ABORTION
GUIDED BY: PRESENTED BY:
MISS LOPAMUDRA ROUT SAGARIKA SAHOO
TUTOR OF SCB COLLEGE [Link] 1ST
OF NURSING YEAR
ROLL NO-32
LEARNING OBJECTIVES:
At 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 and their management.
4) Knowledge about MTP.
INTRODUCTION:
Pregnancy is one of the vital
events in a women’s life. Any
complications may result in the loss of
pregnancy . Bleeding is one of the
complicating factors ,it may occur any
time during pregnancy either early or
late time.
PREGNANCY:
The cause of bleeding in early pregnancy are
broadly divided into 2 groups:-
Those related to the [Link] associated with
pregnancy state: the pregnancy state:
Abortion 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
it’s embryo or fetus weighing 500gms 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 embryo or fetus 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 or deliberate.
About 75% miscarriages occur before
the 16th week and of these about 80%
occur before the 12th week of
pregnancy.
CAUSES OF ABORTION:
Maternal causes: Paternal
Fetal causes: factors:
• Maternal illness
• Chromosomal • Trauma, toxic agents • Age
abnormalities • Cervico -uterine • Defective
• Congenital factors sperm
malformation • Immunological factors • Lifestyle
• Blighted ovum • Blood group
• Faulty placental incompatibility
function • Premature rupture of
• Twins,hydramnios membranes
• Nutritional factors
• Hydatidiform mole
SPONTANEOUS ABORTION:
When products of conceptions are expelled out from
the uterine cavity spontaneously without any
intervention , before the age of viability is known as
spontaneous abortion.
1) Threatened abortion:
Definition:
The process of abortion has started but has not
progressed to a state from which recovery is
impossible.
Clinical manifestations:
o Painless vaginal bleeding without vaginal contraction
o Mild abdominal pain
o Cervical os is closed
o No history of expulsion of any fresh lump
INVESTIGATIONS:
Blood:for Hb, hematocrit,ABO & Rh grouping
Urine:for immunological test of pregnancy
Ultrasonography:shows a living fetus
Management:
o Assess vital sign, general health status an severity of
C/M.
o Advice the pt. for complete bed rest till the bleeding
stop completely.
o Drugs: Sedation and analgesics-
*phenobarbitone 30mg or diazepam 5mg
o Advise to preserve vulval pads & anything expelled out
per vaginam for inspection.
o Report if bleeding or pain gets aggravated.
o Follow up.
PREVENTIVE MEASURES:
Avoid heavy lifting.
Avoid sexual intercourse.
Avoid strenous activity.
Use progesterone tab & [Link].
DIET: high fiber diet to prevent constipation
INEVITABLE ABORTION:
Definition:
It is the clinical type of abortion where the changes
have progressed to a state from where continuation
of pregnancy is impossible.
CLINICAL MANIFESTATIONS:
o Profuse vaginal bleeding
o Colicky pain in lower abdomen
o I/E:reveals dilated internal os of cervix through
which the products of conception are felt.
MANAGEMENT:
o Assess vital signs, general health status & severity
of C/M.
o For controlling bleeding administer inj.
Ergometrine 0.5mg or Methargin 0.2mg as
per doctor’s prescriptions.
o Start iv line and administer fluid such as RL drip.
o Advice the women & her family members to
preserve the perineal pads & other discharges
through the vagina for examination.
o Administer analgesics to relieve pain.
o Evacuation of the uterus.
ACTIVE TREATMENT:
Before 12 weeks After 12 weeks
Dilation and evacuation i. Uterine contraction is
followed by curettage of accelerated by oxytocin
drip(10IU in 500ml NS) 40-
uterine cavity.
60 drops/min.
ii. If the product is expelled
and placenta retained,it is
removed by ovum forceps.
iii. If placenta is not
separated,digital
separation followed by
evacuation under GA.
iv. If bleeding is severe &
cervix is closed then
evacuation of uterus is
done by abdominal
hysterectomy.
Definition
COMPLETE ABORTION:
:
When the
products
of
conceptio
n are
expelled
in
masses ,
it is
called
complete
miscarria
ge.
CLINICAL MANIFESTATIONS:
There is h/o expulsion of a fleshy mass per vagina
Subsidence of abdominal pain
Vaginal bleeding becomes trace or absent.
I/E:
Uterus smaller than period of amenorrhea.
Cervical os closed.
Bleeding in trace.
Examination of the expelled fleshy mass is found
complete.
TVS:reveals empty uterine cavity.
MANAGEMENT:
Note the effect & amount of blood loss.
If there is doubt about complete expulsion of the
products then uterine curettage should be done.
TVS is useful to prevent unnecessary surgical
procedure.
An Rh –ve pt. without antibody in her system
should be protected by Anti-D gamma globulin
50mcg-100mcg I/M in case of early abortion
within 72 hrs.
Definition:
ABORTION:
INCOMPLETE
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
.
CLINICAL FEATURES:
H/O of expulsion of a fleshy mass per vaginam.
Continuation of pain in lower abdomen.
Persistence vaginal bleeding.
I/E:-uterus smaller than period of amenorrhea
- the expelled mass is found incomplete
Complications:
Profuse bleeding
Sepsis
MANAGEMENT:
Before giving active management resuscitate the
patient.
Early abortion:D & E is under GA is to be done.
Late abortion: The uterus is evacuated under GA &
the products are removed by ovum forceps or by
blunt curette.
Late case: D & C is done to remove bits of tissues
left behind.
Tab. Misoprostol 200mcg is used vaginally
4hrs.
MISSED ABORTION:
Definition:
When the fetus is dead and retained inside the
uterus for a viable period, it is called missed
miscarriage or fetal demise.
CLINICAL FEATURES:
Subsidence of pregnancy symptoms.
No bleeding.
No OS opening.
Absent FHR/FHS.
Decrease fundal height acc. to period of gestation.
Complications:
Infection
DIC
MANAGEMENT:
Uterus <12 weeks:
Prostaglandin E1 (misoprostol) 800mcg vaginally in
post. fornix & repeated after 24 hrs.
Suction evacuation or D & E is done.
Uterus> 12 weeks: Induction is done by-
Prostaglandin E1 analog (misoprostol) 200mcg tab
inserted into post. vaginal fornix every 4hr.
Oxytocin 10-20 IU +500ML NS at 30 drops/min is
started.
Evacuation of the retained products of conception
(ERPC).
D & E.
SEPTIC ABORTION:
DEFINITION:
Any abortion associated with clinical evidences of
infection of uterus and it’s contents is called septic
abortion.
Usually consider septic when there are-
Temp 100.4degreeF for 24hrs or more.
Offensive or purulent vaginal discharge.
Pelvic infection such as lower abdominal pain and
tenderness.
INCIDENCE:
• About 10% of abortions requiring admission to
hospital are septic.
• In majority cases , the infection occurs following
illegal induced abortion.
CLINICAL FEATURES: CLINICAL GRADING:
*Temp.>38 degree Grade 1: Grade 2:
*chills and rigors Infection Infection
is involved
*tachycardia >90b/m
localized surround
*hypothermia(endotox ing
ic shock)<36degree to
*abdominal pain uterus Grade 3: organs
*offensive,purulent Infection
vaginal discharge involved to
*uterine tenderness distal
organs
*boggy feel in the
e.g.
POD(pelvic abscess)
hepatitis,
peritonitis
INVESTIGATION:
Routine Special
investigations: investigations:
• Cervical or vaginal • USG
swab • Blood culture
• Hb • Serum electrolytes
• Dc and TLC count • CRP
• Urine analysis • Coagulation profile
• Plain X-ray of
abdomen and chest
COMPLICATIONS:
Immediate: Remote:
Hemorrhage o Chronic debility
Injury to uterus & o Chronic pelvic pain
adjacent structure & backache
Spread of infection o Dyspareunia
leads to-
o Chronic pelvic pain
Generalized peritonitis
ARF
o Emotional
depression
Atelectasis
ARDS
thrombophlebitis
MANAGEMENT:
Principle of management:
a) To control sepsis
b) To remove the source of infection
c) To give supportive therapy
d) To assess the response of treatment
Grade-1:
DRUGS:-Antibiotics
-prophylactic anti gas gangrene serum of
8000units and 3000 units of anti tetanus serum
IM are given
Analgesics and sedatives
Blood transfusion
Evacuation of uterus
GRADE-2:
Drugs:-piperacillin-tazobactum & carbapenem
-vancomycin or teicoplanin
-clindamycin
-gentamycin
-metronidazole
Clinical monitoring: to note pulse,respiration,temp, urine
output,pain,tenderness
Surgery:-evacuation of the uterus
-posterior culpotomy
GRADE_3:
It is known as severe septic abortion along with antibiotic
therapy.
The mother is resuscitated and fluid and electrolyte balance is
maintained.
The laparotomy is done by an experienced surgeon, even
simple drainage of pus is effective.
Septic
abortion
RECURRENT MISCARRIAGE:
Definition:
It is defined as the sequence of two or more
spontaneous abortions as documented by either
sonography or on histopathology before 20 weeks.
Etiology:
Exact cause is not known but there are certain
factors responsible for it.
Genetic chromosomal errors
Anatomical defect:
a. Cervical incompetence
b. Uterine anomalies
Uterine infection
Endocrinal disorders
Immunological factors
INVESTIGATIONS:
Blood glucose
VDRL
Thyroid function test
ABO & Rh grouping
Toxoplasma antibodies IgG, IgM.
USG
Hysterosalpingography
Hysteroscopy
End cervical swab
Management:
Interconceptional period:
o The anxiety of the mother is removed .
o Advise the couple for genetic counselling if there are chromosomal
abnormalities.
o Genital tract infections are treated appropriately following culture
of cervical and vaginal discharge. Empirical treatment with
doxycycline or erythromycin is cost-effective.
DURING PREGNANCY:
o Reassurance and tender loving care (TLC)are very
much helpful. Probably this removes the stress and
improves uterine blood flow.
o Patient should take adequate rest and to avoid
strenuous activities and traveling.
o Patient with cervical incompetence is treated by
cervical suture operation i.e. cerclage operation
named after Mc Donald and Shirodkar.
The operation is done around 14weeks to 16 weeks
of pregnancy.
The stitch should be removed at 37th week or earlier
if labor pain starts or features of abortion appear.
Advice the mother to avoid sex.
Clear all her queries.
Advice her for regular check-ups and follow up.
INDUCED 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 INDIA the abortion was legalized by ‘medical termination of
pregnancy act’ of 1971.
MTP:
Indications:
• The continuation of pregnancy would involve serious risk of
life or gave injury to the physical and mental health of
pregnant woman.
• Substantial risk of the child being born to be handicapped in
life.
• When the pregnancy is caused by rape and in mentally
imbalanced women.
• Pregnancy is caused as a result of failure of a contraceptive.
MEDICAL SURGICAL METHOD:
METHOD:
Manual vaccum
Mifepristone aspiration
Mifepristone
and Suction & evacuation
misoprostol
Methotrexate
Dilatation &
and evacuation
misoprostol
Tamoxifen and Instillation of
misoprostol hypertonic solution
into intramniotic
cavity
TAKE HOME MESSAGE:
MULTIPLE CHOICE QUESTIONS:
1) Abortion is the termination of pregnancy before _____ week of
pregnancy.
a. 16th week
b. 12th week
c. 10th week
d. 24th week
2)Abortion during 2nd trimester of pregnancy mainly occur due to:
e. Congenital anomalies of fetus
f. Hormonal deficiency in mother
g. Congenital anomalies of the uterus
h. Malnutrition
3)A clinical entity where the process of abortion has started but has
not progressed to a state from which recovery is impossible is:
i. Spontaneous abortion
j. Threatened abortion
k. Inevitable abortion
l. Missed abortion
4)The inevitable abortion distinguished from threatened
abortion by:
a. Dilation of cervical canal
b. Rupture of membrane
c. Bleeding
d. Uterine contraction
5)Mc Donald suturing is done in:
e. Missed abortion
f. Septic abortion
g. Recurrent abortion
h. Complete abortion
6)A septic abortion where the infection spreads beyond the
uterus to the parametrium, tubes and ovaries or pelvic
peritoneum is considered:
i. Grade I
j. Grade II
k. Grade III
SUMMMARY:
Today we learnt about abortion ,it’s
definition ,causes , classification, clinical
manifestations, management of different
types of abortion .
Conclusion:
Bleeding during pregnancy may be a sign of
miscarriages or abortion . 80% abortion
occurs in 1st trimester & most common cause
is chromosomal abnormalities. The process of
pathology decide the characteristics of the
subgroups. Ultrasound is helpful in diagnosis.
BIBLIOGRAPHY:
• Textbook of midwifery and obstetrics,Dr
shally magon-sanju sira,Lotus publishers,4th
edition
• DC DUTTA’S textbook of obstetrics,Hiralal
konar 9th edition,Jaypee brother medical
publisher.
• [Link]
ion
• [Link]
n-type-and- its- management/238407327
• [Link]
rhage-in-early-pregnancy-238464609
