ABORTION

I. Brief Description

Abortion refers to the end of pregnancy before the fetus is viable.

Spontaneous abortion or miscarriage is used to describe early pregnancy loss that is

not intentional to avoid confusion with termination of pregnancy that is induced. A

viable fetus is one that is more than 20-24 weeks gestation or weighs 500 g. When a

fetus is born before this, it is considered miscarriage. Early miscarriage occurs before

16 weeks, and late miscarriage occurs between 16-20 weeks of pregnancy.

II. Prevalence and Statistics

20-30% of women who are pregnant experience vaginal bleeding and half of

these spontaneously abort. Thus, the incidence of abortion in confirmed pregnancies

could be about 20%. Around 80% percent of miscarriages occur in the first trimester,

which is between 0 and 13 weeks. In a study done in 2010, 50,000 cases of

miscarriage are recored in United Kingdom. In the Philippines, the most recent study

revealed that 25 in 1,000 women experience abortion in the year 1994, no recent study

has been done since.

III. Anatomy and Physiology

Figure 1.1
 At birth the reproductive system of a female is not fully developed, it reaches

maturity at the introduction of puberty in a woman’s life. The reproductive system of

a female includes the internal organs consisting of the ovaries; fallopian tubes; the

uterus; the vagina; and external organs consisting of the vulva and perineum.

As seen in Figure 1.1, the ovaries are the glands that resemble an almond in

the size and shape.The ovaries produced secondary oocytes called gamates that

eventually develop into a mature egg or ova are released in the uterine tubes of the

female. They have the same embryonic origin to a males testes.

A Female has two uterine tubes or fallopian tubes which are about 4 inches

long (10 cm). These tubes lie within the ligaments of the uterus and provide a route

for sperm to reach the ovum resulting in the fertilization of the ova and transport to

the ovary to the uterus. Fimbre of the infundibulum “catches” the ovary and helps the

ovary to attach to the superior lateral angle of the uterus.

The uterus is apart of the pathway for the sperm deposit within the vagina

towards the uterine or fallopian tubes. This is also the place for implantation of the

fertilized ovum and the development of the fetus from pregnancy until labor. When

implantation does not occur, mensural flow occurs in the shedding of the lining of the

uterus, otherwise known as menstruation. The uterus is located between the bladder

and the rectum in the shape of an inverted pear. Females who have never been

pregnant have a uterus that is about 3 in or 7.5 cm long, 2 in or 5 cm wide and 2.5 cm

thick.

The vagina is a tubular 4 in or 10 cm long fibromuscular canal lined with a

mucous membrane that extends from the outside of the body to the uterine cervix.

This is also where contact with the penis occurs during sexual intercourse. The vagina
is located between the urinary bladder and the rectum. The production of mucosa of

the vagina is continuous.

The vulva refers to the external genitals of a female. The vulva also contains

the opening of the female urethra, and thus serves the vital function of passing urine.

The Perineum is the diamond shaped area located medially to the thighh and buttocks

of the female. The perineum also plays an important role in functions as such

micturition, defecation, sexual intercourse and childbirth. This area covers all of the

external genitals.

IV. Pathophysiology

There are several risk factors that may contribute to spontaneous abortion, one

of which is age. Statistics shows that in women under 35 years old, the risk is 10%,

while in women who are 40 years old and above the risk is about 45%. As Kala ko

may problem lang. As age increases, the reproductive ability of women may decrease.

Previous miscarriages are also noted. Women who have had 2-3 miscarriages are

more prone to having spontaneous abortion in their next pregnancy. Previous or pre-

existing condition such as diabetes may also impose risks due to its complications.

Illicit drug, alcohol, and cigarette use are also risk factors due to the teratogenicity of

their chemical contents or their ability to affect the growing fetus inside the uterus.

Local issues such as uterine or cervical problems that occur when the uterus or cervix

is weak, are also listed as risk factors.

During the first trimester, the most common etiology of miscarriage is

abnormal fetal development caused by a teratogenic factor (a chemical that is harmful

for the fetus) or genetic probem. Certain teratogenic chemicals and drugs such as

nicotine and chemotherapeutic agents may inhibit cell growth and cell division which

may eventually cause damages to the embryo and the placenta. Implantation
abnormalities also cause miscariage. The zygote may not implant securely due to lack

of endometrial formation or wrong implantation site. When improper implantation

occurs, placental circulation may not develop properly and would not be enough to

support the pregnancy. Miscarriage may also be a result of the lack of progesterone to

support the pregnancy. When the corpus luteum in the ovaries fail to produce enough

progesterone, the decidua basalis or the place where implantation takes place and

where the basal plate is formed will not be maintained causing the placenta as well as

the zygote not to develop. Lastly, systemic infections like rubella, polyomyelitis,

syphilis, cytomegalovirus, and toxoplasmosis may also cause miscarriage. These

infections can cross the placenta and may hinder embryonic growth. The estrogen and

progesterone production of the placenta may also fall which could lead to sloughing

of the endometrium and along with are the release of prostaglandin, contraction of the

uterus, dilatation of the cervix, and eventually, the expulsion of the products of

pregnancy.

Cervical dilatation, contraction of the uterus, and expulsion of products of

pregnancy are involved in the 4 stages of miscarriage namely;

 Threatened miscarriage: due to the sloughing of the uterus, threatened

miscarriage begins with vaginal bleeding that is scant and red in color. Mild

uterine contraction may cause slight cramping but there is no cervival

dilatation. Almost 50% of pregnant women who experience threatened

abortion proceed with pregnancy. However, some lead to imminent or

inevitable abortion.

 Imminent miscarriage: this occurs if both uterine contraction and cervival

dilatation already occurs. Along with this, the expulsion of the products of

pregnancy cannot be stopped. Vaginal bleeding with tissue fragments may be

 observed and cramping can be evidently felt due to prominent uterine

contraction

 Incomplete miscarriage: occurs when only the fetus is expelled and the

membranes or the placenta is still inside. Since fragments are retained inside,

th uterus would have a hard time to contract which could eventually lead to

hemorrhage and infection. Excessive bleeding may eventually cause too much

loss of fluid leading to fluid imbalance in the body.

 Complete miscarriage: occurs when all products of conception are expelled.

No therapy is done but the pregnant woman must still be aware that bleeding

still occurs.

As mentioned, when post-abortion hemorrhage or heavy bleeding occurs,

especially in incomplete abortion, fluid loss may be the major result. Loss of too

much blood leads to low blood pressure and having cold and clammy skin, blue lips

and fingernails. Lack of blood supply in the brain may cause dizziness and even

confusion. Also, sudden decrease of body fluid may result to less or no urine output.

Infection may also occur which could cause a foul smelling vaginal discharge,

inflammation, and fever, as a response to the infectious process.

V. Assessment

A. Clinical Manifestations

 Heavy spotting

 Vaginal bleeding

 Discharge of tissue or fluid from vagina

 Severe abdmoninal cramping

B. Diagnostic Findings
 Human Chorionic Gonadotropin (hCg) blood test is done to measure the level of

hCG in the blood. Blood will be taken at the start of bleeding and again after 48

hours. If the hCG level doubles after the second test, the placenta is still intact. The

same or lower hCG level after 48 hours could indicate poor placental function and

may result to miscarriage.

Histopathologic Examination of Uterine Tissue is done by asking the client to save

tissue fragments discharged from the vagina an bring it to the lab for examination.

Abnormalities can be detected and tissue test could confirm if miscarriage has

occured.

Fetal Heart Sound Assessment is a tool to evaluate the viability of the fetus. A

fetal heart rate that is lower than 160-180 at 6-9 weeks and 110-160 in the following

weaks could indicate that the pregnancy is not sustainable and miscarriage is possible.

Utlrasound can also be done to evaluate the viability of the fetus. Diagnostic

results include visible abnormalities or lack of gestational sac, lack of fetal hearbeat,

and absence of fetal heartbeat the embryo that is 5mm in size.

Pelvic Examination is done to assess if th cervix is dilating. A cervix that is dilated

can be a strong indication of miscarriage. However, if vaginal spotting is present but

the cervix is not dilated, it could be diagnosed as threatened abortion.

VI. Management

A. Pharmacologic Therapy

Progestogens are medications that mimic the action of the progesterone hormone.

These medicines could aid in reducing the rate of miscarriage in women who have

threatened miscarriage by suppresing uterine contractions until term. Examples are

medroxyprogesterone and norethisterone.

 Isoxuprine HCl is indicated for women experiencing threatened abortion and

premature labor. This medication is also used to supress uterine activity and prevent

premature uterine contractions. However, heart rate must be regularly checked as it

could cause tachycardia and palpitations.

B. Surgical Management

Surgical Management of Miscarriage (SMM) is an operation done to remove the

remains of the pregnancy. This is done to those clients who have experienced

incomplete abortion. It is also called ERPC or Evacuation of Retained Products of

Conception.

Manual Vacuum Aspiration (MVA) uses a narrow tube to enter the womb and

empty is using gente suction of aspiration. This is recommended to patients who do

not want to have general anaesthetics since this procedure uses local anaesthetics

Slight cramping may be present after surgery and they can be treated using

painkillers. Also, vaginal bleeding may occur but it will gradually lessen within 2

weeks. Hours after the operation the client may be given water or tea and can start

eating as well. Taking a bath is allowed a day after the operation.

C. Prevention

To prevent miscarriage, lifestyle changes are the major factors. Atleast one to two

months before conception, the woman must start taking atleast 400 mg of folic acid

everyday. Regular exercise and a healthy, balanced meal is also recommended.

Cessation and avoidance of cigarette, alcohol, and other illicit drugs and chemicals

that may be teratogenic is strongly adviced. Also, regular visits to the gynecologist to

monitor condition is very important.

VII. Nursing Process

A. Assessment

 Assess for vaginal spotting, vaginal bleeding, amniotic fluid, passage of

pregnancy tissue, and abdominal cramping or pain.

 Conduct initial assessment and be aware of the guidelines in assessing

bleeding during pregnancy.

 Assess patient’s psychological status.

 Check history of client (if client has had previous miscarriage or abortion.)

B. Diagnosis

 Risk for deficient fluid volume related to bleeding during pregnancy.

 Anticipatory grieving r/t loss of pregnancy, cause of abortion, future child

bearing

 Anxiety

 Acute pain

 Risk for maternal injury

C. Planning

Anxiety

 Patient will recognize the presence of anxiety.

 Patient will identify the cause of anxiety.

 Patient will begin to use positive coping strategies to adjust to the

situation.

 Patient will use resources/support systems effectively.

 Patient will report anxiety reduced to a manageable level.

Acute pain
  Patient will identify/use methods that provide relief.

 Patient will state that discomfort is minimized and/or controlled

Risk for maternal injury

 Patient will recognize and report signs/symptoms of complications.

 Patient will institute appropriate corrective measures.

D. Intervention

 Place the women in a side lying position and monitor uterine contractions

and fetal heart rate.

 Monitor intake and output and correlate with weight changes.

 Measure the maternal blood loss by weighing the used pads.

 Monitor vital signs and compare with patient’s normal or previous vital

signs.

 Note patient’s physiological response to bleeding such as changes in

menstruation, weakness, restlessness, and pallor.

E. Evaluation

 The aim for evaluation is inclined towards restoring the maternal blood

volume and stopping the source of the bleeding.

 The client’s blood pressure must be maintained above 100/60 mmHg.

 The pulse rate should be below 100 beats per minute and the fetal heart

rate must be at a normal level of 120-160 beats per minute.

 The client’s urine output should be more than 30 mL/hr, and only minimal

bleeding should be apparent for not more than 24 hours.

 References

Chung, W. (2004). Teratogens and their effects. Retrieved from www.columia

.edu/itc/hs/medical/humadev/2004/Chpt23-Teratogens.pdf

MayoClinic. (2020). Miscarriage. Retrieved from https://www.mayoclinic.org

/diseases-conditions/pregnancy-loss-micarriage/symptoms-causes/syc-20354298

Silbert-Flagg, J. (2014, 2010, 2003, 1999, 1995, & 1992). Maternal & child health
nursing: Care of the childbearing & childrearing family (8th Edition). Philadelphia:
Wolters Kluwer

WebMD. (2020). Understanding miscarriage—Prevention. Retrieved from

https://www.webmd.com/baby/understanding-miscarriage-prevention
 ABORTION

Submitted by:

Agag, Alexander Gabriel

Franche, Nina Ashley

Madria, Edward Joshua

Ramirez, Wilma Rose

Submitted on:

January 21, 2019