Abortion.ppt for 2nd msc

sindhu

1. ABORTION
•
SINDHU SEBASTIAN
LECTURER
FMCON

2. DEFINITION
Abortion is the expulsion or extraction
from its mother of an embryo or fetus
weighing 500gm or less when it is not
capable of independent survival.
WHO

3. Early Abortion: Before 12 weeks
Late Abortion: From 12-20 weeks

4. Viability
•Survival by Gestational age
–Weeks % survival
22 0
23 25
24 55
25 65
26 75
27 90
28 92

5. INCIDENCE:
•10-20% of all clinical pregnancy
•10% Illegal
•75% occur before 16wks

6. CLASSIFICATION
ABORTION
Spontaneous
Induced
Isolated
Recurrent
Threatened InevitableComplete Incomplete
Missed
Septic
Legal Illegal (criminal )
Septic

7. ETIOLOGY:
1.Ovular or Fetal factors(60%):
a) Ovo-fetal factors-
Chromosomal abnormality
Gross congenital malformation
Blighted ovum
Hydropic degenaration of villi
Death or Disease of fetus

8. Contd…
b) Interference with circulation-
Knots
Twists
Entanglements
c) Low attachment of placenta
d) Twins or Hydramnios.
2. Unknown factors

9. Contd…
3. Maternal factors(15%):
Maternal medical illness
-Cyanotic heart diseases
Infections
Maternal hypoxia
Chronic illness
Endocrine and metabolic factors

10. Contd…
Anatomical abnormalities
Cervico-uterine factors-
-Cervical incompetence
-Congenital malformation of uterus
-Uterine fibroid
-Intrauterine adhesions
-Retroverted uterus

11. Trauma- Direct
-Psychic Susceptible individual
-Amniocentesis
Toxic agents
4.Blood group incompatibility
5. Premature Rupture of Membranes

12. 6.Environmental factors – Smoking,
alcoholism, X-ray, Radiation,
Chemotherapy.
7.Dietic factors
8.Paternal factors:Chromosomal anomaly in
sperm
9.Infections – Viral, Bacterial or Parasitic
10. Inherited Thrombophilia

13. 11.Immunological disorder
•Autoimmune disease (mother's immune system
will form antibody against her own placenta and
fetus) or
•Alloimmune disease ( Paternal antigen which
enters mothers body will produce antibody against it.
Maternal antibody accepts as its own so there will be
decreased foetal-maternal immunologic interaction
and ultimately fetal rejection).

14. •11. Immunological disorder –
•Autoimmune disease (mother's immune system
will form antibody against her own placenta and
fetus) or
•Alloimmune disease ( Paternal antigen which
enters mothers body will produce antibody against it.
Maternal antibody accepts as its own so there will be
decreased foetal-maternal immunologic interaction
and ultimately fetal rejection).

15. Common cause
•First trimester
•Genetic factors -50%
•Endocrine disorders
•Immunological
•Infections
•Unexplained (40-60%)

16. •Second trimester
1.Anatomic abnormalities
a)Cervical incompetence
b)Mullerian fusion defects (Bicornuate uterus, septate
uterus )
c)Uterine synechiae (intra uterine adhesion )
d)Uterine fibroid
2.Maternal medical illness
3.Unexplained

17. Mechanism of Abortion
Before 8 weeks: Ovum surrounded by the villi with
the decidual coverings is expelled out. Because the
external os fails to dilate the entire mass remains in the
cervix. Called as “Cervical Abortion”.
8-14 weeks: Expulsion of the fetus commonly occurs
leaving behind the placenta and membranes, so that
there will be bleeding.
Beyond 14
th
week: Expulsion is similar to that of
“mini labour”. The fetus is expelled first followed by
expulsion of placenta.

18. Spontaneous Abortion:
Definition:
It is defined as the involuntary loss of the
products of conception prior to 20 weeks
of gestation.
Incidence:
15% of all confirmed pregnancy
80% occur in first trimester

19. Causes
1.Abnormal fetal formation due to
-Teratogenic factor
-chromosomal aberration
50-80%of early abortion has structural abnormalities
2.Immunological factors –rejection by immune
response
3.Implantation abnormalities –Poor implantation result
from
•inadequate endometial formation
•An inappropriate site of implantation

20. •improper implantation placental circulation
function affected inadequate fetal nutrition
4.Corpus luteum fails to produce enough progesterone
to maintain the decidua basalis –proge therapy is
neeed
5.UTI
7.Ingestion Of Teratogenic Drugs

21. 7.Infections -rubella
syphilis,cytomegalo,toxoplasmosis
Which readily cross the placenta

22. Changes
Infection
Fetus fails to grow

Estrogen and progesterone production by placenta
fails
Endometrial sloughing

23. Prostaglandins are released
Uterine contraction expulsion of products of
pregnancy

Cervical dilatation
Expulsion of products of pregnancy

24. Abnormal Fetal
Formation
Immunologic
Factors
Infection
Teratogenic
Factors
(smoking,
alcohol, drugs)
Rejection of the
embryo through
immunologic
response
Crosses
placenta
Fetus fails
to grow
Decrease estrogen
and progesterone
production
Endometrial
sloughing
Release of
prostaglandin which
causes uterine
contractions and
cervical dilatation
Miscarriage
Schematic Diagram of Abortion

25. 1.Threatened abortion:
It is a clinical entity where the process of
abortion has started but has not
progressed to a state from which
recovery is impossible.

26. Clinical features
Bleeding per vagina:Slight and bright
red in colour.
Pain: Mild backache or dull pain in
lower abdomen.

27. Pelvic examination:
a)Speculum examination-bleeding if any,escapes through
the external os.
b)Digital examination-reveals closed
external os.
c)The uterine size corresponds to the period of
amenorrhoea.
Investigation
a)Blood investigation
b)USG
c) Urine for immunological test for pregnancy

28. Treatment
Rest : 2weeks of bed rest.
Drugs : sedation and analgesics
Phenobarbitone 30mg or
Diazepam 5mg
Advised to preserve vulval pads and anything expelled out per
vaginam for inspection.
To report if bleeding or pain gets aggravated.
Routine note of pulse, temperature and vaginal bleeding.

29. Advice on discharge
-Limit her activities at least for 2 weeks.
- Avoid heavy work.
-Coitus is contraindicated during this period.
-Follow up after 1month to assess the growth of fetus.

30. 2. INEVITABLE ABORTION
•It is the clinical type of abortion where
the changes have progressed to a state
from where continuation of pregnancy
is impossible.

31. Clinical features
-Increased vaginal bleeding
-Severe lower abdominal pain- colicky type
-General condition is proportionate to
visible blood loss.

32. Internal examination
Reveals dilated internal os of the cervix through
which the product of conception are felt.
Management
Principles :

a. To take appropriate measures to look after the
general condition.
b. To accelerate the process of expulsion.
c. To maintain strict asepsis.

33. Active treatment
Before 12weeks : dilatation and evacuation followed
by curettage of uterine cavity.
After 12weeks :
i. Uterine contraction is accelerated by oxytocin drip
(10 U in 500ml NS) 40-60drops/min.
ii. If the product is expelled and placenta retained, it
is removed by ovum forceps(if lying separate)

34. Contd…
iii. If placenta is not seperated, digital seperation
followed by evacuation under GA.
If bleeding is severe and cervix is closed then
evacuation of uterus is done by Abdominal
hysterectomy.

35. 3. COMPLETE ABORTION
•When the products of conception are
completely expelled, it is called
complete abortion.

36. Clinical features
-There is history of expulsion of a fleshy
mass per vagina followed by:
-Subsidence of pain
-Vaginal bleeding becomes trace or absent

37. Cont....
Internal examination reveals:
-Uterus is smaller than the period of amenorrhoea
-Cervical os is closed
-Bleeding is trace
-Examination of the expelled fleshy mass is found
intact.

38. Management
i.Blood loss should be assessed and treated.
i.If there is doubt about complete expulsion of
products, uterine curettage should be done.
i.Transvaginal sonography is useful to prevent
unnecessary surgical procedure.
i.In case of Rh negative mother antiD gamma
globulin should be given.

39. 4. Incomplete abortion
•When the entire products of
conception are not expelled, instead a
part of it is left inside the uterine
cavity, is called incomplete abortion.

40. Clinical features.
-History of expulsion of fleshy mass per vaginam
followed by:
-Continuation of pain lower abdomen
-Persistence of vaginal bleeding

41. Internal examination
-Uterus smaller than the period of
amenorrhoea
-Cervical os may admit the tip of the finger
-Varying amount of bleeding
-On examination,the expelled mass is found
incomplete.

42. Termination
If the products left behind it leads to

Profuse bleeding

Sepsis

Placental polyp

Choriocarcinoma

43. Management
The principles to be followed are same as Inevitable
abortion.
Patient may be in a state of shock due to blood loss.,
she should be resuscitated before any active
treatment.
Early abortion: Dilatation and evacuation
Late abortion: Uterus is evacuated under GA and the
products are removed by ovum forcep or by blunt
curette.

44. 5. Missed abortion / Silent
miscarriage or early fetal
demise
•When the fetus is dead and retained
inside the uterus for a variable
period,it is called as missed abortion
or silent miscarriage.

45. Pathology
Beyond 12wks: Fetus become macerated or
mummified, liquor amnii get absorbed, placenta
becomes pale,thin and adherent.
Before 12wks: Because of haemorrhage blood will get
collected around ovum called as “blood mole".,
water content from the blood gets absorbed and flesh
remains around the ovum called as “Fleshy mole or
Carneous mole”.

46. Clinical features
Persistence of brownish vaginal discharge
Subsidence of pregnancy symptoms
Retrogression of breast changes
Non audibility of fetal heart sound even with doppler
Cervix feels firm
Immunological test for pregnancy becomes negative
USG reveals an empty sac

47. Management
If less than 12wks:
vaginal evacuation by suction
evacuation or slow dilatation of
the cervix by laminaria tent
followed by dilatation and
evacuation of the uterus under GA.

48. If more than 12wks:
Induction is done
-Oxytocin 10-20U in 500ml NS at
30drops/min. If fails increase dose to
maximum of 200mlU/min
-Prostaglandins:misoprostol tab inserted into
the posterior vaginal fornix
:IM administration of 15methyl PGF2α
(carboprost tromethamine)

49. 6. Septic abortion
•Any abortion associated with
clinical evidences of infection of
the uterus and its contents.

50. Criteria
•Rise of temperature 100.4*for 24 hrs
•Offensive or purulent vaginal discharge
•Lower abdominal pain and tenderness

51. Mode of infection
Usually the micro-organisms present in the
vagina are involved in sepsis when the
resistance power of the mother becomes
low.
Majority of cases the infection occurs
following illegal induced abortion.

52. Reasons for infection
•Proper antiseptic and asepsis are not taken
•Incomplete evacuation

53. Clinical features
Pyrexia associated with chills and rigors.
Purulent vaginal discharge
Shock
Pain abdomen of varying degrees
Internal examination reveals:
-Offensive purulent vaginal discharge
- Tender uterus

54. Clinical grading
Grade I : Infection localised to uterus
(commonest)
Grade II : infection spreads beyond the
uterus to the tubes and ovaries.
Grade III : Generalised peritonitis / shock /
jaundice or acute renal failure (associated
with illegal induced abortion).

55. Investigations
Routine investigations :
-Cervical or high vaginal swab for culture and
sensitivity test.
-Blood for haemoglobin, total and differential count,
ABO and Rh grouping.
-Urine analysis including culture
Special investigations :
-USG abdomen and pelvis
-Blood for culture, serum electrolytes, coagulation
profile

56. Complications
Immediate :
Haemorrhage
Injury to uterus and adjacent
structures
Spread of infection causes Peritonitis
Acute renal failure
Thrombophlebitis

57. Remote :
Chronic pelvic pain, Backache
Dyspareunia
Ectopic pregnancy
Secondary infertility due to tubal
blockage
Emotional depression.

58. Prevention
i. Use family planning method
ii. Encourage to go for legal abortion

59. Management
•Hospitalization
•High vaginal or cervical swab
•Vaginal examination to note the
state of abortion process

60. Principles of management:
•To control the sepsis
•To remove the source of infection
•To give the supportive therapy
•To bring back the normal homeostatic
and cellular metabolism
•To assess the response to treatment

61. Specific management
Drugs : 1.Antibiotics
Gram positive aerobes
a)Aqueous Penicillin G 5million U IV every 6 hours
(b)Ampicillin 0.5-1gm IV every 6 hours.
Gram negative aerobes
(a)Gentamicin 1.5mg/kg IV every 8 hours.
(b)Ceftriaxone 1.5gm IV every 12 hours

62. For Anaerobes
(a) Metronidazole 500mg IV every 8hours
(b) Clindamycin 600mg IV every 6hours
Grade I
1.Antibiotics
2. Prophylactic anti gas-gangrene
Serum of 8000 U and 3000 U of anti tetanus serum
IM are given.

63. 3. Analgesics and Sedatives
-Blood transfusion
-Evacuation of the uterus within 24hours following
antibiotic therapy

64. Grade II
Antibiotics
Clinical monitoring- to note pulse, temperature,
urinary output and progress of pain, tenderness and
mass in lower abdomen.
Surgery
i. Evacuation of the Uterus
ii. Posterior colpotomy(pouch of douglas)

65. Grade III
Antibiotics
Clinical monitoring
Supportive therapy with IV fluids.
Active surgery
-Laparotomy

66. •Recurrent miscarriage is defined
as a sequence of three or more
consecutive spontaneous abortion
before 20weeks.
Recurrent / Spontaneous
miscarriage

67. Etiology
During 1
st
trimester
-Genetic factors
-Endocrine and metabolic
-Infection
-Inherited Thrombophiliaintra vascular
coagulation .(protein C-natural inhi-of
coag)
-Immunological cause : Auto & Allo
immunity
-Unexplained

68. During 2
nd
trimester
Cervical incompetence
Defective mullerian fusion-double uterus,bicornuate
uterus,septate uterus.
Cervical incompetence
Uterine fibroid
Retroverted uterus
Chronic maternal illness
Infection, Unexplained

69. Investigations
i. History on previous abortion.
ii. Any chronic illness
iii. Histology of placenta

70. Diagnostic tests
a. Blood glucose , VDRL , Thyroid
function test, ABO and Rh grouping
b. Autoimmune screening
c. USG
d. Hysterosalpingography
e. Hysteroscopy / Laparoscopy
f. Endocervical swab

71. Treatment
During Inter conceptional Period

To alleviate anxiety and improve
psychology

Hysteroscopic resection of uterine septate

Uterine unification operation (metroplasty)
for bicornuate uterus.

Genetic counselling if chromosomal
abnormality .

Endocrine dysfunction has to be controlled.

Genital tract infections are treated.

72. During pregnancy

Reassurance and tender loving care.

Ultrasound

Adequate rest

Avoid strenuous activity


Intercourse


Travelling.

73. •Luteal phase defect:
Progesterone 100mg as vaginal
suppository TID started 2days after
ovulation. During this time if
pregnancy test is positive continue
treatment 12weeks of pregnancy.
(corpus luteal insufficiency)

74. Inherited Thrombophilia :

antithrombotic therapy improves the pregnancy
outcome.heparin 5000IUtwice daily.S/C upto 34
weeks

Medical complications : Specific management is
continued.
Unexplained :

Supportive therapy improves pregnancy outcome.

75. •Circlage operation :non absorbable encircling suture
is placed around the cervix at the level of internal
OS.
Done at 14 weeks of pregnancy or at least two weeks
earlier than the previous pregnancy loss -10
th
week
•;

76. Nursing Diagnosis
•Risk for fluid volume deficit r/t maternal
bleeding
Nursing Interventions
•Report any tachycardia, hypotension, diaphoresis,
or pallor, indicating hemorrhage and shock.
•Draw blood for type and screen for possible blood
administration.
•Establish and maintain an IV with large-bore
catheter for possible transfusion and large quantities
of fluid replacement.

77. •Anticipatory grieving r/t loss of pregnancy, cause of
abortion, future childbearing
Nursing Diagnosis
Nursing Interventions
•Assess the reaction of patient and support person, and
provide information regarding current status, as
needed.
•Encourage the patient to discuss feelings about the
loss of the baby’ include effects on relationship with the
father.
•Do not minimize the loss by focusing on future
childbearing; rather acknowledge the loss and allow
grieving.
•Providing time alone for the couple to discuss their
feelings.

78. Nursing Diagnosis
•Risk for infection r/t dilated cervix and open uterine
vessels
Nursing Interventions
•Evaluate temperature q 4H if normal, and every 2H
if elevated.
•Check vaginal drainage for increased amount and
odor, which may indicate infection.
•Instruct on and encourage perineal care after each
urination and defecation to prevent contamination.

79. • Acute pain r/t uterine cramping and possible
procedures
Nursing Diagnosis
Nursing Interventions
•Instruct patient on the cause of pain to decrease
anxiety.
•Instruct and encourage the use of relaxation
techniques to augment analgesics.
•Administer pain medication as needed and as
prescribed.

80. Nursing Diagnosis
Nursing Interventions
•Knowledge deficit r/t signs and symptoms of possible
complications
•Teach the woman to observe for signs of infection (fever,
pelvic pain, change in character and amount of vaginal
discharge), and advise to report them to provider
immediately.
•Deal with client’s anxiety. Present information out of
sequence, if necessary, dealing first with material that is most
anxiety producing when the anxiety is interfering with the
client’s learning process.
•Teach client of the complications for a mother has reason
to be especially worried about her infant’s health.

81. Thank you

82. Induced abortion

83. Definition
Deliberate termination of
pregnancy before the
viability of the fetus is
called induction of abortion

84. Elective: if performed for a woman’s
desires
Therapeutic: if performed for reasons of
maintaining health of the mother

85. MTP ACT -1971
•The continuation of pregnancy would
involve seroius risk of life or grave injury
to the physical and mental health of the
pregnant women
•There is a substantial risk of the child
being born with serious physical and
mental abnormalities so as to be
handicapped in life

86. •When the pregnancy caused by rape ,both in
case of major and minor girl and in mentally
imbalance women
•Pregnancy result as a result of contraceptive
failure

87. Indication
•To safe the life of the mother
-Cardiac diseases
-Ch.Glomerulonephritis
-Malignant hypertension
-Hyperemesis gravidarum
-Cervical breast malignancy
-DM with retinopathy
-Epilepsy or psychiatric diaseases with
advice of psychiatrist

88. •Social indications
-unplanned pregnancy with low
socioeconomic status
-pregnancy caused by rape or failure of
contraceptive methods

89. •Eugenic
-Structural-anencephaly
,chromosomal (down syndrome) or
genetic (hemophilia)
-Teratogenic
drugs(warfarrin)radiation exposure more
than 10 rads in early pregnancy
- rubella infection

90. RECOMMENDATIONS
1.Qualified Registered medical practitioner
a) One has assisted at least 25 MTP in
authorized centre and having certificate
b)6 months house surgeon training in OBG
c)Diploma or degree in OBG

91. 2.Termination can only performed in hospitals
established or maintained by Govt or places approved
by Govt
3.Pregnancy can only terminated on the written consent
of the women. Husband's consent is not required
4.Pregnancy in a minor girl (below the age of 18 years )
can not be terminated without the written consent of
the parent or legal guardian.
5.Termination is permitted up to 20 weeks of pregnancy
When the pregnancy exceeds 12 weeks opinion of two
medical practitioners is required

92. •The abortion has to be performed
confidentially and to be reported to the
director of health services of state in the
prescribed form

93. Induced abortion: statistics . . .
•1,180,000 abortions
are reported to the
CDC in 1997. This is
constant since 1980
•305 abortions/1000
live births
•National abortion
rate: 20/1000 women
aged 15-44
•79.7% of women
obtaining abortions
are unmarried
•21 % of women
obtaining abortions
are younger 19 years
old
•55.2 % are younger
than 24 years old

94. Contd…
•88% of women who
abort are in the first
trimester of
pregnancy
•97% of women
having first trimester
abortions have no
complications or post
abortion complaints
•2.5 % have minor
complaints that are
handled in a physicians
office
•<0.5% require additional
surgery

95. Roe vs. Wade1/22/73
•“We recognize the right of the individual, married or
single, to be free from unwanted governmental
intrusion into matters so fundamentally affecting a
person as the decision whether to bear or beget a
child. That right necessarily includes the right of a
woman to decide whether or not to terminate her
pregnancy.”

96. Gestational age and procedure
–50% of abortion performed 8 weeks or
earlier
–12% of abortion performed past 12
weeks
–1.4% of abortion performed past 20
weeks

97. First Trimester Abortion
•Early Uterine Evacuation (EUE),
Minisuction
•Menstrual Regulation
•Suction Abortion
•Vacuum Curettage
•Medical Abortion

98. Minisuction
•Introduced in 1972 by Karman and Potts

99. Surgical techniques for abortion
•Menstrual aspiration(menstrual regulation )
–Aspiration of endometrial cavity using a flexible cannula and syringe within
1-3 weeks after failure to menstruate
–Several points at early stage of gestation
•Woman not being pregnant
•Implanted zygote may be missed by the curette
•Failure to recognize an ectopic pregnancy
•Infrequently, a uterus can be perforated

101. Dilatation and curettage (D&C)
•Removal of pregnancy
contents by some
mechanical means
•Vacuum most
commonly used
•12-13 weeks is the
upper limit of
gestational age
•Usually performed in
free standing clinics

106. Medical Abortion
•Mifepristone (RU486)
–Analogue of progestin norethindrone
–Strong affinity for the progesterone
receptor, acting as an antagonist
–A single oral dose given to women 5
weeks or less produces abortion in
85% of cases

107. Mifepristone protocol
•Women less than 49 days LMP with
confirmed b-hCG
•600mg mifepristone on day 1
•On day three, return for prostaglandin,
Misoprostil 400 mcg orally
•Patient remain in clinic four hours, during
which time expulsion of pregnancy
usually occurs

108. Medical
Surgical
Private
More sense of
autonomy
“More natural”
Earlier intervention
unwanted pregnancy
Longer process with
unclear endpoint
More pain
More bleeding
Anxiety regarding
abortion off site

109. Medical Surgical
Less skill needed to
provide
Methotrexate also treats
ectopic pregnancy
Increased anxiety re: off site
management
More unscheduled care: calls,
ER visits
Need to guard against
unnecessary intervention
Limited to 49 days LMP

110. Second Trimester Termination
•Dilatation and evacuation (D&E)
•Intrauterine injection of
abortifacients
•Prostaglandin vaginal suppositories
•High dose oxytocin
•Hysterotomy

111. D & E
•Mechanical and suction removal of
formed pregnancy after cervical dilation
•Technically more difficult than earlier
suction procedures
•Associated with fewer complications than
instillation and suppository methods
•General anesthesia is not required

113. •Picture of laminaria

114. Intrauterine injection of
abortifacients
•Prostaglandin, hypertonic saline,
hypertonic urea are introduced by
amniocentesis
•Fetus and placenta are aborted vaginally
•Osmotic dilators are used to decrease time
to delivery and decrease complications

115. Prostaglandin suppositories
20 mg suppositories of PGE2 typically given
q 3 hours
Prostaglandin F2alpha 250 mg IM q 2 hours
Mean time to
induction 13.4 hours,
with 90% aborting by
24 hours
GI side effects: 39%
vomiting, 25% diarrhea
Fever: temperature
elevation of 1 degree c
Mean time to
abortion 15-17 hours,
with 80% aborting by
24 hours
GI side effects: 83%
vomiting, 71% diarrhea
Misoprostil (PGE1

116. High Dose Oxytocin
•As effective as PGE2 when used in
appropriate doses
•Risk of water intoxication

117. Hysterotomy
•Surgical method to remove pregnancy
abdominally (mini-cesarean section)
•Other methods are preferred

118. Complications - rates
•Varies as a function of the gestational age
they are performed
–Major complications:
•0.25% < 7 weeks
•1% < 12 weeks
•2% over 12 weeks

119. Complications - Immediate
•Complications of local anesthetic
•Cervical shock
•Cervical lacerations
•Uterine perforation
•Hemorrhage
•Post abortal syndrome

120. Complications - Delayed
•Bleeding
–Retained products
•Infection
•Continued pregnancy
–Ectopic
–Intrauterine

121. •Thank you