ABORTION

PRESENTED BY,
MISS. ANSHIKA
SRIVASTAV
 INTRODUCTION

First recorded in 1540–50, abortion is from the Latin

word abortiōn- (stem of abortiō). Abortion is the
termination of a pregnancy by removal or expulsion
of an embryo or fetus. An abortion that occurs
without intervention is known as a miscarriage or
"spontaneous abortion" and occurs in approximately
30% to 40% of pregnancies.
 DEFINITION

 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).

OR

 The National Center for Health Statistics, the Centers for Disease
Control and Prevention (CDC), and the World Health
Organization (WHO) define abortion “as pregnancy termination
prior to 20 weeks' gestation or a fetus born weighing less than 500
g. Despite this, definitions vary widely according to state laws."
This 500gm of fetal development is attained approximately at 22 weeks (154 days) of gestation.

Early Abortion: Before 12 weeks

Late Abortion: From 12-20

VIABILITY

Survival by Gestational age Weeks % survival

22 0
23 25
24 55
25 65
26 75
27 90
28 92
 INCIDENCE

 Globally, 56 million abortions take place

every year. In South and Central Asia, an
estimated 16 million abortions took place
between 2010 and 2014, while 13 million
abortions occurred in Eastern Asia alone.
 There is significant variance in the
estimates for the number of abortions
reported and the total number of estimated
abortions taking place in India.
 Cont…
 According to HMIS reports, the total number of
spontaneous/induced abortions that took place in India in
2016–17 was 970436, in 2015–16 was 901781, in 2014–15
was 901839, and in 2013–14 was 790587. 
 Ten women reportedly die due to unsafe abortions every day
in India. The data, which is dynamic in nature, can be
accessed on the Health Management Information System
(HMIS) portal.
Cont..

 The midpoint abortion rate is lowest in Tamil Nadu (32.8) and highest in Assam
(66.2), and the other four states have rates within this range: Gujarat (47.6), Bihar
(49.4), Madhya Pradesh (57.3) and Uttar Pradesh (61.1).

 Abortion in India is legal and can be performed until 24 weeks pregnancy after
MTP act amendment 2021 comes in force by notification in Gazzett of India with
notification of formation of MTP amendment 2021 rules and regulations. Until
then, abortion law in India allows termination of pregnancy till 20 weeks. In
exceptional cases, a court may allow a termination after 20 weeks.
CLASSIFICATION OF ABORTION
 ETIOLOGY

 More than 80% of abortion occur in first 12 weeks and the rate decreases
rapidly thereafter. Various maternal and fetal factors have been
implicated.
 Fetal Factor: - Abnormal zygote development. The most common
abnormality is seen in development of zygote, embryo, early fetus or
placenta. About 50%-60% of early spontaneous abortions are associated
with a chromosomal anomaly.
 Maternal causes: these includes : Chemotherapy, steroids, AIDS.
 Cont…

 Infections: E.g., Toxoplasma gondii cytomegalo virus, herpes

virus, rubella virus (TORCH) are mainly implicated. The
probable factors that play a role in the risk of abortion due to
infection are the following:
 Primary exposure during early gestation.
 Development of an infectious corner state.
 Immunocompromise caused by immune- suppressants.
Cont..
 Endocrine disorders:
 These account for 25% of habitual abortion and include, corpus
luteum deficiency, hyperthyroidism, poorly controlled diabetes,
polycystic ovarian diseases.
 Anatomical abnormalities
 Cervico-uterine factors-
 Cervical incompetence
 Congenital malformation of uterus
 Uterine fibroid
 Intrauterine adhesions
 Retroverted uterus
 Cont..
 Trauma-

 Psychic Susceptible individual

 Amniocentesis

 Toxic agents

4. Blood group incompatibility

5. Premature Rupture of Membranes

 6. Environmental factors – Smoking, alcoholism, X-ray, Radiation,

Chemotherapy.

 [Link] factors
 Cont..

 [Link] factors: Chromosomal anomaly in sperm

 9. Inherited Thrombophilia
 Drug used and environment factors:
 A variety of agent like Tobacco, Alcohol, smoking have been associated
with increased risk.
 Environmental toxins like anaesthetic gases, arsenic, lead,
formaldehyde, solvent, may cause abortion.
 Cont..

Autoimmune disorders:
 Include anti phospholipid antibody syndrome, systemic lupus erythematous.
10%-16% of women with abortions have antiphospholipic antibodies. Mothers
immune system will form antibody against her own placenta and fetus.

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).
Cont..

 Common cause

 First trimester

 Genetic factors -50%

 Endocrine disorders

 Immunological

 Infections

 Unexplained (40-60%)
Cont..

 Second trimester

 Anatomic abnormalities

a) Cervical incompetence

b) Mullerian fusion defects (Bicornuate uterus, septate uterus ) Uterine

synechiae (intra uterine adhesion )

c) Uterine fibroid

 Maternal medical illness

 Unexplained
Cont..

 Parasitic: toxoplasma, malaria.

 Bacterial: urea plasma, chlamydia,.

Endocrine disorders:

These account for 25% of habitual abortion and include, corpus

luteum deficiency, hyperthyroidism, poorly controlled diabetes,
polycystic ovarian diseases.
Cont..

Drug used and environment factors:

 A variety of agent like Tobacco, Alcohol, smoking have

been associated with increased risk.
 Environmental toxins like anaesthetic gases, arsenic, lead,
formaldehyde, solvent, may cause abortion.
 Miscarriage Symptoms
 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.
 MECHANISM OF MISCARRIAGE

   In the early weeks, death of the ovum occurs first, followed by its
expulsion. In the later weeks, maternal environmental factors are involved
leading to expulsion of the fetus which may have signs of life but is too
small to survive.

 Before 8 weeks: The ovum, surrounded by the villi with the decidual
coverings, is expelled out intact. Sometimes, the external os fails to dilate so
that the entire mass is accommodated in the dilated cervical canal and is
called cervical miscarriage.
 Cont..

 Between 8 weeks and 14 weeks: Expulsion of the fetus commonly

occurs leaving behind the placenta and the membranes. A part of it may
be partially separated with brisk hemorrhage or remains totally attached
to the uterine wall.

 Beyond 14th week: The process of expulsion is similar to that of a

“mini labor”. The fetus is expelled first followed by expulsion of the
placenta after a varying interval.
 SPONTANEOUS ABORTION

DEFINITION

Spontaneous abortion is defined as the involuntary loss of the products of

conception prior to 28 weeks of gestation, when the fetus weights approximately
1,000gm or less.

 Spontaneous abortion occurs once in 15 pregnancies (Park 2000). In India it has

been computed that about 6 million abortions takes place, every year which 2
million are spontaneous and 4 million are induced.
 CAUSES

 The causes of spontaneous abortions in most cases are not known. Where a
cause is determined, 50% of miscarriages are due to chromosomal
abnormalities of the conceptus. Genetic and structural causes are also
attributed to pregnancy loss. Maternal causes are:

 Structural abnormalities of the genital organs such as retroversion of uterus,

bicornate of uterus and fibroids.

 Infections such as rubella and chlamydia.

 Medical conditions such as diabetes, renal disease and thyroid dysfunction,

when not well- controlled.
 TYPES OF SPONTANEOUS ABORTIONS

1. Threatened

2. Inevitable

3. Complete

4. Incomplete

5. Missed

6. Septic.
 1. THREATENED ABORTIONS

Definition

 It is a clinical entity where the process of miscarriage has

started but has not progressed to a state from which recovery
is impossible.
 Clinical Features

The patient, having symptoms

suggestive of pregnancy, complains
of:
(1) Bleeding per vaginam: Is usually
slight and may be brownish or bright
red in color. On rare occasion, the
bleeding may be brisk, especially in
the late second trimester. The bleeding
usually stops spontaneously.
Cont..

2) Pain: Bleeding is usually painless but there may be mild backache or dull pain in
lower abdomen.
 Pain appears usually following hemorrhage.
 Pelvic examination should be done as gently as possible.
 (a) Speculum examination reveals—bleeding if any, escapes through the external
os. Differential diagnosis includes cervical ectopy, polyps or carcinoma, ectopic
pregnancy and molar pregnancy.
 (b) Digital examination reveals the closed external os. The uterine size corresponds
to the period of amenorrhea. The uterus and cervix feel soft. Pelvic examination is
avoided when ultrasonography is available
 Special Investigations

1. Ultrasound (TVS)

a) A well-formed gestational ring with observation of fetal heart rate motion shows
healthy fetus.

b) Observation of fetal cardiac motion. With this there is 98% chance of continuation
of pregnancy.

c) On the other hand, a blighted ovum is evidenced by crevated or irregular gestational

sac, small mean gestational sac diameter, absent fetal echoes and absent fetal
cardiac movements.
Cont..

 Serum progesterone: Value of 25 ng/mL or more generally indicates a viable

pregnancy in about 95% of cases. Serial serum ꞵ- HCG level is helpful to assess
the fetal well-being. Ectopic pregnancy must be ruled out during investigations.

Treatment
 Rest: The patient should be in bed for few days until bleeding stops. Prolonged
restriction of activity

 has got no therapeutic value.

 Drugs: Relief of pain may be ensured by diazepam 5 mg tablet twice daily.

Cont..

 There is some evidence that treatment with progesterone improves the outcome.
Progesterone induces immunomodulation to shift the Th-1 (proinflammatory
response) to Th-2 (anti-inflammatory response). Use of hCG is not prefered

 ADVICE ON DISCHARGE: The patient should limit her activities for at least 2
weeks and avoid heavy work. Coitus is avoided during this period. She should be
followed up with repeat sonography at 3–4 weeks’ time.

 The following indicates unfavourable outcome: falling serum b-hCG,

decreasing size of the fetus, irregular shape of the gestational sac or decreasing
fetal heart rate.
 Cont..

 PROGNOSIS: The prognosis is very unpredictable. In isolated spontaneous

threatened miscarriage, the
 following events may occur:
 (a) In about two-thirds, the pregnancy continues beyond 28 weeks.
 (b) In the rest, it terminates either as inevitable or missed miscarriage. If the
pregnancy continues, there is increased frequency of preterm labor, placenta
previa, intrauterine growth restriction of the fetus and fetal anomalies.
 2. INEVITABLE MISCARRIAGE

Definition

It is the clinical type of abortion where the changes have progressed to

a state from where continuation of pregnancy is impossible.

Clinical Features

 Symptoms— The patient complains of sudden gush of watery fluid

by pain in lower abdomen and increased vaginal bleeding.
Cont..

 Signs—On internal examination internal os is dilated and products of conception

can be felt through os.

 Management

 (a) To accelerate the process of expulsion.

 (b) To maintain strict asepsis.

 General measures: Excessive bleeding should be promptly controlled by

administering Methergine 0.2 mg if the cervix is dilated and the size of the uterus
is less than 12 weeks. The blood loss is corrected by intravenous (IV) fluid therapy
and blood transfusion.
 Treatment

Before 12 weeks

 (a) Dilatation and evacuation followed by curettage of the uterine cavity by blunt
curette using analgesia or under general anesthesia.

 (b) Alternatively, suction evacuation followed by curettage is done.

After 12 weeks

(a)The uterine contraction is accelerated by oxytocin drip (10 units in 500 mL of normal
saline) 40–60 drops per minute. If the fetus is expelled and the placenta is retained, it
is removed by ovum forceps, if lying separated. If the placenta is not separated,
digital separation followed by its evacuation is to be done under general anesthesia.
 3. COMPLETE MISCARRIAGE

DEFINITION

When the products of conception are expelled enmasse, it is called

complete miscarriage.

CLINICAL FEATURES

 There is history of expulsion of a fleshy mass per vaginam followed by:

1. Subsidence of abdominal pain.

2. Vaginal bleeding becomes trace or absent.

Cont..

3. Internal examination reveals:

 (a) Uterus is smaller than the period of amenorrhea and a little firmer.

 (b) Cervical os is closed.

 (c) Bleeding is trace.

4. Examination of the expelled fleshy mass is found complete.

5. Ultrasonography (TVS): Reveals empty uterine cavity.

 Management

Transvaginal sonography is useful to see that uterine cavity is empty, otherwise

evacuation of uterine curettage should be done.

 Rh-negative women: A Rh-negative patient without antibody in her system should

be protected by:

 anti-D gamma globulin 50 μg or 100 μg intramuscularly in cases of early

miscarriage or late miscarriage respectively within 72 hours. However, anti-D may
not be required in a case with complete miscarriage before 12 weeks of gestation
where no instrumentation has been done.
 BIBLIOGRAPHY

1. Myles, Textbook for Midwives,8th Edition 2014, Elsevier Publication, China, Page
no- 140 to 156.
2. Dutta’s DC, Textbook of Obstetrics, 9th edition 2019, Jaypee Brothers Medical
Publishers (P) Ltd, Page No- 185 to 206.
3. Kumari Neelam’s, A Textbook of Midwifery and Gynecological Nursing,5th Edition
2018, S. Vikash and Company (Medical Publishers) INDIA, Page No- 311 to 324.
4. Jacob Annamma’s, A Comprehensive Textbook of Midwifery and Gynecological
Nursing,3rd Edition 2012, Jaypee Brothers Medical Publishers (P) Ltd. Page No- 65-
68.
 1. INCOMPLETE MISCARRIAGE
 Definition
When the entire products of conception are not expelled, instead a part of it
is left inside the uterine cavity, it is called incomplete miscarriage. This is
the commonest type met amongst women, hospitalized for miscarriage
complications.
Clinical Features
History of expulsion of a fleshy mass per vaginam followed by:
1. Continuation of pain in lower abdomen.
2. Persistence of vaginal bleeding.
3. Internal examination reveals—
a. uterus smaller than the period of amenorrhea.
a. patulous cervical os often admitting tip of the finger and.
b. varying amount of bleeding.
 on examination, the expelled mass is found incomplete.
1. Ultrasonography—reveals echogenic material (products of conception)
within the cavity.
Complications
 The retained products may cause:
 (a) profuse bleeding
 (b) sepsis or
 (c) placental polyp.
 Management

 In recent cases—evacuation of the retained products of conception (ERCP) is done.

 She should be resuscitated before any active treatment is undertaken.

 Early abortion: Dilatation and evacuation under analgesia or general anesthesia is to be

done.

 Evacuation of the uterus may be done using manual vacuum aspiration (MVA) also.

 Late abortion: The uterus is evacuated under general anesthesia and the products are
removed
by ovum forceps or by blunt curette. In late cases, dilatation and curettage
operation is to be done.

Medical management of incomplete miscarriage may be done. Tablet

misoprostol 200 μg is used

 vaginally every 4 hours. Compared to surgical method, complications are less

with medical method.
 5. MISSED MISCARRIAGE

Definition

 When the fetus is dead and retained inside the uterus for a variable period, it is called

 missed miscarriage or early fetal demise.

Pathology

 The causes of prolonged retention of the dead fetus in the uterus are not clear. Beyond

 12 weeks, the retained fetus becomes macerated or mummified. The liquor amnii gets absorbed
and

 the placenta becomes pale, thin and may be adherent. Before 12 weeks, the pathological process
differs.
 Clinical Features: The patient usually presents with features of threatened
miscarriage followed by:

1. Persistence of brownish vaginal discharge.

2. Subsidence of pregnancy symptoms.

3. Retrogression of breast changes.

4. Cessation of uterine growth which in fact becomes smaller in size.

5. No audibility of the fetal heart sound even with Doppler ultrasound if it had
been audible before.

6. Cervix feels firm.

7. Immunological test for pregnancy becomes negative.

Complications: The complications of the missed miscarriage are those mentioned in
intrauterine fetal death Blood coagulation disorders are less likely to occur in missed
miscarriage.
Management:
 􀂍 Expectant 􀂍 Medical 􀂍 Surgical
 Uterus is less than 12 weeks:
i. Expectant Management—Many women expel the conceptus spontaneously
ii. Medical Management: -- Prostaglandin E1 (misoprostol) 800 mg vaginally in the
posterior fornix is given and repeated after 24 hours if needed. Expulsion usually
occurs within 48 hours.
[Link] evacuation or dilatation and evacuation is done either as a definitive
treatment or it can be done when the medical method fails. The risk of damage to
the uterine walls and brisk hemorrhage during the operation should be kept in
mind.
 Uterus more than 12 weeks: The same principles of the management as advocated
in the intrauterine fetal death are to be followed).
 Induction is done by the following methods:
 Prostaglandins are more effective than oxytocin in such cases. The methods used
are:
 (a) Prostaglandin E1 analog (misoprostol) 200 μg tablet is inserted into the
posterior vaginal fornix every 4 hours for a maximum of 5 such.
 (b) Oxytocin—10–20 units of oxytocin in 500 mL of normal saline at 30 drops/min
is started. If fails, escalating dose of oxytocin to the maximum of 200 mlU/min may
be used with monitoring.
 (c) Many patients need surgical evacuation following medical treatment. Following
medical treatment, ultrasonography should be done to document empty uterine
cavity. Otherwise, evacuation of the retained products of conception (ERPC)
should be done.
  (d) Dilatation and evacuation is done once the cervix becomes soft with use of
PGE1. Otherwise, cervical canal is dilated using the mechanical dilators or by
laminaria tent.

SEPTIC ABORTION

 Definition: Any abortion associated with clinical evidences of infection of the uterus
and its contents is called septic abortion. Although clinical criteria vary, abortion is
usually considered septic when there are:

i. Rise of temperature of at least 100.4°F (38°C) for 24 hours or more,

ii. Offensive or purulent vaginal discharge.

[Link] evidences of pelvic infection such as lower abdominal pain and tenderness.
Mode of infection
The microorganisms involved in the sepsis are usually those normally
present
 in the vagina (endogenous).
The microorganisms are:
 (a) Anaerobic—Bacteroides group (fragilis),
 anaerobic Streptococci, Clostridium welchii and tetanus bacillus.
 (b) Aerobic—Escherichia coli (E. coli),
 Klebsiella, Staphylococcus, Pseudomonas and group A beta-hemolytic
Streptococcus (usually exogenous),
 methicillin-resistant Staphylococcus aureus (MRSA).
 Clinical Features

 Depending upon the severity and the extent of infection, the clinical picture varies
widely. History of unsafe termination by an unauthorized person is mostly concealed.
Clinical Features of Septic Abortion.

a. Pain in lower abdomen.

b. Fever with chills.

c. Foul smelling discharge per vaginam or lochia.

d. Prolonged bleeding or spotting.

e. Ill health, lethargy and weakness.

 Vaginal examination reveals a bulky subinvoluted uterus and uterine tenderness
with cervical movement.

 Grade I: The infection is localized in the uterus.

 Grade II: The infection spreads beyond the uterus to the parametrium, tubes and
ovaries or pelvic peritoneum.

 Grade III: Generalized peritonitis and/or endotoxic shock or jaundice or acute

renal failure.

 Grade I is the commonest and is usually associated with spontaneous abortion.

 Investigations
1) Haemogram.
2) Routine urine analysis.
3) Kidney and liver function test.
4) Coagulation profile.
5) High vaginal or cervical swab for culture and sensitivity,
6) Upright x-ray abdomen and pelvis to detect uterine and gut perforation
and peritonitis.
7) Pelvic imaging studies which include pelvic ultrasound for retained
products of conception, foreign body in uterus, pelvic abscess
peritonitis, CT scan and MRI are also helpful.
 Complications
 Immediate
 Most of the fatal complications are associated with illegally induced abortions of
grade III type.
 Hemorrhage related due to abortion process and also due to the injury inflicted
during the interference.
 Injury may occur to the uterus and also to the adjacent structures particularly the
bowels.
 Spread of infection leads to
 (a) Generalized peritonitis—the infection reaches through:
 (i) the uterine tubes
 (ii) perforation of the uterus
 (iii) bursting of the micro abscess in the uterine wall.
 Prevention:

1. To boost up family planning acceptance in order to curb the unwanted

pregnancies.

2. Rigid enforcement of legalized abortion in practice and to curb the prevalence of

unsafe abortions.

3. Education, motivation and extension of the facilities are sine qua non to get the
real benefit out of it.

4. To take antiseptic and aseptic precautions either during internal examination or

during operation in spontaneous abortion.
 Management

 GENERAL MANAGEMENT:

 Hospitalization is essential for all cases of septic abortion. The patient is kept in
isolation.

 To take high vaginal or cervical swab for culture, drug sensitivity test and Gram stain.

 Vaginal examination is done to note the state of the abortion process and extension of
the infection.

 Overall assessment of the case and the patient is levelled in accordance with the
clinical grading.
 Investigation protocols as outlined before are done.

Principles of management are:

(a) To control sepsis.

(b) To remove the source of infection.

(c) To give supportive therapy to bring back the normal homeostatic and
cellular metabolism.

(d) To assess the response of treatment.

 GRADE I

 Drugs:

 (1) Antibiotics.

 (2) Prophylactic antigas gangrene serum of 8,000 units and 3,000 units
of antitetanus serum \intramuscularly are given if there is a history of
interference.

 (3) Analgesics and sedatives, as required, are to be prescribed.

 Blood transfusion is given to improve anaemia and body resistance.

Evacuation of the uterus: As abortion is often incomplete,
evacuation should be performed at a convenient time within 24 hours
following antibiotic therapy. Excessive bleeding is, of course, an
removes the nidus of infection. The procedure should be gentle to
avoid injury to the uterus.
GRADE II
 Drugs:
 Antibiotics—Mixed infections including Gram-positive, Gram-
negative and aerobic and
 anaerobic organisms are common. Ideal antibiotic regimens should
cover all of them.
 Antimicrobial therapy: A combination of either piperacillin-tazobactam or carbapenem
plus

 clindamycin (IV) gives broadest range of microbial coverage. Emperical therapy is started
first and is

 changed when culture sensitivity report is available.

 (a) Piperacillin-tazobactam and carbapenems: Covers most organisms except MRSA,

and are not

 nephrotoxic. Piperacillin-tazobactam does not cover extended spectrum b-lactamase

(ESBL) producers.
(b) Vancomycin or teicoplanin may be added for MRSA resistant to
clindamycin.
(c) Clindamycin: Covers most streptococci, staphylococci including MRSA
and is not nephrotoxic.
(d) Gentamycin --(3–5 mg/kg—single dose) can be given when renal function
is normal.
(e) Co-amoxiclav—does not cover MRSA, Pseudomonas or ESBL-producing
organisms.
(f) Metronidazole—covers anaerobes.
 Analgesic, AGS and ATS are given as in Grade I. Blood transfusion is
more often needed than in Grade I cases.
 Clinical monitoring: To note pulse, respiration, temperature, urinary output
and progress of the pain,
 tenderness and mass in lower abdomen, CVP greater than 8 mm Hg.
 Surgery:
1. Evacuation of the uterus—Evacuation should be withheld for at least 48
hours when the infection is controlled and is localized, the only exception
being excessive bleeding.
2. Posterior colpotomy—When the infection is localized in the pouch of
Douglas, pelvic abscess is formed. It is evidenced by spiky rise of
temperature, rectal tenesmus (frequent loose stool mixed with mucus) and
boggy mass felt through the posterior fornix. Posterior colpotomy and
drainage of the pus relieve the symptoms and improve the general outlook
of the patient.