Abortion

abortion

1. Terminology:- Trisomy Monosomy Polyploidy Intrauterine Adhesion Suction evacuation DIC( Disseminated intravascular coagulation)

2. DEFINITION Abortion is the expulsion or extraction of an embryo or fetus weighing 500 g or less from its mother when it is not capable of independent survival (i.e. before the period of viability)

3. Incidence 75% abortions occur before the 16th week

4. Etiology Maternal factor Fetal factor

5. Fetal Factors :- Genetic factor Multiple Pregnancy Degeneration of villi

6. Maternal Factor Endocrine & Metabolic Factor (10–15%): – Luteal Phase Defect – Thyroid abnormalities Anatomical abnormalities Cervicouterine factors Infection

7. • Immunological Factor:- (5–10%)— – • Autoimmune disease • Alloimmune disease Environmental Factors – Cigarette smoking – Alcohol consumption

8. Maternal medical illness : – Cyanotic heart disease Unexplained (40-60%) – In majority, the exact cause is not known.

9. Threatened Abortion :- Condition in which miscarriage has started but has not progressed to a state from which recovery is impossible

10. Clinical Feature Slight bleeding per vaginam The uterus and cervix feel soft. • Differential diagnosis includes :- – cervical ectopy – polyps or carcinoma

11. Management & Prognosis:- Rest: Patient should be in bed for few days until bleeding stops • Relief of pain: Diazepam 5 mg BD If pregnancy continues, there is increased frequency of preterm labor , placenta previa & IUGR

12. Inevitable Abortion :- It is the clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible.

13. CLINICAL FEATURES: vaginal bleeding Aggravation of colicky pain in the lower abdomen Internal examination reveals dilated internal os through which the products of conception are felt

14. Management :- Management is aimed: – To accelerate the process of expulsion – To maintain strict asepsis • If pregnancy < 12 weeks, suction evacuation is done

15. Incomplete abortion :- The process of abortion has already taken place, but the entire products of conception are not expelled & a part of it is left inside the uterine cavity

16.   Clinical features:   History of expulsion of a fleshy mass per vaginam ; – Continuation of pain in lower abdomen • Internal examination reveals :- – uterus smaller than the period of amenorrhea – Open internal os – varying amount of bleeding

17. MANAGEMENT : Early abortion: Dilatation and evacuation under analgesia or general anaesthesia is to be done. Late abortion: Uterus is evacuated under general anaesthesia and the products are removed by ovum forceps or by blunt curette. In late cases, D&C is to be done to remove the bits of tissues left behind

18. Complete Abortion :- When the products of conception are completely expelled from the uterus, it is called complete miscarriage.

19. Clinical features :- There is history of expulsion of a fleshy mass per vaginam followed by – Subsidence of abdominal pain – Vaginal bleeding becomes trace or absent Internal examination reveals: – Uterus smaller than the period of amenorrhea – Cervical os is closed

20. Missed Abortion :- The fetus is dead and retained passively inside the uterus for a variable period. It is diagnosed when there is a fetus with a crown rump length of 5mm without a fetal heart.

21. CLINICAL FEATURES: The patient usually presents with features of threatened miscarriage followed by: – Subsidence of pregnancy symptoms Uterus becomes smaller in size Cervix feels firm with closed internal os No audibility of the fetal heart sound even with Doppler ultrasound

22. Complications :- Retaining the products for long time can lead to sepsis • DIC [Disseminated Intravascular Coagulation] – (very rare) in gestations exceeding 16 weeks

23. Management :- Uterus is less than 12 weeks: Prostaglandin E1 (Misoprostol) 800 mg is given vaginally and repeated after 24 hours if needed. Expulsion usually occurs within 48 hours Suction evacuation is done when the medical method fails

24. Uterus more than 12 weeks 6th or 12th hourly misoprostol tablets given vaginally • If this fails, extra amniotic instillation of ethacridine lactate is used Antibiotics are given

25. Septic Abortion :- Any abortion associated with clinical evidences of infection of the uterus and its contents Most common cause – Attempt at induced abortion by an untrained person without the use of aseptic precautions

26. Clinical Grading: Grade 1 Grade 2 Grade 3 Grade 1 is most common

27. Clinical Features :- Fever, abdominal pain and vomiting or diarrhoea Internal examination reveals: – offensive purulent vaginal discharge – tender uterus usually with patulous os or a boggy feel

28. Investigations :- CBC , Serum urea, creatinine, electrolytes Pelvic USG to detect retained products of conception • X-ray abdomen in suspected bowel injury • X-ray chest if there is difficulty in respiration

29. Complications :- Injury may to uterus & adjacent structures • Spread of infection leads to: – Generalized peritonitis – Endotoxic shock—mostly due to E. Coli – DIC Haemorrhage

30. Management :- Mild cases :- – – Broad spectrum antibiotics started – Uterus is evacuated Severe Cases :- – Vigorous IV infusion with crystalloid – Oxygen given by nasal catheter – Broad spectrum antibiotics

31. Recurrent Abortion :- • Recurrent miscarriage is defined as a sequence of three or more consecutive spontaneous abortion • Seen in ~ 1% of all women

32. Etiology :- First Trimester Abortion:- Genetic factors (3–5%): Endocrine and Metabolic: • Infection: • Immunological cause: Second Trimester Abortion • Anatomic abnormalities Uterine Causes Cervical Insufficiency (Incompetence) :-

33. • Congenital :- Acquired (iatrogenic) Diagnosis :- • History - Repeated mid trimester painless cervical dilatation and escape of liquor amnii followed by painless expulsion of the products of conception • Internal examination: Interconceptual period: – Passage of no. 6–8 Hegar dilator beyond the internal os without any resistance or pain – Funnelling of internal os seen in hysterosalpingography

34. Management   Surgical management – Cervical cerclage • Usually at 12-14 weeks

35. CONTRAINDICATION – Intrauterine infection – Ruptured membranes – History of vaginal bleeding – Severe uterine irritability – Cervical dilatation > 4 cm.

36. Methods 2 main methods – McDonald and Modified Shirodkar Success rates - 80 – 90%

37. Postoperative care : – The patient should be in bed for at least 2–3 days – Progesterone supplementation - Weekly injections of 17 α hydroxy progesterone caproate 500 mg IM – Patient is asked to avoid sexual intercourse • Removal of stitch : – The stitch should be removed at 37th week, or earlier if labor pain starts or features of abortion appear. – If the stitch is not cut in time, uterine rupture or cervical tear may occur.

38. COMPLICATION – Slipping or cutting through the suture – Chorioamnionitis – Rupture of the membranes – Cervical scarring and dystocia requiring cesarean delivery.

39. Prognosis of recurrent miscarriage :- • The overall risk of recurrent miscarriage is about 25–30% irrespective of the number of previous spontaneous miscarriage.

40. Post abortion instruction:- Activity is restricted for 2 weeks Intercourse is avoided for 2 weeks Review performed after 4- 6 weeks Counselling is provided regarding contraceptive intrauterine device may be inserted or oral contraceptive initiated 4 weeks after the abortion Iron supplement is recommended for 4- 12 weeks Emotional support is required for all women after the abortion It is essential to reassure the women that she is in no way responsible for causing the abortion  

41. Complication of Abortion:- Incomplete evacuation of the uterus Hemorrhage Abdominal Pain Low grade fever Injury due to instruments:- Cervical trauma Uterine perforation  

42. Infection Septic abortion Endometritis, parametritis , peritonitis Septicemia /septic shock   Asherman syndrome Due to vigorous curettage . Secondary curettage . Infertility . Injury

43. 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 (criminal).  

44. MEDICAL TERMINATION OF PREGNANCY (MTP) The following provisions are laid down: The continuation of pregnancy would involve serious risk of to the physical & mental health of the pregnant women There is substantial risk of child being born with serious physical & mental abnormalities so as to be handicaped in life When the pregnancy cause by rape Pregnancy cause by failure of contraception

45. T he indications for termination under the MTP Act: To save the life of the mother (therapeutic or medical termination): • Social indications: Eugenic:-

46. RECOMMENDATIONS

47. METHODS OF TERMINATIONOF PREGNANCY:

48. Complication Of MTP:- Immediate : (1) Injury to the cervix (2) Uterine perforation (3) Hemorrhage and shock (4) Thrombosis or embolism. (5) Postabortal triad of pain

49. Remote:- Gynaecological complications include - (a) menstrual disturbances (b) chronic pelvic inflammation (c)infertility due to cornual block Obstetrical complications include- (a) recurrent mid trimester abortion (b) ectopic pregnancy (three-fold increase) (c) preterm labor (d) dysmaturity

50. Nursing Care for Abortion/ Pregnancy Loss:- Pre-operative care for surgical abortion :- For morning appointments: NBM, no smoking, after 12:00 am (midnight) the day of the procedure. For afternoon appointments: NBM, no smoking, after 8am the day of the procedure. No recreational drugs or alcoholic beverages for 48 hours prior to surgery. Please dress comfortably; no make-up, jewellery, contact lenses, or high heel shoes.

51. Nursing responsibilities : . Check pt’s name, type of surgery 2. Monitor input & output, blood test, bleeding and vaginal secretion ( character, colour & volume) 3. Strict aseptic technique 4. Strengthen the perineum care & maintain the vulva cleanliness 5. Psychological care:

52. Post-operative care :- Monitor vital signs . Blood pressure and pulse. Assess the client’s conscious level, Assess for severity of pain using pain scale

53. Summary:-     Induced abortion is the termination of a pregnancy by artificial means. Governments can be permissive or restrictive in their legislation regulating abortion. Induced abortion is legal in the United States today, where more than one in five pregnancies end in induced abortion.