INDEX

[Link] CONTENT PAGE NO

1 Objectives 2
2 Introduction 3
3 Meaning 3
4 Definition 3
5 Review of Anatomy & Physiology of 4
female reproductive system
6 Risk factors for spontaneous abortion 9
7 Signs and symptoms 10
8 Diagnosis 11
9 Prevention 12
10 Management 15
11 Nursing responsibility 17
12 Outcomes 18
13 Relevant research studies 19
14 Summary 20
15 Conclusion 21
16 Bibliography 21

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 SPONTANEOUS ABORTION

OBJECTIVES:

1. GENERAL OBJECTIVES:
At the end of the seminar the group will be able to get the knowledge
about the spontaneous abortions, develop a positive attitude towards it
and practice this knowledge and improve their skills in teaching and clinical
areas.

2. SPECIFIC OBECTIVES:

At the end of the class the students will be able to:

 Define spontaneous abortion.

 Enlist the risk factors of spontaneous abortion.
 Illustrate the signs and symptoms of spontaneous abortion.
 Enlist different diagnostic evaluation of spontaneous abortion.
 Describe the management of spontaneous abortion.
 Identify the nursing role in the management of spontaneous abortion.

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 SPONTANEOUS ABORTION

INTRODUCTION:
Miscarriage, also known in medical terms as a spontaneous abortion and pregnancy
loss, is the natural loss of an embryo or fetus before it is able to survive independently.
Some use the cutoff of 20 weeks of gestation, after which fetal death is known as
a stillbirth. The most common symptom of a miscarriage is vaginal bleeding with or
without pain. Sadness, anxiety, and guilt may occur afterwards Tissue and clot-like
material may leave the uterus and pass through and out of the vagina. Recurrent
miscarriage may also be considered a form of infertility.

MEANING:
Spontaneous abortion is the loss of pregnancy naturally before twenty weeks of gestation.
Colloquially, spontaneous abortion is referred to as a ‘miscarriage’ to avoid association with
induced abortion. Early pregnancy loss refers only to spontaneous abortion in the first trimester.
However, the first trimester is when most spontaneous abortions occur. Therefore, in this article,
these three terms will be used interchangeably.

DEFINITION:
Abortion or miscarriage is defined as the expulsion or extraction from its mother of a fetus or
embryo weighing less than 500 grams (20- 22 weeks of gestation) whether that abortion was
spontaneous or induced.

- NIMA BHASKAR

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 (WHO). This 500 gm of fetal development
is attained approximately at 22 weeks (154 days) of gestation. The expelled embryo or fetus is
called abortus. The term miscarriage is the recommended terminology for spontaneous abortion.

- D C DUTTA

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REVIEW OF ANATOMY & PHYSIOLOGY:
Anatomy is the study of the structures of the human body, i.e. the features of how the organs,
tissues and body systems are constructed. Physiology, on the other hand, is the study of the
coordinated functions of the organs, tissues and systems in the body.

External female genitalia:

All the structures which are visible externally, surrounding the urethral and vaginal openings,
including the Mons pubis, labia majora, labia minora, vestibule and perineum, make the external
female genitalia. Sometimes these structures are collectively named the vulva.

 Mons pubis:

The Mons pubis is a thick, hair-covered, fatty and semi-rounded area overlying the symphysis
pubis. Symphysis is a type of strong and immovable joint between bones. The two halves of the
pubic bone are joined in the middle by the pubic symphysis. The function of the fatty tissue in
the Mons pubis is to protect the woman’s pubic area from bruising during the sex act.

Labia majora and labia minora:

The labia majora are two elongated, hair-covered, fatty skin folds that enclose and protect the
other organs of the external female genitalia.

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The labia minora are two smaller tissue folds enclosed by the labia majora. They protect the
opening of the vagina and the urethra (the tube that carries urine from the bladder to the urethral
opening in the vulva). The labia minora normally have an elastic nature, which enables them to
distend and contract during sexual activity, and labor and delivery.

 Vestibule:
The vestibule is the area between the labia minora, and consists of the clitoris, urethral opening
and the vaginal opening.

The clitoris is a short erectile organ at the top of the vestibule, which has a very rich nerve
supply and blood vessels. Its function is sexual excitation and it is very sensitive to touch. Its
anatomical position is similar to the position of the male penis.

If the clitoris and labia minora are removed by female genital cutting, the vaginal opening will
not expand easily during childbirth due to the scarring where tissue has been removed. This can
result in difficulty in labor and delivery, including severe bleeding and rupture of the scarred
tissue, sometimes even causing a fistula — a hole torn in the wall of the vagina.

The urethral opening is the mouth or opening of the urethra, which is a small tubular structure
that drains urine from the bladder. The vaginal opening is the entrance to the vagina. It is where
you will begin to see the ‘presenting part’ of the baby as it stretches wider open near the end of
labor.

 Perineum and hymen:

The skin-covered muscular area between the vaginal opening and the anus is called
the perineum. It has strong muscles and its own nerve supply, and it helps to support the
contents of the pelvic cavity. The hymen is a fold of thin vaginal tissue which partially covers the
vaginal entrance in girls. It can be torn during strenuous exercise, as well as by the first sexual
penetration.

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  Internal female reproductive organs:

Fallopian tubes and ovaries:

There are two fallopian tubes — one on each side of the uterus — and the finger-like ends of
each tube (called the fimbriae) are close to the ovary on the same side, and open to the pelvic
cavity. This means that if there is an infection in the pelvic cavity, it can get into the uterus
through the fallopian tubes. Similarly, if there is an infection in the uterus, it can spread along the
fallopian tubes and out into the pelvic cavity, and from there all around the woman’s abdomen,
affecting her other organs. This can be very dangerous if it is not treated early.

The ovaries are paired female reproductive organs that produce the eggs (ova). They lie in the
pelvic cavity on either side of the uterus, just below the opening of the fallopian tubes. They are
kept in position through attachment to two ligaments. Ligaments are the fibrous, slightly
stretchy, connective tissues that hold various internal organs in place; they also bind one bone to
another in joints.

Women are born with a fixed number of immature eggs (ova), around 60,000 in number. The
eggs are held in small ‘pits’ in the ovaries, named ovarian follicles. Each ovum has the potential
to mature and become ready for fertilization, but in actuality only about 400 ripen during the

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woman’s lifetime. Every month, several ovarian follicles begin to enlarge and the ovum inside it
begins to mature, but usually only one will ‘win the race’ and be released from the ovary. The
moment when the ovum is released is called ovulation. The other enlarging follicles degenerate.

The enlarging ovarian follicles also produce the female reproductive

hormones, estrogen and progesterone, which are important in regulating the monthly menstrual
cycle, and throughout pregnancy.

Hormones are signaling chemicals that are produced in the body and circulate in the blood;
different hormones control or regulate the activity of different cells or organs.

After ovulation, the lining of the empty follicle grows and forms a yellow body in the ovary
called the corpus luteum, which temporarily functions as a hormone-producing organ.

It secretes estrogen and progesterone for about the next 14 days. Estrogen thickens the fatty
tissues in the wall of the uterus in case pregnancy occurs. Progesterone stops further ovulation
from occurring during the pregnancy. If pregnancy does not occur within 14 days after ovulation,
the corpus luteum degenerates and stops producing progesterone. As a result, the blood supply to
this additional fatty tissue in the wall of the uterus is cut off, and it also degenerates and is shed
through the vagina as the menstrual flow. The levels of estrogen can then begin to rise, and the
woman can ovulate again in the following month.

When an ovary releases a mature ovum (ovulation), the fimbriae of the fallopian tube catch the
ovum and convey it towards the uterus. The male sperm swim along the fallopian tubes, and if
they find the ovum, they fertilize it. The lining of the fallopian tubes and its secretions sustain
both the ovum and the sperm, encourage fertilization, and nourish the fertilized ovum until it
reaches the uterus.

Uterus:
The uterus is a hollow, muscular organ in which a fertilized ovum becomes embedded and
develops into a fetus. Its major function is protecting and nourishing the fetus until birth. During
pregnancy, the muscular walls of the uterus become thicker and stretch in response to increasing
fetal size during the pregnancy. The uterus must also accommodate increasing amounts
of amniotic fluid (the waters surrounding the fetus, contained in a bag of fetal membranes), and
the placenta (the structure that delivers nutrients from the mother to the fetus).

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Body: the major portion, which is the upper two-thirds of the uterus.

 Fundus: the domed area at the top of the uterus, between the junctions with the two
fallopian tubes.
 Endometrial cavity: the triangular space between the walls of the uterus.
 Cervix: the narrow neck at the upper end of the vagina.

The wall of the uterus has three layers of tissue:

 The perimetrium: the outermost thin membrane layer covering the uterus. (It is not
important for you to know this term for obstetric care.)
 The myometrium: the thick, muscular, middle layer.
 The endometrium: the thin, innermost layer of the uterus, which thickens during the
menstrual cycle. This is the tissue that builds up each month in a woman of reproductive
age, under the influence of the female reproductive hormones.
 Cervix and the vagina:
The cervix is the lower, narrow neck of the uterus, forming a tubular canal, which leads into the
top of the vagina. It is usually about 3 to 4 cm long.

The vagina is a muscular passage, 8 to10 cm in length, between the cervix and the external
genitalia. The secretions that lubricate the vagina come from glands in the cervix.

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The vagina has three functions.

 Prevent leaking of urine

 Prevent the vagina and perineum from tearing when they are stretched during childbirth
 Speed healing after birth
 Increase sexual pleasure.

RISK FACTORS FOR SPONTANEOUS ABORTION :

Miscarriage may occur for many reasons, not all of which can be identified. Risk factors are
those things that increase the likelihood of having a miscarriage but don't necessarily cause
miscarriage. Infections, medical procedures, lifestyle factors, occupational exposures, chemical
exposure, and shift work are associated with increased risk for miscarriage. Some of these risks
include endocrine, genetic, uterine, or hormonal abnormalities, reproductive tract infections,
and tissue rejection caused by an autoimmune disorder.
Trimesters:
First trimester:
Most clinically apparent miscarriages occur during the first trimester. About 30% to 40% of all
fertilized eggs miscarry, often before the pregnancy is known. The embryo typically dies before
the pregnancy is expelled; bleeding into the decidua basalis and tissue necrosis causes uterine
contractions to expel the pregnancy. Early miscarriages can be due to a developmental
abnormality of the placenta or other embryonic tissues. In some instances an embryo does not
form but other tissues do. This has been called a "blighted ovum".
Successful implantation of the zygote into the uterus is most likely 8 to 10 days after
fertilization. If the zygote has not implanted by day 10, implantation becomes increasingly
unlikely in subsequent days. A chemical pregnancy is a pregnancy that was detected by testing
but ends in miscarriage before or around the time of the next expected period.
Chromosomal abnormalities are found in more than half of embryos miscarried in the first 13
weeks. Half of embryonic miscarriages (25% of all miscarriages) have an aneuploidy (abnormal
number of chromosomes). Common chromosome abnormalities found in miscarriages include
an autosomal trisomy (22–32%), monosomy X (5–20%), triploidy (6–8%), tetraploidy (2–4%),
or other structural chromosomal abnormalities (2%).Genetic problems are more likely to occur
with older parents; this may account for the higher rates observed in older women.
Luteal phase progesterone deficiency may or may not be a contributing factor to miscarriage.
Second and third trimesters:
Second trimester losses may be due to maternal factors such as uterine malformation, growths in
the uterus (fibroids), or cervical problems. These conditions also may contribute to premature

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birth. Unlike first-trimester miscarriages, second-trimester miscarriages are less likely to be
caused by a genetic abnormality; chromosomal aberrations are found in a third of
cases. Infection during the third trimester can cause a miscarriage.
Age:
The age of the pregnant woman is a significant risk factor. Miscarriage rates increase steadily
with age, with more substantial increases after age 35. In those under the age of 35 the risk is
about 10% while it is about 45% in those over the age of 40. Risk begins to increase around the
age of 30. Paternal age is associated with increased risk.
Obesity, eating disorders and caffeine:
Not only is obesity associated with miscarriage; it can result in sub-fertility and other adverse
pregnancy outcomes. Recurrent miscarriage is also related to obesity. Women with bulimia
nervosa and anorexia nervosa may have a greater risk for miscarriage.
Caffeine consumption also has been correlated to miscarriage rates, at least at higher levels of
intake. However, such higher rates are statistically significant only in certain circumstances.
Endocrine disorders:
Disorders of the thyroid may affect pregnancy outcomes. Related to this, iodine deficiency is
strongly associated with an increased risk of miscarriage. The risk of miscarriage is increased in
those with poorly controlled insulin-dependent diabetes mellitus. Women with well-controlled
diabetes have the same risk of miscarriage as those without diabetes.
Food poisoning:
Ingesting food that has been contaminated with listeriosis, toxoplasmosis, and salmonella is
associated with an increased risk of miscarriage.
Amniocentesis and chorionic villus sampling:
Amniocentesis and chorionic villus sampling (CVS) are procedures conducted to assess the
fetus. A sample of amniotic fluid is obtained by the insertion of a needle through the abdomen
and into the uterus. Chorionic villus sampling is a similar procedure with a sample of tissue
removed rather than fluid. These procedures are not associated with pregnancy loss during the
second trimester but they are associated with miscarriages and birth defects in the first
trimester. Miscarriage caused by invasive prenatal diagnosis (chorionic villus sampling (CVS)
and amniocentesis) is rare (about 1%).
Surgery:
The effects of surgery on pregnancy are not well-known including the effects
of bariatric surgery. Abdominal and pelvic surgeries are not risk factors for miscarriage. Ovarian
tumors and cysts that are removed have not been found to increase the risk of miscarriage. The
exception to this is the removal of the corpus luteum from the ovary. This can cause fluctuations
in the hormones necessary to maintain the pregnancy.

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Medications:
There is no significant association between antidepressant medication exposure and spontaneous
abortion. The risk of miscarriage is not likely decreased by discontinuing SSRIs prior to
pregnancy. Some available data suggest that there is a small increased risk of miscarriage for
women taking any antidepressant, though this risk becomes less statistically significant when
excluding studies of poor quality.
Medicines that increase the risk of miscarriage include:

 retinoids
 nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen
 misoprostol 
 methotrexate
 statins
Immune status:
Autoimmunity is a possible cause of recurrent or late-term miscarriages. In the case of an
autoimmune-induced miscarriage, the woman's body attacks the growing fetus or prevents
normal pregnancy progression. Autoimmune disease may cause abnormalities in embryos, which
in turn may lead to miscarriage. As an example, Celiac disease increases the risk of miscarriage
by an odds ratio of approximately 1.4. A disruption in normal immune function can lead to the
formation of antiphospholipid antibody syndrome. This will affect the ability to continue the
pregnancy, and if a woman has repeated miscarriages, she can be tested for it. Approximately
15% of recurrent miscarriages are related to immunologic factors. The presence of anti-thyroid
autoantibodies is associated with an increased risk with an odds ratio of 3.73 and
95% confidence interval 1.8–7.6. Having lupus also increases the risk for miscarriage.
Anatomical defects and trauma:
Fifteen per cent of women who have experienced three or more recurring miscarriages have some
anatomical defect that prevents the pregnancy from being carried for the entire term. The structure of
the uterus affects the ability to carry a child to term. Anatomical differences are common and can be
congenital.
In some women, cervical incompetence or cervical insufficiency occurs with the inability of the cervix
to stay closed during the entire pregnancy. It does not cause first trimester miscarriages. In the
second trimester, it is associated with an increased risk of miscarriage. It is identified after a
premature birth has occurred at about 16–18 weeks into the pregnancy. During the second trimester,
major trauma can result in a miscarriage.

Smoking:
Tobacco (cigarette) smokers have an increased risk of miscarriage. There is an increased risk
regardless of which parent smokes, though the risk is higher when the gestational mother smokes.

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SIGNS AND SYMPTOMS OF SPONTANEOUS ABORTION :

Warning signs:
 Cramping and pain in the abdomen.
 Mild to severe back pain.
 Weight loss.
 Fluid discharge from the vagina.
 Tissue or clotted discharge from the vagina.
 Feeling faint or light-headed.
 Contractions.

Symptoms of a miscarriage include:

 Bleeding that goes from light to heavy

 Severe cramps
 Belly pain
 Weakness
 Worsening or severe back pain
  Fever with any of these symptoms
  Weight loss
 White-pink mucus
  Contractions
 Tissue that looks like blood clots passing from your vagina
 Fewer signs of pregnancy

DIAGNOSIS:

In the case of blood loss, pain, or both, transvaginal ultrasound is performed. If a viable

intrauterine pregnancy is not found with ultrasound, blood tests (serial βHCG tests) can be
performed to rule out ectopic pregnancy, which is a life-threatening situation.
If hypotension, tachycardia, and anemia are discovered, exclusion of an ectopic pregnancy is
important.
A miscarriage may be confirmed by an obstetric ultrasound and by the examination of the passed
tissue. When looking for microscopic pathologic symptoms, one looks for the products of
conception. Microscopically, these include villi, trophoblast, fetal parts, and background
gestational changes in the endometrium. When chromosomal abnormalities are found in more
than one miscarriage, genetic testing of both parents may be done.

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Classification:

 A threatened miscarriage is any bleeding during the first half of pregnancy. At

investigation it may be found that the fetus remains viable and the pregnancy continues
without further problems.
 An embryonic pregnancy (also called an "empty sac" or "blighted ovum") is a condition
where the gestational sac develops normally, while the embryonic part of the pregnancy
is either absent or stops growing very early. This accounts for approximately half of
miscarriages. All other miscarriages are classified as embryonic miscarriages, meaning
that there is an embryo present in the gestational sac. Half of embryonic miscarriages
have aneuploidy (an abnormal number of chromosomes).
 An inevitable miscarriage occurs when the cervix has already dilated, but the fetus has
yet to be expelled. This usually will progress to a complete miscarriage. The fetus may or
may not have cardiac activity.
 A complete miscarriage is when all products of conception have been expelled; these
may include the trophoblast, chorionic villi, gestational sac, yolk sac, and fetal
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 pole (embryo); or later in pregnancy the fetus, umbilical cord, placenta, amniotic fluid,
and amniotic membrane. The presence of a pregnancy test that is still positive, as well as
an empty uterus upon transvaginal ultrasonography, does, however, fulfil the definition
of pregnancy of unknown location. Therefore, there may be a need for follow-up
pregnancy tests to ensure that there is no remaining pregnancy, including ectopic
pregnancy.
 An incomplete miscarriage occurs when some products of conception have been passed,
but some remains inside the uterus. However, an increased distance between the uterine
walls on transvaginal ultrasonography may also simply be an increased endometrial
thickness and/or a polyp. The use of a Doppler ultrasound may be better in confirming
the presence of significant retained products of conception in the uterine cavity In cases
of uncertainty, ectopic pregnancy must be excluded using techniques like serial beta-
hCG measurements.
 A missed miscarriage is when the embryo or fetus has died, but a miscarriage has not
yet occurred. It is also referred to as delayed miscarriage, silent miscarriage, or missed
abortion.
 A septic miscarriage occurs when the tissue from a missed or incomplete miscarriage
becomes infected, which carries the risk of spreading infection (septicaemia) and can be
fatal.
 Recurrent miscarriage ("recurrent pregnancy loss" (RPL) or "habitual abortion") is the
occurrence of multiple consecutive miscarriages; the exact number used to diagnose
recurrent miscarriage varies. If the proportion of pregnancies ending in miscarriage is
15% and assuming that miscarriages are independent events, then the probability of two
consecutive miscarriages is 2.25% and the probability of three consecutive miscarriages
is 0.34%. The occurrence of recurrent pregnancy loss is 1%. A large majority (85%) of
those who have had two miscarriages will conceive and carry normally afterward.
The physical symptoms of a miscarriage vary according to the length of pregnancy, though most
miscarriages cause pain or cramping. The size of blood clots and pregnancy tissue that are passed
become larger with longer gestations. After 13 weeks' gestation, there is a higher risk of placenta
retention.

PREVENTION:

Prevention of a miscarriage can sometimes be accomplished by decreasing risk factors

Non-modifiable risk factors:
Preventing a miscarriage in subsequent pregnancies may be enhanced with assessments of:

 Immune status
 Chemical and occupational exposures
 Anatomical defects

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 Pre-existing or acquired disease in pregnancy
 Previous exposure to chemotherapy and radiation
 Medications
 Surgical history
 Endocrine disorders
 Genetic abnormalities
Modifiable risk factors:
Maintaining a healthy weight and good pre-natal care can reduce the risk of miscarriage. Some
risk factors can be minimized by avoiding the following:

 Smoking
 Cocaine use
 Alcohol
 Poor nutrition
 Occupational exposure to agents that can cause miscarriage
 Medications associated with miscarriage
 Drug abuse

MANAGEMENT:
Women who miscarry early in their pregnancy usually do not require any subsequent medical
treatment but they can benefit from support and counseling. Most early miscarriages will
complete on their own; in other cases, medication treatment or aspiration of the products of
conception can be used to remove remaining tissue. While bed rest has been advocated to
prevent miscarriage, this has not been found to be of benefit. Those who are experiencing or who
have experienced a miscarriage benefit from the use of careful medical language. Significant
distress can often be managed by the ability of the clinician to clearly explain terms without
suggesting that the woman or couples are somehow to blame.
Evidence to support Rho (D) immune globulin after a spontaneous miscarriage is unclear. In the
UK, Rho (D) immune globulin is recommended in Rh-negative women after 12
weeks gestational age and before 12 weeks gestational age in those who need surgery or
medication to complete the miscarriage.
Methods:
No treatment is necessary for a diagnosis of complete miscarriage (so long as ectopic pregnancy
is ruled out). In cases of an incomplete miscarriage, empty sac, or missed abortion there are three
treatment options: watchful waiting, medical management, and surgical treatment. With no
treatment (watchful waiting), most miscarriages (65–80%) will pass naturally within two to six
weeks.  This treatment avoids the possible side effects and complications of medications and
surgery, but increases the risk of mild bleeding, need for unplanned surgical treatment, and
incomplete miscarriage. Medical treatment usually consists of

15
using misoprostol (a prostaglandin) alone or in combination with mifepristone pre-
treatment. These medications help the uterus to contract and expel the remaining tissue out of the
body. This works within a few days in 95% of cases. Vacuum aspiration or sharp curettage can
be used, with vacuum aspiration being lower-risk and more common.
Delayed and incomplete miscarriage:
In delayed or incomplete miscarriage, treatment depends on the amount of tissue remaining in
the uterus. Treatment can include surgical removal of the tissue with vacuum
aspiration or misoprostol. Studies looking at the methods of anaesthesia for surgical management
of incomplete miscarriage have not shown that any adaptation from normal practice is beneficial.
Induced miscarriage:
An induced abortion may be performed by a qualified healthcare provider for women who
cannot continue the pregnancy. Self-induced abortion performed by a woman or non-medical
personnel can be dangerous and is still a cause of maternal mortality in some countries. In some
locales it is illegal or carries heavy social stigma.

Sex:
Some organizations recommend delaying sex after a miscarriage until the bleeding has stopped
to decrease the risk of infection. However, there is not sufficient evidence for the routine use of
antibiotic to try to avoid infection in incomplete abortion. Others recommend delaying attempts
at pregnancy until one period has occurred to make it easier to determine the dates of a
subsequent pregnancy. There is no evidence that getting pregnant in that first cycle affects
outcomes and an early subsequent pregnancy may actually improve outcomes.
Support:
Organizations exist that provide information and counseling to help those who have had a
miscarriage. Family and friends often conduct a memorial or burial service. Hospitals also can
provide support and help memorialize the event. Depending on locale others desire to have a
private ceremony. Providing appropriate support with frequent discussions and sympathetic
counseling are part of evaluation and treatment. Those who experience unexplained miscarriage
can be treated with emotional support.

NURSING RESPONSIBILITY:

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Abortion may seem to be a minor procedure but many management issues are surrounding this
procedure and they include the following:
1. The vital signs have to be frequently monitored.
2. All patients should have 2 large-bore IVs and oxygen, even if they initially appear to be
stable. Blood must be crossed and typed in cases of bleeding.
3. Always obtain a thorough gynecological and obstetric history so as not to miss any other
cause of the symptoms.
4. The rate and amount of bleeding can be easily underestimated especially when the patient
is in the supine position. Thus, clinicians should always perform a pelvic exam in a post-
abortion patient to determine that no blood has collected in the vagina or uterus. The
nurse should check the vaginal area for blood.
5. Uterine perforation if missed can be life-threatening. If the patient has abdominal pain
post-abortion, the gynecologist should be consulted as soon as possible and a CT scan
ordered. Some patients may benefit from a diagnostic laparoscopy.
6. In any post-abortion patient, clinicians should never rule out an ectopic pregnancy.
7. If the patient appears septic, broad-spectrum antibiotics need to be started even before the
diagnostic workup is complete.
8. Consider the fact that the patient may have retained products of conception, which may
be the cause of complications.
9. Bowel injury in post-abortion should be considered; nurses may note that the patient has
a tender abdomen with peritoneal signs and should consult with the clinician immediately
because if missed, it carries a high mortality.
10. Provide psychological support as the patient may go through anxiety and maintain the
confidentiality of the patient.

 If the patient is hemodynamically unstable

 Acute vaginal bleeding
 Diffusely tender abdomen
 High-grade fever
 If the patient is unresponsive
 No urine output

HEALTH TEACHING AND HEALTH PROMOTION :

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  Once the post-abortion complication has been managed, the interprofessional
team including the nurse practitioner should:
 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.
 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.

OUTCOMES:

Every woman's personal experience of miscarriage is different, and women who have more than
one miscarriage may react differently to each event.
In Western cultures since the 1980s, medical providers assume that experiencing a miscarriage
"is a major loss for all pregnant women". A miscarriage can result in anxiety, depression or stress
for those involved. It can have an effect on the whole family. Many of those experiencing a
miscarriage go through a grieving process."Prenatal attachment" often exists that can be seen as
parental sensitivity, love and preoccupation directed toward the unborn child. Serious emotional
impact is usually experienced immediately after the miscarriage. Some may go through the same
loss when an ectopic pregnancy is terminated. In some, the realization of the loss can take weeks.
Providing family support to those experiencing the loss can be challenging because some find
comfort in talking about the miscarriage while others may find the event painful to discuss. The
father can have the same sense of loss. Expressing feelings of grief and loss can sometimes be
harder for men. Some women are able to begin planning their next pregnancy after a few weeks
of having the miscarriage. For others, planning another pregnancy can be difficult. Some
facilities acknowledge the loss. Parents can name and hold their infant. They may be given
mementos such as photos and footprints. Some conduct a funeral or memorial service. They may
express the loss by planting a tree.

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RELEVANT RESEARCH STUDIES:

1. Roy Yoke conducted a study in India (2019), to analyze the rates of and risk
factors for unsafe abortion and abortion-related maternal death in India among 1 
876 462 pregnant women aged 15–58 years from nine states in the Indian Annual
Health Survey (2010–2013).Multivariable logistic regression models examined
the associations of sociodemographic characteristics, health seeking behaviours
and family planning with unsafe abortion and abortion-related mortality. The
study shows results that there were 89 447 abortions among 1 876 462 pregnant
women in 2007–2011 (4.8%; 95% CI 4.8 to 4.9). Of these, 58 266 were classified
as unsafe (67.1%; 95% CI 66.7 to 67.5). There were 253 abortion-related maternal
deaths (0.3%; 95% CI 0.2 to 0.3). Factors associated with unsafe abortion:
maternal age 20–24 years (adjusted OR (aOR): 1.13; 95% CI 1.09 to 1.18),
illiteracy (aOR: 1.48; 95% CI 1.39 to 1.59), rural residence (aOR: 1.26; 95% CI
1.21 to 1.32), Muslim religion (aOR: 1.16; 95% CI 1.12 to 1.22), Schedule caste
social group (aOR: 1.08; 95% CI 1.04 to 1.12), poorest asset quintile (aOR: 1.45;
95% CI 1.38 to 1.53), antenatal care (aOR: 0.69; 95% CI 0.67 to 0.72), no
surviving children (aOR: 1.30; 95% CI 1.16 to 1.46), all surviving children being
female (aOR: 1.12; 95% CI 1.07 to 1.17), use of family planning methods (aOR:
0.69; 95% CI 0.66 to 0.71). Factors associated with abortion-related deaths:
maternal age 15–19 (aOR: 7.79; 95% CI 2.73 to 22.23), rural residence (aOR:
3.28; 95% CI 1.76 to 6.11), Schedule tribe social group (aOR: 4.06; 95% CI 1.39
to 11.87).The study concludes that despite abortion being legal, the high estimated
prevalence of unsafe abortion demonstrates a major public health problem in
India. Socioeconomic vulnerability and inadequate access to healthcare services
combine to leave large numbers of women at risk of unsafe abortion and abortion-
related death.

2. An article published by Reproductive Health stated that abortion services were

legalized in India in 1972, however, the access to safe abortion services is
restricted, especially in rural areas. In 2002, medical abortion using mifepristone-
misoprostol was approved for termination of pregnancy; however, its use has been
limited in primary care settings. This article describes a service delivery
intervention for women attending with unwanted pregnancies over 14 years in
four primary care clinics of Rajasthan, India. Prospective data was collected to
document the profile of women, method of abortion provided, contraceptive use
and follow-up rates after abortion. This analysis includes data collected during
August 2001-March 2015. The results shows that a total of 9076 women with
unwanted pregnancies sought care from these clinics, and abortion services were
provided to 70 % of these. Most abortion seekers were married, had one or more
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 children. After 2003, the use of medical abortion increased over the years and
ultimately accounted for 99 % of all abortions in 2014. About half the women
returned for a follow-up visit, while the proportion using contraceptives declined
from 74 % to 52 % from 2001 to [Link], abortion into primary care
settings is feasible and has a potential to improve access to safe abortion services
in rural areas.

SUMMARY:

The knowledge about the abortion is very important for nurses to know the causes, risk factors,
signs and symptoms of the abortion and the correct management of abortion to prevent maternal
morbidity and mortality.

CONCLUSION:

Till now we discussed about spontaneous abortion. The effective management of abortion will
prevent untoward instances. Hence, this knowledge will help the nurses to apply practical skills
in clinical areas, nursing education and in research programmes.

BIBLIOGRAPHY :

1. D. C. DUTTA, “A TEXTBOOK OF OBSTETRICS”, published by new central

agency , 7th edition (2014), page no:
2. NIMA BHASKAR, “MIDWIFERY AND OBSTETRICAL NURSING”,
published by Emmess medical publishers, 3rd edition, page no:
3. GLORIA HOFFMANN WOLD, “CONTEMPORARY MATERNITY
NURSING”, Mosby publications, Philadelphia (1997), page no:

SEMINAR
ON
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 SPONTANEOUS ABORTION

SUBMITTED TO, SUBMITTED BY,

Mrs. Fouzia madam, Mrs. Sara Mohsin,
Associate professor, [Link] (N) 1st year,
Dep.t of Obstetrics &Gynecological Nursing, OBG Speciality,
Owaisi College Of Nursing
Owaisi college of Nursing,
Kachan bagh, Kanchan Bagh,
Hyderabad. Hyderabad.

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