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Abortion seminar

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easy for the students those who want to study abortion in a easy way

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Abortion seminar

  1. 1. WELCOMEWELCOME
  2. 2. ABORTION
  3. 3. 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” Dutta D. C • “Abortion is defined as [a] fetus or embryo removed or expelled from the uterus during the first half of gestation—20 weeks or less, or in the absence of accurate dating criteria, born weighing < 500 g." -The National Center for Health Statistics
  4. 4. CLASSIFICATION OF ABORTION SPONTANEOUS INDUCED
  5. 5. Spontaneous abortion • Abortion occurring without medical or mechanical means to empty the uterus is referred to as spontaneous • Another widely used term is miscarriage • Pathology • Hemorrhage into the decidua basalis, followed by necrosis of tissues adjacent to the bleeding • If early, the ovum detaches, stimulating uterine contractions • Gestational sac is opened , fluid surrounding a small macerated fetus or alternatively no fetus is visible → blighted ovum
  6. 6. Spontaneous abortion • Pathology • In later abortion, the retained fetus may undergo maceration • The skull bones collapse, the abdomen distends with blood- stained fluid, and the internal organs degenerate • The skin softens and peels off in utero or at the slightest tough • When amniotic fluid is absorbed, the fetus may become compressed and desiccated → fetal compressus • The fetus become so dry and compressed that it resembles parchment – a fetus papyraceous
  7. 7. Spontaneous abortion • Etiology • More than 80 percent of abortions occur in the first 12 weeks of pregnancy • At least half result from chromosomal anomalies • After the first trimester, both the abortion rate & the incidence of chromosomal anomalies decrease
  8. 8. Spontaneous abortion • The exact mechanism responsible for abortion are not apparent • In the first 3 months of pregnancy • Death of the embryo or fetus nearly always precedes spontaneous expulsion of the ovum • Finding of the cause of early abortion involves ascertaining the cause of fetal death • In subsequent months • The fetus frequently does not die before expulsion − Other explanations for its expulsion should be sought
  9. 9. Spontaneous abortion - Fetal factors • Abnormal zygotic development • Early spontaneous abortion commonly display a developmental abnormality of the zygote, embryo, early fetus, or placenta • 1000 spontaneous abortions analyzed by Hertig and Sheldon • Half demonstrated degenerated or absent embryos, that is, blighted ova
  10. 10. F9-3
  11. 11. Spontaneous abortion - Fetal factors • Aneuploid abortion • Approximately 50 to 60 percent of embryos and early fetuses that are spontaneously aborted contain chromosomal abnor-malities accounting for most of early pregnancy wastage • Jacobs and Hassold (1980) • 95 percent of chromosomal abnormalities − d/t maternal gametogenesis error • 5 percent → d/t paternal error
  12. 12. Spontaneous abortion - Fetal factors • Aneuploid abortion - Autosomal trisomy • The most frequently identified chromosomal anomaly associated with first-trimester abortions • Most trisomies result from isolated nondisjunction , balanced structural chromosomal rearrangements are present in one partner in 2 to 4 percent of couples with a history of recurrent abortions • Autosomes 13, 16, 18, 21, and 22 – most
  13. 13. Spontaneous abortion - Fetal factors • Monosomy X • The second frequent chromosomal abnormality • Usually results in abortion • Much less frequently in liveborn female infant (Turner syndrome) • Triploidy • Associated with hydropic placental (molar) degeneration • Incomplete (partial) hydatidiform moles may contain triploidy or trisomy for only chromosome 16
  14. 14. Spontaneous abortion - Fetal factors • Tetraploid abortuses • Rarely are liveborn and most often are aborted early in gestation • Chromosomal structural abnormalities • Identified only since the development of banding techniques, infrequently cause abortion
  15. 15. Spontaneous abortion - Fetal factors • Euploid abortion • Abort later in gestational than aneuploid • Three fourths of aneuploid abortions occurred before8 weeks • Euploid abortions peak at about 13 weeks • The incidence of euploid abortions increased dramatically after maternal age exceeded 35 years
  16. 16. Spontaneous abortion – Maternal factors • Infections • Uncommon causes of abortion in human • Listeria monocytogenes • Clamydia trachomatis • Mycoplasma hominis • Ureaplasma urealyticum • Toxoplasma gondii
  17. 17. Spontaneous abortion – Maternal factors • Chronic debilitating diseases • In early pregnancy, fetuses seldom abort secondary to chronic wasting disease such as tuberculosis or carcinomatosis
  18. 18. Spontaneous abortion – Maternal factors • Endocrine abnormalities • Hypothyroidism • Iodine deficiency associated with excessive miscarriages • Thyroid autoantibodies → incidence of abortion↑ • Diabetes mellitus • The rates of spontaneous abortion & major congenital malformations • Poor glucose control → incidence of abortion↑ • Progesterone deficiency • Luteal phase defect • Insufficient progesterone secretion by the corpus luteum or placenta
  19. 19. Contd… • Nutrition • Dietary deficiency of any one nutrients → not important cause • Drug use and environmental factor • Tobacco • ↑ Risk for euploid abortion • More than 14 cigarettes a day → the risk twofold greater ↑ • Alcohol • Spontaneous abortion & fetal anomalies → result from frequent alcohol use during the first 8 weeks of pregnancy • Drinking twice a week → abortion rates doubled ↑ • Drinking daily → abortion rates tripled ↑ • Caffeine • At least 5 cups of coffee per day → slightly increased risk of abortion
  20. 20. Contd… • Drug use and environmental factor • Radiation • Contraceptives • When intrauterine devices fail to prevent pregnancy → abortion↑ • Environmental toxins • Anesthetic gases : exact fetal risk of chronic maternal exposure is unknown • Arsenic, lead, formaldehyde, benzene, ethylene oxide → abortifacient • Video display terminal & accompanying electromagnetic fields short waves & ultrasound do not increase the risk of abortion
  21. 21. • Immunological factors – autoimmune factors • Recurrent pregnancy loss patients : 15% • Antiphospholipid antibody : most significant • LCA (lupus anticoagulant), ACA (anticardiolipin Ab) • Reduce prostacyclin production → facilitating thromboxane dominant milieu → thrombosis • Prostacyclin : produced by vascular endothelial cell → potent vasodilator & inhibit platelet aggregation • Thromboxane A2 : produced by platelets → vasoconstrictor & platelet aggregator • Strong association with − Decidual vasculopathy , placental infarction, fetal growth restriction Early-onset preeclampsia, recurrent abortion, fetal death
  22. 22. Spontaneous abortion – Maternal factors • Immunological factors – autoimmune factors • Therapy of anti phopho lipid antibody syndrome : low dose aspirin, prednisone, heparin, intravenous Ig → affect both immune & coagulation system → counteract the adverse action of antibodies
  23. 23. Spontaneous abortion – Maternal factors • Inherited thrombophilia • Many studies of aggregated thrombophilias → excessive recurrent abortions • Laparotomy • Surgery performed during early pregnancy → no evidence of tncreased abortion • Peritonitis increases the likelihood of abortion • Physical trauma • Major abdominal trauma → abortion↑
  24. 24. • Uterine defects – acquired uterine defects • Uterine leiomyoma : usually do not cause abortion • Placental implantation over or in contact with myoma → placental abruption, abortion, preterm labor ↑ → location is more important than size • Uterine synechiae (Asherman syndrome) • Partial or complete obliteration of the uterine cavity by adherence of uterine wall • Cause : destruction of large areas of endometrium by curettage → insufficient endometrium to support implantation & menstruation → recurrent abortion, amenorrhea, hypomenorrhea
  25. 25. Spontaneous abortion – Maternal factors • Uterine defects – developmental uterine defects • Consequence of abnormal mullerian duct formation or fusion • Spontaneously • Induced by in utero exposure to DES (diethylstilbestrol) Bi Septate Bi carnuate
  26. 26. • Incompetent cervix • Painless dilatation of cervix in the 2nd or early in the 3rd trimester → prolapse & ballooning of membranes into vagina → rupture of membrane & expulsion of immature fetus • Unless effectively treated, tends to repeat in each pregnancy • Diagnosis in nonpregnant women • Hysterography • Pull-through techniques of inflated Foley catheter balloons • Acceptance without resistance at the internal os of specifically sized cervical dilators • The use of trans vaginal ultrasound in pregnant women • Cervical length - shortening • Funneling
  27. 27. Spontaneous abortion – Maternal factors • Incompetent cervix – Cerclage procedures • Types of operations commonly used • McDonald • Modified Shirodkar → 85~90% success rate
  28. 28. Spontaneous abortion – Paternal factors • Little is known in the genesis of spontaneous abortion • Chromosomal translocations in sperm can lead to abortion
  29. 29. Categories of spontaneous abortion • Threatened abortion • Inevitable abortion • Complete • incomplete abortion • Missed abortion • Recurrent abortion • Septic
  30. 30. Threatened abortion • Definition • Any bloody vaginal discharge or bleeding during 1st half of pregnancy • Bleeding is frequently slight, but may persist for days or weeks • Frequency • Extremely common (one out of four or five pregnant women) • Prognosis • Approximately ½ will abort • Risk of preterm delivery, low birthweight, perinatal death↑ Categories of spontaneous abortionCategories of spontaneous abortion
  31. 31. Threatened abortion • 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 • Treatment • Bed rest & acetaminophen-based analgesia • Progesterone (IM) or synthetic progestational agent (PO or IM) • Lack of evidence of effectiveness • Often results in no more than a missed abortion • D-negative women with threatened abortion • Probably should receive anti-D immunoglobulin
  32. 32. Threatened abortion • Treatment : slight bleeding persists for weeks • Vaginal sonography • Serial serum quantitative hCG • Serum progesterone → can help ascertain if the fetus is alive & its location • Vaginal sonography • Gestational sac(+) & hCG < 1000mIU/ml → gestation is not likely to survive → If any doubt(+), check the serum hCG level at intervals of 48hrs → if not increase more than 65%, almost always hopeless • Serum progesterone value < 5 ng/ml → dead conceptus
  33. 33. Threatened abortion • Treatment : 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
  34. 34. Inevitable abortion • Gross rupture of membrane, evidenced by leaking amnionic fluid, in the presence of cervical dilatation, but no tissue passed during 1st half of pregnancy • Placenta (in whole or in part) is retained in the uterus → Uterine contractions begin promptly or infection develops • The gush of fluid is accompanied by bleeding, pain, or fever, abortion should be considered inevitable
  35. 35. Complete or incomplete abortion • Complete abortion • Following complete detachment & expulsion of the conceptus • The internal cervical os closes • Incomplete abortion • Expulsion of some but not all of the products of conception during 1st half of pregnancy • The internal cervical os remains open & allows passage of blood • The fetus & placenta may remain entirely in utero or may partially extrude through the dilated os → Remove retained tissue without delay
  36. 36. Missed abortion • Retention of dead products of conception in utero for several weeks • Many women have no symptoms except persistent amenorrhea • Uterus remain stationary in size, but mammary changes usually regress → uterus become smaller • Most terminates spontaneously • Serious coagulation defect occasionally develop after prolonged retention of fetus
  37. 37. Recurrent abortion • Definition : Three or more consecutive spontaneous abortions • Clinical investigation of recurrent miscarriage • Parental cytogenetic analysis • Lupus anticoagulant & anticardiolipin antibodies assays • Post conceptional evaluation • Serial monitoring of ß–hCG from missed menses 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
  38. 38. Septic abortion • A septic abortion or septic miscarriage is a form of miscarriage that is associated with a serious uterine infection. The infection carries risk of spreading infection to other parts of the body and cause septicemia, a grave risk to the life of the woman Causes • A septic abortion can occur when bacteria enters the uterus. The bacteria may also belong to the vaginal flora. Also, sexually transmitted infections (STI) such as chlamydia may also cause septic abortion.
  39. 39. Symptoms • High fever, usually above 101 °F • Chills • Severe abdominal pain and/or cramping /or strong perineal pressure • Beginning miscarriage symptoms (heavy bleeding and or cramping) that suddenly stops and does not resume • Prolonged or heavy vaginal bleeding • Foul-smelling vaginal discharge • Backache or heavy back pressure
  40. 40. Managament • The woman should have intravenous fluids to maintain blood pressure and urine output. Broad-spectrum intravenous antibiotics should be given until the fever is gone. • Prevention • Better birth control and legal abortion (to prevent unsafe abortions) have dramatically reduced the number of septic abortions. To decrease the risk further, a woman should be tested for common sexually transmitted infections in the first trimester of her pregnancy. If a woman thinks she might be miscarrying or has miscarried, she should call her healthcare provider immediately.
  41. 41. INDUCED ABORTION
  42. 42. 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
  43. 43. Induced abortion • Indication • Continuation of pregnancy may threaten the life of women or seriously impair her health • Persistent heart disease after cardiac decompensation • Advanced hypertensive vascular disease • 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
  44. 44. Induced abortion • 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
  45. 45. Surgical techniques for abortion • Dilatation and curettage • Performed first by dilating the cervix & evacuating the product of conception • Mechanically scraping out of the contents (sharp curettage) • Vacuum aspiration (suction curettage) • Both • Before 14 weeks, D&C or vacuum aspiration should be performed • After 16 weeks, dilatation & evacuation (D&E) is performed • Wide cervical dilatation • Mechanical destruction & evacuation of fetal parts
  46. 46. Surgical techniques for abortion • Hygroscopic dilators : swell slowly & dilate cervix → cervical trauma can be minimized • Laminaria tents : stem of brown seaweed ( Laminaria digitata or japonica) → drawing water from proteoglycan complexes of cervix → dissociation allow the cervix to soften & dilate • Insertion technique : tip rests just at the level of internal os • Usually after 4-6hours, laminaria dilate the cervix sufficiently to allow easier mechanical dilation & curettage • May cause cramping pain → easily managed with 60 mg codeine every 3-4 hours
  47. 47. Surgical techniques for abortion • Menstrual aspiration • Aspiration of endometrial cavity using a flexible cannula and syringe within 1-3 weeks after failure to menstruate • Several points at early stage of gestation • Woman not being pregnant • Implanted zygote may be missed by the curette • Failure to recognize an ectopic pregnancy • Infrequently, a uterus can be perforated
  48. 48. Surgical techniques for abortion • Laparotomy • Abdominal hysterotomy or hysterectomy • Indications • Significant uterine disease • Failure of medical induction during the 2nd trimester
  49. 49. Medical induction of abortion • Early abortion • Outpatient medical abortion is an acceptable alternative to surgical abortion in women with pregnancies of less than 49 days’ gestation • Three medications for early medical abortion • Antiprogestin mifeprostone • Antimetabolite methotrexate • Prostaglandin misoprostol
  50. 50. Medical induction of abortion • Oxytocin • Successful induction of 2nd trimester abortion is possible with high doses of oxytocin administered in small volumes of IV fluids • Satisfactory alternatives to PG E2 for midtrimester abortion • Laminaria tents inserted the night before • Chance of successful induction is greatly enhanced
  51. 51. Prostaglandins • Used extensively to terminate pregnancies, especially in the 2nd Trimester • PG E1, E2, F2α • Technique : Can act effectively on the cervix & uterus (86~95% effectiveness) • Vaginal prostaglandin E2 suppository & prostaglandin E1 (misoprostol) • As a gel through a catheter into the cervical canal & lowermost uterus • Injection into the amnionic sac by amniocentesis • Parenteral injection • Oral ingestion
  52. 52. Intra-amnionic hyperosmotic solutions • 20-25% saline or 30-40% urea injected into amnionic sac → stimulate uterine contraction & cervical dilatation • Action mechanism : prostaglandin mediated • Complications of hypertonic saline • Death • Hyperosmolar crisis (early into maternal circulation) • Cardiac failure • Septic shock • Peritonitis • Hemorrhage • DIC • Water intoxication − Hyperosmotic urea : less likely to be toxic
  53. 53. Resumption of ovulation after abortion • Ovulation may resume as early 2 weeks after an abortion • Therefore, if pregnancy is to be prevented, effective contraception should be initiated soon after abortion
  54. 54. Contra indications • • pregnancy beyond 63 days of gestation • • suspected ectopic pregnancy • • evidence of adrenal dysfunction • • hemorrhagic disorders treated with anti-coagulants • • where the duration of pregnancy is not known
  55. 55. Side effects • • nausea • • occasional vomiting • • malaise • • faintness • • headache • • skin rashes
  56. 56. Signs and symptoms of abortion • Bleeding which progresses from light to heavy • Severe cramps • Abdominal pain • Fever • Weakness • Back pain
  57. 57. Ultra sound riteria • Crown-rump length of at least 7 mm and no heartbeat. • Mean gestational sac diameter of at least 25 mm and no embryo. • Absence of embryo with heartbeat at least 2 weeks after an ultrasound scan that showed a gestational sac without a yolk sac. • Absence of embryo with heartbeat at least 11 days after an ultrasound scan that showed a gestational sac with a yolk sac.
  58. 58. MTP Act • 1971 • Indications • Pre requisites • Performing personnel
  59. 59. Post abortion care • Prevention • • Treatment • • Counseling and services
  60. 60. Essential elements • Community and service provider partnerships for prevention (of unplanned • pregnancies and unsafe abortion); • 2. Counseling to identify and respond to women's emotional and physical health • needs and other concerns; • 3. Treatment of incomplete and unsafe abortion and complications that are • potentially life-threatening; • 4. Contraceptive and family planning services to help women prevent an unplanned pregnancy or practice birth spacing; and • 5. Reproductive and other health services that are preferably provided on-site or via referrals to other accessible facilities in providers' networks.
  61. 61. Nursing assessment • Vaginal bleeding , spotting, clots • Low abdominal cramping • Passing of tissue • Shock – decreased blood pressure, increased heart rate. • Fear, anxiety, disappointment, and feeling of guilt.
  62. 62. Nursing diagnoses • Risk for fatal injury • Risk for fluid volume deficit • Ineffective air way clearance • Actual/ risk for aspiration • Risk for infection • Ineffective family coping • Ineffective family process • Health seeking behavior
  63. 63. IMPLEMENTATION • Observe for vaginal bleeding and cramping pain • Save expelled tissue and lot for examination • Monitor vital signs for every 5 minutes to 4 hours according to the maternal status • Maintain woman on bed rest • Observe for signs of shock, and institute treatment measures • Prepare for dilation and curettage if appropriate • Assess signs of infection • Handle every article in a sterile manner • Provide support but avoid false assurance.
  64. 64. Complication Shock Infection Coagulation failure Thromboembolism Infertility
  65. 65. Thank you friends

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