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ABORTION

• SINDHU SEBASTIAN
LECTURER FMCON

DEFINITION Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing 500gm or less when it is not capable of independent survival.
WHO

Early Abortion: Before 12 weeks

Late Abortion: From 12-20 weeks

Viability • Survival by Gestational age – Weeks 22 23 24 25 26 27 28 % survival 0 25 55 65 75 90 92 .

INCIDENCE: • 10-20% of all clinical pregnancy • 10% Illegal • 75% occur before 16wks .

CLASSIFICATION ABORTION Spontaneous Induced Isolated Recurrent Legal Illegal (criminal ) Septic Threatened Inevitable Complete Incomplete Missed Septic .

Ovular or Fetal factors(60%): a) Ovo-fetal factors- Chromosomal abnormality Gross congenital malformation Blighted ovum Hydropic degenaration of villi Death or Disease of fetus .ETIOLOGY: 1.

Unknown factors .Contd… b) Interference with circulation- Knots Twists Entanglements c) Low attachment of placenta d) Twins or Hydramnios. 2.

Maternal factors(15%): Maternal medical illness -Cyanotic heart diseases Infections Maternal hypoxia Chronic illness Endocrine and metabolic factors .Contd… 3.

Contd… Anatomical abnormalities Cervico-uterine factors-Cervical incompetence -Congenital malformation of uterus -Uterine fibroid -Intrauterine adhesions -Retroverted uterus .

Trauma.Blood group incompatibility 5. Premature Rupture of Membranes .Direct -Psychic Susceptible individual -Amniocentesis Toxic agents 4.

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 fetus) or • 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 fetal rejection).

• 11. Immunological disorder –
• Autoimmune disease (mother's immune system will form antibody against her own placenta and fetus) or • 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 fetal rejection).

Common cause • First trimester • Genetic factors -50% • Endocrine disorders • Immunological • Infections • Unexplained (40-60%) .

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.• Second trimester 1.Unexplained .

so that there will be bleeding. The fetus is expelled first followed by expulsion of placenta. Called as “Cervical Abortion”.Mechanism of Abortion Before 8 weeks: Ovum surrounded by the villi with the decidual coverings is expelled out. . Beyond 14th week: Expulsion is similar to that of “mini labour”. Because the external os fails to dilate the entire mass remains in the cervix. 8-14 weeks: Expulsion of the fetus commonly occurs leaving behind the placenta and membranes.

Spontaneous Abortion: Definition: It is defined as the involuntary loss of the products of conception prior to 20 weeks of gestation. Incidence: 15% of all confirmed pregnancy 80% occur in first trimester .

Abnormal fetal formation due to -Teratogenic factor -chromosomal aberration 50-80%of early abortion has structural abnormalities 2.Implantation abnormalities –Poor implantation result from • inadequate endometial formation • An inappropriate site of implantation .Causes 1.Immunological factors –rejection by immune response 3.

Ingestion Of Teratogenic Drugs .• improper implantation placental circulation function affected inadequate fetal nutrition 4.UTI 7.Corpus luteum fails to produce enough progesterone to maintain the decidua basalis –proge therapy is neeed 5.

cytomegalo.toxoplasmosis Which readily cross the placenta .7.Infections -rubella syphilis.

Changes Infection Fetus fails to grow Estrogen 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 .

alcohol.Schematic Diagram of Abortion Abnormal Fetal Formation Immunologic Factors Infection Crosses placenta Teratogenic Factors (smoking. drugs) Rejection of the embryo through immunologic response Fetus fails to grow Decrease estrogen and progesterone production Endometrial sloughing Release of prostaglandin which causes uterine contractions and cervical dilatation Miscarriage .

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. .

. Pain: Mild backache or dull pain in lower abdomen.Clinical features Bleeding per vagina:Slight and bright red in colour.

Pelvic examination: a)Speculum examination-bleeding if any. Investigation a)Blood investigation b)USG c) Urine for immunological test for pregnancy .escapes through the external os. c)The uterine size corresponds to the period of amenorrhoea. b)Digital examination-reveals closed external os.

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 vaginam for inspection. temperature and vaginal bleeding. To report if bleeding or pain gets aggravated. . Routine note of pulse.

Advice on discharge -Limit her activities at least for 2 weeks.Avoid heavy work. . . -Follow up after 1month to assess the growth of fetus. -Coitus is contraindicated during this period.

INEVITABLE ABORTION • It is the clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible. .2.

Clinical features -Increased vaginal bleeding -Severe lower abdominal pain. .colicky type -General condition is proportionate to visible blood loss.

. To accelerate the process of expulsion. To take appropriate measures to look after the general condition. Management Principles : a. To maintain strict asepsis. c. b.Internal examination Reveals dilated internal os of the cervix through which the product of conception are felt.

Active treatment Before 12weeks : dilatation and evacuation followed by curettage of uterine cavity. it is removed by ovum forceps(if lying separate) . If the product is expelled and placenta retained. Uterine contraction is accelerated by oxytocin drip (10 U in 500ml NS) 40-60drops/min. After 12weeks : i. ii.

If bleeding is severe and cervix is closed then evacuation of uterus is done by Abdominal hysterectomy.Contd… iii. digital seperation followed by evacuation under GA. If placenta is not seperated. .

COMPLETE ABORTION • When the products of conception are completely expelled. . it is called complete abortion.3.

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..Cont.. ..

Blood loss should be assessed and treated. .Management i. i. If there is doubt about complete expulsion of products. uterine curettage should be done. i. Transvaginal sonography is useful to prevent unnecessary surgical procedure. In case of Rh negative mother antiD gamma globulin should be given. i.

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

Clinical features. -History of expulsion of fleshy mass per vaginam followed by: -Continuation of pain lower abdomen -Persistence of vaginal bleeding .

the expelled mass is found incomplete.Internal examination -Uterus smaller than the period of amenorrhoea -Cervical os may admit the tip of the finger -Varying amount of bleeding -On examination. .

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

it is called as missed abortion or silent miscarriage.5. Missed abortion / Silent miscarriage or early fetal demise • When the fetus is dead and retained inside the uterus for a variable period. .

liquor amnii get absorbed. water content from the blood gets absorbed and flesh remains around the ovum called as “Fleshy mole or Carneous mole”.Pathology Beyond 12wks: Fetus become macerated or mummified.. Before 12wks: Because of haemorrhage blood will get collected around ovum called as “blood mole". .thin and adherent. placenta becomes pale.

Clinical features Persistence of brownish vaginal discharge Subsidence of pregnancy symptoms Retrogression of breast changes Non audibility of fetal 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 fails increase dose to maximum of 200mlU/min -Prostaglandins:misoprostol tab inserted into the posterior vaginal fornix :IM administration of 15methyl PGF2α (carboprost tromethamine) .If more than 12wks: Induction is done -Oxytocin 10-20U in 500ml NS at 30drops/min.

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

4*for 24 hrs • Offensive or purulent vaginal discharge • Lower abdominal pain and tenderness .Criteria • Rise of temperature 100.

. Majority of cases the infection occurs following illegal induced abortion.Mode of infection Usually the micro-organisms present in the vagina are involved in sepsis when the resistance power of the mother becomes low.

Reasons for infection • Proper antiseptic and asepsis are not taken • Incomplete evacuation .

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).

-Blood for haemoglobin. serum electrolytes. ABO and Rh grouping.Investigations Routine investigations : -Cervical or high vaginal swab for culture and sensitivity test. coagulation profile . total and differential count. -Urine analysis including culture Special investigations : -USG abdomen and pelvis -Blood for culture.

Complications Immediate : Haemorrhage Injury to uterus and adjacent structures Spread of infection causes Peritonitis Acute renal failure Thrombophlebitis .

. Backache Dyspareunia Ectopic pregnancy Secondary infertility due to tubal blockage Emotional depression.Remote : Chronic pelvic pain.

Use family planning method ii. Encourage to go for legal abortion .Prevention i.

• Hospitalization • High vaginal or cervical swab • Vaginal examination to note the state of abortion process Management .

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 .

5gm IV every 12 hours . (b)Ceftriaxone 1.Specific management Drugs : 1.Antibiotics Gram positive aerobes a)Aqueous Penicillin G 5million U IV every 6 hours (b)Ampicillin 0.5mg/kg IV every 8 hours.5-1gm IV every 6 hours. Gram negative aerobes (a)Gentamicin 1.

.Antibiotics 2.For Anaerobes (a) Metronidazole 500mg IV every 8hours (b) Clindamycin 600mg IV every 6hours Grade I 1. 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 .

Posterior colpotomy(pouch of douglas) .to note pulse. tenderness and mass in lower abdomen.Grade II Antibiotics Clinical monitoring. temperature. urinary output and progress of pain. Evacuation of the Uterus ii. Surgery i.

Grade III Antibiotics Clinical monitoring Supportive therapy with IV fluids. Active surgery -Laparotomy .

.Recurrent / Spontaneous miscarriage • Recurrent miscarriage is defined as a sequence of three or more consecutive spontaneous abortion before 20weeks.

(protein C-natural inhi-of coag) -Immunological cause : Auto & Allo immunity -Unexplained .Etiology During 1st trimester -Genetic factors -Endocrine and metabolic -Infection -Inherited Thrombophiliaintra vascular coagulation .

During nd 2 trimester Cervical incompetence Defective mullerian fusion-double uterus. Unexplained . Cervical incompetence Uterine fibroid Retroverted uterus Chronic maternal illness Infection.bicornuate uterus.septate uterus.

Investigations i. ii. History on previous abortion. Histology of placenta . Any chronic illness iii.

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

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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.

During this time if pregnancy test is positive continue treatment 12weeks of pregnancy.• Luteal phase defect: Progesterone 100mg as vaginal suppository TID started 2days after ovulation. (corpus luteal insufficiency) .

.S/C upto 34 weeks Medical complications : Specific management is continued.Inherited Thrombophilia :  antithrombotic therapy improves the pregnancy outcome.heparin 5000IUtwice daily.  Unexplained :  Supportive therapy improves pregnancy outcome.

Done at 14 weeks of pregnancy or at least two weeks earlier than the previous pregnancy loss -10th week .• Circlage operation :non absorbable encircling suture is placed around the cervix at the level of internal OS.

•Draw blood for type and screen for possible blood administration. indicating hemorrhage and shock. or pallor. hypotension. . diaphoresis. •Establish and maintain an IV with large-bore catheter for possible transfusion and large quantities of fluid replacement.Nursing Diagnosis •Risk for fluid volume deficit r/t maternal bleeding Nursing Interventions •Report any tachycardia.

Nursing Diagnosis •Anticipatory grieving r/t loss of pregnancy. . •Do not minimize the loss by focusing on future childbearing. •Providing time alone for the couple to discuss their feelings. as needed. cause of abortion. rather acknowledge the loss and allow grieving. and provide information regarding current status. •Encourage the patient to discuss feelings about the loss of the baby’ include effects on relationship with the father. future childbearing Nursing Interventions •Assess the reaction of patient and support person.

. •Instruct on and encourage perineal care after each urination and defecation to prevent contamination.Nursing Diagnosis •Risk for infection r/t dilated cervix and open uterine vessels Nursing Interventions •Evaluate temperature q 4H if normal. which may indicate infection. •Check vaginal drainage for increased amount and odor. and every 2H if elevated.

Nursing Diagnosis • Acute pain r/t 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.

and advise to report them to provider immediately. Present information out of sequence. . change in character and amount of vaginal discharge). pelvic pain. dealing first with material that is most anxiety producing when the anxiety is interfering with the client’s learning process. •Deal with client’s anxiety. if necessary.Nursing Diagnosis •Knowledge deficit r/t signs and symptoms of possible complications Nursing Interventions •Teach the woman to observe for signs of infection (fever. •Teach client of the complications for a mother has reason to be especially worried about her infant’s health.

Thank you .

Induced abortion .

Definition Deliberate termination of pregnancy before the viability of the fetus is called induction of abortion .

Elective: if performed for a woman’s desires Therapeutic: if performed for reasons of maintaining health of the mother .

MTP ACT -1971 • The continuation of pregnancy would involve seroius risk of life or grave injury to the physical and mental health of the pregnant women • There is a substantial risk of the child being born with serious physical and mental abnormalities so as to be handicapped in life .

both in case of major and minor girl and in mentally imbalance women • Pregnancy result as a result of contraceptive failure .• When the pregnancy caused by rape .

Indication • To safe the life of the mother -Cardiac diseases -Ch.Glomerulonephritis -Malignant hypertension -Hyperemesis gravidarum -Cervical breast malignancy -DM with retinopathy -Epilepsy or psychiatric diaseases with advice of psychiatrist .

• Social indications pregnancy with low socioeconomic status -pregnancy caused by rape or failure of contraceptive methods -unplanned .

• Eugenic
-Structural-anencephaly

,chromosomal (down syndrome) or genetic (hemophilia) -Teratogenic drugs(warfarrin)radiation exposure more than 10 rads in early pregnancy - rubella infection

RECOMMENDATIONS
1.Qualified Registered medical practitioner a) One has assisted at least 25 MTP in authorized centre and having certificate b)6 months house surgeon training in OBG c)Diploma or degree in OBG

2.Termination can only performed in hospitals established or maintained by Govt or places approved by Govt 3.Pregnancy can only terminated on the written consent of the women. Husband's consent is not required 4.Pregnancy in a minor girl (below the age of 18 years )can not be terminated without the written consent of the parent or legal guardian. 5.Termination is permitted up to 20 weeks of pregnancy When the pregnancy exceeds 12 weeks opinion of two medical practitioners is required

• The abortion has to be performed confidentially and to be reported to the director of health services of state in the prescribed form .

180. .Induced abortion: statistics . . This is are unmarried constant since 1980 • 21 % of women obtaining abortions • 305 abortions/1000 are younger 19 years live births old • National abortion rate: 20/1000 women • 55.000 abortions • 79.2 % are younger than 24 years old aged 15-44 .7% of women obtaining abortions are reported to the CDC in 1997. • 1.

5% require additional surgery • 97% of women having first trimester abortions have no complications or post abortion complaints .5 % have minor complaints that are handled in a physicians office • <0.• 88% of women who abort are in the first trimester of pregnancy Contd… • 2.

to be free from unwanted governmental intrusion into matters so fundamentally affecting a person as the decision whether to bear or beget a child.” .Roe vs. Wade 1/22/73 • “We recognize the right of the individual. That right necessarily includes the right of a woman to decide whether or not to terminate her pregnancy. married or single.

Gestational age and procedure –50% of abortion performed 8 weeks or earlier –12% of abortion performed past 12 weeks –1.4% of abortion performed past 20 weeks .

Minisuction • Menstrual Regulation • Suction Abortion • Vacuum Curettage • Medical Abortion .First Trimester Abortion • Early Uterine Evacuation (EUE).

Minisuction • Introduced in 1972 by Karman and Potts .

Surgical techniques for abortion • Menstrual aspiration(menstrual regulation ) – 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 .

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Dilatation and curettage (D&C) • Removal of pregnancy contents by some mechanical means • Vacuum most commonly used • 12-13 weeks is the upper limit of gestational age • Usually performed in free standing clinics .

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acting as an antagonist –A single oral dose given to women 5 weeks or less produces abortion in 85% of cases .Medical Abortion • Mifepristone (RU486) –Analogue of progestin norethindrone –Strong affinity for the progesterone receptor.

Mifepristone protocol • Women less than 49 days LMP with confirmed b-hCG • 600mg mifepristone on day 1 • On day three. during which time expulsion of pregnancy usually occurs . Misoprostil 400 mcg orally • Patient remain in clinic four hours. return for prostaglandin.

Medical Surgical Private More sense of autonomy “More natural” Earlier intervention unwanted pregnancy Longer process with unclear endpoint More pain More bleeding Anxiety regarding abortion off site .

ER visits Need to guard against unnecessary intervention Limited to 49 days LMP .Medical Surgical Less skill needed to provide Methotrexate also treats ectopic pregnancy Increased anxiety re: off site management More unscheduled care: calls.

Second Trimester Termination • Dilatation and evacuation (D&E) • Intrauterine injection of abortifacients • Prostaglandin vaginal suppositories • High dose oxytocin • Hysterotomy .

• Mechanical and suction removal of formed pregnancy after cervical dilation • Technically more difficult than earlier suction procedures • Associated with fewer complications than instillation and suppository methods • General anesthesia is not required D&E .

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• Picture of laminaria .

hypertonic saline.Intrauterine injection of abortifacients • Prostaglandin. hypertonic urea are introduced by amniocentesis • Fetus and placenta are aborted vaginally • Osmotic dilators are used to decrease time to delivery and decrease complications .

25% diarrhea vomiting. 71% diarrhea Fever: temperature Misoprostil (PGE1 elevation of 1 degree c .Prostaglandin suppositories 20 mg suppositories of PGE2 typically given q 3 hours Prostaglandin F2alpha 250 mg IM q 2 hours Mean time to Mean time to induction 13. abortion 15-17 hours.4 hours. with 90% aborting by with 80% aborting by 24 hours 24 hours GI side effects: 39% GI side effects: 83% vomiting.

High Dose Oxytocin • As effective as PGE2 when used in appropriate doses • Risk of water intoxication .

Hysterotomy • Surgical method to remove pregnancy abdominally (mini-cesarean section) • Other methods are preferred .

rates • Varies as a function of the gestational age they are performed –Major complications: •0.25% < 7 weeks •1% < 12 weeks •2% over 12 weeks .Complications .

Immediate • Complications of local anesthetic • Cervical shock • Cervical lacerations • Uterine perforation • Hemorrhage • Post abortal syndrome .Complications .

Delayed • Bleeding –Retained products • Infection • Continued pregnancy –Ectopic –Intrauterine .Complications .

•Thank you .