abortion_034049.pdfobstetric nursing 000

abortion_034049.pdfobstetric nursing 000

1. 1

2. Objectives:
Bytheendofthislecturethestudentwillbe
ableto:
KnowTypesandcausesofbleedinginearly
pregnancy.
Defineabortions.
Listdifferenttypesofabortion.

3. Mention clinical picture, prognosis and
management of each type.
Differentiate between all types.

4. INTERODUCTION:
Abortionistheprocessofendingthepregnancy
itcanbespontaneousorbyinducedbeforethe
20
thto22thweeksofpregnancy.

Between
10to15%ofallterminatesas
spontaneousabortion.
Morethan10/60%isterminatingbyinduced
(legalorcriminal).
13%ofmaternaldeathduetoabortion95%of
theseoccursindevelopingcountries(WHO).

5. Causes of EARLY BLEEDING:
1-Abortion.
2-Ectopic pregnancy.
3-Molar pregnancy.
4-Trauma.
5-Local gynaecological (lesions, lymphoma,
dysplasia, carcinoma and rupture of varicose
vein).

6. Risk factors:
Faultyimplantation.
Geneticandchromosomal.
Medicalandobstetriccondition.
Lowprogesteronelevel.

8. Abortion
Definitionandincidence:
Terminationofpregnancybeforeviabilityofthe
foetus,before20---22weeksorifthefoetal
weightislessthan500gm.Whenabortion
occursspontaneously,theterm"miscarriage"is
oftenused.

9. •Miscarriageoccursin20%ofpregnancies.
•Majorityofmiscarriageoccurinfirsttrimester.
•Only2—5%ofpregnancymiscarriesafter
fetalheartactivityhasbeendetectedbyU/S

10. Types of abortion:
Theyaretwotypes:
1-Spontaneousabortion(miscarriage)
2-Inducedabortion(therapeuticorcriminal).

11. Classified OF Spontaneous abortion:
Sixcategoriesbasedonthesignsand
symptoms:
1-Threatenedabortion.
2-Inevitableabortion:.
3-Incompleteabortion.
4-Completeabortion.
5-Missedabortion.
6-Septicabortion.

13. Aetiology of spontaneous:
1-Chromosomalabnormalities:causeatleast50%
ofearlyabortions.
2-Blightedovum(anembryonicgestationalsac).
3-Maternalinfections:Acutefeverforwhatever
thecausecaninduceabortion.
4-Trauma:externaltotheabdomenorduring
abdominalorpelvicoperations.

14. 5-Endocrinecauses:Progesteronedeficiency
,Diabetesmellitus,Hyperthyroidism.
6-Drugsandenvironmentalcauses.
7-Maternalanoxiaandmalnutrition.
8-Overdistensionoftheuteruse.gacute
hydramnious,multiplepregnancy.

15. 9-Immunologicalcause:
Systemiclupuserythematous(SLE).
Antiphospholipidantibodiesthataredirected
againstplateletsandvascularendothelium
leadingtothrombosis,placentaldestruction
andabortion.

16. 10-Ageingspermorovum.
11-UterinedefectsSeptum:
Asherman'ssyndrome(intrauterineadhesions).
12-Idiopathic.

18. Spontaneous abortion:

19. INVESTIGATIONS:
Theseinvestigationsarerequiredtoalltypes
ofabortion.
1-Bloodtypeandcross-matching(toany
abortedwoman).
2-Ultrasound.
3-HCGlevel.

20. 1-Threatened Abortion
Clinicalpicture:
1.Symptomsandsignsofpregnancycoincide
withitsduration.
2.Irregularspotting,slightormildvaginal
bleeding,brightredincolour.
3.Painisabsentorslight.
4.Cervixisclosed.
5.Pregnancytestispositive.
6.Ultra-sonographyshowsalivingfoetus.

21. Prognosis:
Ifthebloodlossislessthananormalmenstrual
flowandisnotaccompaniedbypainofuterine
contractionthereisareasonablechancefor
continuingpregnancy.Thisoccursin50%ofcases
whileotherhalfwillproceedtoinevitableor
missed.

22. Treatment:
1.Bed rest until one week after stoppage of
bleeding.
2.No intercourse as it may disturb pregnancy by
the mechanical effect and the effect of semen
prostaglandins on the uterus.
3.Sedatives: if the patient is anxious.
4.If RH negative -Anti D therapy in low dose
100mg is to be given within 24 hours of her
first bleeding episode.

23. Treatment of conservation:
•Progestogens(progesterone).
•Gonadotrophinsmay be of benefit in cases of
luteal phase deficiency and those get pregnant
with ovulatory drugs.

24. 2-Inevitable Abortion
Clinicalpicture:
1.Ruptureofmembranesbefore20weeksisa
signoftheinevitabilityofabortion.
2.TheinternalOsofthecervixisdilatedand
productsofconceptionmaybefeltthroughit.

25. 3.Freshvaginalbleedingisexcessiveandmay
accompaniedwithclots.
4. Painiscolickyfeltinthesuprapubicregion
radiatingtotheback.
5.Uterinesizeiscorrespondswithperiodof
amenorrhea.

26. Diagnosis:
A.Bydilatationofcervixatvaginalexamination.
B.HCGleveltoindicatepregnancyloss.
C.Ultrasoundshowemptysac.

27. Treatment:
Anyattempttomaintainpregnancyis
useless.
Thepregnancywillbeabortedspontaneously
butoftenneedtoacceleratetheprocesswith
syntocinonsoastominimizedtheduration,
bloodloss,andchancesofinfection.

28. Complications:
1.Occasionallysevereshockmaybeduetomassive
hemorrhage.
2.Cervicalshocksyndromeduetodistensionofthe
cervixbytheproducts(treatedbyimmediateremove
ofproductfromos).
3.Retentionofapartoftheproductsofconception
insidetheuterus.Itmaybethewholeorpartofthe
placentaormembraneswhichisretained.
4.Butthemainsignismassivebleedingandseverpain.

29. 3-Incomplete Abortion
Clinicalpicture:
1-ThePregnantwomenpresentwithmorepain
likeminidelivery,morebleedingpassageof
clotsandfewpiecesofplacentaltissueor
membraneThereispartialretentionofRPOC.

30. 2-Uterus is smaller, osis open and RPOC is felt
in uterine cavity with examining finger.
3-Dependinguponamountandrateofblood
losspatientmaydevelopedhemorrhagicand
hypovolemicchock.

31. Surgical treatment:
1.ImmediateevacuationofRPOCunder
oxytocin.
2.Suctionevacuationissafertechniquethan
sharpcurettage(lowerrateof:bloodloss,
perforation,andsubsequentintrauterine
adhesionformation).

32. Medical treatment:
1.Prostaglandins: givenintra-vaginally,
intravenously,intra-orextra-amniotic.
2.Mifepristone:(blockstheactionof
progesterone,alterstheuterinelining).
3.Methotrexate:(interfereswithDNAsynthesis
andcellgrowth).

33. 4.Misoprostol:(stimulateuterinecontractions,
inducescervicalsoftening).
5.Fluidreplacement(ringerlactate/blood).
6.Prophylacticantibiotic.
7.Tetanustoxoidarethebasicrequirementsto
treatsuchwoman

34. Contra indication to medication:
1.Confirmedorsuspectedectopicpregnancy.
2.Allergytoeithermethotrexateormisoprostol.
3.Presenceofanintrauterinedevice.
4.Prolongusedofcorticosteroid.
5.Currentusedofanticoagulants.
6.Chronicadrenalfailure.

35. 4-Complete Abortion
Allproductsofconceptionhavebeenexpelled
fromtheuterus.
Clinicalpicture:
1.Thebleedingisslightandgradually
diminishes.
2.Thepainsubsidesbyitself.
3.Thecervixisclosed.
4.Ultrasound:showsemptycavity.

36. Treatment:
1.Prophylacticantibiotic.
2.Fluidreplacementasneeds.
3.Contraceptiveadviceforspacing.
4.Vitalsignsandgeneralobservation.

37. 5-Missed Abortion
Othernamed:Earlyembryonic/fetaldemiseor
silentabortion.
Retentionofdeadproductsofconceptionfor4
weeksormore.

38. Symptoms:
Darkbrownvaginaldischargemayoccur.
Theabdomendoesnotincreaseandmayeven
decreaseinsize.
Thefetalmovementsarenotfelt.
Absentofuterinecontractions.

39. Signs:
1.Theuterusfailstogrowandbecomesfirmer
andthecervixisclosed.
2.Thefetalheartsoundscannotbeheard.

40. Investigations:
1.Pregnancytestbecomesnegativewithintwo
weeksfromtheovumdeath.
2.Ultrasoundshowscollapsedgestationalsac,
absentfetalheartrateandfetalmovement.

41. Treatment:
The dead conceptions is expelled
spontaneously in the majority of cases.
Evacuation of the uterus is indicated in the
following conditions:
spontaneous expulsion does not occur within
four weeks,
There is bleeding, infection or DIC developed
or, patient is anxious.

42. Evacuation is carried out as following:
Iftheuterinesizeislessthan12weeks’
gestation:vaginalorsuctionevacuationis
done.
Iftheuterinesizeismorethan12weeks'
gestation:evacuationcanbedoneby
1.Prostaglandins: givenintra-vaginally,
intravenously,intra-orextra-amniotic.

43. 2.Oxytocininfusion.
3.Combination:startingwithprostaglandinand
completedwithoxytocin.
4.Hysterectomy:israrelyindicatedin2nd
trimestermissedabortionifthemedical
inductionfailsinitiallyandafterrepetitionfew
dayslater.

44. Complications:
a.Disseminated intravascular coagulation (DIC)
may occur if the dead conceptions is retained
for more than 4 weeks.
b. Infection.

45. 6-Septic Abortion
Acomplicationofincompletemiscarriage
whentheremainingproductbecomesinfected
byascendingorganismw/outinstrumentation
oftheuterus,usuallycriminalabortion,
complicatedbyinfection.
Common organism:E.coli,Bacteroid,
streptococci,clostridiumwelchii.

46. Diagnosis:
A.Historyofamenorrhea.
B.U/Sisessentialindiagnosis(Transvaginally).

47. Clinical picture:
Generalexamination:
Pyrexiaandtachycardia.
Malaise,sweating,headache,andjointpain.
Jaundiceand/orhaematuria.

48. Abdominalexamination:
Subrapubicpainandtenderness.
Abdominalrigidityanddistensionindicates
peritonitis.

49. Local examination:
Offensive vaginal discharge. Minimal and it
often associated with severe cases.
Products of conception may be felt.
Local trauma may be detected.
Fullness and tenderness of Douglas pouch
indicates pelvic abscess which will be
associated with diarrhoea.

50. Intervention:
1.Isolatethepatient.Bedrestinsemi-sitting
position.
2.Anintravenouslineisestablishedfortherapy.
3.Observationofvitalsign(tem,HR,RR,BP).
4.Acervico-vaginalswabistakenforculture
andsensitivity.
5.Inserturethralcathetertomonitor
input/output.

51. Treatment:
1.Bloodtransfusion:Itisimportancetocorrect
anemia,coagulationdefectsandinfection.
2.Fluidtherapy.(G5%,Ns/R.L).
3.Antibiotictherapy.cephalosporin(asabroad
spectrum)+gentamycin(forgram-ve
organisms)+metronidazole(foranaerobic
infection)aregivenbyintravenous.
4.Oxytocininfusion:tocontrolbleedingandto
enhanceexpulsionoftheretainedproducts.

52. Surgicalevacuation:canbedoneafter6
hoursofcommencingIVtherapybutmaybe
earlierincaseofseverebleedingdeteriorating
conditioninspiteoftheprevioustherapy.
Hysterectomy:
Maybethelastchoicetosafemotherlifein
endotoxicshocknotrespondingtotreatment
particularlyduetogasgangrene.

53. Complication
1.Septicemialeadtochock(bactaremic)and
finallymaternaldeath.
2.Pelvicabscessandendometritis.
3.Peritonitis.
4.Secondaryinfertility.
5.Pelvicadhesionsandpelvicinflammatory
diseasePID.
6.Hysterectomy.

54. Other types of abortion
2-Inducedabortion:-Intentionalmedicalor
surgicalterminationofapregnancy.
 Typesofinduced:
A.Elective:ifperformedforawoman’sdesires.
B.Therapeutic:ifperformedforreasonsof
maintaininghealthofthemother.
C.Criminal:Illegalabortioninducedforanon-
medicalindications(bylessskilledpersons).

55. Therapeuticabortion:InducedMedical
Abortion--Whengrowthofembryoisdisturbed
asinblightedovum,afterexpectedtreatmentof
threatenedabortion,medicalterminationinearly
gestationperiod>49days.
Theconceptusistobeexpelledoutwithmedical
methodorbysurgicalmethods.

56. INDUCED ABORTION –MEDICO-LEGAL
ASPECTS:
1.Onlyallowedformedicalindications.
2.Ifcontinuationofpregnancyisrisktolifeof
thewoman.
3.Atleasttwomedicaldoctorsshouldreachthe
decisionandsign.

57. COMPLICATIONS:
Becausemostinducedabortionsaredonebyless
skilledpersons(CRIMINAL)theyareusually
associatedwithfatalcomplicationsincluding:
1.Perforationofuterusorintestines.
2.Severehemorrhage.
3.Sepsisanditsassociatedcomplications.
4.Asherman’ssyndrome.

58. Recurrent (Habitual) Abortion
Three(twobysomeauthors)ormore
consecutiveabortion.
Itistowtypes:
A.Primary-nopreviouslivebirth.
B.Secondary-atleastoneprevioussuccessful
pregnancy.

59. Causes:
1-Chromosomalabnormalities.
2-Uterineabnormalitieseg.hypoplasia,
Asherman’s syndrome, cervical
incompetenceanduterinemyomas.
3-Infections: Toxoplasma, Brucella,
Chlamydiaandsyphilis.

60. 4.Hormonal:Hypothyroidism,Diabetes,Luteal
phasedeficiency.
5.Immunological:Antiphospholipidantibodies
andSLE.
6. Miscellaneous(chronicmalnutrition
anemia,cardiac-renaldiseases,
andalcoholabuse.

61. Treatment:
Medically:
1.Treatmentofinfectionsaschlamydiaand
toxoplasmabysuitableantibiotic.
2.Lutealphasedefecttreatedbyprogesterone
orprogestogensinthesecretoryphase
(to.16thweekofpregnancy).

62. Surgical treatment:
U/S is done before operation to:
1-Confirm viability of fetus.
2-Exclude congenital anomalies.
3-Measure the internal os.

63. 1-Cervicalcerclage:suturingthecervixat/as
nearaspossibletotheinternalosfrom12-14
wks.removedat38wks.oriflabourstartedat
anytime.
2-Vaginalcerclage(Shirodkaroperation):two
incisionsatthereflectionisappliedaroundthe
internalosunderthecervicalmucosa.

64. 3-Myomectomy:Incaseofsubmucous-myoma
whichdisturbtheendometriumandits
vasculatureaffectingimplantationand
subsequentfetaldevelopment.Thiscanbedone
throughhysteroscopyalso.

65. Nursing assessment:
1.Evaluatetheamountandcoloroflousedblood.
2.Monitorvitalsignforindicationof
complication(hemorrhage-infection).
3.Observebleedingorclottissueforpresenceof
fetus,fetalmembranes,orplacenta.

66. Nursing diagnosis and intervention:

67. 1.Riskfordeficientfluidvolumerelatedto
bleeding.
Goal:Maintainingfluidvolume:
A.Reporttachycardia,hypotension,pallor,
indicationhemorrhageandshock.
B.BloodtestforCBCaswellasg-typeand
screening.
C.EstablishandmaintainI.Vwithlargebore
catheterforpossibletransfusionandlarge
quantitiesfluidsreplacement

68. 1.Riskforinfectionrelatedtodilatecervixand
openuterinevessels.
Goal:Preventinginfection:
A.Evaluatetemperatureevery4hoursifnormal
orevery1to2hoursifelevated.
B.Checkvaginalderaingesforincreasedamount
andodorwhichindicateinfection.
C.Instructonandencourageperinealcareafter
eachurinationordefecation.

69. 3.Acutepainrelatedtouterinecrampingand
possibleprocedures.
Goal:Promotingcomfort:
A.Instructptonthecauseofpaintodecrease
anxiety.
B.Instructandencouragerelaxationtechniques
toaugmentanalgesic.
C.Administerpainkillerasneededandas
prescribed

70. Summary:
•Some types of abortion lead to septicemia
and death of maternity.
•Not treat abortion lead to secondary
infertility.

71. References
•Simplified, by DIAA El-Mowafi, forth edition,
2007, page 51-69-84.
http://americanpregnancy.org/unpldnnedpregna
ncy/possiblsideeffect.html
http://www.webmd.com/women/tc/abortion-
reasons-women-choose-aportion
http://www.crusadeforlife.org/whatisabortion.h
tm

72. http://www.babycenter.com.au/x2313/why-do-
i-have-light-bleeding-in-early-
pregnancy#ixzz3Xnkv5tVX
www.freelivedoctor.comhttp://www.babycente
r.com.au/x2313/why-do-i-have-light-bleeding-
in-early-pregnancy#ixzz3Xnkv5tVX