ABORTION

SINDHU SEBASTIAN
LECTURER FMCON

DEFINITION Abortion 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 22 23 24 25 26 27 28 % survival 0 25 55 65 75 90 92

INCIDENCE:

10-20% of all clinical pregnancy 10% Illegal 75% occur before 16wks

CLASSIFICATION ABORTION
Spontaneous
Induced

Isolated

Recurrent

Legal

Illegal (criminal )

Septic

Threatened

Inevitable

Complete

Incomplete Missed

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 Infections Maternal hypoxia Chronic 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 -Amniocentesis Toxic agents 4.Blood group incompatibility
5. Premature Rupture of Membranes

6.Environmental factors Smoking, alcoholism, X-ray, Radiation, Chemotherapy. 7.Dietic factors 8.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 Abortion
Before 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

Schematic Diagram of Abortion Abnormal Fetal Formation Immunologic Factors Infection Crosses placenta Teratogenic Factors (smoking, alcohol, drugs)

Rejection of the embryo through immunologic response

Fetus fails to grow Decrease estrogen and progesterone production

Endometrial sloughing
Release of prostaglandin which causes uterine contractions and cervical dilatation

Miscarriage

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.

Investigation
a)Blood investigation

b)USG
c) Urine for immunological test for pregnancy

Treatment
Rest : 2weeks of bed rest.

Drugs : sedation and analgesics Phenobarbitone 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 bleeding Sepsis Placental polyp Choriocarcinoma

Management
The 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.

Pathology
Beyond 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 features
Persistence 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

Management

If 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 PGF2 (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 features
Pyrexia associated with chills and rigors. Purulent vaginal discharge Shock

Pain abdomen of varying degrees

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

Clinical grading
Grade 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).

Investigations
Routine 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

Complications
Immediate :

Haemorrhage Injury to uterus and adjacent structures Spread of infection causes Peritonitis Acute renal failure Thrombophlebitis

Remote :

Chronic pelvic pain, Backache Dyspareunia Ectopic pregnancy Secondary infertility due to tubal blockage Emotional depression.

Prevention
i. Use

family planning method

ii. Encourage to go for legal abortion

 Hospitalization High vaginal or cervical swab Vaginal examination to note the state of abortion process

Management

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 aerobes

a)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 6hours
Grade I 1.Antibiotics 2. Prophylactic anti gas-gangrene

Serum 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 / Spontaneous miscarriage

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

Etiology
During 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

nd 2

trimester

Cervical 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 illness iii. Histology of placenta

Diagnostic tests a. Blood glucose , VDRL , Thyroid function test, ABO and Rh grouping b. Autoimmune screening c. USG d. Hysterosalpingography e. Hysteroscopy / Laparoscopy f. Endocervical swab

Treatment
During 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 -10th 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.

Nursing Diagnosis
Anticipatory grieving r/t loss of pregnancy, cause of abortion, future childbearing

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.

Nursing Diagnosis
Acute pain r/t uterine cramping and possible procedures

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
Knowledge deficit r/t signs and symptoms of possible complications

Nursing Interventions
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 clients anxiety. Present information out of sequence, if necessary, dealing first with material that is most anxiety producing when the anxiety is interfering with the clients learning process. Teach client of the complications for a mother has reason to be especially worried about her infants 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 womans

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
pregnancy with low socioeconomic status -pregnancy caused by rape or failure of contraceptive methods
-unplanned

 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 79.7% of women obtaining abortions are reported to the CDC in 1997. This is are unmarried constant since 1980 21 % of women obtaining abortions 305 abortions/1000 are younger 19 years live births old National abortion rate: 20/1000 women 55.2 % are younger than 24 years old aged 15-44

 88% of women who abort are in the first trimester of pregnancy

Contd

2.5 % have minor complaints that are handled in a physicians office <0.5% require additional surgery

97% of women having first trimester abortions have no complications or post abortion complaints

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 b-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

Private More sense of autonomy More natural Earlier intervention unwanted pregnancy

Longer process with unclear endpoint More pain More bleeding Anxiety regarding abortion off site

Medical

Surgical

Less skill needed to provide Methotrexate also treats ectopic pregnancy

Increased anxiety re: off site management More unscheduled care: calls, ER visits Need to guard against unnecessary intervention Limited to 49 days LMP

Second Trimester Termination

Dilatation and evacuation (D&E) Intrauterine injection of abortifacients Prostaglandin vaginal suppositories High dose oxytocin Hysterotomy

 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

D&E

 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 Mean time to induction 13.4 hours, abortion 15-17 hours, with 90% aborting by with 80% aborting by 24 hours 24 hours GI side effects: 39% GI side effects: 83% vomiting, 25% diarrhea vomiting, 71% diarrhea Fever: temperature Misoprostil (PGE1 elevation of 1 degree c

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