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1. LECTURE ON ‘ABORTION’ BY –RAVINDER KAUR BHULLAR NURSING TUTOR MSC NURSING (OBG)

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

3. DEFITION Abortion is 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. CLASSIFICTION ABORTION SPONTANEOUS INDUCED

5. CLASSIFICATION SPONTANEOUS ABORTION * THREATENED ABORTION * INEVITABLE ABORTION * COMPLETE ABORTION * INCOMPLETE ABORTION * MISSED ABORTION * SEPTIC ABORTION (LESS COMMON)

6. CLASSIFICATION INDUCED * LEGAL ABORTION (MTP) * ILLEGAL ABORTION (CRIMINAL) SEPTIC (COMMON)

7. CAUSES In most cases its unknown chromosomal abnormalities. Genetic Maternal cause such as retroversion of uterus, bicornuate uterus, fibroids . Infections like rubella and Chlamydia Medical conditions- diabetes, renal disease, thyroid dysfunction.

8. THREATENED ABORTION Vaginal bleeding with or without recognizable uterine contractions. The blood loss may be scanty with or without accompanying backache and cramp like pain. Pain resemble to dysmenorrhea . The cervix remains closed and soft uterus no tenderness on palpation. Outcome could be either stop bleeding and continue pregnancy to term or expel the products of conception.

9. MANAGEMENT General and systematic examination Investigations Admit and complete bed rest Treat as per cause found If pregnancy continues watch for IUGR Treat as high risk pregnancy because more chances of preterm labor

10. INEVITABLE ABORTION Bleeding often heavy, with clots or products of conception, blood loss may be heavy and the mother in shocked state. Cervix dilated on examination, products may seen in the vagina. Uterus feels smaller than expected. MANAGEMENT- * Control bleeding- ergometrine IV/IM * Analgesics

11. INCOMPLETE ABRTION In this parts of placenta remains within the uterine cavity, contributing to heavy and perfuse bleeding MANAGEMENT- Ergometrine IV/IM D&E under general anesthesia

12. COMPLETE ABORTION The conception products, placenta and membranes are expelled completely from the uterus. The pain stops. No further medical intervention is required

13. MISSED ABORTION The embryo dies despite the presence of a viable placenta and the sac is retained. Death of the embryo occurs before 8 weeks of gestation but the mothers body fails to recognized the demise. brown discharge is suspected Failure to weight gain Uterus is smaller than expected and soft MANGEMENT - D&E under general anesthesia

14. HABITUAL ABORTION Spontaneous abortion in three or more successive pregnancies may occur, usually abortion occurs at the same gestational age, mostly after 16 weeks. Cause may be genetic or immunological Management- complete bed rest at the time of occurrence Special treatment if cause is identified

15. INDUCED ABORTION MTP (medical termination of pregnancy) (legal abortion) Act 1971 ( revised in 1975) Legal abortion is the deliberate induction of abortion prior to 20 weeks of gestation by a register medical practitioner in the interest of mothers health and life

16. PROVISION FOR MTP UNDER THE MTP ACT. The continuation of pregnancy would involve serious risk of life or grave injury to the physical or mental health of the pregnant women. There is substantial risk of the child being born with serious physical and mental abnormalities so as to be handicapped in life The pregnancy is the result of rape The pregnancy is the result of failure of contraceptives Foreseeable environment (social or economical)

17. INDICATIONS FOR MTP THERAPEUTIC- Deteriorating health due to pulmonary TB Cardiac disease Chronic glomerulonephritis Malignant hypertension intractable hyperemesis gravidarum Cervical or breast malignancy Diabetes mellitus with retinopathy Psychiatric illness

18. SOCIAL Parous women having unplanned pregnancy with low socioeconomic status Pregnancy caused by rape Pregnancy due to failure of contraceptives

19. EUGENIC Risk of baby born with various physical and mental abnormalities like- Chromosomal and gene disorders Exposure to drugs or radiation Rubella infection in first trimester One or both parents are mentally ill Congenital malformation in siblings

20. CONDITIONS TO BE MET PRIOR TO THE PROCEDURE Register medical practitioner is required for MTP to save the mother The procedure can only be performed in hospital Written consent is necessary of pregnant women If minor is pregnant consent from parents is required for legal purpose Procedure has to be reported to the directorate of Health Services of state

21. METHODS OF MTP Suction evacuation and curettage Dilation and evacuation Pharmacological method Histerotomy

22. SUCTION EVACUATION AND CURETTAGE In this method the product of conception is sucked out from the uterus with the help of cannula attached with the suction apparatus. Cervix dilated with metal dilators and then cannula introduced into uterine cavity and with a small flushing curettage uterine cavity curetted and suction out the remaining portion of the conception. A dose of Methergine is administered IV to control bleeding

23. DILATION AND EVACUATION There are two methods of D&E that is two stage method (slow method) and one stage method (rapid method) (1) In slow method cervix is dilated by introducing laminaria tent into the cervical canal and women kept 12 hours in bed during which time tent swell up and dilate the cervix. (2) After 12 hours with dilators cervix further dilated and with ovum forceps conception products are removed, curette can also done, antibiotics and methergine are administered.

24. PHARMACOLOGICAL METHOD Mifepristne – used to termination of pregnancy up to 9 weeks, a single dose of 600 mg is given orally and abortion is likely to occurs in about 36 hours. If fails prostaglandin E1 methyl ester pessary (1mg) is introduced virginally to complete the abortion, abortion occurs within 4 hours

25. METHOTREXATE Termination with methotrexate has been used effectively up to 8 weeks of pregnancy. A single dose is give IM with misoprostol vaginally, abortion occurs within 3-4 hours.

26. HYSTEROTOMY It is used as a method of termination of midtrimester pregnancy where other methods of termination have failed or are contraindicated. The products of conception are expelled out of the uterus by cutting through the anterior wall of the uterus.

27. SEPTIC ABORTION This abortion is characterized by infection of he products of the conception and the uterus. This condition is most commonly complication of induced or incomplete abortion. Illegal abortion carried out in non sterile conditions are often leads to septic abortion. Causes- Criminal abortion- inexpert attempts Abortion with infection MTP with infection

28. CLINICAL MANIFESTATION Pyrexia Headache Nausea Foul smelling vaginal discharge Tenderness in lower abdomen Septicemia Peritonitis Shock TREATMENT IV antibiotics Hospitalization

29. NURSING PROCESS IN ABORTION ASSESSMENT * Vaginal bleeding , spotting and clot * Low abdominal cramps * Passing of tissue through vagina * Increased pulse rate * Women may verbalize fear, disappointment or feelings of guilt

30. NURSING DIAGNOSIS Risk for fetal injuries Risk for infection Ineffective airway clearance Actual risk for aspiration Anxiety Grieving Altered family processes Health seeking behaviour

31. PLANNING Provide information regarding treatment plan Provide support regarding nursing care Promote maternal physical well-being Provide opportunity for counseling and support Provide teaching regarding self care

32. IMPLEMENTATION Observe for vaginal bleeding and cramping Save excelled tissue and clots for examination Observe vital signs carefully Maintain women on bed rest Observe for signs for shock Prepare for D&C if appropriate Provide support but avoid offering false assurance

33. EVALUATION Ensure that the women - Is free from anemia and infection Is free from vaginal bleeding Return to normal physiological status following the abortion Understand self care measures

34. ANY QUESTION?

35. SUMMERY Today we have discussed topic abortion * Introduction * Definition * Classification (spontaneous and induced abortion * MTP (medical termination of pregnancy) * Nursing process

36. RECAPTULIZATION:- Define abortion What is the classification of abortion Explain missed abortion What are the indications of MTP

37. ASSIGNMENT Tomorrow will be your oral test of abortion

38. BIBLIOGRAPHY Jacob A, a comprehensive textbook of midwifery & gynecological nursing, 5 th edi , Jaypee publication, 2019 Dutta DC, A text book of Obstetrics ( Hiralal Koner ) 8 th edi . New Delhi. Jaypee publications 2016 Raynor Maureen, Marshall Jayne. Myles text book for Midwives, 7 th international edi . London. Elsever publications 2014

39. Thank You