Abortion

Dr. Asmaa Morgan

Lecturer of Obstetrics and
Gynevological Nursing
 A) Abortion

It is the termination of pregnancy before 20- 24

Weeks, or products of conception weighing
below 500g.

Abortion may be spontaneous or induced.

About 20% of all pregnancies end in abortion.

Incidence:
Six out of 10 of all unintended pregnancies
end in an induced abortion.

Around 45% of all abortions are unsafe, of

which 97% take place in developing countries.
 Etiology of spontaneous abortion :
Fetal

1- Chromosomal abnormalities
2-Diseases of fetus
Maternal
3-Hypoxia
A] General conditions B] Local
conditions
1- Acute febrile (fever) 1-Trauma to the abdomen
2- Chronic nephritis 2-Incompitant cervix
4- Drugs. 3- Uterine malformation
5- Psychological disturbances 4- lower uterine implantation
6- Endocrine dysfunctions.
7- RH incompatibility
‫صورة لجنين برأسين ورقبتين بجسد‬
‫واحد تم إجهاضه‪.‬‬
 Types of abortion :

1 Threatened. 6 Septic .
2 Inevitable .
8 Therapeutic .

3 Incomplete . 9 Criminal

4 Complete . 10 Recurrent .

5 Missed .
 Signs and Symptoms of
Abortion / Miscarriage :
• Abortions can occur in two ways:
• Death of the embryo or the fetus followed by its
expulsion from the uterus. This is usually seen in
very early pregnancies.

• Abnormal uterine activity causing the uterus to

expel a healthy fetus. This is usually a feature of
abortions in the second trimester (after 13
completed weeks of pregnancy).
 Signs and Symptoms:
pain and bleeding

If the death of the fetus occurs first, the woman will

notice bleeding as her first symptom. Death causes
separation of the product of gestation

(embryo + early placenta and membranes) from the

uterine wall. This causes bleeding which is slight at
first but later increases. The woman may complain of
passage of blood clots per vagina.
 Pain occurs when the uterus starts to contract to
expel the product of gestation. It is usually
intermittent and is often described as ‘colicky’.

 Pain continues to increase until the product is

expelled from the uterus.

 If the abortion is due to abnormal uterine

activity, pain is the first symptom followed by
bleeding.
 1
Threatened abortion
Starts with pain that occurs as a result of abnormal
uterine activity.
The embryo is usually live.

Signs & symptoms

A crampy pain that may increases in severity.
- A mild bleeding or blood stained vaginal discharge can
occur.
-The cervix remains closed, and membranes are intact
-There is a possibility of continuation of the pregnancy on
proper and timely management .
 Nursing management of Threatened abortion

The aim of treatment is to try and conserve the

pregnancy by decreasing the uterine contractions.

- Complete bed rest

-Estimate the amount of blood loss, color, and content.
-Checking vital signs/4h.
-Measures to avoid constipation or diarrhea
-Enema is contraindicated
-Provide good hygienic care
-Provide diet rich in protein, iron, and Vit. C
-Instruction to avoid sexual intercourse .
Medical treatment of Threatened abortion

- Uterine relaxants like ritodrine or isoxsuprine

hydrochloride .
- Sedatives to prevent uterine contraction as
phenobarbital 60 mg.
- Pethidine for pain.
- Human Chorionic Gonatrophin (HCG) injections
can also be prescribed to support the
pregnancy.
- Progesterone supplements are given if
progesterone deficiency is suspected to be the
cause of the threatened abortion.
 2 Inevitable abortion

If the treatment of threatened abortion is

not adequate or timely, the abortion may
become inevitable.

Signs and symptoms

- Severe colicky lower abdominal pain
-Bleeding is excessive (more than 10 days).
-Blood is red in color with clots.
- Dilation of the cervix and the process of
expulsion of fetus cannot be stopped.
- The women may becomes shock
 Medical Treatment of inevitable abortion

The aim of treatment is to prevent further pain and

bleeding
by emptying the uterus as early as possible.

- Oxytocin in solution to help expulsion of the uterine

content

- Dilation of the cervix and curettage (D&C) of the

uterine cavity.

- If bleeding is already severe, supportive treatment

like IV fluids and blood transfusion may also become
necessary.
Suction Aspiration or Vacuum
Aspiration Abortion
 Nursing Management of inevitable abortion

Before D&C or induction

• Measuring vital signs
• Observe amount of bleeding
• Encourage bed rest
• Administer prescribed medication as ,sedative &
analgesics,…..
• Provide comfortable measures as, back rub
• Prepare client physically & emotionally for D&C
• I.V Dextrose 5% + oxytocin for induction as order
• Prepare the needed instruments.
 Nursing Management of inevitable abortion

• After D&C or induction

• Emotional support
• Administer RHIg if indicated
• I.V infusion monitoring
• Administer blood transfusion and antibiotic if
prescribed
Teach the client about:
• Family planning methods
• Measures to reduce breast discomfort due to
breast engorgement.
 3 Incomplete Abortion

Some part of the gestational tissue (embryo+

early placenta +membranes) may be retained
within the uterus during the process of abortion
while other parts may be expelled.
Signs & symptoms
- Severe bleeding
-Parts of product are expulsed
-Pain may or may not present
-Cervical os is partly opened.
-Uterus is soft & smaller than expected period of pregnancy
Medical & Nursing management as
in Inevitable abortion
 4 Complete Abortion

The embryonic and placental components have been

expelled completely without assistance.

Signs & Symptoms

-Complete cessation of pain

- Minimal bleeding.
- Uterus is hard and smaller
- Cervix is closed

An ultrasonography becomes necessary to confirm that

the uterus is empty.

Treatment: Supportive, with prophylactic antibiotics.

 5
Missed Abortion

The product is dead but retained inside the uterus.

An USG is necessary to confirm the diagnosis.
Signs & Symptoms
- Missed menstruation for a month or two.
- Mild brown vaginal discharge. Bleeding is rare.
- Signs of pregnancy disappear
- Size of the uterus found to be smaller than the
duration of pregnancy.
-Absence fetal heart rate.
- Pregnancy test become negative.
-Cervix is closed.
-Secretion of milk may occur.
 Medical Treatment of Missed Abortion

• The aim is to remove the dead product as

early as possible.
- Oycytocin in solution to help expulsion of
the uterine content
- Dilation of the cervix and curettage (D&C)
of the uterine cavity.

Nursing Management include care

before and after D&C
 6 Septic abortion

A type of abortion where there is sepsis or infection

of the uterus and its contents.
- The underlying abortion is usually incomplete, but
- Sometimes, inevitable or threatened.
- It is more commonly seen in criminal abortions.
- Extra-uterine spread of infection can occur.
Signs & Symptoms
-High fever.
- Offensive vaginal discharge which may be blood stained.
-Tender painful uterus.
-Rapid pulse, chills
-Unstable blood pressure
- Shock
 Medical treatment of septic abortion

-High-grade antibiotics.

-Anti-inflammatory drugs are given.

-An IV line to provide fluids and nutrition to the patient.

-If the infection is restricted to the uterus, careful

evacuation of the products are carried out.

-If there is evidence of spread of infection outside

the uterus, evacuation is carried out only after the

infection has been controlled.

Nursing Management of septic abortion

- Isolation
- Accurate observation of vital signs
- Soiled pads probably collected & burned
- Administered prescribed medications & fluids.
- I&O chart
- General hygienic care.
- Accurate observation of renal functions.
- Bacteriological & hematological investigations
 7 - Recurrent abortion
• Habitual Abortion: When three or more
abortions have occurred consecutively and
spontaneously.

Causes :
Cervical Incompetence: The most important cause.
may due to congenitally weakness, lacerations or injury
to any cause (childbirth).
- RH incompatibility
-Chronic nephritis, and essential hypertension
-Uncontrolled DM.
-Toxoplasmosis
-Hormonal deficiency.
-Uterine fibroids or malformation.
Treatment of recurrent abortion
Prophylactic therapy should be started when
the woman is in a non pregnant state through
prevention of its causes.
Investigations to identify the cause :
– blood tests for hormonal levels and for
infections, blood glucose level, Ultra sonography
(USG) for uterine causes, Histo-salpenography
(HSG) to identify cervical incompetence and for
uterine causes.
 Treatment depend on the cause
Once a new pregnancy has started, treatment
is as the identified cause.

** If cervical incompetence is the cause, the

cervical opening is sutured (tied up) until the
37th week of gestation.

** Hormonal deficiencies and infections are

treated by medicines and bed rest.
 8- Therapeutic abortion

Termination of pregnancy before

viability for medical reason .
 9- Criminal abortion

Termination of
pregnancy before
viability for non
medical reason .
Safe Abortion Care
 Nursing diagnosis
The risk for infection (including pelvic
inflammatory disease) related to the dilated
cervix and open uterine vessels

Acute pain related to uterine cramping

secondary to the expulsion of some products of
conception
Fluid volume deficit related to profuse vaginal
bleeding secondary to incomplete abortion

Nausea and vomiting

Fever

Vaginal discharge

Anxiety
 Post-abortion Complications
Develop as a result of three major mechanisms:
Infection.

Incomplete evacuation of the products of

conception, leading to hemorrhagic
complication.

Injury from the surgical procedure itself.

 Risk Factors for
complications

The frequency and severity of abortion

Gestational age at the time of the abortion

The method of abortion.

Complications based on gestational age are as
follows:
Eight weeks and under - Less than 1%
8-12 weeks - 1.5-2%
12-13 weeks - 3-6%
2nd trimester - Up to 50%
 Nursing management
 Monitor vital signs frequently.

 Patient preparation: 2 large-bore IVs and oxygen,

Blood crossmatching and typed in cases of bleeding.

 Obtain a thorough gynecological and obstetric history

so as not to miss any other cause of the symptoms.
 Cont;
 Keep the patient in the supine position for easily
underestimate the rate and amount of bleeding.

 Check the vaginal area for blood.

 Post-abortion: If the patient has abdominal pain, the

gynecologist should be consulted as possible and a
CT scan/ diagnostic laparoscopy ordered. To detect/
prevent uterine perforation.

 Tender abdomen with peritoneal signs may indicate

to bowel injury.
 Cont;
In any post-abortion patient, clinicians should
never rule out an ectopic pregnancy.

If the patient appears septic, broad-spectrum

antibiotics need to be started.

Consider the fact that the patient may have

retained products of conception, which may be
the cause of complications.
 Cont;
 Provide psychological support as the patient may go
through anxiety and maintain the confidentiality of
the patient.
When To Seek Help
If the patient is hemodynamically unstable
Acute vaginal bleeding
Diffusely tender abdomen
High-grade fever
If the patient is unresponsive
No urine output
 Heath Education
 Educate the patient on proper contraceptive measures
as a means of birth control, to avoid unwanted
pregnancies.

 The patient should be urged to remain compliant with

antibiotic therapy if the abortion was septic.

 Educate the patient to pay more attention to nutrition

(iron-containing diet) to prevent anemia.
 Cont;
Encourage adequate fluid intake to maintain
fluid and electrolyte balance in the body.

Avoid exertion and heavy exercises and

promote rest for 2 weeks.

Avoid long travels.

Avoid drinking alcohol for at least 48 hours as

it may increase the risk of heavy bleeding.