2. • Abortion is the expulsion or extraction of an embryo or fetus
weighing 500 g or less from its mother when it is not capable of
independent survival (i.e. before the period of viability).
• The fetus is generally considered to be viable any time after the fifth to
sixth month of gestation.
• An abortion that occurs without intervention is known as
a miscarriage or "spontaneous abortion" and occurs in
approximately 30% to 40% of pregnancies.
• When deliberate steps are taken to end a pregnancy, it is called
an induced abortion, or less frequently "induced miscarriage". The
unmodified word abortion generally refers to an induced abortion.
3. DEFINITION
“Abortion is the termination of pregnancy before 20
gestational weeks”.
“Abortion is the process of partial or complete
separation of the products of conceptus from the uterine
wall with or without partial or complete expulsion from
the uterine cavity”.
“Interruption of pregnancy or expulsion of the product of
conception before the fetus is viable is called abortion”.
4. INCIDENCE
• 10–20% of all clinical pregnancies
• 75% abortions occur before the 16th week
• Rates vary with maternal age; also high in
women with past miscarriages
7. Fetal Factors
• Genetic
– 50% of early miscarriage is due to chromosomal
abnormalities like Trisomy, Polyploidy,
Monosomy
– Structural defects like translocation, deletion,
inversion
• Multiple Pregnancies
• Degeneration of villi
10. • Environmental Factors
– Cigarette smoking
– Alcohol consumption
– Contraceptive agents
• Maternal medical illness
– Cyanotic heart disease
– Hemoglobinopathies
• Unexplained (40-60%) – In majority, the
exact cause is not known.
11. SPONTANEOUS ABORTION
• Miscarriage, also known as spontaneous abortion, is the
unintentional expulsion of an embryo or fetus before the
24th week of gestation.
• It is estimated that 1 of every 5 to 10 conceptions results in
spontaneous abortion.
• Most of these occur because an abnormality in the fetus
makes survival impossible.
• Other causes may include systemic diseases, hormonal
imbalance, or anatomic abnormalities.
•Spontaneous abortion occurs most commonly in the second or
third month of gestation.
12. There are various kinds of spontaneous abortion,
depending on the nature of the process
• Threatened
• Inevitable
• Complete
• Incomplete
• Missed
• Septic
13. ThreatenedAbortion
• Condition in which miscarriage
has started but has not
progressed to a state from
which recovery is impossible.
• In a threatened abortion, the
cervix does not dilate.
CLINICAL FEATURES:-
1. Bleeding per vaginam
2. Pain - mild backache or dull
pain in lower abdomen.
15. Management & Prognosis
• Rest: Patient should be in bed for few days until
bleeding stops
• Relief of pain: Diazepam 5 mg BD
• 80% of pregnancies with threatened abortions go on
until term.
• If a live fetus is seen on USG, pregnancy is likely
to continue in over 95% cases.
• If pregnancy continues, there is increased frequency
of preterm labor, placenta previa & IUGR
16. InevitableAbortion
• It is the clinical type of abortion where the
changes have progressed to a state from where
continuation of pregnancy is impossible.
• Inevitable abortion is an early pregnancy with
vaginal bleeding and dilatation of the cervix.
• Typically, the vaginal bleeding is worse than with a
threatened abortion, and more cramping is present.
• No tissue has passed yet.
• On ultrasound, the products of conception are
located in the lower uterine segment or the cervical
canal.
17. CLINICAL FEATURES:
• The patient, having the features of threatened
miscarriage, presents with
– vaginal bleeding
– Aggravation of colicky pain in the lower abdomen
• Sometimes, the features may develop quickly
without prior clinical evidence of threatened
miscarriage
• Internal examination reveals dilated internal os
through which the products of conception are felt.
18. Management
• Management is aimed:
– To accelerate the process of expulsion
– To maintain strict asepsis
• If pregnancy < 12 weeks, suction evacuation is done
• If pregnancy > 12 weeks, expulsion by oxytocin
infusion
• General measures:
– Excessive bleeding is controlled by
administering methergin 0.2 mg
– Blood loss is corrected by IV fluid therapy and
blood transfusion
19. Incomplete abortion
• The process of abortion has already taken place, but the
entire products of conception are not expelled & a part of it
is left inside the uterine cavity.
• Incomplete abortion is a pregnancy that is associated with
vaginal bleeding, dilatation of the cervical canal, and
passage of products of conception.
• Usually, the cramps are intense, and the vaginal bleeding is
heavy. Patients may describe passage of tissue, or the
examiner may observe evidence of tissue passage within the
vagina.
• Ultrasound may show that some of the products of
conception are still present in the uterus.
20. Clinical features:
• History of expulsion of a fleshy mass per vaginam;
– Continuation of pain in lower abdomen
– Persistence of vaginal bleeding
• Internal examination reveals
– uterus smaller than the period of amenorrhea
– Open internal os
– varying amount of bleeding
• On examination, the expelled mass is found incomplete
Complications:
• The retained products may cause:
(a) bleeding (b) sepsis or (c) placental polyp.
21. MANAGEMENT:
• Evacuation of the retained products of conception (ERCP)
• Early abortion: Dilatation and evacuation under analgesia or
general anesthesia is to be done.
• Late abortion: Uterus is evacuated under general anesthesia
and the products are removed by ovum forceps or by blunt
curette. In late cases, D&C is to be done to remove the bits of
tissues left behind.
• Prophylactic antibiotics are given; removed materials are
subjected to a histological examination.
• Medical management - Tab. Misoprostol 200 Mg every
4 hours
22. CompleteAbortion
• When the products of conception are
completely expelled from the uterus, it is
called complete miscarriage.
• Complete abortion is a completed
miscarriage. Typically, a history of
vaginal bleeding, abdominal pain, and
passage of tissue exists.
• After the tissue passes, the patient notes
that the pain subsides and the vaginal
bleeding significantly diminishes.
23. Clinical features
• There is history of expulsion of a fleshy mass per
vaginum followed by
– Subsidence of abdominal pain
– Vaginal bleeding becomes trace or absent
• Internal examination reveals:
– Uterus smaller than the period of amenorrhea
– Cervical os is closed
– Bleeding is trace.
24. INVESTIGATION
• Transvaginal sonography confirms that uterus is
empty.
• The examination reveals some blood in the vaginal
vault; a closed cervical os; and no tenderness of the
cervix, uterus, or abdomen.
25. â–Ş There is no treatment other than rest is usually needed.
â–Ş All of the tissues that came out should be saved for
examination by a doctor to make sure that the abortion is
complete.
â–Ş The laboratory examination of the saved tissue may determine
the cause of abortion.
â–Ş The effect of blood loss, if any, should be assessed and treated.
â–Ş If there is doubt about complete expulsion of the products,
uterine curettage should be done.
MANAGEMENT
26. Missed Abortion
• The fetus is dead and retained passively inside the uterus for a
variable period.
• A missed abortion is a nonviable intrauterine pregnancy that
has been retained within the uterus without spontaneous
abortion.
• Typically, no symptoms exist besides amenorrhea, and the
patient finds out that the pregnancy stopped developing
earlier when a fetal heartbeat is not observed or heard at
the appropriate time.
• An ultrasound usually confirms the diagnosis.
• No vaginal bleeding, abdominal pain, passage of tissue, or
cervical changes are present.
27. CLINICAL FEATURES:
The patient usually presents with features of
threatened miscarriage followed by:
–Subsidence of pregnancy symptoms
–Uterus becomes smaller in size
–Cervix feels firm with closed internal os
–Nonaudibility of the fetal heart sound even with
Doppler ultrasound
–Immunological test for pregnancy becomes negative
28. Complications
• Retaining the products for long time can lead
to sepsis
• DIC [Disseminated Intravascular Coagulation]
– (very rare) in gestations exceeding 16 weeks
29. Management
Uterus is less than 12 weeks:
• Prostaglandin E1 (Misoprostol) 800 mg is given
vaginally and repeated after 24 hours if needed.
Expulsion usually occurs within 48 hours
• Suction evacuation is done when the medical method
fails
Uterus more than 12 weeks
• 6th or 12th hourly misoprostol tablets givenvaginally
• If this fails, extra amniotic instillation of
ethacridine lactate is used
• Antibiotics are given
30. SepticAbortion
• Any abortion associated with clinical evidences of
infection of the uterus and its contents
• Most common cause – Attempt at induced abortion by an
untrained person without the use of aseptic precautions.
• A septic abortion is an infection of the placenta and fetus .
• Infection is centred in the placenta and there is risk of
spreading to the uterus, causing pelvic infection or
becoming systemic to cause sepsis and potential damage
of distant vital organs.
31. Clinical Grading:
• Grade–I: The infection is localized in the uterus.
Is the commonest and is usually associated with
spontaneous abortion
• Grade–II: The infection spreads beyond the uterus ,
the tubes and ovaries or pelvic peritoneum.
• Grade–III: Generalized peritonitis and/or
endotoxic shock or jaundice or acute renal
failure.
32. Clinical Features
• Fever, abdominal pain and vomiting or diarrhoea
• A rising pulse rate of 100–120/min or more is a
significant finding than even pyrexia. It indicates
spread of infection beyond the uterus.
• Examination shows abdominal tenderness,
guarding, rigidity
• Internal examination reveals:
– offensive purulent vaginal discharge
– tender uterus
– Soft cervix with open internal os
33. Investigations
• CBC
• Serum urea, creatinine, electrolytes
• vaginal swab
• Blood culture in suspected septicaemia
• Pelvic USG to detect retained products of
conception
• X-ray abdomen in suspected bowel injury
• X-ray chest if there is difficulty in respiration
34. Complications
Immediate:
• Hemorrhage
• Injury may to uterus & adjacent structures
• Spread of infection leads to:
– Generalized peritonitis
– Endotoxic shock—mostly due to E. Coli
– DIC
– Acute renal failure
– Thrombophlebitis.
• All these lead to increased maternal deaths
35. Management
• Mild cases –
– Broad spectrum antibiotics started
– Uterus is evacuated
• Severe Cases
– Vigorous IV infusion with crystalloid
– Oxygen given by nasal catheter
– Broad spectrum antibiotics – combination of
ampicillin, gentamicin, metronidazole is started
– Uterus is evacuated in 4-6 hrs of commencing therapy.
37. •Habitual or recurrent abortion is defined as
successive, repeated, spontaneous abortions
of unknown cause.
•As many as 60% of abortions may result
from chromosomal anomalies.
•After two consecutive abortions, patients are
referred for genetic counselling and testing,
and other possible causes are explored
38. ETIOLOGY
FIRST TRIMESTER ABORTION:
• Genetic factors
• Endocrine and Metabolic
• Infection
• Inherited thrombophilia
• Immunological cause
SECOND TRIMESTER MISCARRIAGE
• Anatomic abnormalities - responsible for
10– 15% of recurrent abortion
• Uterine Causes
• Cervical Insufficiency (Incompetence)
40. Diagnosis
• History - Repeated mid trimester painless
cervical dilatation and escape of liquor amnii
followed by painless expulsion of the products of
conception
• Internal examination:
Interconceptual period:
–Passage of no. 6–8 Hegar dilator beyond the
internal os without any resistance or pain
–Funnelling of internal os seen in
hysterosalpingography
41. During pregnancy
– Clinical digital – Painless cervical shortening and
dilatation
– Sonography: Trans vaginal ultrasound is performed. Short
cervix < 25 mm; Funnelling of the internal Os > 1 cm.
42. MANAGEMENT
• If bleeding occurs in these patients, conservative
measures, such as bed rest and administering
progesterone to support the endometrium, are tried in
an attempt to save the pregnancy.
• Supportive counselling is crucial in this stressful
condition.
• Bed rest, sexual abstinence, a light diet, and no
straining on defecation are recommended in an effort
to prevent spontaneous abortion.
• If infection is suspected, antibiotics may be prescribed.
43. •When an incomplete abortion occurs, oxytocin may
be prescribed to cause uterine contractions before
dilation and evacuation (D & E) or uterine suctioning.
•In the rare case of heavy bleeding, the patient may
require blood component transfusions and fluid
replacement.
•An estimate of the bleeding volume can be
determined by recording the number of perineal pads
44. Management
• Surgical management – Cervical circlage
• Ususally at 12-14 weeks
• The procedure involves placing a purse-string
suture around the cervix at the level of the internal
os.
• !
45. Prognosis of recurrent miscarriage
• The overall risk of recurrent miscarriage is
about 25–30% irrespective of the number of
previous spontaneous miscarriage.
• The overall prognosis is good even without
therapy.
• The chance of successful pregnancy is about
70–80% with an effective therapy.
47. • A voluntary induced termination of pregnancy is called
an elective abortion and is usually performed by skilled
health care providers.
• An elective abortion is the interruption of a pregnancy
before the 20th week of gestation at the woman’s
request for reasons other than maternal health or fetal
disease.
• Most abortions in the United States are performed for
this reason.
48.
49. Vacuum Aspiration
• The cervix is dilated manually with instrumentation or by laminaria (small
suppositories made of seaweed that swells as it absorbs water).
• Laminaria may be used to soften and dilate the cervix prior to the procedure.
• A uterine aspirator is introduced.

• Suction is applied, and tissue is removed from the uterus.

This is the most common type of termination procedure and is used early in
pregnancy, up to 14 weeks.
Dilation and Evacuation
Cervical dilation with laminaria followed by vacuum aspiration
50. Labor Induction
These procedures account for less than 1% of all
terminations and generally take place in an inpatient
setting.

1. Installation of saline or urea results in uterine
contractions.
• Although rare, serious complications can occur, including
cardiovascular collapse, cerebral edema , pulmonary
edema, renal failure, and disseminated intravascular
coagulopathy (DIC).
51. 2. Prostaglandins

• Prostaglandins are introduced into the amniotic fluid or by
vaginal suppository or intramuscular injection in later
pregnancy.
• Strong uterine contractions begin within 4 hours and usually 

result in abortion.
• Gastrointestinal side effects (eg, nausea, vomiting, diarrhea, 

and abdominal cramping) and fever can occur.
3. Intravenous oxytocin
Used for later abortions for genetic indications. Requires
patient to go through labor.
52. Medical Abortion
Mifepristone
• Mifepristone (formerly known as RU-486) is a
progesterone antagonist that prevents implantation of the
ovum.
• Administered orally within 10 days of an expected
menstrual period, mifepristone produces a medical abortion
in most patients.
• Combined with a prostaglandin suppository, mifepristone
causes abortion in up to 95% of patients.
•
53. Methotrexate
• Methotrexate has also been used to terminate pregnancy
because it is a teratogen that is lethal to the fetus. It has
been found to have minimal risk and few side effects in the
woman. Its a low cost medication.
Misoprostol
• Misoprostol is a synthetic prostaglandin analog that
produces cervical effacement and uterine contractions.
• Inserted vaginally, misoprostol is effective in terminating
a pregnancy in about 75% of cases.
• When combined with methotrexate or mifepristone,
misoprostol’s effectiveness rate is high.
54. MEDICAL MANAGEMENT
• Before the procedure is performed, a nurse or counselor trained in pregnancy
counseling explores with the patient her fears, feelings, and options.
• A pelvic examination is performed to determine uterine size.
• Laboratory studies before an abortion must include a pregnancy test to confirm the
pregnancy, hematocrit to rule out anemia, Rh determination, and an STD screen.
• A patient with anemia may need an iron supplement, and an Rh-negative patient
may require RhoGAM to prevent isoimmunization.
• Before the procedure, all patients should be screened for STDs to prevent
introducing pathogens upward through the cervix during the procedure.
55. NURSING MANAGEMENT
• Recognize the client’s anxiety and encourage to express her feelings.
• Establish a therapeutic relationship, conveying empathy and
unconditional positive regard.
• Provide comfort measures such as breathing and relaxation techniques.
• Explain procedures before they are performed, and stay with the client
to provide concurrent feedback.
• Determine the extent/severity and location of discomfort.
• Provide comfort measures such as relaxation and breathing techniques.
• Administer narcotic/nonnarcotic analgesics, sedatives, and antiemetics,
as prescribed.
57. • An unsafe abortion is the termination of
a pregnancy by people lacking the necessary skills,
or in an environment lacking minimal medical
standards, or both.
• An unsafe abortion is a life-threatening procedure.
• It includes self-induced abortions, abortions in
unhygienic conditions, and abortions performed by
a medical practitioner who does not provide
appropriate post-abortion attention.
• About 25 million unsafe abortions occur a year, of
which most occur in the developing world.
58. • Unsafe abortions result in complications for about 7 million women
a year.
• Unsafe abortions are also one of the leading causes of deaths during
pregnancy and childbirth (about 5-13% of all deaths during this
period).
• Most unsafe abortions occur where abortion is illegal or
in developing countries where affordable and well-trained medical
practitioners are not readily available, or where modern birth
control is unavailable.
• Unsafe abortion was and is a public health crisis.
• More specifically, lack of access to safe abortion was and is a public
health risk.
• The more restrictive the law, the higher the rates of death and other
complications.
59. Methods of unsafe abortion include:
1.Trying to break the amniotic sac inside the womb with a sharp object
or wire . This method can cause infection or injury to internal organs
resulting in death.
2.Pumping toxic mixtures, such as chili peppers and chemicals
like alum, Lysol, permanganate, or plant poison into the body of the
woman. This method can cause the woman to go into toxic shock and
die.
•
60. 3.Inducing an abortion without medical supervision by self-
administering abortifacient over-the-counter drugs or drugs obtained
illegally or by using drugs not indicated for abortion but known to
result in miscarriage or uterine contraction.
• D r u g s t h a t c a u s e u t e r i n e
contractions include oxytocin , prostaglandins, and ergot alkaloids.
• Risks include uterine rupture, irregular heartbeat, a rise in blood
pressure (hypertension), a drop in blood pressure
(hypotension), anemia requiring transfusion, cardiovascular
problems, pulmonary edema, and death.
