Arortion and types

1. B.Sc (BASIC)NURSING DEGREE
Midwifery & Obstetrical Nursing
UNIT VII – High Risk Pregnancy
ABORTION
Dr. Latha Venkatesan
Principal

2. OBJECTIVES
The students will be able to
 define abortion
 Identify the difference between various types of
abortion
 Perform medical induction for abortion
 Describe various surgical techniques used for
abortion
 Detect the consequences that occur by abortion
and provide appropriate care

3. CONTENT OVERVIEW
 Definition
 Types of abortion- Spontaneous, Induced,
Complete abortion, Incomplete abortion, Missed
abortion, Recurrent abortion, Induced abortion
 Risk factors, etiology, mechanism, clinical
manifestations of each type
 Management – medical & surgical
 Nursing management

4. INTRODUCTION
Abortion or pregnancy loss is accounts to
spontaneous events or through legal
termination.
The first large scale study on abortions and
unintended pregnancies conducted by The
Lancet in 2017 said one in three of the 48.1
million pregnancies in India end in an abortion
with 15.6 million taking place in 2015.

5. DEFINITION
Abortion is the expulsion or
extraction from its mother of an
embryo or fetus weighing 500 gm or
less when it is not capable of
independent survival
-WHO

6. DEFINITION …contd
The 500gm of fetal development is attained
approximately at 22 weeks(154 days of gestation).
The expelled embryo or fetus is called abortus
Abortion is the cause for bleeding in early pregn

7. TYPES OF ABORTION

9. SPONTANEOUS ABORTION
Abortion occurring without medical or
mechanical means to empty the uterus is
referred to as spontaneous
Another widely used term is miscarriage

10. INCIDENCE (INDIA)
10-20% of cases of all clinical pregnancies
end in miscarriage.
 About 75%miscarriages –before 16th
week
 About 80% occur –before 12th week of
pregnancy.

11. RISK FACTORS
Increases with parity
Increased maternal and paternal age
The frequency of abortion increases from 12% in
women younger than 20 years to 26% in those
older than 40 years
Women conceiving within 3 months following a
term birth, have a higher incidence of abortion

12. ETIOLOGY
The exact mechanism responsible for abortion
are not apparent
Factors responsible for abortion
Maternal Fetal

13. FETAL FACTORS
1.Abnormal zygotic
development
Developmental abnormality
of the zygote, embryo, early
fetus, or placenta
Degenerated or absent
embryos or fetal pole with
diameter of 3cm or more or
blighted ova/Silent
miscarriage.
2.Aneuploid abortion
Chromosomal
abnormalities
- Maternal
gametogenesis error
-Paternal error

14. BLIGHTED OVUM
- Anembryonic Gestational sac
- Positive HCG test as placenta secretes HCG and stops
later
- Presents in first few weeks of pregnancy
- Removal through medical or surgical induction

15. BLIGHTED OVUM

16. MATERNAL FACTORS CONTRIBUTING
TO ABORTION
1. INFECTIONS
2.CHRONIC
ILLNESSES
3.ENDOCRINE
ABNORMALITIES
4. DRUGS
5. NUTRITION
6. IMMUNOLOGICAL
FACTORS
7.UTERINE/CERVICAL
DEFECTS

17. INFECTIONS
- Uncommon causes
of abortion in human
• Listeria
monocytogenes
• Clamydia
trachomatis
• Mycoplasma
hominis
• Ureaplasma
urealyticum
• Toxoplasma
gondii
CHRONIC
DEBILITATING
DISEASES
– Diabetes mellitus
– Celiac sprue
• Cause both male
and female
infertility and
recurrent
abortions

18. ENDOCRINE ABNORMALITIES
– Hypothyroidism
• Thyroid autoantibodies → incidence of
abortion is high
– Diabetes mellitus
• Poor glucose control → incidence of
abortion increased
– Progesterone deficiency
• Luteal phase defect
• Insufficient progesterone secretion by the
corpus luteum or placenta

19. DRUG USE AND ENVIRONMENTAL
FACTORS
• At least 5 cups of coffee per day → slightly increased risk of
abortion
Caffeine
• Arsenic, lead, formaldehyde, benzene, ethylene oxide in
sufficient doses → abortifacient
Radiation/
exposure to metals
• When intrauterine devices fail to prevent pregnancy →
abortion↑
Contraceptives
• Anesthetic gases : exact fetal risk of chronic maternal
exposure is unknown
Environmental
toxins
• ↑ Risk for euploid abortion
• More than 14 cigarettes a day → the risk twofold greater ↑
Tobacco
• Spontaneous abortion & fetal anomalies → result from
frequent alcohol use during the first 8 weeks of pregnancy
Alcohol

20. IMMUNOLOGICAL FACTORS –
AUTOIMMUNE FACTORS
– Recurrent pregnancy loss patients : 15%
– Antiphospholipid antibody : most significant
• LCA (lupus anticoagulant), ACA
(anticardiolipin Ab)
ALLOIMMUNE FACTORS
- Inherited thrombophilia

21. UTERINE DEFECTS – ACQUIRED
UTERINE DEFECTS
Uterine synechiae
(Asherman syndrome)
Partial or complete
obliteration of the
uterine cavity by
adherence of uterine
wall

22. INCOMPETENT CERVIX
The retention power of
the cervix(Internal os)
may be impaired
functionally and or
anatomically in an
incompetent cervix

23. INCOMPETENT CERVIX
Painless
dilatation
of cervix
Prolapse &
ballooning of
membranes
into vagina
Rupture of
membranes
& expulsion
of immature
fetus
Unless
effectively
treated, tends
to repeat in
each
pregnancy

24. INCOMPETENT CERVIX
Diagnosis in nonpregnant
women
Hysterography
Pull-through techniques of inflated
Foley catheter balloons
Specifically sized cervical dilators
Transvaginal ultrasound in
pregnant women
• Cervical length -
shortening
• Funneling
Etiology
– Previous trauma to the
cervix
• Dilatation &
curettage
• Conization
• Cauterization
– Abnormal cervical
development
• Exposure to DES in
utero

25. MANAGEMENT OF INCOMPETENT
CERVIX
Prophylactic surgery performed between 12
& 16weeks
Delayed until after 14 weeks’ gestation for
other factors to be elicited
The more advanced the pregnancy, the more
likely the risk that surgical intervention
stimulate preterm labor or membrane rupture
Usually do not perform after about 23 weeks

26. CERVICAL ENCIRCLAGE SURGERY
Reinforcement of weak cervix by purse string suture or
banding
Types of operations commonly used
– McDonald
– Modified Shirodkar
85~90% success
rate is achieved

27. PREOPERATIVE EVALUATION
– Sonography : Confirm living fetus & exclude
major fetal anomalies
– Cervical cytology
– Cultures for gonorrhea, chlamydia, group
B streptococci
• Obvious cervical infections → treatment is
given
• For at least a week before & after surgery
→ sexual intercourse should be restricted

28. NUTRITION
• Dietary
deficiency of
vitamins, iron
and folic acid
• Not a major
cause
PATERNAL FACTORS
-Little is known in the genesis
of spontaneous abortion
-Chromosomal translocations
in sperm can lead to abortion
OTHER FACTORS
-Laparotomy
Physical trauma

29. Mechanism of Miscarriage
In Earlier Weeks
Death of the ovum occurs
first
Its Expulsion
In Later weeks
Maternal environment
factors are involved
Expulsion of the fetus which
may have signs of life but
it is small to survive

31. CATEGORIES OF SPONTANEOUS
ABORTION
Threatened abortion
Inevitable abortion
Complete or incomplete abortion
Missed abortion
septic abortion

32. THREATENED ABORTION
Definition
It is a clinical entity where the process of miscarriage
has started but has not progressed to a state from which
recovery is possible.
-Any bloody vaginal
discharge or bleeding
during 1st half of
pregnancy
-Bleeding is frequently
slight, but may persist for
days or weeks

33. Frequency
• Extremely common (one out of four or five pregnant
women)
Prognosis
• Approximately 50% will abort
• Risk of preterm delivery, low birthweight, perinatal
death
• Risk of malformed infant does not appear to be
increased
Symptoms
• Usually bleeding begins first
• Cramping abdominal pain follows a few hours to
several days later
• Presence of bleeding & pain
• Poor prognosis for pregnancy continuation

34. DIAGNOSIS
BIOCHEMICAL TESTS
• Serial serum quantitative hCG
• Serum progesterone
• ( can help ascertain if the fetus
is alive & its location)
• Serum progesterone value < 5
ng/ml→ dead conceptus
• VAGINAL SONOGRAPHY
• Gestational sac(+) & hCG <
1000mIU/ml
• → gestation is not likely to survive
• → In case of doubt of survival,
check the serum hCG level at
intervals of 48hrs
• → if no increase more than 65%,
almost always hopeless

35. TREATMENT
– Bed rest & acetaminophen-based analgesia
– Progesterone (IM) or synthetic progestational agent
(PO or IM)
– D-negative women with threatened abortion
• should receive anti-D immunoglobulin 50 mcg IM
After Death of Conceptus
– Uterus should be emptied, examination of all passed
tissue whether the abortion is complete
– Ectopic pregnancy should be considered if gestational
sac or fetus are not identified

36. INEVITABLE ABORTION
DEFINITION
Inevitable Abortion It is the clinical type of abortion
where the changes have progressed to a state from
where continuation of pregnancy is impossible
MANIFESTATIONS
Increased Vaginal Bleeding
-Aggravation of pain in the lower abdomen which may be
colicky in nature
-Internal Examination-dilated IO of the cervix which the
products of conception are felt
DIAGNOSIS
Blood-Hb,Hematocrit,ABO and Rh grouping
MANAGEMENT
IV therapy
Oxytocic drugs
-Before 12 weeks- D&E,D&C
-After 12 Weeks-Induction of Labour

37. MISSED MISCARRIAGE/
EARLY FETAL DEMISE
Definition
When the fetus is dead and retained inside the uterus for a variable period
Manifestations
-Persistence of brownish vaginal discharge
-Subsidence of pregnancy symptoms
-Retrogression of breast changes
-cessation of uterine growth
-Non audiability of FHR
Diagnosis
Blood-Hb,Hematocrit,ABO and Rh grouping
USG
Management
Before 12 weeks – Prostoglandin E1-800mg-vaginally
Suction and Evacuation
Complications IUD

39. COMPLETE ABORTION
When the
products of
conception
are expelled
enmasse
- Vaginal Bleeding
becomes trace or
Absent
-Subsidence of
abdominal pain
-Uterus is smaller
than the period of
amenorrhea
-Cervical os is
closed
Blood-
Hb,Hematocrit,A
BO and Rh
grouping
Conservative
care
ANTI D
administration

40. INCOMPLETE ABORTION
When the entire
products of
conception are
not expelled
,instead a part of
it is left inside the
uterine cavity
-Persistence of Vaginal bleeding
-Continuation of pain in lower abdomen
- Internal Examination-
- Uterus is smaller than the period of amenorrhea
-Patulous cervical os often admitting tip of the finger.
-Varying amount of bleeding
Blood-
Hb,Hematocrit,
ABO and Rh
grouping
USG
Management
Misoprostol 200 micro gm-
vaginally every 4 hrs
Surgical Management
-ERCP
-MVA

41. Complications
Profuse Bleeding
Sepsis
Placental Polyp

42. SEPTIC ABORTION
• Looks sick and anxious
• -T >38◦ C
• -Chills and Rigorous
• -Persistent Tachycardia > 90 bpm
• -Hypothermia(Endo toxic
shock)<36◦ C
• - Abdominal or Chest pain
• -Tachypnea (RR) >20/mt
• -Impaired Mental state
• -Diarrhea and/or Vomitting
• -Renal Angle Tenderness
Any abortion
associated with clinical
evidences of infections
of the uterus and its
contents
Blood-Hb,Hematocrit,ABO
and Rh grouping,
• -Cervical or high vaginal
swab
• -USG
• -Plain Xray
DIAGNOSIS

43. MANAGEMENT
Grade-I-The Infection is
localized in the uterus
• Antibiotics
• -Antigas gangrene serum
of 8000 units,and 3000
units of Antitetanus
• Analgesics and sedatives
• -Evacuation of the Uterus
Grade-II- The
Infection spreads
beyond the uterus to
the
parametrium,tubes
and ovaries or pelvic
peritoneum-Same
the treatment of
Grade 1
• Posterior
Colpotomy
Grade-III- Generalised
peritonitis and/or endotoxic
shock or jaundice or acute
renal failure
- Intensive care treatment

44. RECURRENT ABORTION
Definition :
Three or more consecutive spontaneous
abortions before 20 weeks
Clinical investigation of recurrent
miscarriage
– Parental cytogenetic analysis
– Lupus anticoagulant & anticardiolipin antibodies
assays

45. Postconceptional evaluation
– Serial monitoring of ß–hCG from missed mens period
• ß–hCG>1500mIU/ml → USG
– Maternal serum α-fetoprotein assessment (GA16-18wks)
– Amniocentesis → fetal karyotype
Prognosis
– Depends on potential underlying etiology & number of
prior losses

46. MANAGEMENT
1. Adequate rest
2. Appropriate diet
3. Anemia correction
4. Treatment of systemic illness
5. Reassurance and tender loving care
6. Surgical management of incompetent
cervix

47. INDUCED ABORTION
The medical or surgical termination of
pregnancy before the time of fetal viability
Therapeutic abortion
– Termination of pregnancy before of fetal
viability for the purpose of saving the life of
the mother due to
– Invasive carcinoma of the cervix
– Pregnancy resulted from rape or incest
– Continuation of pregnancy is likely to result in the
birth of child with severe physical deformities or
mental retardation

48. TYPES
Elective (voluntary) abortion
– Interruption of pregnancy before viability at
the request of the women, but not for reasons
of impaired maternal health or fetal disease
Counseling before elective abortion
– Continued pregnancy with its risks & parental
responsibilities
– Continued pregnancy with its risks & its
responsibilities of arranged adoption
– The choice of abortion with its risks

49. MEDICAL INDUCTION
Early abortion
– Outpatient medical abortion is an acceptable
alternative to surgical abortion in women with
pregnancies of less than 49 days’ gestation
(ACOG, 2001b)
– Three medications for early medical abortion
• Antiprogestin mifepristone
• Antimetabolite methotrexate
• Prostaglandin misoprostol

52. SURGICAL INDUCTION

53. DILATATION AND CURETTAGE

56. POST ABORTION MANAGEMENT
Support the
woman
Anti D
administration
counselling
Use of
contraceptives
Follow up care

58. KEY FEATURES
Detailed the composition and tenure of the DLC
Abortion sites approved for
- A – upto 12 weeks
- B- 12 – 20 weeks , facilities and equipments
required
Need for registered medical practitioner and
referral hospitals

60. NURSING CARE PLAN
1. Anxiety
2. Acute pain
3. Fluid volume deficit
4. Deficient knowledge
5. Risk for complications
6. Situational Self Esteem

61. REFERENCES
1. Myles, M. F., Bennett, V. R., & Brown, L. K.
(1993). Myles textbook for midwives. Edinburgh:
Churchill Livingstone.
2. Reeder, S. J., Martin, L. L., & Koniak, D.
(1997). Maternity nursing: Family, newborn, and
women's health care. Philadelphia: Lippincott.
3. Dutta, D. and Konar, H., 2013. DC Dutta's
Textbook Of Obstetrics. 7th ed. New Delhi: Jaypee
Brothers Medical Publishers
4. Orshan (2009). Maternity Nursing. LWW
5. Ricci(2009). Essentials of maternity nursing,
Lippincotts
6. Lowdermilk(2008). Maternity Nursing,Elsevier

62. THANK YOU