ABORTION naiwnshis gsjekeo hsuejnsis uaijwis

Abortion

1. ABORTION PRESENTED BY - MUKESH KUMAR CHOUDHARY BSC NURSING 4 TH YEAR BATCH :- 2021-22

2. INTRODUCTION- Abortion is the medical termination of a pregnancy before the fetus reaches viability. the termination of pregnancy before 20–24 weeks of gestation or when the fetus weighs less than 500 grams. Abortion laws differ across countries; in India, it is governed by the Medical Termination of Pregnancy (MTP) Act, 1971 (amended in 2021).

3. DEFINITION - According to the WHO. - abortion is the expulsion or extraction of an embryo or fetus occurring before 20–22 weeks of gestation OR weighing less than 500 gMS. OR Expelled embryo or fetus before period of viability called abortION Miscarriage - Spontaneous naturally abortioN.

4. ETIOLOGY - 1- Faulty development of the embryo resulting from chromosomal abnormalities (50% cause of abortion in fiRST trimester), like Down syndrome (most common). 2- Interference with the circulation, due to knot of umbilical cord and low attachment of placenta etc. 3- Maternal infection - e.g. TORCH. Toxoplasmosis, RubelLA, CytomegaloviRus, and HerpeS SIMPLEX other transplacental infections - HUMAN immunodeficiency virus, hepatitis B, and syphilis.

5. C0NT.... TORCH infections can attack a growing embryo or fetus and cause abortion, 4 - severe congenital anomalies, mental retardation and fetal or neonatal death. 5- Cervical incompetence (main cause of abortion in second trimester). 6- Premature rapture of membrane. 7- Deficiency of folic acid & vitamin E

6. SIGNS AND SYMPTOMS SPONTANEOUS VAGINAL BLEEDING LOWER ABDOMINAL PAIN / CRAMPING TISSUE OR BLOOD CLOTS FROM VAGINA SHOCK LIKE CONDITION DUE TO EXCESSIVE BLEEDING

7. TYPES -

8. SPONTANEOUS ABORTION - NATURAL TERMINATION OF PREGNANCY BEFORE 20 - 28 WEEKS GESTATION WITHOUT ANY MEDICAL OR SURGICAL INTERVENTION . TYPES- Threatened Inevitable Complete Incomplete Missed Septic

9. THREATENED ABORTION definition- It is a condition where the process of miscarriage has started (bleeding, pain), but pregnancy may still continue because the cervix remains closed and recovery is possible. CLINICAL FEATURE - Vaginal bright red bleeding with or without intermittent pain is usually the FIRST SIGN. Closed cervicaL OS. Mild backache aND DULL pain in lower abdomen

10. . Investigations - Blood tests: Hb, hematocrit, ABO & Rh grouping. Urine pregnancy test: not helpful (remains positive after fetal death). Ultrasonography Normal: gestational sac with embryo & cardiac activity → 98% chance of continuation. Abnormal: blighted ovum (empty sac, absent cardiac activity). Serum progesterone ≥ 25 ng/mL → viable pregnancy (95%). Serial serum β-hCG: helps assess viability.

11. TREATMENT - Rest: Bed rest until bleeding stops (prolonged rest not beneficial). Drugs:- Diazepam 5 mg BID for pain relief. Progesterone therapy may help (shifts immune response to favorable Th-2) Blood transfusion: if heavy bleeding/inevitable miscarriage Rh-negative women: give Anti-D immunoglobule. Advice on Discharge - Limit activity, avoid intercourse. Follow-up with repeat USG in 3–4 weeks.

12. INEVITABLE (COMPULSORY) ABORTION - If threatened abortion that cannot prevented (if pain & bleeding it continue) and the cervix opens the products of COnception will pass into vagina which called inevitable abortion. There is no chance of contiNUation of pregnancY CLINICAL FEATURES - 1. Increased vaginal bleeding 2. Severe abdominal pain

13. CONT.... 3. Internal examination: - Cervical os dilated Products of conception felt through os In 2nd trimester → may begin with rupture of membranes or intermittent pain MANAGEMENT - Aims: -1. COMPLETE expulsion of products of conception. 2. Maintain strict asepsis. MEDICAL - Induction of labour by administration of oxytocin (10-20-unit oxytocin in 500 ml NS with 30 drops/minute) SURGICAL- Dilation and CURETTAGE (D & C) if pregnancy less than 12 weeks.

14. C0MPLETE ABORTION- An abortion in which the total products of conception have been expelled. Clinical Features History:- Passage of a products of conception per vaginam. :- 1. Abdominal pain REDUCED 2. Vaginal bleeding reduces internal examination:- Uterus SIZE smaller - Cervical os closed. -Minimal or no bleeding.

15. . Ultrasonography :- Shows empty uterine cavitY Management- Confirm by USG:- Ensure uterine cavity is empty. If empty → no further intervention needed. If not empty → evacuation / uterine curettage is required. Observe the patient for excessive bleeding, infection, or anemia.

16. INCOMPLETE ABORTION- An abortion in which part of the products of conception has been retained in the uterus. Remaining product may cause bleeding and sepsis. Clinical Features Symptoms after expulsion: 1. Pain in lower abdomen persists. 2. Vaginal bleeding continues. Internal examination: Uterus smaller than period of amenorrhea.

17. . Cervical os patulous (often admits fingertip). Varying amount of bleeding present. Ultrasonography : retained products of conception in uterine cavity. management - medical- Misoprostol 200 µg vaginally every 4 hours until expulsion . surgical- Early abortion (<12 weeks): Dilatation & evacuation (D&E) under analgesia or GA. Manual vacuum aspiration (MVA) can be used.

18. . Late abortion (>12 weeks): Evacuate uterus under GA. Remove retained parts with ovum forceps or blunt curette. Dilatation & curettage if bits remain. Complications- Profuse bleeding → hemorrhagic shock. Sepsis → due to retained tissue.

19. MISSED ABORTION- When the fetus is dead and retained inside the uterus for a variable period Dead fEtUs if remain in uterus for more than 3-4 weeks may cause... (disseminated intravascular coagulation). Clinical Features 1. Symptoms of threatened miscarriage. 2. Persistence of brownish vaginal discharge. 3. Subsidence of pregnancy symptoms. 4. Retrogression of breast changes. 5. Cessation of uterine growth → uterus becomes smaller.

20. .. 6. Non-audibility of fetal heart (even with Doppler). 7. Cervix feels firm. 8. Pregnancy test becomes negative. 9. Ultrasound → empty sac or absent fetal cardiac activity. Management- 🔹 Depends on uterine size (<12 weeks or >12 wks If < 12 weeks: . Expectant: Spontaneous expulsion may occur. . Medical : Misoprostol 800 mg vaginally, repeat after 24 hrs if needed. . Surgical : - Suction evacuation or D&E if medical fails. Risk of uterine damage/hemorrhage considered.

21. . If > 12 weeks: 1. Induction methods: - (a)PROSTAGLANDIN E1 ( Misoprostol) : 200 mIUg vaginally every 4 hrs (max 5 doses). (b) Oxytocin: 10–20 units in 500 ml NS, start 30 drops/min, increase up to 200 mIU/min. (c) Surgical evacuation if medical fails - D&E SEPTIC ABORTION - Any abortion which is associated with infection of uterus or products of conception called septic abortion. Incomplete abortion and illegal abortion are mainly septic abortion.

22. . CLINICAL FEATURE- The woman looks sick and anxious Temperature: >38 °℃ Chills and rigors (suggest-bacteremia) Persistent tachycardia ≥ 90 bpm (spreading infection) Hypothermia (endotoxic shock) < 36 °℃ Abdominal or chest pain Tachypnea (RR) > 20/min Impaired mental statUS Diarrhea and/or vomiting Pelvic examination: Offensive, purulent vaginal discharge

23. . I nvestigations- Routine: 1. Cervical or high vaginal swab (before internal exam): Culture (aerobic & anaerobic) → detect organisms Sensitivity to antibiotics Gram stain SMEAR - Gram-negative: E. coli, Pseudomonas, Bacteroides. - Gram-positive: Staphylococci, StreptococcI ... 2. Blood tests:- Hb, WBCs , ABO & Rh grouping 3. Urine analysis including culture

24. . 4 . ULTRASONOGRAPHY - ( pelvis and abdomen) to detectintrauterine retained products of conception, foreign body-intrauterine or intra-abdominal free fluid in the peritoneal cavity MANAGEMENT - MEDICAL - 1. Hospitalization & Isolation – essential for all cases. 2. Antibiotics (broad-spectrum, IV, empirical → then culture-based): Piperacillin–tazobactam OR Carbapenem + Clindamycin (best coverage).

25. . Add Vancomycin/Teicoplanin if MRSA suspected. Metronidazole – for anaerobes. 3. Prophylaxis (if interference suspected): Anti-gas gangrene serum (AGS) – 8,000 units IM. Anti-tetanus serum (ATS) – 3,000 units IM. 4. Analgesics & Sedatives – for pain relief. 5. Supportive therapy: - IV fluids, crystalloids, oxygen. Blood transfusion – correct anemia, improve resistance. Monitor vitals, urine output, mental statUS. SURGICAL - D&E , POSTRIOR COLPOTOMY IN PELVIS ABSCESS , LAPAROTOMY FOR PERITONITIS ( AFTER INFECTION CONTROL )

26. . COMPLICATIONS - HEMORRHAGE INJURY IN UTERUS AND ASSOCIATE STRUCTURES . SPREAD OF INFECTION LEADS TO- GENERALIZED PERITONITIS -ACUTE RENAL FAILURE -ENDOTOXIC SHOCK - THROMBOPHLEBITIS ECTOPIC PREGNANCY CHRONIC PELVIC PAIN AND BACKACHE

27. INDUCED ABORTION- TERMINATION OF PREGNANCY BEFORE FETUS IS VIABLE PERFORMED BY MEDICALLY OR SURGICALLY. MEDICAL TERMINATION OF PREGNANCY ACT ( 1971)- MTP ALSO KNOWN AS INDUCED ABORTION . IT IS MEDICAL WAY TO GETTING TERMINATE THE UNWANTED PREGNANCY. IN WHICH REMOVAL OR EXPULSION OF AN EMBRYO OR FETUS FROM THE UTERUS.

28. INDICATION FOR MTP. - Abnormalties in fetus . Pregnancy caused by rape. Contraceptive failure. RISK OF INJURY TO MENTAL & PHYSICAL HEALTH OF HUMAN .

29. METHOD OF TERMINATION- 1st trimester :- MEDICAL - Mifepristone + Misoprostol (BLOCKS PROGESTRONE AND UTERINE CONTRACTIONS) methotrexate +misoprostol SURGICAL -MANUAL vaccum aspiration , D& C , D&E. 2nd trimester- MEDICAL - misoprostol, carboprost SUGICAL- D& C , HYSTEROTOMY ,Hystrectomy

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