Welcome

Every day, 10 woman in India die

as a result of abortion related
causes
ABORTION

Submitted by - Dibyajyoti
Muduli
Msc nursing 1st year
Learning objectives
By the end of this session, students will be able to

1. Define abortion , causes ,

classification
2. Explain various types of abortion
3. Understand the clinical features of
different sub types & there
management.
4. Knowledge about how to prevent
abortion
 INTRODUCTION
• Pregnancy is one of the vital events in a woman’s life . Any complications may
result in the loss of pregnancy . Bleeding is one of the complicating factor it may
occur any time during pregnancy either early or late time.
• Bleeding in early pregnancy
– The cause of bleeding in early pregnancy are broadly divided into two groups:-
1.Those related to the pregnancy 2.Those associated with the pregnancy
state:- state :-
This group relates :- This group includes
● Abortion(95%) • Cervical lesion i.e. vascular erosion
● Ectopic pregnancy • Polyp
● Hydatidiform mole • Ruptured varicose veins
● Implantation bleeding • Malignancy
 DEFINITION
• Abortion is the expulsion or extraction from its
mother of an embryo or fetus weighing 500 gms or
less when it is not capable of independent survival
(WHO).
• This 500 gm of fetal development is attained Before 22 weeks
approximately at 22 weeks (154 days) of gestation.
• The expelled embryo or fetus is called abortus.
 INCIDENCE
• About 15 -20 % of all clinical
Pregnancies end in miscarriage.
• About 75 % miscarriages occurs
before the 16th weeks and of these
about 80% occurs before the 12th
week of pregnancy.
 CAUSES OF ABORTION
• Chromosomal abnormalities
• Congenital malformation
Fetal causes • Blighted ovum
• Faulty placental function
• Twins, hydramnios
• Hydatidiform mole
• Maternal illness(Infection, Maternal hypoxia &
shock, chronic illness, Endocrine factors)
• Trauma, Toxic agents
• Cervico –uterine factors (cervical incompetence,
Maternal causes congenital malformation of uterus, uterine fibroid )
• Immunological factors
• Blood group incompatibility
• Premature rupture of membrane Miscarriage
• Nutritional factors
• Age
Paternal causes • Defective sperm
• Lifestyle
Missed
SPONTANEOUS ABORTION
When products of conceptions are
expelled out from the uterine cavity
spontaneously without any
6.7M
6.7M
intervention, before the age of
viability, is known as spontaneous
abortion .
 THREATENED ABORTION
Clinical features:-
• Slight vaginal bleeding
• Slight brownish or bright
Definition red in color
“It is the clinical entity • Usually painless ,may
where the process of have abdominal cramps &
abortion has started but backache
has not progressed to a • Cervix soft with closed
state from which internal os
recovery is impossible.” • Size of uterus corresponds
to period of amenorrhea.
• Ultrasonography shows a
living fetus
 Management :-
• Advised to preserve
vulval pads and
anything expelled out
Investigation:- per vaginam for
• Blood investigation inspection.
• Urine test • To report if bleeding or
• Ultrasonography Treatment :- pain gets aggravated.
• Rest- The patient • Routine note of pulse,
should be in bed rest BP, Temperature ,
until the bleedings stop vaginal bleeding and
. fetal heart rate.
• Drugs- Relief of pain
may be ensured by
diazepam 5mg tablet
or phenobarbitone 30
mg twice daily
 INEVITABLE ABORTION
Clinical features :-
• Profuse Vaginal
Definition:-
bleeding
It is the clinical type of • Colicky pain in lower
abortion where the abdomen
changes have • Internal examination
progressed to a state reveals dilated internal
from where os of the cervix through
continuation of which the products of
pregnancy is conception are felt.
impossible. • Size of uterus equal or
less corresponds to
Open internal os
gestational age
 Management of inevitable abortion
• The principles in the management are
• to look after general condition.
• to accelerate the process of expulsion
• to maintain strict asepsis
• General measures:-
• Excessive bleeding should be promptly controlled by
administering methergin 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 fluid
therapy and blood transfusion.
• Anti D is given to Rh negative mother.
 Active treatment

Before 12weeks:- After 12 weeks:-

• Dilatation and evacuation • The uterine contraction is
followed by Curettage of the accelerated by oxytocin
uterine cavity by blunt curette drip(10units in 500ml of normal
using analgesia or under saline) 40-60 drops per minute.
general anesthesia . • If the fetus is expelled and the
• Alternatively, suction placenta is retained, it is
evacuation followed by removed by dilatation and
curettage is done. evacuation under general
anesthesia.
 COMPLETE ABORTION
Clinical features:-
• History of expulsion of a
Definition:-
fleshy mass per vaginam
When the • Subsidence of abdominal
products of pain
conception are • Vaginal bleeding becomes
completely trace or absent .
• Uterus is smaller than the
expelled, it is
period of amenorrhea
called complete • Cervical os is closed
abortion. • Ultrasonography reveals
empty uterine cavity
Management of complete abortion
• Blood loss should be assessed and
treated
• If there is doubt about complete
expulsion of product, uterine curettage
should be done.
• Transvaginal sonography is useful to
prevent unnecessary surgical procedure.
• Incase of Rh negative mother anti D
gamma globulin should be given.
 INCOMPLETE ABORTION
Clinical features:-
Definition:- • History of expulsion of a
When the entire fleshy mass per vaginam
products of • Pain in lower abdomen
conception are not • Persistence of vaginal
bleeding
expelled, instead a
• Uterus smaller than the
part of it is left inside period of amenorrhea
the uterine cavity, it is • Internal os is open
called incomplete • Ultrasonography reveals
abortion. echogenic material within
the cavity.
Management of incomplete abortion
• Same as inevitable abortion
• Before giving active management resuscitate
the patient
• Early abortion:- Dilatation and evacuation is
done under general anesthesia
• Late abortion:- the uterus is evacuated under
general anesthesia and the products are
removed by ovum forceps or by blunt curette.
• The removed material is sent for histological
examination.
• In stable patient with closed os, tablet
misoprostol 200 mcg used vaginally every 4
hours.
MISSED ABORTION
Definition:-
When the fetus is
dead and retained
inside the uterus for a
variable period, it is
called missed
miscarriage/silent
abortion/ fetal
demise.
 Clinical features
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
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 cardiac motion and fetal movements.
 Management of missed abortion
• Uterus less than 12 weeks:- • Uterus more than 12 weeks :-
• Expectant management –Many • Induction is done by following methods-
women expel the conceptus • Misoprostol 200 mcg tablet is inserted
spontaneously into the posterior vaginal fornix every 6
• Medical management –Misoprostol hours for a maximum of 5 such .
800 mcg vaginally in posterior fornix • Oxytocin 10 IU in 500ml of normal
is given and repeated after 24 hours saline at 30 drops/min is started. If fails,
if needed. Expulsion usually occurs escalate the dose of oxytocin 200 mIU/
within 48 hours. min used with precautions.
• Surgical management – Suction • Following medical treatment
evacuation or dilatation and ultrasonography should be done to
evacuation is done either as a document empty uterine cavity,
definitive treatment or it can be Otherwise evacuation of the retained
done when the medical method fails. products of conception should be done
by dilatation and evacuation.
 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 the:
(1) rise of temperature of at least 100.4°F (38°C) for 24
hours or more
(2) offensive or purulent vaginal discharge
(3) other evidences of pelvic infection such as lower
abdominal pain and tenderness.
 Clinical features:-
• Pyrexia associated with chills Clinical grading:-
and rigors • Septic abortion is graded into
• Pain in abdomen of varying three:
degree • Grade 1: Infection localized to
• Persistent tachycardia > 90 bpm
• Abdominal tenderness
uterus (80%) associated with
• Cervix may be soft and os open spontaneous abortion
• Offensive, purulent vaginal • Grade 2: Infection spread to pelvic
discharge structures(15%)
• Soft boggy mass may be felt • Grade 3: Generalized peritonitis
and /septic shock (5%)
 Investigation:-
• Cervical or high vaginal swab for
culture and sensitivity test.
• Blood for haemoglobin, total and
differential count, ABO and Rh
grouping.
• Urine analysis including culture
• USG abdomen and pelvis
• Blood for culture, serum
electrolytes, coagulation profile
 Management of septic abortion

• Police notification in criminal abortion

• Maintenance of perfusion & ventilation is prime concern
• Crystalloid are used to restore circulation & if necessary blood transfusion
Is given
• Monitoring pulse, respiration, temperature, urine output & progress of the
pain, tenderness and mass in lower abdomen, central venous pressure
• Broad spectrum antibiotics ; combination of ampicillin, gentamicin &
metronidazole or cefotaxime/cefuroxime along with
metronidazole/clindamycin.
• Once infection is controlled evacuation of uterus is done
• If pelvic abscess has formed, it can be drained by posterior colpotomy.
• Indication for exploratory laparotomy:- uterine perforation with suspected
injury to the bowel, no response to evaluation & medical therapy,
generalized peritonitis with intra abdominal abscess.
 RECURRENT ABORTION
• Consecutively two or more spontaneous
abortion before 20 weeks is called recurrent
abortion.
• Affect 1% of women
• Causes
 Investigation of recurrent abortion
• Careful history taking should include
– The nature of previous abortion process
– Histology of the placenta or karyotyping of the conceptus
– Any chronic illness
• Diagnostic tests
– Blood glucose, VDRL, thyroid function test,
ABO & Rh grouping
– Serum LH
– Ultrasonography – to detect congenital malformation of uterus, polycystic ovaries & uterine fibroid
– Hysterosalpingography in the secretory phase to detect – cervical incompetence, uterine
malformation
– Karyotyping
– Endocervical swab test
 Management of recurrent abortion
During pregnancy:-
• During interconceptional
• Psychological support
period :-
• Early pregnancy scan
– Alleviate anxiety and
• Adequate rest
improve psychology
• Progesterone therapy in cases with LPD & recurrent
– Management for congenital abortion
malformation • Patient with cervical incompetence is treated by cervical
– Chromosomal anomalies suture operation i.e. cerclage operation also known as
detect by genetic counseling Mc Donald and shirodkar, this operation done around 14
– Treatment for Endocrine weeks of gestation and the suture must be removed at
about 37 weeks.
disorders
• Intravenous immunoglobulin (IVIG) in a
– Treatment of genital
infection
INDUCTION OF ABORTION

Deliberate termination of pregnancy either by medical or by

surgical method before the viability of the fetus is called
induction of abortion.
• The induced abortion May be legal or illegal
• In many countries, abortion is still illegal.
• In India, abortion was legalized in 1971 by the MTP Act.
 PREVENTION OF ABORTION
• Ensure that family planning services are accessible to all women
of child bearing age to prevent unwanted or unintended
Pregnancies.
• Health personnel should set accurate history in order to identify
women at risk.
• Through physical examination in antenatal clinics to identify risk
factors such as diabetes, anemia, hypertension, infections which
can predispose a woman to having abortion.
• Educate women on sign of abortion, and encourage them to
come to the hospital when they experience such signs
• Educate mother on good nutritious diet and supplements to
prevent any complications
• Counsel all post abortal women and provide family planning
services
 Take home message

Always report any bleeding in early

pregnancy to your health care
provider.
 Questions for students

1. The percentage of 2. Which of the following is the

spontaneous abortion in most common cause of first
the first trimester is about: trimester abortion?

a) 20% A) Uterine anomalies

b) 40% b) Incompetent cervix
c) 60% c) Intrauterine infection
d) 80% d) Fetal chromosomal abnormalities
3.Which of the following is the 4. A clinical entity where
most common cause of second process of abortion has started
trimester abortion? but has not progressed to a
state from which recovery is
A) Uterine anomalies impossible is:
b) Incompetent cervix
c) Intrauterine infection (a) Threatened Abortion
d) Fetal chromosomal
abnormalities (b) Inevitable abortion
(c) Missed abortion
(d) Septic abortion
5.Match the list 1 & list 2 ,and select the correct answer

List 1 List 2
Not progressed to a state from
where recovery is not possible
A. Inevitable
Progressed to a state from where
continuation of pregnancy is not
possible B. Complete
Some products of conception are
expelled & some part is left inside C. Threatened
the uterine cavity
Entire products of conception are
expelled as a mass D. Incomplete
1. Fetus is dead and retained
inside the uterus for a variable E. Missed
period
 SUMMARY
Today we learnt about
abortion its definition,
types, etiology ,
Clinical manifestations,
management of different CONCLUSION
types of abortion The most frequent etiology of miscarriage is a
chromosomal abnormality of the conceptus
and most of the abortions occur in the first-
trimester. The processes of the pathology
decide the characteristics of the subgroups.
Ultrasound is helpful in diagnosis.
 Bibliography
• Textbook of midwifery and obstetrics, Dr shally magon –
sanju sira , Lotus publisher, 4th edition, page 395.
• DC DUTTA’S textbook of obstetrics, Hiralal konar 9th edition,
Jaypee brother medical publisher , page 152.
• https://www.scribd.com/doc/46666854/Abortion
• https://www.slideshare.net/slideshow/abortion-type-and-its-
management/238407317
• https://www.slideshare.net/jaganlogan/hemorrhage-in-early-
pregnancy-238464609