PROGRAM : BSN 1st YEAR

PLACE : MY CAMPUS

TOPIC : ABORTION

GROUP : BSN 1st YEAR STUDENTS

TEACHING METHODS : LECTURE

NAME OF THE STUDENT : LAIBY JOHN

NAME OF THE FACULTY : DR. NASIRA SATHARKHAN

DATE AND TIME : DECEMBER 2007

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 ABORTION

DEFENITION
Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing 500gms or less
when it is not capable of independent survival. This 500gms of fetal development is attained
approximately 22 wks of gestation. The expelled embryo or fetus is called abortus.
Abortions are mainly classified in to two

A . Spontaneous abortions B . Induced abortions

PATHOPHYSIOLOGY AND ETIOLOGY

1 . Cause frequently unknown, but 50% are due to chromosomal anomalies.
2 .Exposure or contact with teratogenic agents.
3. Large doses of any drug consumption.
4. ABO incompatibility between mother and embryo may result in abortion.
5. Poor maternal nutritional status.
6. Maternal illness with virus such as rubella, cytomegalovirus, active herpes, and toxo plasmosis, or
specific bacterial microorganisms that put the pregnany at risk.
7. History of diabetis , thyroid disease, anticardiolipin antibodies, or lupus erythematosus.
8. Smoking or drug abuse or both.
9. Immunologic factor by which the mother and father are gene`tically similar major antigens,.that cause
the maternal immune system to reject the embryo.
10. Psychological factors such as stress and anxiety cause the alteration in the level of pituitary hormones
which affects uterine activity and lead to abortion .
11. Luteal phase defect.
12. Post mature sperm or ova.
13. Structural defect in the maternal reproductive system like incompetent cervix, retroverted uterus and
developmental defects such as bicornuate uterus and myomas can cause abortion.
14. Imperfect sperm or ova.

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CLINICAL MANIFESTATION

1. Uterine cramping , low back pain.

2. Vaginal bleeding usually begins as dark spotting ,then progress to frank bleeding as the embryo
separates from the uterus.
3. Beta –hCG levels may be elevated for as long as 2 weeks after the loss of embryo.

DIAGNOSTIC EVALUATION

1. Ultrasonic evaluation of the gestational sac or embryo.

2. Visualisation of the cervix, presence of dilation or tissue evaluated.

MECHANISM OF ABORTION

Inearly weeks , death of the ovum occurs first , followed by its expulsion. In later weeks , maternal
environmental factors are involved leading to expulsion of fetus which may have signs of life but is too
small to survive.
BEFORE 8 WEEKS-The ovum surrounded by the villi with the desidual covering , is expelled out intact.
Some times the external os fails to dilate so that the entire mass is accommodated in the dilated cervical
canal and is called cervical abortion.
8-14WEEKS- Expulsion of the fetus commonly occurs leaving behind the placenta and the membranes. A
part of it may be partially separated with brisk haemorrhage or remains totally attached to the uterine wall.

BEYOND 14th WEEK-The process of expulsion is similar to that of a “mini labour”. The fetus is
expelled first followed by expulsion of the placenta after a varying interval.

TYPES OF SPONTANEOUS ABORTION

1.THREATENED ABORTION

It is a clinically entity where the process of abortion has started but has not progressed to a state from
which recovery is impossible.

CLINICAL MANIFESTATION

Vaginal bleeding or spotting, mild cramps ,tenderness over uterus, simulates mild labour or persistent low
back ache with feeling of pelvic pressure. Cervix closed or slightly dilated, symptoms subside or develop
into an inevitable abortion.

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INVESTIGATIONS

Blood test- Hb, haematocrit, ABO RH, Serum HCG level, serum projesterone level.

MANAGEMENT

Bed rest till the bleeding stops.

Vaginal examination .
Pad count.
Observation of the vital signs.
Drugs for sedation and relief of pain to be given.

2.INEVITABLE ABORTION

It is the clinical type of abortion where the changes have progressed to a state from where the continuation
of pregnancy is impossible.

CLINICAL MANIFESTATION

Bleeding more profuse.

Dilated cervix.
Membranes rupture.
Painful uterine contractions.

MANAGEMENT

BEFORE 12 WEEKS-. Embryo delivered ,followed by dilatation and curettage.

AFTER 12 WEEK- The uterine contraction is accelerated by oxitocin drip.If the fetus is expelled and
placenta is retained , it is removed by ovum forceps,if lying separated. If placenta is not separated digital
separation followed by its evacuation is to be done under general anaesthesia.
Excessive bleeding should be promptly controlled by administering methergin 0.2mg if the cervix is
dilated and the uterine size is less than 12 weeks.The shock is corrected by IV fluid therapy and blood
transfusion.
If bleeding is profuse with the cervix closed evacuation of the uterus may have to be done by abdominal
hysterectomy.

HABITUAL ABORTION

It is defined as a sequence of three or more consecutive spontaneous abortion before 20 weeks.

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MANAGEMENT

D&C
Treatment of possible causes : Hormonal imbalance, tumors, thyroid dysfunction, abnormal uterus,
incompetent cervix.
With treatment 70-80% carry a pregnancy successfully.
Surgical suturing of the cervix if incompetent cervix is a causative factor.
Hysterogram to rule out uterine abnormalities or infections.

COMPLETE ABORTION

A complete abortion is likely to occur prior to 8th week of pregnancy and constitutes the expulsion of the
embryo , placenta and intact membranes.

CLINICAL MANIFESTATION

Subsidence of abdominal pain.Vaginal bleeding becomes trace or absent.

Internal examination reveals
a)Uterus is smaller than the period of amnorrhoea and a little firmer.
b)Cervical os is closed.
c)Bleeding is trace.
d)Examination of the expelled fleshy mass is found intact.

MANAGEMENT

The effect of blood loss , if any , should be assessed and treated.

If there is any doubt about complete expulsion of the product uterine curettage should be done.

INCOMPLETE ABORTION

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

CLINICAL MANIFESTATION

Fetus usually expelled, placenta and membranes retained.

MANAGEMENT

D&C

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MISSED ABORTION

When the fetus is dead and retained inside the uterus for a variable period it is called missed abortion.

CLINICAL MANIFESTATION
Fetus dies in utero and is retained.
Maceration.
No symptoms of abortion, but symptoms of pregnancy regress.

MANAGEMENT
Real time ultrasound, and if second trimester , fetal monitoring to determine if fetus is dead.If fetus is not
passed after diagnosis, oxitocin induction may be used. Retained dead fetus may lead to development of
disseminated intra vascular coagulation or infection.
Fibrinogen concentration should be measured weekly.

SEPTIC ABORTION
Any abortion associated with clinical evidences of infection of the uterus and its contents , is called septic
abortion.

CLINICAL MANIFESTATION
Rise of temperature of at least 38C for 24 hrs or more.
Offensive or purulent vaginal discharge .
Other evidences of pelvic infection such as lower abdominal pain and tenderness.

CLINICAL GRADING
Grade 1: The infection is localized in the uterus.
Grade2 : The infection spreads beyond the uterus to the parametrium , tubes and ovaries or pelvic
peritoneum.
Grade 3 Generalised peritonitis and / endotoxic shock or jaundice or acute renal failure.

MANAGEMENT
Hospitalisation and isolation, to take high vaginal or cervical swab for culture , drug sensitivity test and
gram stain , vaginal examination , over all assessment , investigation protocols to be done.
Control sepsis, remove the source of infection.
To give supportive therapy to bring back the normal homeostatic and cellular metabolism.
To asses the response of treatment.

THERAPEUTIC OR VOLANTARY ABORTION

Therapeutic abortion is the termination of pregnancy before fetal viability for the purpose of safeguarding
the womans health .
Voluntary abortion is the termination of a pregnancy before fetal viability as a choice of the woman.

MANAGEMENT
First trimester can be managed by D&C.
Second trimester by prostaglandin induction.
Late second trimester by using intra amniotic saline induction, hysterotomy, or hysterectomy.

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COMPLICATIONS OF ABORTION

Haemorrhage, uterine infection, septicemia, disseminated intravascular coagulation in a missed abortion.

NURSING ASSESMENT

Evaluate the amount and color of blood, the time of bleeding started and the precipitating factor.
Determine if a positive PT obtained before and the date of LMP.
Monitor vital signs for the indication of complications such as hemorrhage, infection.
Evaluate any blood or clot tissue for retained products.

NURSING DIAGNOSIS

1. Risk for fluid volume deficit related to maternal bleeding.

2. Anticipatory grieving related to loss of pregnancy , cause of the abortion, future child bearing.
3. Risk for infection related to dilated cervix and open uterine vessels.
4. Pain related to uterine cramping and possible procedures.

NURSING INTERVENTIONS

A. Maintaining fluid volume

1. Report any tachycardia , hypotension, diaphoresis or pallor indicating hemorrhage and shock.
2. Draw blood for type and screen for possible blood transfusion.
3. Maintain IVline for fluid replacement and possible BT.
4. Inspect all tissue passed for completeness.
B. Providing support through the grieving process.
1. Assess the reaction of the patient and support person.
2. Encourage the patient and father to discuss their feelings about the loss of the baby .
3. Provide the time alone for the couple to discuss their feelings.
4. Discuss the prognosis of the future pregnancies.
5. If the fetus is aborted intact , provide an opportunity for viewing if parents desire.

C. Preventing infection
1. Evaluate temperature every 4 hrs if normal, and every 2hrs if elevated.
2. Check vaginal drainage for increased amount and odor, which may indicate infection.
3. Encourage perineal care following each urination and defecation to prevent contamination.

D. Promoting comfort
1. Instruct patient on cause pain to decrease anxiety.
2. Instruct and encourage the use of relaxation techniques to augment analgesics.
3. Administer pain medications as needed and as prescribed.

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NURSING CARE PLAN

ASSESMENT NURSING GOAL PLANNING IMPLIMENTATION EVALUATION

DIAGNOSIS
1.Infection Risk for To avoid 1. Check 1. Checked temp. No signs of
infection infection. temp. every every 4 hrly. infection.
related to 4 hrly if Temp. 37.2°C
dilated cervix normal and
and open 2hrly if
uterine elevated.
vessels.
2.Check 2.Checked vaginal
vaginal drainage.
drainage for Normal discharge, no
increased signs of infection.
amount and
odor , which
may indicate
infection.

3.Encourage 3. Perineal care

perineal given.
care.
2.Pain Altred To relieve 1.Explain 1.Explained the Releaved pain,
comfort pain. the cause cause of pain to and slept well.
related to of pain to reduce anxiety.
uterine reduce
cramping and anxiety.
possible
procedures. 2.Instruct 2.Instructed and
and encouraged
encourage relaxation technique.
relaxation
technique.

3.Give 3.Analgesics given

analgesics as needed and as
as needed ordered.
and as
ordered.

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3.Hypovolemea Risk for fluid To avoid 1.Report any 1.Observed closely Protected the
volume hypovole signs of to find out any signs patient from the
deficit related mea. shock. of shock. possibility for
to maternal hypovolemea.
bleeding. 2.Do blood 2.Blood grouping
grouping and cross matching
and cross done.
matching
for
possible
BT.

3.Maintain 3. Maintained I/V

I/V line line with large bore
with large catheter for BT and
bore large quantity fluid
catheter replacement.
for BT and
large
quantity
fluid
replaceme
nt.

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PATIENT EDUCATION

1. Discuss the methods of contraception to be used, and explain the need to wait at least 3-6 months
for another pregnancy.
2. Teach the woman to observe for the signs of infection, and to get medical care immediately.
3. Provide information regarding the genetic testing of the product of conception if indicated, send
specimen according to policy.

EVALUATION
A. Vital signs remain normal, minimal blood loss.
B. Expresses feelings regarding the loss of pregnancy.
C. No signs of infection , temp. normal, performs perineal care.
D. Verbalizes relief of pain.

BIBLIOGRAPHY

1. Suzanne C. Smelter,etal,Brunner& Suddarth’s text book of medical surgical

nursing,LippincottWilliams& Wilkins, 11th edition , Philadelphia,2008.pg no-1647-1650.
2. D. C. Dutta,Text book of obstretics,New central book agency, 6th edition, Culcutta, 2004,pg no.-159-
178.
3. Sandra M. Nettina,The lippincott manual of nursing practice, Lippincott,6th edition,Philadelphia,1996,
pg no.1026-1028.
4. V. Ruth Bennett& Linda k. brown,Myles Text Book for midwives, ELBS,12th edition,Edinburgh UK,
1993, pg no.-272-279.

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