abortionsPresented by:

Phiri Reagan - RN Student(BSc nursing)-

UNZA

OBJECTIVES:Define abortion.State causes of abortionDescribe the different types of abortion using

a tree diagramState the signs and symptoms of each type of

abortionDescribe the general management of a

patient with an abortion

IntroductionAbortion has become rampant all over the world. It is

a common issue among the teenagers and adult women in the society. Issues relating to abortion has been on and generated a heated argument and distressing statistics concerning abortion have been documented. The peak time for abortions is between 6-12th week of pregnancy when the level of progesterone secreted by the corpus luteum falls and the placental hormone has not reached its sufficiently high level to sustain the conceptus.

Definitions of abortion vary across and within countries as well as among different institutions.

What is abortion?-Abortion is the interruption of pregnancy

before the 28th week, after which the fetus is said to be viable( Zambian law)

- Abortion is the expulsion of the conceptus before 20-22 completed weeks of gestation, or a fetus weighing less than 500g.( WHO)

Types of Abortion

Spontaneous Abortion Induced Abortion

ABORTION

SPONTANEOUS

THREATENED

MISSED INEVITABLE

BLOODMOLE COMPLETE INCOMPLETE

CARNEOUSMOLE

INDUCED

THERAPEUTIC CRIMINAL

SEPTIC

May go to term

HABITUAL

causes -Disease or mal-development of the ovum and the

fetus. -Defective implantation of the trophoblast which

results in the inability to synthesize progesterone. -hydatidiform mole -metabolic disorders such as DM, anemia, thyroid

disease, renal disease and/or failure, hypertensive disorders.

-acute infections such as influenza, rubella, malaria. Toxoplasmosis.

-uterine abnormalities: myomas, bi-cornuate uterus, double uterus and vagina. Infantile uterus ,fibroids

Causes--cont. -cervical incompetence caused by

trauma due to previous D & C or cone biopsy.

-extreme emotional stress result in the release of pituitary hormones which affect uterine function.

-certain toxic drugs and substances e.g. anesthetic gases, antimetabolic drugs, oxytocics and herbs.

ABO and Rhesus incompatibility.

anatomic defects

Spontaneous abortion Spontaneous abortion / miscarriage: This is commonly

referred to as miscarriage. It occurs when pregnancy ends before the baby has any chance of survival. Most spontaneous abortion occurs in the first 12 weeks of pregnancy. Spontaneous abortion can be divided into

Threatened abortion Missed abortion Blood mole and carneous mole Inevitable abortion, which can be complete or

incomplete. Habitual or recurrent abortion

·.

An abortion characterized by slight bleeding through an un-dilated cervix.

Signs and symptoms

- vaginal bleeding (usually slight)

- slight abdominal cramps

- internal os is closed

- viable fetus on U/S examination

Threatened abortion

Management of a threatened abortion - Reassurance of patients - Rest for few days until the bleeding

has settled down - may require progesterone

supplementation - folic acid - anti D if RH negative

MISSED ABORTION

Missed abortion: an abortion that occurs when the fetus dies and is retained in utero, together with the placenta and membranes.Signs and symptoms - Disappearance of symptoms of pregnancy -Size of uterus < duration of gestation- U/S shows no signs of fetal life-breasts soften

Management of missed abortions

Diagnosis:

-blood sample for plasma fibrinogen to rule out DIC

Treatment

-uterine evacuation if less than 12 weeks pregnant

-give oxytocin or prostaglandin infusion if patient is more than 12 weeks pregnant.

Blood mole

This is a condition that occurs as a complication of a missed abortion. The ovum dies in utero, and the decidua capsularis remains intact. The zygote is surrounded by layers of blood, due to bleeding between the gestational sac and the uterine wall.

Signs and symptoms of blood mole

-usually occurs before 12 weeks of gestation.

-brownish vaginal discharge -signs of pregnancy disappear -uterus larger than dates. -cramping lower abdominal pains

Management of blood mole

-evacuation of the uterus if less than 12 weeks pregnant

-give oxytocics or prostaglandins to abort the mole if condition is diagnosed after 12 weeks pregnant

Carneous mole

This is a molar pregnancy that is formed when fluid drains from a blood mole. It’s a fleshy, firm, hard mass.

Management: the clinical features and management is the same as for blood mole

INEVITABLE ABORTION

An abortion is said to be inevitable if it can no longer continue. It may be complete or incomplete.

Complete abortion

An abortion that happens when all the products of conception (embryo, placenta with intact membranes) are expelled from the uterus

Signs and symptoms of complete abortion

- bleeding is minimal

- lower abdominal pain

- cervix closed

- empty uterus on U/S examination

-history of expulsion of products of conception

Management Reassurance of patients Rest for few days until the bleeding has settled down folic acid/feso4

analgesics IV fluids with or without blood transfusion.

Incomplete abortion An abortion in which part of the products of

conception (usually the foetus) is passed, while the placenta and membranes are retained.

Clinical features

-profuse bleeding

-Abdominal pains and backache

-Signs of shock such as weak and rapid pulse, - hypotension, cyanosis, unconsciousness,

-dilated cervix

-history of passing something. –

-retained products of conception on U/S scan

Management of incomplete abortion

- assessment of general condition - blood sample for blood group, RH factor,

and CBC - removal of POC if felt in cervical canal - ergometrine 0.5mg IV or IM to ↓ blood loss - IV fluids with or without blood transfusion. -antibiotics and analgesics -sedation to relieve anxiety

HABITUAL OR RECURRENT ABORTION

This occurs when a patient has experienced 3 or more consecutive spontaneous abortions, usually after 14 weeks gestation. There is usually no warning signs but the sudden rapture of membranes and expulsion of abortus occurs after a gradual painless dilation of the internal cervical os. The cause is usually mechanical e.g. uterine abnormality or cervical incompetence. May also be due to psychological, immunological, infective, or chromosomal causes. Manage the patient according to

Threatened Abortion Inevitable

Incomplete Missed

INDUCED ABORTION This is the deliberate termination of pregnancy

for various reasons such as threat to the life of the pregnant woman or for social reason. It can be therapeutic or criminal abortion.

THERAPEUTIC ABORTION An abortion performed by qualified trained

medical doctor, for a valid medical reason. The procedure must be performed only in the interest of the mother’s life and her total well-being. It is carried out in a hospital where haemorrhage can be effectively controlled and resuscitative facilities at hand, and where aseptic measures are always taken. The consent of the medical superintendent, patient and her husband or guardian if less than 18 is required by law.

Procedures used in therapeutic abortions

Vacuum Aspiration-uterus is vacuumed with a syringe through a dilated cervix to remove conceptus, placenta and endometrial tissue. Also called menstrual aspiration

Dilation and Evacuation (D & E) removal of fetus, conceptus and placenta by a suction curettage through a dilated cervix.

Prostaglandin or Saline Administration Dilation and Curettage (D & C)-cramping

fetus, conceptus and placenta using an instrument called a curette through a dilated cervix

Criminal abortion This is an abortion which is illegally procured. It

may be performed by an unqualified person under unhygienic conditions, utilizing a variety of methods. This abortion is punishable by law in Zambia. Risks involved include:

-sepsis -uterine perforation -cervical laceration -haemorrhage. -acute renal failure -shock and death. -infertility

Septic abortion This abortion can follow incomplete abortion, but is

more often associated with a criminal abortion.

Signs and symptoms -anaemia -pyrexia -tachycardia -headache - profuse offensive lochia -bulky and tender uterus on palpation -jaundice is often present. Management diagnosis Cervical swab U/S examination for retained parts

Treatment of septic abortion

Iv. Broad spectrum antibiotic IV fluids ± blood transfusion if needed Analgesia Evacuation of uterus Anti D

Management of any abortion Aim -determine the cause of bleeding -preserving the life of the mother -maintaining the foetal life if possible -Ensuring continued fertility where possible -preparing patient for and family for future stable relationships.

Immediate management -full history taking -complete bed rest is essential -assess for signs of shock -Monitor vital signs i.e. temperature, pulse, respiration, and blood

pressure. -save all lost blood for doctor’s inspection -obtain consent, where necessary. -Insert iv line if patient’s condition is unsatisfactory. -keep patient warm and prepare for OT if needed.

Subsequent care-vulvar toilet every 4hours for the first 24 hrs. after theatre

-attend to her personal hygiene until she is able to care for herself.

-high protein diet or as prescribed by the doctor.

MEDICAL MANAGEMENT

Diagnosis

-urinalysis

-Blood for compatibility, grouping and FBC, urea & electrolytes, RH factor,

-Ultrasound examination

- HCG test to confirm pregnancy

NB; if fetal heart seen on U/S examination, pregnancy will continue in 98%.

treatment-sedation to relieve anxiety

-analgesics to relieve pain

-broad spectrum antibiotics

-give anti D gamma globulin if rhesus is negative

-oxytocin or prostaglandin infusion to terminate the pregnancy or evacuate products of conception.

-insertion of shirodkar suture to save the pregnancy where possible

Nursing management

Nursing Diagnosis•Risk for fluid volume deficit d/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.

•Anticipatory grieving d/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.

Nursing Diagnosis

• Risk for infection d/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.

• 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.

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.

COMPLICATIONS

Uterine infectionSepticemiaHemorrhageDisseminated Intravascular Coagulation(DIC) in missed abortionInfertilityShockRenal failureHydatidiform moledeath

QuestionsDefine abortion? What causes abortions?Classify abortions using a tree diagram What is a spontaneous abortion? Define the different

types of spontaneous abortion?What is an induced abortion?Differentiate therapeutic from criminal abortion What is a septic abortion and how would you manage

it? Name 4 procedures done in induced abortion Describe the general management of abortionsState five complications of abortions

Thank you for listening