This document defines abortion and discusses the different types of abortion. It defines abortion as the expulsion or extraction of a fetus weighing less than 1000g before 28 weeks of gestation. It classifies abortions as spontaneous or induced, and discusses the various types in more detail including threatened abortion, inevitable abortion, complete abortion, incomplete abortion, missed abortion, and habitual abortion. It also covers septic abortion, its causes, signs and symptoms, investigations, complications and management.

1. ABORTION

2. Introduction
• Any bleeding in pregnancy is abnormal. It is
also known as haemorrhage in early
pregnancy. The term miscarriage and
abortion are synonymous.

3. DEFINITION
• The expulsion or extraction of the fetus or
embryo from the uterus weighing less than
1000gm is called abortion.
OR
• Termination of pregnancy before 28wks. Of
gestation or before the period of viability
either spontaneously or by induction is called
abortion

4. CLASSIFICATION
ABORTION
SPONTANEOUS INDUCED
THREATENED
INEVITABLE
COMPLETE
INCOMPLETE
MISSED
SEPTIC
LEGAL
(MTP)
ILLEGAL
HABITUAL

5. Incidence
• Approximately 20% of all pregnancies are
terminated spontaneously and 80% are
terminated by induction with in 2- 5 months
of gestation.

6. SPONTANEOUS ABORTION
• Spontaneous abortion is defined as the
involuntary loss of the products of
conception prior to 28 weeks of gestation,
when the fetus weighs approximately 1,000
gm or less.

7. CAUSES OF SPONTANEOUS ABORTION
• Maternal cause-
• Structural abnormalities of the genital organ such
as retroversion of uterus, bicornuate uterus and
fibroids
• Maternal Infections such as rubella, UTI,
hyperpyrexia, hepatitis
• Medical condition such as diabetes, renal disease
and thyroid dysfunction, when not well controlled
• Genetic factor

8. • Immunological factor- placental infarction,
placental thrombosis.
• Blood group incompatibility
• Drugs- antimalarial, antipsychotic,
anticonvulsant drugs.
• Environmental factors- excessive
consumption of alcohol & smoking
• Lack of iron & vitamin in diet.
• Exposure to radiation

9. • Fetal cause-
• Chromosomal abnormalities
• Blighted ovum (structural abnormality of
ovum)
• Multiple congenital defects
• Multiple pregnancy

10. TYPES
1.Threatened abortion-
• It is a clinical entity where the process of abortion
has started but has not progressed to a state from
which the recovery is impossible.
• Signs & symptoms-
• Amenorrhea more than 6 wks.
• it is an abortion characterized by vaginal bleeding
with or without uterine contraction.
• The blood loss may be scanty with or without
accompanying backache and cramp like
pain(resembling dysmenorrhoea).

12. • The cervix and uterus feels soft
• Os may be closed, and blood seen in the
external os.
• The outcome of a threatened abortion could
be either stoppage of bleeding by
management and continuation of pregnancy
to term.
• continuation of bleeding and uterine
contraction to expel the products of
conception if not treated.

13. investigations
• Blood- HB estimation, ABO & RH factor,
cross match, VDRL, HIV, torch test, thyroid
function test.
• USG- sometimes a blood clot may be seen
around the gestational sac.
• Urine test- UPT is always +ve. Culture test,
sugar & albumin

14. treatment
• 1. complete bed rest
• 2. drugs- hormonal supportive therapy- HCG
5000 IU ( inj. Proluton 500mg(2ml) deep I/M
twice a week)
• Sedative- T. phenobarb- 30mg HS
T. diazepam 5 mg bd
Laxative- milk of mag or cremaffin 2tsf- HS
enema should be avoided

15. Nursing management
• Advice the woman to Preserve all the vulval pads to
observe amount of bleeding.
• Anything is expelled out from the vagina should be reported
immediately.
• Note the vital signs.
• If bleeding & abdominal pains is aggravated should be
reported immediately.
• Advice patient should limit her activities at least 2 wks.
• Avoid heavy weight lifting
• Avoid unnecessary journey
• Coitus should be avoided in this period

16. • Advice to continue the treatment & follow-up
• Nutritive diet may be advice that may contain
high protein, vitamin & Iron
• Perineal care should be given twice daily
with aseptic technique

17. 2. Inevitable abortion-
• It is a clinical type of abortion where the changes
have progressed to a state from where
continuation of pregnancy is impossible.
• Signs & symptoms-
• In this type of abortion the women present with
bleeding, often heavy, with clots or products of
conception.
• The vaginal examination cervix feels soft, os is
open & blood clot may be seen in the vagina or
protruding through the os.

18. • ↑ pain in the lower abdomen which may be
colicky or like labour pains
• Cervical dilatation & uterine contraction are
present
• Patient may look pallor due to blood loss
• Tachycardia, hypotension, cold & clammy
extrimities, patient may go in shock.
• Investigations- HB%, bloodgroup, RH
factor, USG

19. Treatment
• If pregnancy is less than 12 wks. S/E is done
• Intravenous fluids & blood transfusion to
treat shock.
• If pregnancy is more than 12 wks. Tab.
Misoprost 400 µg p/v or Inj. Oxytocin 20 unit
with 5% dext. Should be given for
spontaneous expulsion.
• If fetus is expelled out & placenta is retained
should be removed by D&C.
• Inj. T.T should be given

20. • If mother is RH-ve than Anti-D 50- 150 µmg.
I/M given.
• If bleeding is excessive should be controlled
by administering inj. Methargin (0.2mg) or
inj. Prostadin 250 mg I/M

21. 3 . Complete abortion –
when the products of conception is expelled
Completely from the uterus & the uterine
cavity is empty it is called complete abotion
S/S- decreased amount of vaginal bleeding
& lower abdominal pain.
- Uterus is smaller than the period of
amenorrhea
- Cervical os is closed

22. • Management-
• Antibiotic, T.T, anti-D( if Rh-ve), methergin
• If bleeding is continous than D&C should be
done.

23. 4. Incomplete abortion-
• When the entire products of conception are
partialy expelled and some products are left
inside the uterine cavity is called incomplete
abotion.
• S/S- continous and profuse vaginal bleeding
• Lower abdominal pain
• Pallor and signs of shock
• Internal os is open
• Uterus feels soft, smaller than the period of
amenorrhea.

24. management
• If pregnancy is less than 12 wks. S/E done.
• If pregnancy is more than 12 wks. I/V oxytocin 20
unit may be given for spontaneous expulsion
• If fetus is expelled & placenta is retained should be
removed by D&C. if placenta is not separated than
S/E is done under G.A
• Inj. Morphine 15 mg should be given before S/E.
inj.T.T, antibiotic should be given before D&C
• Excessive bleeding may be controlled by
administering inj. Methergin/ prostadin or tab.
Misoprost 200µg P/R

25. 5. Missed abortion-
This is also known as silent miscarriage
• The embryo dies despite the presence of
viable placenta and retained inside of the
uterus
• Death of the embryo occurs but the
mothers body fails to recognize the
demise.

26. Signs & symptoms
• H/O brownish vaginal discharge or spotting
• Retrogression of breast changes
• Ceasation of uterine growth
• FHS may not be audible (after 20 wks.) in
late pregnancy
• Cervix feels firm, internal os closed
• ↓fetal movement in late pregnancy
• Uterus size is smaller than period of
gestation

27. investigations
• UPT- becomes –ve
• USG- reveals absence of FHS
• X-ray- shows patchy skeletal shadows
• Blood- B.T,C.T, platelet count, HB should be
done

28. management
• If pregnancy is less than 12 wks.- D&C/ S&E
of uterine cavity under G.A
• Antibiotic should be given without delay
• If more than 12 wks.- induction is done by
oxytocin (10-20 unit with 5%D) at the rate of
30 drops/min
• Prostaglandin ( tab. misoprost/carboprost)
should be given for cervical dilatation

29. 6. Habitual abortion
• Occurrence of spontaneous abortion in 3 or
more successive pregnancy is called
recurrent of habitual abortion, it may be
occur in first or second trimester
• Causes-
maternal diseases- syphilis, diabetes, chronic
nephritis, hypertension, RH incompatibility,
metritis, TORCH test is +ve
Progestrone defficiency- luteal phase defect

30. investigations
• Blood group & Rh factor
• HB, complete blood count
• Urine- routine, microscopic & culture
• Glucose tolerance test
• Liver, thyroid, renal function test
• TORCH test
• Cervical swab culture
• USG, hysterosalpingogram- to visualize the
uterus & fallopian tube for any infection

31. management
• Systemic illness should be treated promptly
• Hormonal therapy is useful in case of luteal
defects.
• The patient should be advice for adequate
rest & appropriate diet
• In case of cervical incompetence cervical
encircling should be done between 3- 4
month of pregnancy ( this operation is called
shirodkar suture/ macdonald suture)
• At the time of delivery(37- 38wks.)this suture
is cut to allow the vaginal delivery.

32. 7. Septic abortion- characterized by infection
of the products of conception in uterus, this
condition is mostly common in induced or
incomplete abortion, some illegal abortion carried
out in non- sterile conditions often lead to septic
abortion.
C/M- pyrexia 100.4 & above chills with rigor
• c/o vomiting & diarrohea
• Abdominal pain
• Foul smelling vaginal discharge which is often
purulent
• Vaginal bleeding with products of conception

33. • Pallor & sweating
• Tachycardia and ↓ B.P
• Abdominal distension and tenderness
• Signs of toxemia
• Clinical grading of infection-
• Grade-I- localized in the uterus- involves
endometrium & myometrium
• Grade-II- infection spread beyond the uterus,
tubes, ovaries & pelvic structure also.
• Grade-III- generalized peritonitis or endotoxic
shock, jaundice & acute renal failure.

34. investigations
• Complete blood count & urinalysis
• BUN & serum electrolytes
• High vaginal swab
• Blood culture if septicemia suspected
• Pelvic USG
• Blood coagulation profile
• X-ray of pelvis & abdomen.

35. complications
• Hemorrhage
• Injury may occur to uterus & other organs
• Peritonitis
• Perforation of the uterus
• Endotoxic shock
• Acute renal failure
• thrombophlebitis

36. management
• Hospitalized the patient- start I/V fluids
• Broad spectrum antibiotics I/V should be started
• Take high vaginal swab & blood culture for
investigations
• If pelvic abscess is present should be drain out
• Vital signs should be monitored- if pyrexia should
be treated with antipyretic
• Strict I/O charting
• Uterus should be evacuated to remove the source
of infection

37. Cont.
• Blood transfusion should be done if needed
• If patient is having respiratory difficulty O2
should be provided
• Laporotomy will also be needed if there is no
response to evacuation & adequate medical
therapy.

38. MEDICAL TERMINATION OF
PREGNANCY
(LEGAL ABORTION)
• It is the deliberate induction of labour
prior to viability of the fetus (before 28
weeks gestation) by a registered
medical practitioner in the interest of
mother’s health and life.

39. Provision of MTP under the MTP Act
indications
• The pregnancy would involve serious risk of life
or grave injury to the physical and mental health
of the pregnant women
• There is risk of child being born with serious
physical and mental abnormalities.
• The pregnancy is result of rape
• The pregnancy is caused as a result of failure of
contraceptives where there are social or
economic environment which could lead to risk or
injury to the health of the mother

40. • Chronic diseases like cervical or breast
malignancy, psychiatric illness
• Exposure to teratogenic drugs or radiation in
early pregnancy
• Rubella infection in 1st trimester
• Congenital malformation of the fetus.

41. Methods of termination in
first trimester
• MVA (manual vaccum aspiration- before 7wks.)
• Suction evacuation & curretage (upto 12 wks.)
• Dilatation and evacuation (slow method)
• Pharmacological methods (mifepristone,
methotrexate)

42. Methods of termination in second
trimester
• Intrauterine instillation
• Extra uterine instillation
• Prostaglandin and oxytocin
• Hysterotomy

43. Intrauterine (intra-amniotic)
instillation
• Between 16-20 wks.- (Hypertonic solution 20%
saline)
• Preliminary amniocentesis is done (18 no. needle)
I/V drip set is connected with hypertonic solution.
The amount of saline to be instilled is calculated as
no. of wks. Of gestation multiplied by 10. the rate
of infusion is 10ml/min.
• Eg. G.A = 16 wks. X 10= 160 ml should be run in
16 min.
•

44. complications
• Should not used in cardiac, renal or severe
anemic patient because of sodium load.
• Hypernatremia
• Retained products
• Infection- endometriosis
• Sometimes hypotension & shock
• Cervical tear & laceration
• Fever, nausea & vomiting, abdominal pain

45. Extra uterine (extra-amniotic) instillation
• Instillation of 0.1% ethacrydine lactate (M-
cradil, vicradyl)
• No.16 foleys catheter is introduced through
the cervical canal about 10 cm. above the
internal os b/w the membrane & myometrium
and the balloon is inflatted (10-15ml saline)
this method is less hazardous and effective
90-95%.

46. Complications of extra uterine instillation
• trauma to the cervix leading to haemorrhage
& shock.
• Atonic uterus
menstrual disturbance
• Chronic pelvic inflamation
• Endometriosis
• Infertility
• Recurrent mid trimester abortion due to
cervical incompetence
( cervix become weak)

47. Cont.
• Ectopic pregnancy
• Premature labour pains
• Rupture uterus
• Dysmaturity
• Rh-isoimmunization in Rh-ve woman if not
protected with immunoglobulin.

48. • Oxytocin & prostaglandin is used with intra-
uterine & extra-uterine instillation.
• Hysterotomy is done when the extra- uterine
instillation is failed.