range of resources that can improve his or her health and life.

For the treatment of abortion I will not talk because, as I said above, there are mixed opinions. I am of the opinion that we need to look for the ‘happy middle ground’ and optimize treatment, not with more medication but with more knowledge and skills. Fortunately, we have very good ultrasound machines that can detect anomalies in very early stages of pregnancy. However, high resolution, 3D and 4D ultrasounds can not diagnose themselves. In my opinion, it is important to inquire about where and how long your doctor has been trained on these technologies. You understand that courses for 2-3-7 days are absolutely inadequate and only demonstrative, but not practical, because of the wide variety of abnormalities, diagnosis techniques and behavior.

There are abortions where either there is no fetus or the fetus has died but is still in the uterus. This state we call Missed abortion. In this case, the fetus, fetal sac and placenta should be evacuated from the uterus. This can be done in three ways:

  • Expectation method - we expect this to happen naturally without intervention from the medical team. It is almost not practiced in Bulgaria. It is protracted and with an unexpected end, and there may be retained fetal parts, which may require a surgical method to be performed.
  • Medication method - it uses medications to induce contractions and clear the uterus. It has recently entered Bulgaria, often used in Western Europe. This method may take up to a week until the uterus is completely cleared. There is a risk of incomplete cleansing and imposing the use of a surgical method. When using medication, bleeding is more profound. An advantage to the surgical method is the lack of complications from manipulation.
  • Surgical method - most commonly used in Bulgaria. This method is one-stage. The patient is put to sleep and surgical technique removes the pregnancy. It can rarely lead to profuse bleeding; uterine perforation requiring open abdominal surgery; infections; irregular uterine bleeding; sterility, etc.

Personal motives for discontinuing pregnancy may be of a different nature and it is legal to be performed on the territory of Bulgaria until the 12th week of pregnancy. Personal reasons are not a topic of discussion among medical circles, and they are a sacred secret for our patients, which should always be kept. Unfortunately, there is a tendency for abortion to be used as a method of contraception. Everyone is aware of the risks, though minimal, of this intervention - infections, difficulty or inability to get pregnant, broken monthly cycle, and so on. Therefore, every sexually active woman should be aware of the different methods of preventing unwanted pregnancy (methods of contraception).

The manipulation itself lasts for 15-20 minutes. The woman should  be fasting from the previous evening or at least 6 hours – neither for nor water is permitted. There are examinations such as blood group and complete blood count. The blood group is examined to determine the rhesus factor. In the case of a woman’s negative rhesus factor, after manipulation, an anti-D gammaglobulin is made to prevent complications from future pregnancies. After proper preparation in the clinic, the woman is put to sleep with complete anesthesia, the generic canal is expanded and the uterus is emptied with a vacuum system. The woman is left under surveillance for 2 hours, after which she can go home. Manipulation is a short one-stage procedure, but it can by no means neglect the risk of unwanted consequences, which should be discussed by the patient and the doctor.