ABORTION•

SINDHU SEBASTIAN

LECTURER

FMCON

DEFINITIONAbortion 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

Early Abortion: Before 12 weeks

Late Abortion: From 12-20 weeks

Viability

• Survival by Gestational age

– Weeks % survival 22 0 23 25 24 55 25 65 26 75 27 90 28 92

INCIDENCE:

• 10-20% of all clinical pregnancy

• 10% Illegal

• 75% occur before 16wks

CLASSIFICATION ABORTION

Spontaneous Induced

Isolated Recurrent

Threatened Inevitable Complete Incomplete Missed Septic

Legal Illegal (criminal )

Septic

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

Contd…

b) Interference with circulation-

Knots

Twists

Entanglements

c) Low attachment of placenta

d) Twins or Hydramnios.

2. Unknown factors

Contd…3. Maternal factors(15%):Maternal medical illness

-Cyanotic heart diseases InfectionsMaternal hypoxiaChronic illness Endocrine and metabolic factors

Contd…

Anatomical abnormalities

Cervico-uterine factors- -Cervical incompetence

-Congenital malformation of uterus

-Uterine fibroid

-Intrauterine adhesions

-Retroverted uterus

Trauma- Direct -Psychic Susceptible individual

-AmniocentesisToxic agents4.Blood group incompatibility

5. Premature Rupture of Membranes

6.Environmental factors – Smoking, alcoholism, X-ray, Radiation, Chemotherapy.

7.Dietic factors8.Paternal factors:Chromosomal anomaly in

sperm

9.Infections – Viral, Bacterial or Parasitic

10. Inherited Thrombophilia

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).

• 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).

Common cause • First trimester

• Genetic factors -50%

• Endocrine disorders

• Immunological

• Infections

• Unexplained (40-60%)

• 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

Mechanism of AbortionBefore 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 14th week: Expulsion is similar to that of “mini labour”. The fetus is expelled first followed by expulsion of placenta.

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

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

• 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

7.Infections -rubella syphilis,cytomegalo,toxoplasmosis

Which readily cross the placenta

Changes

Infection

Fetus fails to grow

Estrogen and progesterone production by placenta fails

Endometrial sloughing

Prostaglandins are released

Uterine contraction expulsion of products of pregnancy

Cervical dilatation

Expulsion of products of pregnancy

Abnormal FetalFormation

Immunologic Factors

InfectionTeratogenic

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

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.

Clinical features

Bleeding per vagina:Slight and bright red in colour.

Pain: Mild backache or dull pain in lower abdomen.

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.

Investigationa)Blood investigation

b)USG

c) Urine for immunological test for pregnancy

Treatment

Rest : 2weeks of bed rest.

Drugs : sedation and analgesicsPhenobarbitone 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.

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.

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.

Clinical features

-Increased vaginal bleeding

-Severe lower abdominal pain- colicky type

-General condition is proportionate to visible blood loss.

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.

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)

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.

3. COMPLETE ABORTION

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

Clinical features

-There is history of expulsion of a fleshy mass per vagina followed by:

-Subsidence of pain

-Vaginal bleeding becomes trace or absent

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.

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.

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.

Clinical features.

-History of expulsion of fleshy mass per vaginam followed by:

-Continuation of pain lower abdomen

-Persistence of vaginal bleeding

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.

Termination

If the products left behind it leads to Profuse bleedingSepsisPlacental polypChoriocarcinoma

ManagementThe 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.

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.

PathologyBeyond 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”.

Clinical featuresPersistence 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

ManagementIf 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.

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)

6. Septic abortion

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

Criteria

• Rise of temperature 100.4*for 24 hrs

• Offensive or purulent vaginal discharge

• Lower abdominal pain and tenderness

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.

Reasons for infection

• Proper antiseptic and asepsis are not taken

• Incomplete evacuation

Clinical featuresPyrexia associated with chills and rigors.

Purulent vaginal discharge

Shock

Pain abdomen of varying degrees

Internal examination reveals:-Offensive purulent vaginal discharge- Tender uterus

Clinical gradingGrade 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).

InvestigationsRoutine 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

ComplicationsImmediate : HaemorrhageInjury to uterus and adjacent

structuresSpread of infection causes Peritonitis Acute renal failureThrombophlebitis

Remote :

Chronic pelvic pain, BackacheDyspareuniaEctopic pregnancySecondary infertility due to tubal

blockageEmotional depression.

Prevention

i. Use family planning method

ii. Encourage to go for legal abortion

Management • Hospitalization • High vaginal or cervical swab• Vaginal examination to note the

state of abortion process

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

Specific management

Drugs : 1.Antibiotics

Gram positive aerobesa)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

For Anaerobes(a) Metronidazole 500mg IV every 8hours

(b) Clindamycin 600mg IV every 6hoursGrade I1.Antibiotics

2. Prophylactic anti gas-gangreneSerum of 8000 U and 3000 U of anti tetanus serum IM are given.

3. Analgesics and Sedatives

-Blood transfusion

-Evacuation of the uterus within 24hours following antibiotic therapy

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)

Grade III

Antibiotics

Clinical monitoring

Supportive therapy with IV fluids.

Active surgery-Laparotomy

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

Recurrent / Spontaneous miscarriage

EtiologyDuring 1st trimester-Genetic factors-Endocrine and metabolic-Infection-Inherited Thrombophiliaintra vascular

coagulation .(protein C-natural inhi-of coag)

-Immunological cause : Auto & Allo immunity

-Unexplained

During 2nd trimesterCervical incompetence

Defective mullerian fusion-double uterus,bicornuate uterus,septate uterus.Cervical incompetence

Uterine fibroid

Retroverted uterus

Chronic maternal illness

Infection, Unexplained

Investigations

i. History on previous abortion.ii. Any chronic illnessiii. Histology of placenta

Diagnostic testsa. Blood glucose , VDRL , Thyroid

function test, ABO and Rh groupingb. Autoimmune screeningc. USG d. Hysterosalpingographye. Hysteroscopy / Laparoscopyf. Endocervical swab

TreatmentDuring 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.

During pregnancy Reassurance and tender loving care.

Ultrasound

Adequate rest

Avoid strenuous activity Intercourse Travelling.

• 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)

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.

• 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

• ;

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.

•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.

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.

• 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.

Thank you

Induced abortion

Definition

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

Elective: if performed for a woman’s desires

Therapeutic: if performed for reasons of maintaining health of the mother

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

• 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

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

• Social indications -unplanned pregnancy with low

socioeconomic status

-pregnancy caused by rape or failure of contraceptive methods

• Eugenic

-Structural-anencephaly ,chromosomal (down syndrome) or genetic (hemophilia)

-Teratogenic drugs(warfarrin)radiation exposure more than 10 rads in early pregnancy

- rubella infection

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

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

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

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

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

Roe vs. Wade 1/22/73

• “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.”

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

First Trimester Abortion

• Early Uterine Evacuation (EUE), Minisuction

• Menstrual Regulation• Suction Abortion • Vacuum Curettage• Medical Abortion

Minisuction

• Introduced in 1972 by Karman and Potts

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

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

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

Mifepristone protocol• Women less than 49 days LMP with

confirmed β-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

Medical Surgical

PrivateMore sense of autonomy “More natural”Earlier intervention unwanted pregnancy

Longer process with unclear endpointMore painMore bleedingAnxiety regarding abortion off site

Medical Surgical

Less skill needed to provideMethotrexate also treats ectopic pregnancy

Increased anxiety re: off site managementMore unscheduled care: calls, ER visitsNeed to guard against unnecessary interventionLimited to 49 days LMP

Second Trimester Termination

• Dilatation and evacuation (D&E)• Intrauterine injection of

abortifacients • Prostaglandin vaginal suppositories• High dose oxytocin• Hysterotomy

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

• Picture of laminaria

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

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 hoursGI side effects: 39% vomiting, 25% diarrheaFever: temperature elevation of 1 degree c

Mean time to abortion 15-17 hours, with 80% aborting by 24 hoursGI side effects: 83% vomiting, 71% diarrhea

Misoprostil (PGE1

High Dose Oxytocin

• As effective as PGE2 when used in appropriate doses

• Risk of water intoxication

Hysterotomy

• Surgical method to remove pregnancy abdominally (mini-cesarean section)

• Other methods are preferred

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

Complications - Immediate

• Complications of local anesthetic

• Cervical shock

• Cervical lacerations

• Uterine perforation

• Hemorrhage

• Post abortal syndrome

Complications - Delayed

• Bleeding–Retained products

• Infection

• Continued pregnancy–Ectopic–Intrauterine

•Thank you