BOOK PICTURE PATIENT PICTURE

DEFINITION

Abortion is the expulsion or extraction from its

mother of an embryo or foetus weighing 500gm or
less when it is not capable of independent survival.
-WHO

Early abortion at 11 weeks

Early Abortion: Before 12 weeks
Late Abortion: From 12-20 weeks

ETIOLOGY:
1.Ovular or Foetal factor
a) Ovo-foetal factors-
 Chromosomal abnormality
 Gross congenital malformation
 Blighted ovum
 Hydronic degeneration of villi
 Death or Disease of foetus
b) Interference with circulation-
 Knots
 Twists
 Entanglements
c) Low attachment of placenta
d) Twins or Hydramnios.
Unknown factors
2. Unknown factors
3. Maternal factors (15%):
 Maternal medical illness
 Cyanotic heart diseases
 Infections
 Maternal hypoxia
 Chronic illness
  Endocrine and metabolic factors
Anatomical abnormalities
Cervico-uterine factors-
 Cervical incompetence
 Congenital malformation of uterus
 Uterine fibroid
 Intrauterine adhesions
 Retroverted uterus
**Trauma
 Direct
 Psychic Susceptible individual
 Amniocentesis
**Toxic agents
4.Blood group incompatibility
5. Premature Rupture of Membranes
6.Environmental factors
 Smoking,
 alcoholism X-ray, Radiation,
 Chemotherapy.
7.Dietic factors
8.Paternal factors: Chromosomal anomaly in
sperm
9.Infections
 Viral, Bacterial or Parasitic
10. Inherited Thrombophilia
11.Immunological disorder
• Autoimmune disease (mother's immune system
will form antibody against her own placenta and
foetus)
• Alloimmune disease (Paternal antigen which
enters mothers’ body will produce antibody against
it. Maternal antibody accepts as its own so there
will be decreased foetal-maternal immunologic
interaction and ultimately foetal rejection).
Common cause
First trimester
• Genetic factors -50%
• Endocrine disorders
• Immunological
• Infections
• Unexplained (40-60%)
Second trimester
1.Anatomic abnormalities
a) Cervical incompetence
b) Mullerian fusion defects (Bicornuate uterus,
septate uterus)
c)Uterine synechiae (intra uterine adhesion)
d)Uterine fibroid
2.Maternal medical illness
3.Unexplained
CLASSIFICATION In my patient incomplete abortion is
1.SPONTANEOUS diagnosed.

*Isolated
*Recurrent
 Threated
 Inevitable
 Complete
 Incomplete
 Missed
 Septic
*Induced
 Legal
 Illegal

Mechanism of Abortion
 Spotting present since 10 days.
Before 8 weeks:

Ovum surrounded by the villi with the decidual

coverings is expelled out. Because the external os

fails to dilate the entire mass remains in the cervix.

Called as “Cervical Abortion”.

8-14 weeks:

Expulsion of the foetus commonly occurs

leaving behind the placenta and membranes, so that

there will be bleeding.

Beyond 14th week:

Expulsion is similar to that of mini labour”.

The foetus is expelled first followed by expulsion

of placenta.

TYPES OF ABORTION
Spontaneous Abortion:
 Definition:

It is defined as the involuntary loss of the products of conception prior to 20 weeks of gestation

Causes

1.Abnormal foetal formation due to

-Teratogenic factor

-chromosomal aberration

50-80%of early abortion has structural abnormalities

2.Immunological factors –rejection by immune response

3.Implantation abnormalities –Poor implantation result from

• Inadequate endometrial formation

• An inappropriate site of implantation

• Improper implantation placental circulation

function affected inadequate foetal nutrition

4.Corpus luteum fails to produce enough progesterone to maintain the decidua basalis –progesterone
therapy is need

5.UTI

7.Ingestion of Teratogenic Drugs

8Infections -rubella syphilis, cytomegalo, toxoplasmosis, Which readily cross the placenta

Changes

Infection

Foetus fails to grow

Oestrogen and progesterone production by placenta fails

Endometrial sloughing

Prostaglandins are released

Uterine contraction expulsion of products of pregnancy

Cervical dilatation

Expulsion of products of pregnancy

1.Threatened abortion:

It is a clinical entity where the process of abortion has started but has not progressed to a state from
which recovery is impossible.

Clinical features

Bleeding per vagina: Slight and bright red in colour.

Pain: Mild backache or dull pain in lower abdomen.

Pelvic examination:

a) Speculum examination-bleeding if any escapes through the external os.

b) Digital examination-reveals closed external os.

c)The uterine size corresponds to the period of amenorrhoea.

Investigation

a) Blood investigation

b) USG

c) Urine for immunological test for pregnancy

Treatment

 Rest: 2weeks of bed rest.

 Drugs: sedation and analgesics
 Phenobarbitone 30mg or
 Diazepam 5mg
 Advised to preserve vulval pads and anything expelled out per vagina for inspection.
 To report if bleeding or pain gets aggravated.
 Routine notes of pulse, temperature and vaginal bleeding.

Advice on discharge

-Limit her activities at least for 2 weeks.

- Avoid heavy work.

-Coitus is contraindicated during this period.

-Follow up after 1month to assess the growth of fetus

2. INEVITABLE ABORTION

• It is the clinical type of abortion where the changes have progressed to a state from where
continuation of pregnancy is impossible

Clinical features

 Increased vaginal bleeding

 Severe lower abdominal pain- colicky type
 General condition is proportionate to visible blood loss
Internal examination
 Reveals dilated internal os of the cervix through which the product of conception are felt.
Management
Principles:
 a. To take appropriate measures to look after the general condition.
b. To accelerate the process of expulsion.
c. To maintain strict asepsis
Active treatment
Before 12weeks: dilatation and evacuation followed by curettage of uterine cavity.

After 12weeks:
 Uterine contraction is accelerated by oxytocin drip (10 U in 500ml NS) 40-60drops/min.
 If the product is expelled and placenta retained, it is removed by ovum forceps (if lying separate)
 If placenta is not separated, digital separation followed by evacuation under GA.
 If bleeding is severe and cervix is closed then evacuation of uterus is done by Abdominal
Hysterectomy
3. COMPLETE ABORTION
• When the products of conception are completely expelled, it is called complete abortion
Clinical features
 There is history of expulsion of a fleshy mass per vagina followed by:
 Subsidence of pain
 Vaginal bleeding becomes trace or absent

Internal examination reveals:

 Uterus is smaller than the period of amenorrhoea

 Cervical os is closed
 Bleeding is trace
 Examination of the expelled fleshy mass is found intact

Management

 Blood loss should be assessed and treated.

 If there is doubt about complete expulsion of products, uterine curettage should be
done.
 Transvaginal sonography is useful to prevent unnecessary surgical procedure.
 In case of Rh-negative mother antiD gamma globulin should be given

4. Incomplete abortion
  When the entire products of conception are not expelled, instead a part of it is left
inside the uterine cavity, is called incomplete abortion

Clinical features.

 History of expulsion of fleshy mass per vagina

 Continuation of pain lower abdomen
 Persistence of vaginal bleeding

Internal examination

 Uterus smaller than the period of amenorrhoea

 Cervical os may admit the tip of the finger
 Varying amount of bleeding
 On examination, the expelled mass is found incomplete.

Termination

If the products left behind it leads to

 Profuse bleeding
 Sepsis
 Placental polyp
 Choriocarcinoma

Management

 The principles to be followed are same as Inevitable abortion.

 Patient may be in a state of shock due to blood loss. She should be resuscitated before
any active treatment.
 Early abortion: Dilatation and evacuation
 Late abortion: Uterus is evacuated under GA and the products are removed by ovum
forceps or by blunt curette

Book picture Patient picture

Incomplete abortion Incomplete abortion
 When the entire products of conception are
not expelled, instead a part of it is left inside
the uterine cavity, is called incomplete
abortion Clinical features.
Spotting since 10 days present
*History of expulsion of fleshy mass per
Vaginal bleeding since 2 days
vagina
*Continuation of pain lower abdomen
*Persistence of vaginal bleeding
Internal examination
PV findings reveal cervical os admit the tip of
*Uterus smaller than the period of
finger.
amenorrhoea
*Cervical oz. may admit the tip of the finger
*Varying amount of bleeding
*On examination, the expelled mass is found
incomplete.

Termination

If the products left behind it leads to

*Profuse bleeding

* Sepsis

*Placental polyp

*Choriocarcinoma

Management

**The principles to be followed are same as

Inevitable abortion.

**Patient may be in a state of shock due to D&C done on 14 /7/2021

blood loss. She should be resuscitated before

any active treatment.

**Early abortion: Dilatation and evacuation

 **Late abortion: Uterus is evacuated under
T miso 400ug given at 24 hr interval
GA and the products are removed by ovum

forceps or by blunt curette

Medical Management

Tab.misoprostol 200ug is used for vaginally

every 4 hours

5.Early foetal demise

 When the foetus is dead and retained inside the uterus for a variable period, it is called
as missed abortion or silent miscarriage

Pathology

Beyond 12wks: Foetus become macerated or mummified, liquor amnii get absorbed, placenta
becomes pale, thin and adherent.

Before 12wks: Because of haemorrhage blood will get collected around ovum called as “blood
mole"., water content from the blood gets absorbed and flesh remains around the ovum called as
“Fleshy mole or Carneous mole”.

Clinical features

 Persistence of brownish vaginal discharge

 Subsidence of pregnancy symptoms
 Retrogression of breast changes
 Non audibility of foetal heart sound even with doppler
 Cervix feels firm
  Immunological test for pregnancy becomes negative
 USG reveals an empty sac

Management

 If less than 12wks:

vaginal evacuation by suction evacuation or slow dilatation of the cervix by laminaria
tent followed by dilatation and evacuation of the uterus under GA.
 If more than 12wks:
Induction is done
**Oxytocin 10-20U in 500ml NS at 30drops/min. If fails increase dose to maximum of
200mlU/min
**Prostaglandins: misoprostol tab inserted into the posterior vaginal fornix
**IM administration of 15methyl PGF2α (carboprost tromethamine)

6. Septic abortion
• Any abortion associated with clinical evidences of infection of the uterus and its contents
Mode of infection

Usually, the micro-organisms present in the vagina are involved in sepsis when the

resistance power of the mother becomes low. Majority of cases the infection occurs

following illegal induced abortion

Criteria

• Rise of temperature 100.4*for 24 hrs

• Offensive or purulent vaginal discharge

• Lower abdominal pain and tenderness

Clinical features

 Pyrexia associated with chills and rigors.

 Purulent vaginal discharge
 Shock
 Pain abdomen of varying degrees

Internal examination reveals:

  Offensive purulent vaginal discharge
 Tender uterus

Clinical grading

 Grade I: Infection localised to uterus (commonest)

 Grade II: infection spreads beyond the uterus to the tubes and ovaries.
 Grade III: Generalised peritonitis / shock / jaundice or acute renal failure (associated with
illegal induced abortion)

Investigations

Routine investigations:

 Cervical or high vaginal swab for culture and sensitivity test.

 Blood for haemoglobin, total and differential count,
 ABO and Rh grouping.
 Urine analysis including culture

Special investigations:

 USG abdomen and pelvis

 Blood for culture, serum electrolytes, coagulation profile

Complications

Immediate:

 Haemorrhage
 Injury to uterus and adjacent structures
 Spread of infection causes Peritonitis
 Acute renal failure
 Thrombophlebitis

Remote:

 Chronic pelvic pain, Backache

 Dyspareunia
 Ectopic pregnancy
 Secondary infertility due to tubal blockage
  Emotional depression

Prevention

i. Use family planning method

ii. Encourage to go for legal abortion

Management

• Hospitalization

• High vaginal or cervical swab

• Vaginal examination to note the state of abortion process

Principles of management:

• To control the sepsis

• To remove the source of infection

• To give the supportive therapy

• To bring back the normal homeostatic and cellular metabolism

• To assess the response to treatment

Specific management

Drugs: 1.Antibiotics

Gram positive aerobes

a) Aqueous Penicillin G 5million U IV every 6 hours

(b)Ampicillin 0.5-1gm IV every 6 hours.

Gram negative aerobes

(a)Gentamicin 1.5mg/kg IV every 8 hours.

(b)Ceftriaxone 1.5gm IV every 12 hours

For Anaerobes

(a) Metronidazole 500mg IV every 8hours

 (b) Clindamycin 600mg IV every 6hours

Grade I

1.Antibiotics

2. Prophylactic anti gas-gangrene Serum of 8000 U and 3000 U of anti-tetanus serum IM are
given.

3. Analgesics and Sedatives

 Blood transfusion
 Evacuation of the uterus within 24hours following antibiotic therapy

Grade II

 Antibiotics
 Clinical monitoring- to note pulse, temperature, urinary output and progress of pain,
tenderness and mass in lower abdomen.

Surgery

i. Evacuation of the Uterus

ii. Posterior colpotomy (pouch of Douglas)

Grade III

 Antibiotics
 Clinical monitoring
 Supportive therapy with IV fluids.
 Active surgery

-Laparotomy

7.Recurrent / Spontaneous miscarriage

• Recurrent miscarriage is defined as a sequence of three or more consecutive spontaneous

abortion before 20weeks.
Etiology

During 1st trimester

 Genetic factors
 Endocrine and metabolic
 Infection
 Inherited Thrombophiliaintra vascular coagulation.
 Immunological cause : Auto & Allo immunity
 Unexplained

During 2nd trimester

 Cervical incompetence
 Defective Mullerian fusion-double uterus, bicornuate uterus, septate uterus.
 Cervical incompetence
 Uterine fibroid
 Retroverted uterus
 Chronic maternal illness
 Infection, Unexplained

Investigations

 History on previous abortion.

 Any chronic illness
 Histology of placenta

Diagnostic tests

a. Blood glucose , VDRL , Thyroid function test, ABO and Rh grouping

b. Autoimmune screening
c. USG
d. Hysterosalpingography
e. Hysteroscopy / Laparoscopy
f. Endocervical swab
 Treatment

During Inter conceptional Period

 To alleviate anxiety and improve psychology
 Hysteroscopic resection of uterine septate
 Uterine unification operation (metroplasty) for bicornuate uterus.
 Genetic counselling if chromosomal abnormality .
 Endocrine dysfunction has to be controlled.
 Genital tract infections are treated.

During pregnancy
 Reassurance and tender loving care.
 Ultrasound
 Adequate rest
 Avoid strenuous activity
 Intercourse
 Travelling.
Luteal phase defect:
 Progesterone 100mg as vaginal suppository TID started 2days after ovulation. During this
time if pregnancy test is positive continue treatment 12weeks of pregnancy. (corpus luteal
insufficiency)
Inherited Thrombophilia:
 antithrombotic therapy improves the pregnancy outcome. Heparin 5000IUtwice daily’s/C up to
34 weeks
 Medical complications: Specific management is continued.
Unexplained:
Supportive therapy improves pregnancy outcome.
Cerclage operation:
non absorbable encircling suture is placed around the cervix at the level of internal OS.
Done at 14 weeks of pregnancy or at least two weeks earlier than the previous pregnancy
loss -10th week
NURSING MANAGEMENT

ASSESSMENT

Pre-operative care for surgical abortion

1. Check patients name, type of surgery

2. Monitor Vitals, blood test, bleeding and vaginal secretion (character, colour & volume)

3. Strict aseptic technique

4. Strengthen the perineum care & maintain the vulva cleanliness

5. Psychological care: sympathizing, understanding & caring

6. To check/ trace ultrasound result

7. prevent infection

8. Empty the bladder.

9. Comfort the patient.

Post-operative care

 Monitor vital signs to identify any internal bleeding or infection. Blood pressure and pulse.
 Assess the client’s conscious level, the presence of malaise, cold clammy skin, pale or
dizziness to rule out possibility of hypovolemic shock.
 Assess for severity of pain using pain scale. Administer analgesics as prescribed and assess the
effectiveness of the medication.
 Check for any excessive vaginal bleeding or soakness of the sanitary pad and its characteristic.
(Vaginal bleeding normally stop within 3-5 days.)
 Assess the IV line and drip to make sure no kinking, no obstruction and in accurate rate flow.
 Encourage fluid intake to prevent dehydration due to blood loss during surgery.
 Monitor and strict on intake and output.
 Strictly aseptic technique to prevent cross infection and provide perineum care. Educate the
client to maintain effective hand washing technique and perineal care.
 Note any pus or foul smelling from the vaginal discharge to rule out possible infection.
 Maintain healthy diet to provide the body with enough nutrition for fast recovery of the
operated site and regaining of energy
 Provide emotional support encourage family support due to pregnancy loss.
 Allow grieving and expression of her concerns over the loss pregnancy.

Nursing Diagnosis and intervention

1.Risk for fluid volume deficit related to maternal bleeding

Nursing Interventions

•Report any tachycardia, hypotension, diaphoresis, or pallor, indicating haemorrhage and shock.

•Draw blood for type and screen for possible blood administration.

•Establish and maintain an IV with large-bore catheter for possible transfusion and large quantities
of fluid replacement

2.Anticipatory grieving related to loss of pregnancy, cause of abortion, future childbearing

Nursing Interventions

•Assess the reaction of patient and support person, and provide information regarding current
status, as needed.

•Encourage the patient to discuss feelings about the loss of the baby’ include effects on
relationship with the father.

•Do not minimize the loss by focusing on future childbearing; rather acknowledge the loss and
allow grieving.

•Providing time alone for the couple to discuss their feelings.

3.Risk for infection related to dilated cervix and open uterine vessels

Nursing Interventions

•Evaluate temperature q 4H if normal, and every 2H if elevated.

•Check vaginal drainage for increased amount and odor, which may indicate infection.

•Instruct on and encourage perineal care after each urination and defecation to prevent
contamination

4. Acute pain related to uterine cramping and possible procedures

Nursing Interventions

•Instruct patient on the cause of pain to decrease anxiety.

•Instruct and encourage the use of relaxation techniques to augment analgesics.

•Administer pain medication as needed and as prescribed.

5.Knowledge deficit related to signs and symptoms of possible complications

Nursing Interventions

•Teach the woman to observe for signs of infection (fever, pelvic pain, change in character and
amount of vaginal discharge), and advise to report them to provider immediately.

•Deal with client’s anxiety. Present information out of sequence, if necessary, dealing first with
material that is most anxiety producing when the anxiety is interfering with the client’s learning
process.

•Teach client of the complications for a mother has reason to be especially worried about her
infant’s health.

Book picture Patient picture

Pre-operative management Pre-operative management
 Monitor vital signs  Consent taken
 Consent  Provide emotional support
 NPO  Administer inj cifran1 gm iv stat given
 Psychological well being
 Monitor bleeding
 medication
Post-operative management
Post-operative management
 Vitals monitored
 Monitor vital signs
 Assess conscious level
 Maintain aseptic
 Monitored bleeding level not
 Monitor conscious level
any abnormal clot seen
 Assess bleeding level
 Provide emotional support
 Provide emotional support
.

REFERENCE

*DC DUTTA’S Text book of Obstetrics Publications page number: 359,386,481,528 to 530

*MYLE’S Text book of Midwives;15th edition Elsevier publication Page number 486 to 510

*ANNAMMA JACOB Text book of Maternal and Neonatal nursing care plan Publications 259-
260,263.