Abortion

-is the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability. A spontaneous abortion (also called a miscarriage) occurs on its own. An induced abortion is the intentional termination of a pregnancy and expulsion of a fetus, whether by surgery or the administration of pharmaceuticals.

Type of abortions

Spontaneous Miscarriage

Interruption of a pregnancy before a fetus is viable (more than 20 to 24 weeks of gestation or one that weighs at least 500 g) without outside intervention

Early miscarriage- if it occurs before 16week of pregnancy

Late miscarriage- occurs between weeks 16 and 24

Causes:

Abnormal fetal formation, due either to a teratogenic factor or to a chromosomal aberration

Immunologic factors Rejection of the embryo through an immune

responseImplantation of abnormalities (50% of zygotes are

probably never implanted Corpus luteum fails to produce enough

progesterone to maintain the decidua basalisInfection (rubella, syphilis, poliomyelitis,

cytomegalovirus, and toxoplasmosis and also UTI) Ingestion of teratogenic drugs (isotretinoin)Ingestion of alcohol

Assessment:

Vaginal spotting

Intervention:

Depends on the symptoms and the description of the bleeding

Threatened Miscarriage

 a condition that suggests a miscarriage might take place early--under 16 weeks; late--16 to 24 weeks

Causes:

Unknown; possibly chromosomal ,uterine abnormalities

Assessment:

Vaginal bleeding, initially beginning as scant bleeding, and usually bright red

Slight crampingNo cervical dilatation

Diagnostic exam:

Sonogram Beta HCG (quantitative) test over a period

of days or weeks to confirm whether the pregnancy is continuing

Complete blood count (CBC) to determine amount of blood loss

Pregnancy test to confirm pregnancyProgesterone levelWhite blood count (WBC)

with differentil to rule out infection

Treatment:(dilation and curettage or D&C)avoid or restrict some forms of activity for

24 to 48 hoursNot having sexual intercourse for 2 weeks

is usually recommended after bleeding episode to prevent infection and to avoid inducing further bleeding.

bedrest

Imminent (Inevitable) Miscarriage

A threatened miscarriage becomes an imminent miscarriage if uterine contractions and cervical dilation occur. With cervical dilation, the loss of the products of conception cannot be halted.

Assessment:Vaginal spottingCramping Cervical dilatation

Diagnostic exam:Sonogram

Treatment:Vacuum extraction (dilation and

evacuation)Suction Curettage

Complete Miscarriage

In a complete miscarriage, the entire products of conception (fetus, membranes, and placenta) are expelled spontaneously without any assistance

Assessment:Vaginal spottingCrampingCervical dilatationComplete expulsion of uterine contents

Diagnostic exam:Ultrasound

Treatment:If there is no fetal tissue left in the womb

(a complete miscarriage), no further medical treatment is required

Incomplete Miscarriage

Part of the conceptus (usually the fetus) is expelled, but membrane or placenta is retained in the uterus.

Assessment:

Vaginal spottingCrampingCervical dilatationIncomplete expulsion of uterine contents

Diagnostic exam:Ultrasound

Treatment:Dilation and curettageSuction curettage

Missed Miscarriage

(early pregnancy failure), the fetus dies in utero but is not expelled.

Assessment:Vaginal spottingSlight crampingNo apparently loss of pregnancy Embryo died 4 to 6 weeks before the

onset of miscarriage

Diagnostic exam:Sonogram

Treatment:Dilation and evacuationProstaglandin suppository or misoprostol

(Cytotec) to dilate the cervix, followed by oxytocin stimulation or administration of mifepristone

Recurrent Pregnancy Loss In the past, women who had three spontaneous miscarriages

that occurred at the same gestational age were called ‘habitual aborters.’ today the term recurrent pregnancy loss is used to described this miscarriage pattern, and a thorough investigation is done to discover the cause and the loss and help ensure the outcome of the future pregnancy.

Causes: Defective spermatozoa or ova Endocrine factors such as lowered levels of protein-bound

iodine (BPI), butanol-extractable iodine (BEI), and globulin-bound protein (GBI), poor thyroid function, or luteal phase defect

Deviations of the uterus, such as septate or bicornuate uterus Infection Autoimmune disorders such as those involving lupus

anticoagulant and antiphospholipid antibodies

Treatment:surgery to correct problems with the

shape of the uterus medication to correct immune problems

and hormone imbalances.

Complication of miscarriage1. hemorrhage- blood loss2. infection- who have lost appreciable amounts

of blood, most likely from the debilitating effect of blood loss.

3. septic abortion- complicated in infection.4. Isoimmunization- by spontaneous birth or

D&C at any point in pregnancy, some blood from the placental villi may enter maternal circulation. If the fetus was RH positive and the woman is Rh negative, enough Rh positive fetal blood may enter her circulation.

5. powerlessness or anxiety- Assess woman’s adjustment to spontaneous miscarriage.

Elective Termination of Pregnancy (Induced Abortion)

A procedure performed to deliberately end a pregnancy before fetal viability.

Induced abortions are done for a number of reasons:

To end a pregnancy that threatens a woman’s life (e.g., pregnancy in a woman with class IV heart disease)

To end a pregnancy that involves a fetus found on amniocentesis to have a chromosomal defect

To end a pregnancy that is unwanted because it is the result of rape or incest

To terminate the pregnancy of a women who chooses not to have a child at this time in her life for such reasons as being too young, not wanting to be a single parent, wanting no more children, or having financial difficulties

Medically Induced Abortion

Mifepristone (a progesterone antagonist) is a compound that blocks the effect of progesterone, preventing implantation of the fertilized ovum and therefore causing abortion. The compound is taken as a single oral dose of 600mg anytime within 49 days of gestational age. Three days later, Misoprostol 400 mcg is administered in a single oral or vaginal dose.

Methotrexate- an antimetabolite that causes trophoblastic cell death is also be used although it is not approved for used in medical abortions

*Mifepristone has additional approved applications, such as regression of uterine leiomyomas, induction of labor, and detoxification in cocaine overdose

* Misoprostol can cause nausea, vomiting, diarrhea, and severe abdominal cramping

Medical abortion is contraindicated under the following circumstances:

Confirmed or suspected ectopic pregnancy

An intrauterine device is in placeA woman has a serious medical condition

such as chronic adrenal failureCurrent long-term systemic corticosteroid

therapy History of allergy to mifepristone,

misoprostol, or other prostaglandinsHemorrhagic disorders or concurrent

anticoagulant therapy

Advantages:

Decrease risk of damage to the uterus through instrument insertion

Decrease use of anesthesia necessary for surgically performed abortions

Complications:Incomplete abortionPossibility of prolonged bleeding

The woman should return for post-procedure ultrasonography or a pregnancy test to ensure that the pregnancy has ended.

It is important that women receive contraceptive counseling after the procedure so they can avoid having to undergo such a procedure again in the future

Surgically Induced Abortion

Elective surgical abortions involve a number of techniques, depending on the gestational age at the time the abortion is performed.

Menstrual Extraction or Suction Evacuation (5-7 weeks after the LMP)It is performed on an ambulatory basisProcedure:The woman voids, and her perineum is washed

with an antisepticA speculum is then introduced vaginally, the

cervix is stabilized by a tenaculum, and a narrow polyethylene catheter is introduced through the vagina into the cervix and uterus

The lining of the uterus that would be shed with a normal menstrual flow is then suctioned and removed by means of the vacuum pressure of a syringe

Post-op Intervention:The woman should remain supine for about 15

minutes after the procedure until uterine cramping quiets, to prevent hypotension in standing

She may be given oral oxytocin to ensure full uterine contraction after the procedure

Inform to expect some vaginal bleeding, similar to a normal menstrual flow, for a week after the procedure; they may have occasional spotting for up to 2 weeks

Advised, not to douche, use tampons, or resume coitus until 1 week after the procedure, to avoid introducing infection

Return visit after 2 weeks that include pelvic examination and pregnancy test

It is important that women receive contraceptive counseling after the procedure so they can avoid having to undergo such a procedure again in the future

Dilatation and Curettage(gestational age of the pregnancy is less than 13

weeks)

This procedure is usually done in an ambulatory setting using a paracervical anesthetic block

*A paracervical block does not eliminate pain but limits what the woman experiences to cramping and a feeling of pressure at her cervix.

Procedure:The woman voids, the perineum is washed, the

anesthetic block is administered, and the cervix is dilated

The uterus is then scraped clean with the curette, removing the zygote and trophoblast cells with the uterine lining.

Post-op Intervention:The woman remains in the hospital or

clinic for 1-4 hours with careful assessment of v/s and perineal care

She may be given oxytocin to ensure firm uterine contruction and minimize bleeding

Offer contraceptive counseling to avoid repeat procedure

Complications:Uterine perforation from the instruments

used and carries increased risk of uterine infection because of greater cervical dilatation

*woman may be given prophylactic antibiotics to prevent infection

Dilatation and Vacuum Extraction(between 12 and 16 weeks)Inpatient or an ambulatory procedureProcedure:Dilatation of the cervix is begun the day before

the procedure by administration of oral misoprostol or insertion of a laminaria tent (seaweed that has been dried and sterilized) into the cervix under sterile conditions

Over a 24-hour period, gradually, painlessly, and without trauma, it dilates the cervix enough for a vacuum extraction tip to be inserted

After either misoprostol or laminaria dilatation or dilatation by traditional dilators, a narrow suction tip is specially designed for the incompletely dilated cervix is introduced into the cervix

The negative pressure of a suction pump or vacuum container then gently evacuates the uterine contents over a 15 minute period

Post-op Intervention:The woman lies flat for at least 15 mins.The woman remains in the hospital or clinic for

1-4 hours with careful assessment of v/s and perineal care

She usually receives oxytocin to ensure firm uterine contruction and minimize bleeding

Offer contraceptive counselingInform to expect bleeding comparable to a

menstrual flow for the first week afterward, and spotting for up to 2 or 3 weeks afterward

Cramping may continue for up to 24 to 48 hours*she can take a mild analgesic such as

acetaminophen or ibuprofen for discomfort

Advised not to douche, use tampons, or resume coitus until after she returns in 2 weeks for a follow-up examination

Complications:Potential for uterine perforation because a

rigid cannula is used for the procedureinfection

Prostaglandin Saline Induction(between 16 and 24 weeks)Inpatient or ambulatory procedureProcedure:The woman is admitted to a same-day surgery

unit and has oral misoprostol or vaginal laminaria inserted to help prepare the cervix for dilatation

The prostaglandin is then administered *F2-alpha by injection; E2 by suppositoryLabor, which follows the administration of

prostaglandin by several hours, may be shortened by administration of a dilute intravenous solution of oxytocin

Nursing Intervention:If large amounts of oxytocin is necessary to

induce labor –observe closely for signs of water intoxication, or body fluid accumulating in body tissue

*signs of water intoxication are severe headache, confusion, drowsiness, edema, and decreased urinary output

If such symptoms occur, the oxytocin drip should be stopped immediately

*always infuse oxytocin using a piggyback method during an abortion procedure, the same as with the woman in term labor

Post-op Intervention:Examine the products of conception

whether the entire conceptus (fetus, placenta and membranes) has been delivered

Carefully observed for vaginal hemorrhage

Complications:May develop disseminated intravascular

coagulation from trauma because her blood clotting is compromised

Saline Induction(between 16 and 24 weeks)Hypertonic (20%) saline causes fluid shifts and

sloughing of the placenta and endometriumProcedure:Woman voids to reduce the size of her bladder so

it will not be accidentally punctured by the saline injection

A sterile spinal needle is then inserted into the uterus through the anesthetized abdominal wall, into the amniotic fluid

The needle is then withdrawn Within 12 to 36 hours after the injection, labor

contractions begin

Complications:Hypernatremia –from accidental injection of the

hypertonic saline solution into a blood vessel within the uterine cavity

Severe dehydration– due to the presence of concentrated salt solution in the bloodstream causing body fluid to shift into the blood vessels in an attempt to equalize osmotic pressure

Post-op Intervention:Inform to expect vaginal spotting for as long as 2

weeksA first menstrual flow usually occurs 2 to 8 weeks

after the procedureFollow-up examination after 2 to 4 weeks Sexual relations and douching are generally

contraindicated until the time of postabortion checkup

Hysterotomy: (more than 16 to 18 weeks)This procedure is the same as a cesarean section (in whichthe doctor cuts through the abdomen and uterus to deliverthe baby), except that in a hysterotomy, no medical attentionis given to the baby upon delivery to help it survive. Mostoften, a wet towel is placed over the baby’s face so it can’tbreathe. Sometimes the baby placed in a bucket of water.The goal is to have a baby that won’t survive.

Partial Birth Abortion(used during last 3 months of pregnancy)

Surgical technique used if the fetus had been discovered to have a congenital anomaly that would be incompatible with life or would result in a severely compromised child (e.g., encephalocele, high meningocele)

Procedure:Labor was induced by a combination of oxytocin

and cervical ripeningThe fetus was turned so that the breech

presented to the birth canal A clamp was then inserted into the base of a fetal

skull, the head contents were destroyed, and the head was collapsed and then delivered

When to resume intercourse after abortion?

For 2-4 weeks - no sex, no tampons, no douches. After the 2-4 weeks is over, you should NOT have sexagain unless you feel physically recovered, and havediscussed with your partner what you want to do if anunplanned pregnancy occurs again. Do NOT let yourselfbe pressured into having sex again before you arephysically and emotionally ready, and have had aserious discussion about the course of action for futureunplanned pregnancies. You can get pregnant as soonas two weeks after an abortion! Your body normally willgo back to it's regular cycle, and release an egg(ovulation) at 2 weeks post-ab. So once you decide youare ready to resume sexual intercourse again, makesure you are using birth control right away.