abortion ...pptx

abortion and its types

1. seminar on abortion Presented By: Mandeep Kaur M.Sc. (N) Final Year

2. INTRODUCTION: Any bleeding in pregnancy is abnormal. Vaginal blood loss in early pregnancy should be thought of as a threatened miscarriage until shown otherwise. The term miscarriage and spontaneous abortion are synonymous.

3. DEFINITION Abortion is the process of partial or complete separation of the products of conception from the uterine wall with or without partial or complete expulsion from the uterine cavity before the age of viability. The age of viability is 28 weeks in India.

4. Conti... Abortion is the expulsion or extraction from its mother of an embryo or foetus weighing 500gm or less when it is not capable of independent survival (WHO). This 500gm of fetal development is attained approximately at 22 weeks (154 days) of gestation. The expelled foetus is called abortus.

5. INCIDENCE: The incidence of abortion is difficult to work out but probably 10-20% of all clinical pregnancies end in miscarriage and another optimistic figure of 10% are induced illegally. 75% abortions occur before the 16 th week and of these, about 75% occur before the 8 th week of pregnancy.

6. ETIOLOGY: The etiology of miscarriage is often complex and obscure. The following factors (embryonic or parental) are important: Genetic factors (50%) Endocrine and metabolic factors (10-15%) Anatomic abnormalities (10-15%) Infections(5%) Blood group incompatibility Unexplained (40-60%)

7. CLASSIFICATION

8. Spontaneous Abortion: S pontaneous abortion is defined as the involuntary loss of products of conception prior to 28 weeks of gestation, when the fetus weights approximately 1000gm or less. Spontaneous abortions occur in every 15 pregnancies. In India it has been computed that about 6 million abortions take place, every year of which 2 million are spontaneous and the 4 million are induced.

9. Causes: The causes of spontaneous abortion in most cases are not known. Where a cause is determined, 50% of miscarriages are due to chromosomal abnormalities of the conceptus . Genetic and structural causes are also attributed to pregnancy loss. Maternal causes are: Structural abnormalities of the genital organs. Infections such as rubella and Chlamydia. Medical conditions

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

11. Clinical features Vaginal bleeding with or without recognized uterine contractions. The blood loss may be scanty with or without accompanying backache and cramp like pain. The pain may resemble dysmenorrhoea. The cervix remains closed and the uterus soft with no tenderness when palpated. The outcome of threatened abortion could be either stoppage of bleeding and continuance of bleeding and uterine contractions to expel the products of conception.

12. Investigations: Blood: for Hb , haematocrit , ABO and grouping Urine for immunoglogical test of pregnancy. Ultrasonography .

13. Treatment: Rest Drugs: For Relief of pain.

14. Inevitable Abortion : The women presents with bleeding, often heavy, with clots or products of conception. Blood loss may be heavy and the mother in a shocked state. The cervix is dilated and on examination, products may be seen in the vagina or protruding trough the os . The uterus if palpable may be smaller than expected.

15. Management: Management is aimed: a) to accelerate the process of expulsion. b) to maintain strict asepsis. General measures: Excessive bleeding should be promptly controlled by administering methergin 0.2mg if the cervix is dilated and the size of the uterus is less than 12 weeks. The blood loss is corrected by intravenous fluid therapy and blood transfusion.

16. Active treatment Before 12 weeks: Dilatation and evacuation followed by curettage using analgesia or under general anaesthesia. Alternatively, suction evacuation followed by curettage is done. After 12 weeks : The uterine contraction is accelarted by oxytocin drip (10 units in 500ml of normal saline) 40-60 drops per minute. If the fetus is expelled and the placenta is retained, it is removed by ovum forceps, if trying separated. If the placenta is not separated, digital separation followed by its evacuation is to be done under general anaesthesia.

17. Complete Abortion: The conceptus , placenta and membranes are expelled completely from the uterus.

18. Clinical features : There is history of expulsion of a fleshy mass per vagina followed by: Subsidence of abdominal pain Vaginal bleeding becomes trace or absent Internal examination reveals: uterus is smaller than the period of amenorrhoea and a little firmer. Cervical os is closed. Bleeding is trace. Examination of the expelled fleshy mass is found complete

19. Management: Transvaginal ultra sonography is usefull to see that uterine cavity is empty, otherwise evacuation of uterine curettage should be done.

20. Incomplete Abortion When the entire products of conception are not expelled, instead a part of it is left inside the uterine cavity it is called incomplete miscarriage or abortion.

21. Clinical features History of expulsion of a fleshy mass per vagina followed by: Continuation of pain lower abdomen. Persistence of vaginal bleeding. Internal examination reveals- a) uterus smaller than the period of amenorrhoea. b) patulous cervical os often admitting tip of the finger and c) varying amount of bleeding. On examination, the expelled mass is found incomplete

22. Complications The retained products may cause: Profuse bleeding Sepsis Placental polyp

23. Management: In recent cases: Evacuation of the retained products of conception (ERCP) is done. Medical management of incomplete abortion may be done. Tablet Misoprostal 200μg is used vaginally every 4 hours. Compared to surgical methods, complications are less with medical methods.

24. Missed Abortion When the fetus is dead and retained inside the uterus for a viable period, it is called missed abortion or early fetal desmise .

25. Clinical features The patient usually presents with features of threatened abortion followed by: Persistence of brownish vaginal discharge. Subsidence of pregnancy symptoms. Retrogression of breast changes. Cessation of uterine growth which in fact becomes smaller in size. Non audibility of the fetal heart sound even with Doppler ultrasound if it had been audible before.

26. Conti... Cervix feels firm Immunological test for pregnancy becomes negative. Real time ultrasonography reveals an empty sac early in the pregnancy or the absence of fetal motion or fetal cardiac movements.

27. Management : Uterus is less than 12 weeks: Expectant management: many women expel the conceptus spontaneously. Medical management: prostaglandin E1 ( Misoprostal ) 800mg vaginally in the posterior fornix is given and repeated after 24 hours if needed. Expulsion usually occurs within 48 hours. Suction evacuation or dilatation and evacuation is done either as a definitive treatment.

28. Conti... Uterus more than 12 weeks: Induction is done by the following methods: Prostaglandin E1 ( misoprostal ) 200μg tablet is inserted into the posterior vaginal fornix every 4 hours for a maximum of 5 such. Oxytocin-10-20 units of oxytocin in 500ml of normal saline at 30 drops per minute is started. Many patients need surgical evacuation following medical treatment. Dilatation and evacuation is done once the cervix becomes soft with use of PGE1.

29. Septic Abortion Any abortion associated with clinical evidences of Infection of the uterus and its contents, is called septic abortion. Although clinical criteria vary, abortion is usually considered septic when there are: Rise of temperature of atleast 100ºF for 24 hours or more. Offensive or purulent vaginal discharge. Other evidences of pelvic infection such as lower abdominal pain and tenderness.

30. Incidence: About 10% abortions requiring admission to hospital are septic. The majority of septic abortions are associated with incomplete abortion. While in the majority of cases the infection occurs following illegal induced abortion but infection can occur even after spontaneous abortion.

31. Causes: Criminal abortion which is inexpert attempts at termination of pregnancy by passing sticks, catheters, pastes or soap solution into the uterine cavity. Inevitable abortion with infection. Medical termination of pregnancy with infection.

32. Clinical features: Depending upon the severity and the extent of infection, the clinical picture varies widely. Pyrexia associated with chills and rigor suggest of blood stream spread of infection. Pain abdomen A rising pulse rate of 100-120/min or more is a significant finding then even pyrexia. It indicates spread of infection beyond the uterus. Internal examination reveals offensive purulent discharge or a tender uterus usually with patulous os or a boggy feel of the uterus.

33. Clinical grading : Grade 1: The infection is localised in the uterus. Grade 2: The infection spreads beyond the uterus to the parametrium , tubes and ovaries or pelvic peritoneum. Grade 3: Generalised peritonitis and/or endotoxic shock or jaundice or acute renal faiure .

34. Investigations: Routine investigations include: Cervical or high vaginal swab is taken prior to internal examination. Blood for haemoglobin estimation, total and differential count of white cells, ABO and Rh grouping. Urine analysis for culture.

35. Special investigations include : Ultrasonography of pelvis and abdomen. Blood culture- if associated with spell of chills and rigors, Serum electrolytes and coagulation profile. Plain X-ray.

36. Complications: Immediate complications: Haemorrhage related to abortion. Injury may occur to uterus and also to the adjacent structures particularly gut. Spread of infection leads to generalised peritonitis, endotoxic shock, acute renal failure, etc. Remote complications: Chronic pelvic pain and backache Dyspareunia Ectopic pregnancy Secondary infertility Emotional depression

37. Management of septic abortion: Hospitalization is essential for all cases of septic abortion. The patient is kept in isolation. To take high vaginal or cervical swab for culture, drug sensitivity test and gram stain. Vaginal examination is done to note the state of abortion. Overall assessment and patient is levelled in accordance with clinical grading. Investigation protocols. Drugs: Antibiotics, analgesics and sedatives. Pelvic abscess if present will be drained. Evacuation of the uterus. Laparotomy : Removal of the uterus should be done irrespective of parity.

38. Induced abortion: T his is deliberate interruption of an intact pregnancy. Induced abortions are performed legally in India since the Medical termination pregnancy (MTP) Act of 1971 (revised in 1975).

39. MTP ACT PROVISIONS:- The continuation of pregnancy would involve serious risk of life of the pregnant women. There is also risk of child being born with serious physical and mental abnormalities. The pregnancy as the result of rape. Pregnancy caused as a result of failure of contraceptive. When there are actual or reasonably foreseeable environments which may lead to risk or injury to the health of the mother.

40. A registered medical practitioner is qualified to perform MTP. Termination can only be performed in Government hospital or places approved by the Government. Pregnancy can only be terminated on the written consent of the women. Termination is permitted up to 20 weeks of pregnancy. Pregnancy in a minor girl or lunatic cannot be terminated without written consent of the parents or legal guardian. The abortion has to be performed confidentially.

41. THERAPEUTIC OR MEDICAL TERMINATION: Cardiac disease Chronic glomerulonephritis . Cervical or breast malignancy Diabetes mellitus Psychiatric illness

42. Cont… SOCIAL INDICATIONS : Porous women having unplanned pregnancy with low socioeconomic status. Pregnancy caused by rape. Pregnancy due to failure of contraceptive methods.

43. Cont… EUGENIC INDICATIONS: Structural and chromosomal abnormalities Exposure to teratogenic drugs or radiations exposure Rubella infection in first trimester

44. IMMEDIATE: Injury to the cervix Uterine perforation Haemorrhage and shock Post abortal triad of pain, bleeding and low grade fever Due to prostaglandins: vomiting, diarrhoea and fever.

45. Cont…. REMOTE: GYNAECOLOGICAL COMPLICATIONS : Menstrual disturbances Chronic pelvic inflammation OBSTETRICAL COMPLICATIONS : Preterm labour Dysmaturity Rupture uterus

46. Role of nurse Assessment: Assess for the following manifestations: Vaginal bleeding, spotting, clots. Low abdominal cramping. Passing of tissue through the vagina. Shock-decreased blood pressure, increased pulse rate. Women may verbalize fear, disappointment or feelings of guilt.

47. Nursing diagnosis: Risk for fetal injury. Risk for infection related abortion. Fluid volume deficit related to vaginal bleeding as evidenced by cool and clamy skin, dry mucosa. Anticipatory grieving related to loss of pregnancy. Anxiety related to outcomes of abortion and its effect on future pregnancies. Altered family processes related to abortion. Knowledge deficit related to abortion and its complications.

48. Planning: Provide information regarding treatment plan. Provide support and reassurance regarding nursing care. Promote maternal physical well-being. Provide opportunities for counselling and support. Provide teaching related to self care.

49. Implementation: Observe for vaginal bleeding and cramping. Save expelled tissue and clot for examination. Monitor vital signs every 5 minutes to 4 hours depending on maternal status. Maintain women on bed rest. Observe for signs of shock and institute treatment measures. Prepare for dilatation and curettage if appropriate. Provide support, but avoid offering false assurance.

50. Summarization: Definition of abortion. Incidence of abortion. Aetiology of abortion. Classification of abortion. MTP act. Role of nurse for the client with abortion

51. REFERENCES: Jacob annamma . A comprehensive textbook of midwifery. Edi 2 nd . Jaypee publishers. P.275-282. Fraser M. Diane, cooper A. Margaret. Myles texebook of midwives. Edi. 14 th . Churchill livingstone . P.600-18. Dutta’s DC. Textbook of obstetrics. Edi. 7 th . Hiralal konar . P.158-168. Daftary N. Shirish , chakravarti sudip . Manual of obstetrics. Edi ; 3 rd . Elsevier publishers. P. 364-69 Salhan sudha . Textbook of obstetrics. Edi; 1 st . Jaypee publishers. P. 705-0.