2. ABORTION.pdf

Good notes

1. ABORTION
MR NKOLE J
Lecturer-Dept. of Nursing Sciences -LIAS
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2. Introduction
Abortionisthecommonestcauseofvaginalbleedinginearly
pregnancyandisoneoftheleadingcausesofmaternal
mortalityworldwide.
Thetermmiscarriageiscommonlyusedinsomeliteratureto
meantermabortion.Inmedicalterms,whetherinducedor
spontaneousitisgenerallycalledabortion.
Themajorityoftheabortionsoccurinthefirsttrimester,orwithin
thefirst12weeksofpregnancy.
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3. General objective
•Attheendofthelecture/discussion,studentsshouldbeableto
acquireknowledgeandskillinthemanagementofapatient
withanabortion
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4. Specific objectives
Bytheendofthislecture/discussion,students
shouldbeableto:
Defineofabortion
Statethecausesofabortion
Explainclassificationsofabortion
Explainthedifferenttypesandmanagementofabortions
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5. Definition of terms
Abortionistheterminationorinterruptionofpregnancyorfetal
growthbeforethe28
th
weekofpregnancy
Abortionislossofpregnancybeforethe28thweekorlossof
fetusweighinglessthan500g(WHO).
Abortionistheinterruptionofpregnancybefore28thweek,
afterwhichthefetusissaidtobeviable.
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6. •UnsafeAbortionis“aprocedureforterminatinganunintended
pregnancythatiscarriedouteitherbypersonslacking
necessaryskillsorinanenvironmentthatdoesnotconformto
minimalmedicalstandards,orboth(WHO,2008).
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7. Causes of abortion
•They are divided into two namely maternal and fetal causes;
MATERNAL CAUSES
i.MaternalinfectionsBacteria,virusesandparasitesinvadethe
placentaandaffectthemetabolismoftheplacentaleadingto
earlydegeneration.Toxoplasmosis,cytomegalovirus,syphilis,
Chlamydiaandmalariaarecommoncausesofabortion
ii.Hormonalimbalance-Thehormonesresponsibleforsustaining
thepregnancymightnotbesufficiente.g.
Oestrogen/progesterone.Theriskincreaseswithadvancing
maternalageduetoimbalanceofhormones..
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8. Causes of abortion
iii)Structuralabnormalitiesofthegenitaltract–Retroversionof
theuterus,bicornuateuterusandfibroidshinderthegrowthofthe
fetusandthisleadstoabortion.
iv)Incompetentcervix–inabilitytoholdthepregnancydueto
inadequatecervicalcollagenfibreswhichmakesthecervicalos
weakleadingtofailureofthecervixtocontaintheweightofthe
growingfetus.
v)Maternalchronicconditions–conditionssuchasanaemia,
hypertension,renaldiseases,andcardiacdiseasesleadtoPoor
placentalperfusionmakesitweakerandeventuallystartsdetaching
causingabortion
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9. Causes of abortion
vi)ExtremeemotionalStressandanxiety-Causealterationsinthe
levelsofpituitaryhormonesandassociatedhormoneswhichmaintain
andsustainthepregnancy.Thisalterationmayaffectuterinefunction
andmaycauseabortion
vii)Noxiousagents(Poisonoussubstance)e.g.Drugs,chemicals
andradiation.Theseareembryotoxicandcanleadtoabortion.
viii)Trauma-Externalpressuresuchasassaultandstrenousactivities
mayinduceanabortioninthatitmayleadplacentaldetachment.
ix)Nutritionaldeficiencies-MalnutritionandLackoffolicAcid.
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10. x)SocialhabitssuchasCigarettesmoking,nicotineincigarette
constrictthebloodvesselsandmayleadtohypoxia
•Excessivealcoholintakemayleadtoreducedfoodintakeand
fallswhichcanleadtoabortion.
xi)BloodIncompatibility-ABOincompatibilityandRhesus
incompatibility(Iso-immunisation).TheRhesusantibodiescancross
theplacentaandattacktheRBCleadingtohemolysis.
xii)Abodominalsurgery:traumaofsurgerymayinitiateabortion
e.g.myomectomy,appendicitisorperitonitis(laparatomy).
xiii)Multiparity:uterusbecomesweakbecauseofhavingtoo
manychildren.
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11. •FETAL CAUSES
i.ChromosomalanomaliesThemalformationsandabnormalities
oftheconceptus.Anychangeinthenormalstructureornumberof
chromosomesmayleadtomalformationsandabnormalitiesof
theconceptusandthismayleadtoabortion.Thisaccountsfor
50%causesofabortion.
ii.DefectiveImplantationAnydefectiveimplantationofthe
blastocystwhichmaynotpromotefetalgrowthmayleadtoan
abortion
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12. •Multiplepregnancy-Hasanincreasedtendencyto
spontaneousabortionsinthesensethattheuterusmayfailto
accommodatethem
•Fetalinfections-FetalinfectionslikeRubella(Germanmeasles)
cancauseextensivedamagetothefetusleadingtoabortion
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13. Classification of Abortions
•There are two (2);
i.Spontaneous abortion
ii.Induced abortion
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14. •SpontaneousAbortionistheterminationofpregnancythat
occurswithoutexternalinterference.
•SpontaneousAbortioninvoluntarylossofproductofconception
priorto28weeksgestationwithoutanyexternal
interference(Myles,2006)
•TypesofSpontaneousAbortions
i.Threatened v)Missed
ii.Inevitable vi)Habitual
iii.Incomplete vii)septic
iv.Complete
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15. •Inducedabortionistheterminationofpregnancybeforethe
28thweeksofgestationthatoccursduetoexternalinterference
•Inducedabortionistheterminationofpregnancybychoiceofa
womanpriorto28thweeksgestationalage
onwards(Myles,2006)
•TypesofInducedAbortion
i.Therapeuticabortion
ii.Criminalabortion
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16. ABORTION
SPONTANEOUS ABORTION INDUCED ABORTION
THREATENING
TERM MISEED INERVITABLE THERAPEUTIC CRIMINAL
BLOOD MOLE COMPLETE INCOMPLETE COMPPLTE INCOMPLETE
CARNEOUS HABITUAL SEPTIC SEPTIC
ABORTION TREE
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17. Types of abortion under spontaneous
•Threatened Abortion
•Itisaspontaneoustypeofabortion,in
whichapregnantwomanpresentswith
slightbleedingthroughtheun-dilated
cervix.
•Diagnosedwhenapregnantwoman
presentswithslightbleeding,withor
withoutlowbackacheandcramplike
pain.Thereisminordisturbancetothe
pregnancy
•Thepregnancymay;Gototerm,
MissedorInevitable
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18. •Inevitable abortion
•Itatypeofabortioninwhichthereis
progressivedilatationofthecervix.The
pregnancyismoreadvanced<12
weeks
•Bleedingisheavierandabdominalpain
ismoresevere,colickyinnatureand
situatedinthesuprapubicarea.
•Amnioticmembranesmaybefeltbulging
intothecervicalcanalormaybe
alreadyrupturedandfetalparts
palpable
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19. •Complete abortion
•Theterm“completeabortion”indicatesthatallproductsof
conceptionhavebeenexpelled.
•Uterusbecomessmalleronpalpation
•Onvaginalexaminationcervixisclosed
•Patientusuallynoticesexpulsionofthetissueorevenfoetusand
placenta
•Abdominalpainsubsidesandbleedingmaystoporslowsdown
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20. •Incomplete abortion
•Thisiswhenthefoetusisexpelled
however;theplacentaandmembranes
areretained(Expulsionofproductsof
conceptionisincomplete)
•Abdominalpaincontinuesalthoughmay
belesssevere
•Bleedingcontinuesandbecomesheavier
•Uterusisenlarged,palpableandmay
feelboggy.
•Cervixmayeitherbedilatedorclosed.
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21. •There will be signs of shock if severe bleeding
•Placenta and foetus may appear to have been expelled , but
some trophoblastic or placental tissue remain adhering to the
uterine wall causing profuse bleeding.
•Products of conception may be felt or seen.
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22. •Missed abortion
•Typeofabortioninwhichthefetusdies
andisretainedinuterotogetherwiththe
placentaandmembranes.
•Signsofpregnancydisappearanduterus
doesnotgrow/ceasestoincrease
•Brownishvaginaldischargewhichmaybe
offensive.
•Cervixisclosedandfetalheartcannotbe
heardbyeitherfetal-scopeorDoppler
•Pregnancytestusuallyisnegative
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23. •Blood mole
•Amissedabortioncanoccasionallyprogresstoabloodmole
•Thefoetusdiesandretainedinuterus,howeverthedecidua
capsularisremainsintact.
•Thezygoteissurroundedbylayersofblood,duetobleeding
betweenthegestationalsacanduterinewall.
•Thesignsofpregnancydisappearandabrownishdischargeis
usuallypresent.
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24. •Corneous mole
•Thisiswhenfluiddrainsfromabloodmoleleavingathefleshy,
firm,hardmass.
•Examinationofthemoleuponexpulsionrevealsanembryoin
thecentreofthemass
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25. •Habitual abortion
•Thisiswhenawomanhasexperiencedthreeormore
consecutivespontaneousabortion,usuallyat12weeksgestation
•Itcanalsooccurbetween22to24weeksgestation.
•Inthemajorityofpatientsnoobviouscausescanbefound.
•Howeversomeoftheknowncausesarechronicillness,suchas
diabetesmellitus,andabnormalitiessuchasaseptateuterus
andcervicalincompetenceandtheymayexperiencethe
following;
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26. sudden rupture of membranes
expulsion of a fresh abortus
painless dilatation of the internal cervical os.
•These women should always be referred to the hospital
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27. •Septic Abortion
•Itisaninfectedabortionoranyabortionwhichisassociated
withthepresenceofpathogenicmicrobesandmayresultfrom
spontaneousincompleteorcriminalabortions.
•SepticAbortionischaracterizedbyFeveraccompaniedby
tachycardia,Headache,offensivelochia,usuallyprofuse.
•Theuterusisbulkyandverytender
•Thereisbodymalaise,nauseaandvomiting
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28. •Risk factors of septic abortion may include;
retained products of conception
unsterile instruments or environment
associated injuries to the birth canal
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29. Molar pregnancy/ hydatid mole
•Anabnormalityduringpregnancyin
whichthechorionicvilliaroundan
abortingembryodegenerateandform
clustersoffluid-filledsacs
•GrossMalformationoftrophoblast(of
thedevelopingfetus)inwhichthe
chorionicvilliproliferateandbecome
avascular,thevilliarefilledwithfluidso
thattheycollectivelytakean
appearanceofabunchofgrape
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30. •Bloodsupplyisthencutoff
givingitacreamywhite
appearance/snowwhite
•Thefetusreceivesnomore
oxygenandnutrientsanddies
out.
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31. Types under induced abortion
•Itcanbeeithertherapeuticorcriminalabortion.
•Therapeuticabortion
•Thisisanabortioninwhichtheuterusisevacuatedbya
qualifiedtrainedmedicalDoctor(personal)foravalidmedical
reason.
•Thisproceduremustonlybeperformedintheinterestofthe
mother’slifeandthefoetalwell-being.Itiscarriedoutina
hospital.Haemorrhagecanbeeffectivelybecontrolledand
resuscitativefacilitiesareathand,andwherestrictaseptic
measuresarealwaystaken.
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32. •Theconsentofthemedicalsuperintendentofthehospitalis
requiredbylaw,aswellastheconsentofthepatientandthe
husbandorguardianifsheislessthan18years.
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33. •Criminal abortion
•Thisisatypeofabortionwhichisillegallyperformed.Itmaybe
performedbyanunqualifiedperson,possiblyunderunhygienic
conditions
•Canbedoneusingavarietyofmethodsandplacescausing
themtobecomesepticabortions,alsoifqualifiedpersonaldo
notuseaseptictechniques.
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34. INVESTIGATIONS
•History-Historyofbeingpregnant-askthewomanabouther
lastmenstrualperiodtoconfirmpregnancyanditsduration.
Askabouttheamountofbleedingandhowmanytimesshehas
changedherpadstoruleouthaemorrhagicshock.
Severityofthelowerabdominalcrampingasitcanbeasignof
pendingabortion.
•Bloodtests-Gravindextestconfirmspregnancybypresenceof
HCGwhichisusedasabasisforpregnancytest.

35. Investigations cont.
•Bloodforcultureandsensitivitywillconfirmtheincreased
leucocytes,thecausativeorganismanditssensitivityifthereis
sepsis.
•Fullbloodcountmayshowreducedhemoglobindueto
haemorrhageandincreasedleucocytescountifthereisinfection.
•Rhesusgroupshouldbecheckedtoruleoutrhesusiso-
immunization.

36. Investigations Cont…
Ultrasoundexamination-thisaconfirmatorytestthatwillreveal:
Gestationalsacwhichwillshowthatthepatientwaspregnantor
hasproductsofconception.
Ifthegestationsacisempty,itsignifiesthatthepatienthasan
incompleteabortion.
Absenceoffetalheartsoundswillsignifyintrauterinefetal
deathasinmissedabortion.

37. Management of abortions
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38. Itisaspontaneoustypeofabortion,inwhichapregnantwoman
presentswithslightbleedingthroughtheun-dilatedcervix
Diagnosedwhenapregnantwomanpresentswithslight
bleeding,withorwithoutlowbackacheandcramplikepain
Thereisminordisturbancetothepregnancy
Thepregnancymay;
Gototerm
Missed
Inevitable
Threatened Abortion
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39. Threatened Abortion
Clinical features
History of amenorrhea
Signs of pregnancy present
Pregnancy test is positive
Blood loss is scant/ slight per vaginal bleeding
with or without lower abdominal pain and backache
cervix closed
uterus is soft and non tender
Management of abortions
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40. Management
Aim
To prevent abortion to become inevitable
Threatened Abortion
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41. Investigations
History from the patient will reveal amenorrhea
Urine for Gravindex test will positive
U/sound scanningwill show gestational sac which will show that the
patient has products of conception
Bloodfor RPR to rule out syphilis
FBC for Hb estimation and to ascertain if the patient requires blood
transfusion
Speculum examination to determine the level of cervical dilatation
V. E not done but speculum examination to assess cervical opening
Medical management
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42. Medication
SedativessuchasDiazepamtofacilitaterest
AnalgesicssuchasPanadolforpainmanagementifany
Folic/Feso4forfacilitationofbloodformation
Ventolintab4mgtdswillbegiventorelaxtheuterinemuscles
(tocholitic)
VitaminCmaybegivenasitfacilitatesabsorptionofiron
Threatened Abortion
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43. Environment
ThepatientwillbeadmittedinGynaeward.Ensurethattheroomiswell
ventilatedandclean.
Psychologicalcare
Mothermaybeagitatedwiththepossibleloseofthefetus,beempathetic
Explainthepossiblecauseofhercondition
Explaintheconditionofthefetustoherselfandsignificantothers
Explainthepossibleoutcome
Whysheisbeingadmitted
Needforrestandwhytheneedforrestrictionofvisitors
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44. Rest
Bedrestisthemostimportantformoftreatmentsothatthewomanhas
totalphysicalandmentalrest.
Bedrestincreasesbloodflowtotheplacentaandreducespain.
Thepatientshouldremaininbedfor5-7daysorforaslongasbloodis
brightred.
Theenvironmentshouldbequiteandvisitorsshouldberestrictedto
promoterest.
Allnursingproceduresshouldbedoneinoneblock
Givemildsedativese.g.Phenobarbitone60mg8hourlytoenablepatient
restinbed.
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45. Observations
Vitalsigns(TPR+BP)
ObserveP/vbleedingforamountandcolour
Padsshouldbesavedinordertohelpassesstheamountof
bloodloss(padcount)
Reportanyincreaseinbleedinglikeclotsandanyabnormal
tissuethroughthevaginawhichcouldbethesignofinevitable
abortion.
Observeforpainandpresenceofcontractions.
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46. Diet
Wellbalanceddiet/Mixeddiet
Carbohydrate
Proteins
Vitamins
Ironrichfoods
Fluidstopreventconstipation
Roughagetopreventconstipation
Shouldbelightandnonstimulatingtopreventuterinecontractions.
Nursing care of patient with threatened abortion
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47. Hygiene / Infection Prevention
Sanitarypadschangedwhensoiledtopreventinfections
Padcountdone
Vulvaswabbingdonetopreventascendinginfection
Dailybaths(assistedorbedbathsdependingonthecondition)forcomfortand
promotingbloodcirculation\
Oralcare
Haircare
Nailcare
Changeofsoiledlinen
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48. Ensure aseptic techniques are followed during all the procedures
done on the client
Use clean and sterile equipment such as speculum, pads
Hand washing
Personal protective equipment (Aprons, gloves)
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49. Exercises
Avoided as bleeding maybe provoked
Complete bed rest encouraged
If they should be done then it should to a minimal degree
Coitus should be avoided until the woman recovers fully as it may
worsen the condition
Elimination
Monitorbowelopeningandbladderemptying
Constipationanddiarrhoeashouldbeavoidedastheymayprovoke
bleeding
Constipationispreventedbygivingfluidsandroughage
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50. Information, Education and Communication
Importance of taking Medication
Danger signs e.g. Pv bleeding, spotting, fever
Review dates
Antenatal care
Diet
Avoidance of coitus
Hygiene
Rest (avoid strenuous exercises)
Avoidance of tampons to prevent cervical excitation
Avoidance of constipation
Threatened Abortion
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51. Incompleteabortionisatypeofabortioninwhichthefetusisexpelledbut
partoftheproductsofconception(placenta,membranes)areretained.Itis
anemergencyandrequiresurgentattention.
Clinicalpicture
i.Backacheandabdominalpainswhichmaybesevere
ii.PVbleedingisprofusebecausetheuteruscantcontractwithretained
productsofconceptions
iii.Signsofshocksuchascoldclammyskin,threadypulse,hypothermia,
hypotensionmaybeseen.
iv.Uterusisbulky(enlarged)
v.Uterusispalpableandmayfeelboggy
vi.Cervixmayeitherbedilatedorclosed,butwillfeelpatulous
Management of Incomplete Abortion
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52. Management of Incomplete Abortion
•Aims
i.To resuscitate the patient
ii.Remove retained products of conception
iii.To arrest haemorrhage
iv.To prevent complication
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53. 1.Resuscitation
Callforhelp
Toassistinresuscitation–mobilizeavailablepersonnel.
Airway
Maintainaclearairway
Supinepositionandtheheadtiltedonthesideorlateralposition
Anysecretionsshouldbesuckedusingasuctioningmachine
Oralpharyngealairwaycanalsoinserted
Anytightclothingaroundherneckshouldbeloosened.
Management of Incomplete Abortion
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54. Breathing
Ensurethatthepatientisbreathingwellandmonitortherespirations
Humidifiedoxygenviaafacemaskornasalcathetershouldbe
administeredat5L/min
Circulation -commence intravenous infusion of Normal Saline 0.9%
1000mls. Depending on the blood loss patient may get as many litres as
possible to replace lost fluids and to combat shock.
•Urgenthaemoglobin,groupingandcrossmatchingforbloodtransfusion
torestorebloodvolume.
•Footendofthebedwillbeelevatedtoimprovebloodsupplytothevital
organs.Patientisalsocoveredtopreventhypothermia
Management of Incomplete Abortion
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55. 2.Evacuationofretainedproductsfromtheuterus:
•Manualvacuumaspiration(MVA)-Thisisthesurgicalmethod
involvedinthetreatmentofincompleteabortionwhichisdoneto
evacuatetheremainingproductsofconception.
•MVAusessuctiontoremoveuterinetissuethroughacannulawith
minimalscrappingoftheuterinewalls.
•Thisprocedureisimportanttominimizebleedingbyenhancing
uterinecontraction.
Immediate management

56. Ifgestationis16weeksormore;
•Infuseoxytocin40unitsin1LIVfluidsat40drops/min.until
expulsionofproductsofconceptionoccurs.
•Evacuateanyremainingproductsofconceptionfromuterusby
dilatationandcurettage.
•Ifnecessary,givemisoprostol200µgvaginallyevery4hours
untilexpulsion,butdonotadministermorethan800µg
Immediate management

57. •3.Medicaltherapy–thefollowingAntibioticsaregivensuchas
topreventinfection:
•Amoxil500mgtdsfor5days
•Metronidazole400mgtdsfor5days.
•Paracetamol500mgprntoreliefpain.
•GiveErgometrine0.5mgintramuscularlytopreventfurther
bleeding.
Immediate management

58. Aims
To allay anxiety
To prevent complications
To provide post abortal counselling
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59. Environment
•PatientwillbenursedinGynaeward.Theroomshouldbecleanto
preventinfectionandwarmenoughforpatientscomfort.Itshould
alsohaveenoughlightingforeasyobservation.
•Psychologicalcare
•Thesewomenwomanmayhavefeelingsofguilt,shame,depression,
worthlessnessandshemayfeelsheisnolongercapableof
providingherhusbandwithachild
•Explainthepossiblecauseofabortiontothemotherandthe
significantothersandinvolvethesupportpersoninthecare
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60. Ifthecauseispreventable,explainhowsuchcanbeavoidedinthe
subsequentpregnancies
Explainalltheproceduresbeingdoneincludingthemethodofuterine
evacuation
Allowthepatientandsignificantotherstoaskquestions
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61. Rest
Duetoexcessivelossoffluidsandpain,thewomanwillbe
feelingweakandtired,thereforerestshouldensureduntil
completerecovery
Maintain the quiet environment by doing the following;
Do the procedures in one block
Restrict visitors
Sedatives
Analgesics
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62. •Observation
•Monitorthevitalsignsoftemp,B.Ppulseandrespirationsevery.
•AlowB.Pmaysignifypostoperativebleeding;Lowpulseand
respirationratesaresuggestiveofimpendingshock.
•Ahightempafter48hrs.maybesuggestiveofinfection.
•Checkforothersignsshocklikecoldclammyskin,restlessnessand
feeblepulse
•Observethedegreeofbleedingbyrequestingthewomanto
keepthepads(padcount)andeventuallyestimationoftheloss
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63. •If on IV fluids maintain a fluid balance chart and note the intake
and out put to rule out hypovolemic shock and renal failure.
•Pain Relief
•Give Analgesics like paracetamol 1g tds
•Diversion therapy
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64. HygieneandInfectionPrevention
Sanitarypadschangedwhensoiledtopreventinfections
Vulvaswabbingdonetopreventascendinginfection
Dailybaths(assistedorbedbathsdependingonthecondition)
forcomfortandpromotingbloodcirculation)
Oralcare
Haircare
Nailcare
Changeofsoiledlinen
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65. Ensureaseptictechniquesarefollowedduringallthe
proceduresdoneontheclient
Usecleanandsterileequipmentsuchasspeculum,pads
Handwashing
Personalprotectiveequipment(Aprons,gloves)
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66. Nutrition
Giveawellbalanceddiet/Mixeddietcontainingthefollowing;
Carbohydrate
Proteins
Vitamins
Ironrichfoods
Fluidstopreventconstipation
Roughagetopreventconstipation
Shouldbelightandnonstimulatingtopreventuterinecontractions.
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67. Exercise
Complete bed rest encouraged initially
Exercises are introduced slowly
Strenuous ones are avoided until full recovery
Coitus should be avoided until the woman recovers fully
Elimination
Monitorbowelopeningandbladderemptying
Constipationispreventedbygivingfluidsandroughage
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68. PostAbortalCounselling
Themainaimofcounsellingistoensurethattheclientisavailedwith
familyplanningservicestopreventrepeatedabortions
Thisshouldbedonetoallwomen.
Counsellingshouldbedoneusingprofilingsystemanditcandone
individuallyoringroupswhilstupholdingthepatientsconfidentiality
Patientsshouldbereferredappropriatelytothenextlevelofcareif
necessary
Involvethepartnerorsupportpersonandexplaintheimportanceofpost
abortalcontraception
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69. Hygiene
Nutrition
Rest
Family planning
Sexual advice
Review date
Medication
Danger signs e.g. Pv bleeding, spotting, fever
Information, Education, Communication
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70. Infertilitysecondarytoinfectionandhealingbyfibrosiswhichmayblock
fallopiantubes
Shockduetobleeding
Anaemiaduetoseverebleeding
Uterineperforation
Peritonitisduetoperforationofuterusandinfectionoftheperitoneum
Disseminatedintravascularcoagulation(DIC)morecommoninmissed
abortion
Secondarybacterialinfectionsduetouseofunsterileinstrumentstoabort
orfromanendogenousinfectiveorganism
Complications
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71. Septic Abortion
•Septic Abortion
•Itisaninfectedabortionwhichisassociatedwiththepresenceof
pathogenicmicrobesandmayresultfromspontaneous
incompleteorcriminalabortionscharacterizedbyFever
accompaniedbytachycardia,Headache,offensivelochia,
usuallyprofuse.
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72. •Risk factors of septic abortion may include;
retained products of conception
unsterile instruments or environment
associated injuries to the birth canal
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73. i.Severepainaroundthesuprapubicregion.
ii.Uterusbulkyandverytenderonpalpation
iii.Foulsmellingvaginaldischargeusuallyprofuse.
iv.CervicalOSopenandproductsofconceptionmaybefeltin
thecervicalcanal.
v.Chillsandfeversignifiesseriousinfection.
vi.Thereisbodymalaise,nauseaandvomiting
S/S of septic abortion

74. •Septicabortionisanemergencyasdelaymayresultinsevere
complicationsordeath.
•Mostseriouscomplicationofsepticabortionissepticshock
characterizedbyhypotensionwithtachycardia,normalor
subnormaltemperature.
•Thereforethefollowingshouldbeinstituted;
•Resuscitatewithintravenousfluidsinordertoreplacelostfluids
Immediate management

75. Management
Treatmentofthesepatientswithsepticabortionisanemergency
asdelaymayresultinseverecomplicationsordeath
Managementisthesameasforincompleteabortion.
Septic Abortion
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76. Isolatethepatient
Resuscitatewithintravenousfluids
Mostpatientswillhavefluiddeficitfrombloodlossduring
abortionorfrompoorfluidintakeduetoillhealthorfever
Evacuationoftheuterusshouldbeinstitutedimmediately
resuscitationiscompleteandantibioticsstarted
Septic Abortion
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77. Takeacervicalswabforcultureandsensitivitybeforestartingantibiotic
treatment
Giveparenteralbroadspectrumantibiotics
i. Metronidazole 500mgs TDS
ii. Gentamycin 80mg BD
iii. Ceftriaxone 1g OD
Blood transfusion can be given in cases of low haemoglobin
Folic/ Feso4
Analgesics
Septic Abortion
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78. •Alsocalledrecurrentabortionorrecurrentpregnancyloss(RPL).
•Thisiswhenthepatienthasexperienced3ormoreconsecutive
spontaneousabortions,usuallyafter14weeksofgestation
(Ladewig1996).
•Thereisusuallynoobviouscausebutthecommonestpredisposing
factorsareuterineabnormalitiesandcervicalincompetence.
•Thesewomenshouldalwaysbereferredtothehospital.
HABITUAL ABORTION

79. •The abortion occurs in the second trimester between 22-24
weeks.
•There is no warning sign but the woman experiences sudden
rupture of membranes and expulsion of fresh abortus occurs.
•This occurs after gradual painless dilatation of the internal os.
Signs and Symptoms

80. •Management
•Investigatethewomanthoroughlytoruleoutanysystemic
diseaselikeDM,syphilis.
•Evacuateanyretainproductsofconceptionandallowstrictbed
rest
•Thewomanshouldrefrainfromliftingheavyobjectsonce
conceivesagain.
•EncouragehertobookforANCassoonaspregnancyis
suspectedinthesubsequentpregnancy.
Habitual abortion cont.

81. •Sheshouldavoidcoitusinthe1
st
and2
nd
trimester
•Sheshouldnotbeallowedtotravelinthe1
st
and2
nd
trimester
•Ifsheworksadvisehertotakeleavesothatshecanrestat
home.
•Toenablethecervixholdtheweightofthegrowingfetusand
ensuresustenanceandviabilityofthepregnancy,thedoctorcan
insertaShirodikasutureat10weeksto38weeks.
Habitual abortion cont.

82. •This occur when the fetus dies and is retained in utero, together
with the placenta and membranes (Ladewig 1996).
•Signs and symptoms
i.History of amenorrhea
ii.Signs of pregnancy disappear
iii.Height of fundus less than expected because the uterus does
not grow.
iv.Brownish vaginal discharge.
v.Cervical OS closed.
MISSED ABORTION

83. vi)Thereisnopain.
vii)FetalheartcannotbeheardbyeitherfetoscopeorDoppler
viii)Pregnancytestusuallyisnegative

84. •Auterineevacuationisperformedifthepatientislessthan16
weekspregnant.
•Ifthepatientismorethan16weekspregnant,anoxytocinor
prostaglandininfusioniserectedtoexpelthefetus.
•Iftheconditionofmissedabortionpersistsforover6-8weeks,
disseminatedintravascularcoagulation(DIC)disorderscan
occur,therefore,weeklybloodsamplesaretakensothat
estimatesofplasmafibrinogencanbemade.
Immediate management

85. •DIC comes about when a dead foetus is retained in utero for
more than 3 to 4 weeks.
•Thromboplastins are released from the dead foetal tissues.
•These enter the maternal circulation and deplete clotting factors.

86. Blood mole
•Thisconditionarisesincasesofmissedabortion.
•Theovumdiesinutero,andthedeciduacapsularisremains
intact.
•Thezygoteissurroundedbylayersofblood,duetobleeding
betweenthegestationalsacandtheuterinewall.
•It usually occurs before the 12
th
week of gestation. The signs of
pregnancy disappear and there is a brown discharge present.
•When fluids drain from the blood mole, the fleshy, firm, hard
mass which is left, is known as a carneousmole
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87. •An evacuation of the uterus is performed if it is diagnosed
before 12 weeks.
•Oxytocics or prostaglandins are used to abort the mole if the
condition is diagnosed after the 12
th
week of pregnancy.
•Pethidine 100mg i.m to reduce pain
•Conduct strict observation on the mother.
Immediate management

88. •Itoccurswhenfluidsdrainfromthebloodmoleleavingafresh,
firmandhardmass.
•Theexaminationofthemassafterexpulsionwillrevealan
embryointhecenterofthemass.
•Management
•Evacuationoftheproductsifdiagnosedat12weeks.
•Ifdiagnosedafter12weeksinductionwillbedonetoevacuate
theproducts.
Carneous Mole

89. INDUCED ABORTION
•Inducedabortioncaneitherbe;
•Therapeuticabortion,or
•Criminalabortion.

90. •A therapeutic abortion is one in which the uterus is evacuated by
a qualified, trained medical doctor, for a valid medical reason
(Sellers 2008).
•Therefore this procedure must only be performed in the interest
of the mother’s life and her total well-being.
•Therapeutic abortion is provided for under the legal abortion
Act of 1972.
THERAPEUTIC ABORTION

91. •It can also be done if there is increased chance of gross fetal
abnormalities.
•It is only carried out in a hospital where haemorrhage can be
effectively controlled, resuscitative facilities are at hand and
where strict aseptic measures are always taken.
•The consent of the medical superintendent of the hospital is
required by law, as well as the consent of the patient and her
husband or guardian if she is less than 18 years.

92. •Evacuation of the uterus if pregnancy is less than 16 weeks by
MVA, beware of infection setting in and also haemorrhage.
•If the pregnancy is more than 16 weeks oxytocin and cytotec is
given to expel the products of conception.
•Psychological care is given throughout the procedure to gain
cooperation.
•Complete bed rest is essential.
•Observe the blood loss through pad count to assess the amount of
blood loss to prevent shock.Drugs like Benzylpenicillin, gentamycin
and metronidazole are given to combat and prevent infection
Immediate management

93. •Introduction
•Thisisanabortionwhichisillegallyprocessed(Sellers,2008).
•Thistypeofabortionispunishablebylaw.
•Itisusuallyperformedbyunqualifiedperson,possiblyunderunhygienic
conditions.
•Itmaybebythewomanherselforanyotherperson.
•MethodsUsed
•Useofherbalmedicinetakenorallyorinsertedinthevagina,drugs
intoxicationanduseofsharpobjectsintroducedfromthevaginatothe
uteruswithanintentionofdisturbingtheuterineenvironmenttoinduce
abortion.
CRIMINAL ABORTION

94. •This type of abortion can lead to incomplete or septic abortions.
•If it is incomplete then it should be treated as incomplete
abortion as described above with an antibiotic cover to combat
infection.
Criminal abortion

95. •Anaemia due severe bleeding
•Infection
•Cervical laceration which may lead to habitual abortion.
•Acute renal failure due to reduced renal perfusion.
•Secondary infertility
•Uterine perforation
•Shock
Complications of abortions

96. Summary
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97. TOGETHER WE CAN MAKE IT A REALITY
Motherhood … .
.. A dream of every woman
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