SEMINAR

ON
ABORTION
Presented By:
Mandeep Kaur
[Link]. (N) Final Year
INTRODUCTION:

 Any bleeding in pregnancy is

abnormal. Vaginal blood loss in early
pregnancy should be thought of as a
threatened miscarriage until shown
otherwise. The term miscarriage and
spontaneous abortion are synonymous.
DEFINITION
 Abortion is the process of partial or
complete separation of the products of
conception from the uterine wall with or
without partial or complete expulsion from
the uterine cavity before the age of viability.
 The age of viability is 28 weeks in India.
 Conti...
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). This 500gm
of fetal development is attained
approximately at 22 weeks (154 days) of
gestation.
 The expelled foetus is called abortus.
 INCIDENCE:
 The incidence of abortion is difficult to
work out but probably 10-20% of all clinical
pregnancies end in miscarriage and another
optimistic figure of 10% are induced
illegally. 75% abortions occur before the 16th
week and of these, about 75% occur before
the 8th week of pregnancy.
 ETIOLOGY:
 The etiology of miscarriage is often complex and
obscure. The following factors (embryonic or parental)
are important:
 Genetic factors (50%)
 Endocrine and metabolic factors (10-15%)
 Anatomic abnormalities (10-15%)
 Infections(5%)
 Blood group incompatibility
 Unexplained (40-60%)
CLASSIFICATION
Spontaneous
Induced abortion
abortion

Threatened abortion
Legal abortion

Inevitable abortion

Illegal abortion
Complete abortion

Incomplete abortion

Missed abortion

Septic abortion
Spontaneous Abortion:
 Spontaneous abortion is defined as the involuntary
loss of products of conception prior to 28 weeks of
gestation, when the fetus weights approximately
1000gm or less.
 Spontaneous abortions occur in every 15
pregnancies.
 In India it has been computed that about 6 million

abortions take place, every year of which 2 million

are spontaneous and the 4 million are induced.
 Causes:
 The causes of spontaneous abortion 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.

 Infections such as rubella and Chlamydia.
 Medical conditions
Threatened abortion:
 It is clinical entity where the process of
miscarriage has started but has not
progressed to a state from which recovery is
impossible.
 Clinical features
 Vaginal bleeding with or without recognized uterine
contractions.
 The blood loss may be scanty with or without

accompanying backache and cramp like pain. The pain

may resemble dysmenorrhoea.
 The cervix remains closed and the uterus soft with no

tenderness when palpated.

 The outcome of threatened abortion could be either

stoppage of bleeding and continuance of bleeding and

uterine contractions to expel the products of conception.
Investigations:
 Blood: for Hb, haematocrit, ABO and
grouping
 Urine for immunoglogical test of pregnancy.

 Ultrasonography.
Treatment:

 Rest
 Drugs: For Relief of pain.
 Inevitable Abortion:
 The women presents with bleeding,
often heavy, with clots or products of
conception. Blood loss may be heavy
and the mother in a shocked state.
 The cervix is dilated and on
examination, products may be seen in
the vagina or protruding trough the os.
 The uterus if palpable may be smaller

than expected.
 Management:
 Management is aimed:
a) to accelerate the process of expulsion.
b) to maintain strict asepsis.
 General measures: Excessive bleeding should
be promptly controlled by administering
methergin 0.2mg if the cervix is dilated and the
size of the uterus is less than 12 weeks.
 The blood loss is corrected by intravenous fluid

therapy and blood transfusion.

 Active treatment
Before 12 weeks:
 Dilatation and evacuation followed by curettage using
analgesia or under general anaesthesia.
 Alternatively, suction evacuation followed by curettage is done.

After 12 weeks: The uterine contraction is accelarted by oxytocin

drip (10 units in 500ml 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 trying separated.
If the placenta is not separated, digital separation followed by its
evacuation is to be done under general anaesthesia.
 Complete Abortion:

 The conceptus, placenta and

membranes are expelled completely
from the uterus.
 Clinical features:
There is history of expulsion of a fleshy mass per vagina
followed by:
 Subsidence of abdominal pain

 Vaginal bleeding becomes trace or absent

 Internal examination reveals: uterus is smaller than the

period of amenorrhoea and a little firmer. Cervical os is

closed. Bleeding is trace.
 Examination of the expelled fleshy mass is found

complete
 Management:
 Transvaginal ultra sonography is usefull to
see that uterine cavity is empty, otherwise
evacuation of uterine curettage should be
done.
Incomplete Abortion
 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 or
abortion.
 Clinical features
History of expulsion of a fleshy mass per vagina
followed by:
 Continuation of pain lower abdomen.

 Persistence of vaginal bleeding.

 Internal examination reveals-

a) uterus smaller than the period of amenorrhoea.

b) patulous cervical os often admitting tip of the finger and
c) varying amount of bleeding.
 On examination, the expelled mass is found
incomplete
 Complications
The retained products may cause:
 Profuse bleeding

 Sepsis

 Placental polyp
 Management:
In recent cases: Evacuation of the retained
products of conception (ERCP) is done.
 Medical management of incomplete abortion

may be done. Tablet Misoprostal 200μg is

used vaginally every 4 hours.
 Compared to surgical methods, complications

are less with medical methods.

Missed Abortion

 When the fetus is dead and retained

inside the uterus for a viable period, it is
called missed abortion or early fetal
desmise.
Clinical features
The patient usually presents with features of threatened
abortion followed by:
 Persistence of brownish vaginal discharge.

 Subsidence of pregnancy symptoms.

 Retrogression of breast changes.

 Cessation of uterine growth which in fact becomes

smaller in size.
 Non audibility of the fetal heart sound even with

Doppler ultrasound if it had been audible before.

 Conti...
 Cervix feels firm
 Immunological test for pregnancy becomes

negative.
 Real time ultrasonography reveals an
empty sac early in the pregnancy or the
absence of fetal motion or fetal cardiac
movements.
 Management:
Uterus is less than 12 weeks:
 Expectant management: many women expel the

conceptus spontaneously.
 Medical management: prostaglandin E1
(Misoprostal) 800mg vaginally in the posterior
fornix is given and repeated after 24 hours if
needed. Expulsion usually occurs within 48 hours.
 Suction evacuation or dilatation and evacuation is

done either as a definitive treatment.

 Conti...
Uterus more than 12 weeks:
 Induction is done by the following methods:

 Prostaglandin E1 (misoprostal) 200μg tablet is inserted into

the posterior vaginal fornix every 4 hours for a maximum of

5 such.
 Oxytocin-10-20 units of oxytocin in 500ml of normal saline

at 30 drops per minute is started.

 Many patients need surgical evacuation following medical

treatment.
 Dilatation and evacuation is done once the cervix becomes

soft with use of PGE1.

 Septic Abortion
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:
 Rise of temperature of atleast 100ºF for 24 hours or

more.
 Offensive or purulent vaginal discharge.

 Other evidences of pelvic infection such as lower

abdominal pain and tenderness.

 Incidence:

 About 10% abortions requiring admission to

hospital are septic.
 The majority of septic abortions are associated

with incomplete abortion.

 While in the majority of cases the infection

occurs following illegal induced abortion but

infection can occur even after spontaneous
abortion.
Causes:
 Criminal abortion which is inexpert attempts
at termination of pregnancy by passing
sticks, catheters, pastes or soap solution into
the uterine cavity.
 Inevitable abortion with infection.

 Medical termination of pregnancy with

infection.
 Clinical features:
 Depending upon the severity and the extent of infection,
the clinical picture varies widely.
 Pyrexia associated with chills and rigor suggest of blood
stream spread of infection.
 Pain abdomen
 A rising pulse rate of 100-120/min or more is a significant
finding then even pyrexia. It indicates spread of infection
beyond the uterus.
 Internal examination reveals offensive purulent discharge
or a tender uterus usually with patulous os or a boggy feel
of the uterus.
 Clinical grading:

 Grade 1: The infection is localised in the

uterus.
 Grade 2: The infection spreads beyond the

uterus to the parametrium, tubes and ovaries or

pelvic peritoneum.
 Grade 3: Generalised peritonitis and/or
endotoxic shock or jaundice or acute renal
faiure.
 Investigations:
 Routine investigations include:
 Cervical or high vaginal swab is taken

prior to internal examination.

 Blood for haemoglobin estimation, total

and differential count of white cells, ABO

and Rh grouping.
 Urine analysis for culture.
Special investigations include:
 Ultrasonography of pelvis and abdomen.

 Blood culture- if associated with spell of

chills and rigors, Serum electrolytes and

coagulation profile.
 Plain X-ray.
 Complications:
Immediate complications:
Haemorrhage related to abortion.

Injury may occur to uterus and also to the adjacent structures

particularly gut.
Spread of infection leads to generalised peritonitis, endotoxic shock,

acute renal failure, etc.

Remote complications:
Chronic pelvic pain and backache

Dyspareunia

Ectopic pregnancy

Secondary infertility

Emotional depression
Management of septic abortion:
 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 abortion.
 Overall assessment and patient is levelled in accordance with clinical
grading.
 Investigation protocols.
 Drugs: Antibiotics, analgesics and sedatives.
 Pelvic abscess if present will be drained.
 Evacuation of the uterus.
 Laparotomy : Removal of the uterus should be done irrespective of
parity.
 Induced abortion:
 This is deliberate interruption of an intact
pregnancy. Induced abortions are
performed legally in India since the
Medical termination pregnancy (MTP) Act
of 1971 (revised in 1975).
 MTP ACT
PROVISIONS:-
 The continuation of pregnancy would involve serious

risk of life of the pregnant women.

 There is also risk of child being born with serious

physical and mental abnormalities.

 The pregnancy as the result of rape.

 Pregnancy caused as a result of failure of contraceptive.

 When there are actual or reasonably foreseeable

environments which may lead to risk or injury to the
health of the mother.
 RECOMMENDATI
ONS

 A registered medical practitioner is qualified to perform

MTP.
 Termination can only be performed in Government hospital
or places approved by the Government.
 Pregnancy can only be terminated on the written consent of
the women.
 Termination is permitted up to 20 weeks of pregnancy.
 Pregnancy in a minor girl or lunatic cannot be terminated
without written consent of the parents or legal guardian.
 The abortion has to be performed confidentially.
 INDICATIONS FOR MTP

 THERAPEUTIC OR MEDICAL
TERMINATION:

 Cardiac disease
 Chronic glomerulonephritis.
 Cervical or breast malignancy
 Diabetes mellitus
 Psychiatric illness
 Cont…
 SOCIAL INDICATIONS:

 Porous women having unplanned pregnancy with

low socioeconomic status.
 Pregnancy caused by rape.
 Pregnancy due to failure of contraceptive methods.
 Cont…
 EUGENIC INDICATIONS:

 Structural and chromosomal abnormalities

 Exposure to teratogenic drugs or radiations exposure
 Rubella infection in first trimester
 COMPLICATIO
NS
 IMMEDIATE:

 Injury to the cervix

 Uterine perforation
 Haemorrhage and shock
 Post abortal triad of pain, bleeding and low grade
fever
 Due to prostaglandins: vomiting, diarrhoea and fever.
 Cont….
 REMOTE:

 GYNAECOLOGICAL COMPLICATIONS:
 Menstrual disturbances
 Chronic pelvic inflammation

 OBSTETRICAL COMPLICATIONS:
 Preterm labour
 Dysmaturity
 Rupture uterus
 Role of nurse
Assessment: Assess for the following manifestations:
 Vaginal bleeding, spotting, clots.

 Low abdominal cramping.

 Passing of tissue through the vagina.

 Shock-decreased blood pressure, increased pulse rate.

 Women may verbalize fear, disappointment or

feelings of guilt.
Nursing diagnosis:
 Risk for fetal injury.
 Risk for infection related abortion.
 Fluid volume deficit related to vaginal bleeding as
evidenced by cool and clamy skin, dry mucosa.
 Anticipatory grieving related to loss of pregnancy.
 Anxiety related to outcomes of abortion and its effect on
future pregnancies.
 Altered family processes related to abortion.
 Knowledge deficit related to abortion and its complications.
 Planning:
 Provide information regarding treatment plan.
 Provide support and reassurance regarding

nursing care.
 Promote maternal physical well-being.

 Provide opportunities for counselling and

support.
 Provide teaching related to self care.
 Implementation:
 Observe for vaginal bleeding and cramping.
 Save expelled tissue and clot for examination.
 Monitor vital signs every 5 minutes to 4 hours
depending on maternal status.
 Maintain women on bed rest.
 Observe for signs of shock and institute treatment
measures.
 Prepare for dilatation and curettage if appropriate.
 Provide support, but avoid offering false assurance.
 Summarization:
 Definition of abortion.
 Incidence of abortion.

 Aetiology of abortion.

 Classification of abortion.

 MTP act.

 Role of nurse for the client with abortion

 REFERENCES:
 Jacob annamma. A comprehensive textbook of
midwifery. Edi 2nd. Jaypee publishers. P.275-282.
 Fraser M. Diane, cooper A. Margaret. Myles texebook of
midwives. Edi. 14th. Churchill livingstone. P.600-18.
 Dutta’s DC. Textbook of obstetrics. Edi. 7 th. Hiralal
konar. P.158-168.
 Daftary N. Shirish, chakravarti sudip. Manual of
obstetrics. Edi ; 3rd. Elsevier publishers. P. 364-69
 Salhan sudha. Textbook of obstetrics. Edi; 1 st. Jaypee
publishers. P. 705-0.