ABORTION/ MISCARRIAGE

A spontaneous or planned interruption of pregnancy in

which there is complete expulsion or partial expulsion
(incomplete) of the products of conception before the
period of viability.
Period of gestation is 20 weeks or less, the conceptus
will weigh below 500g and will be less than 16.5 cm
long.
May be caused by the presence of embryonic defects,
external mechanical force, or trauma.

definition

 Threatened abortion
Cervix closed, but bleeding, cramping and backache
occur; pregnancy may continue uninterrupted

Threatened
abortion

Imminent or inevitable abortion

Incomplete abortion
Inevitable
abortion

Bleeding and cramping become more severe, cervix

dilates, and membranes may rupture

Incomplete abortion
All the products of conception are not expelled after
dilation of cervical os

Complete abortion
All products of conception expelled within 24 to 48
hours

Missed abortion
Fetus dies in utero but not expelled; client must be
monitored for disseminated intravascular coagulopathy

Habitual abortion
Three consecutive pregnancies that end in abortion

Vaginal
bleeding
occurs.

Some products of conception have

been expelled, but some remain.

Membranes rupture, and

cervix dilates.

Types/ clinical findings

Causes/ risk
factors

Clinical
Manifestations

Diagnostic
Evaluation

Complications

Chromosomal abnormalities
Exposure or contact with teratogenic agents, viruses
Poor maternal nutritional status
Hx of DM, thyroid disease, anticardiolipin antibodies, or lupus erythematosus
Smoking or drug abuse
Immunologic factors
Abnormal uterine development or structural defect (ex: incompetent cervix)
Environmental factors such as drugs, radiation, or trauma

Uterine cramping
Low back pain
Vaginal bleeding usually begins as dark spotting, then progresses to frank
bleeding as the embryo separates from the uterus
B-hCG levels may be elevated for as long as two weeks after loss of the embryo

Ultrasound evaluation of the gestational sac or embryo

Visualization of the cervix, presence of dilation or tissue evaluated

Hemorrhage
Infection
Septic abortion
Isoimmunization
Powerlessness or Anxiety

Pathophysiology Spontaneous Abortion

1. Hemorrhage
2. Infection
3. Septic abortion
4. Isoimmunization
5. Powerlessness or Anxiety

Complications

 Common in incomplete abortion or in a woman who

develops an accompanying coagulation defect (DIC)
A woman needs clear instructions on how much bleeding
is abnormal
RULE OF THE THUMB: more than one sanitary pad
per hour is excessive
Oral medication such as methylergonovine maleate
(Methergine) is usually prescribed to aid in contraction

Hemorrhage

Signs of Hypovolemic
shock
Confusion
Pallor
Increased pulse/
tachycardia
Decreased blood
pressure
Decreased cardiac
output
Fetal bradycardia
Peripheral
vasoconstriction
(placenta reacts as a
peripheral organ)
Decreased urinary
output
Cold extremities

 Tends to occur when women have loss appreciable amounts of

blood
SIGNS OF INFECTION:
Fever
Abdominal pain or tenderness
Foul vaginal discharge

Escherichia coli usually the organism responisble for infection

Wipe perineal area from front to back after voiding and
defecation to prevent the spread of bacteria from the rectal area
Avoid tampons to control vaginal discharge stasis of any body
fluid increases the risk for infection

Infection

 When some blood from the placental villi (the fetal blood)
enters to maternal circulation, if the fetus was Rh positive and
the woman is Rh negative, enough Rh-positive fetal blood
may enter her circulation to cause Isoimmunization the
production of antibodies against Rh-positive blood from her
immunologic system.
If her next child is Rh-positive, these antibodies would attempt
to destroy the red blood cells of the next infant in the utero.
Treatment: After miscarriage, all Rh-negative blood should
receive Rh (D antigen) immune globulin (RhIG) to prevent
the buildup of antibodies in the event the conceptus was Rh
positive.

Isoimmunization

 Is an abortion that is complicated by infection

Infection can happen after a spontaneous miscarriage, but more
frequently it occurs in women who have tried to self-abort or were
aborted illegally using nonsterile instrument such as a knitting needle
SYMPTOMS: fever, crampy abdominal pain, and uterus feels tender
on palpation
If untreated can lead to Toxic shock syndrome, septicemia, kidney
failure, and death
Treatment: broad-spectrum antibiotic therapy; a combination of
penicillin (gram-positive coverage), gentamicin (gram-negative
aerobic coverage), and clindamycin (gram-negative anaerobic
coverage)

Septic abortion

 Sadness and grief over the loss or a feeling that a woman has lost
control of her life is to be expected.
Dont forget to assess a partners feelings as well
Nurses can help by emphasizing that most spontaneous abortions occur
because of factors or abnormalities that could not be avoided.
Anger, disappointment, and sadness are commonly experienced
emotions, although the intensity of the feelings may vary.
Providing information and simple, brief explanations of what has
occurred and what will be done facilitates the familys ability to grieve
It is helpful for the family to realize that grief may last from 6 months
to a year, or even longer.
Family support, knowledge of the grief process, spiritual counselors,
and the support of other bereaved couples may provide needed
assistance during this time.

Powerlessness or
Anxiety

1. Complete bed rest

2. Diagnostic/ therapeutic blood studies:

Blood cell count

Blood typing
Rh incompatibility
Cross matching with availability of blood

3. Assessment of serum progesterone or serial beta-hCG

4. Dilatation and curettage or vacuum aspiration performed if
all products of conception are retained

Therapeutic interventions

Nursing Care of Clients

Experiencing Abortion

1.

2.
3.
4.
5.
6.

Evaluate the amount of and color of blood that is present:

determine the time the bleeding began and any precipitating
factors.
Determine whether a positive pregnancy test has previously been
obtained, also the date of the last menstrual period.
Monitor vital signs for indication of complications such as
haemorrhage, infection
Evaluate any blood or clot tissue for the presence of fetal
membranes, placenta or fetus
Pain
Emotional response to loss

Assessment

1. Risk for fluid volume deficit related to maternal

bleeding
2. Anticipatory grieving r/t loss of expected infant
3. Pain r/t uterine contractions
4. Risk for infection related to dilated cervix and
open uterine vessel
5. Situational low self-esteem r/t inability to carry
pregnancy to term

Analysis/ Nursing Diagnoses

INTERVENTION
1. Monitor intake and output. Calculate insensible loses
and fluid balance. Note decreased urine in presence of
adequate intake. Measure specific gravity and pH
to gauge urinary retention
2. Weigh daily. Monitor BP and HR
3. Evaluate skin turgor, capillary refill and general
condition of mucous membranes
- indicators of fluid status/ hydration
4. Encourage moderate amount of fluid as indicated
- promote urine flow
5. Bed rest
---Collaborative--6. Administer IV fluids as indicated
- maintains fluid and electrolyte balance
7. Monitor lab studies
8. Administer RBC, platelets, clotting factors
- to prevent hemorrhage

Desired Outcome
o Demonstrate adequate
fluid volume, as
evidenced by stable
vita signs, palpable
pulses, urine output,
specific gravity, and
pH within normal
limits
o Identify individual risk
factor and appropriate
interventions.
o Initiate behaviours/
lifestyle changes to
prevent development
of fluid volume deficit

Risk for fluid volume deficit related to maternal bleeding

 DATA
Verbal
expression of
distress
Denial of loss
Altered eating
habits, sleep/
dream patterns
crying
Labile affect,
feeling of
sorrow, guilt,
anger
Difficulty
expressing loss

INTERVENTION
1. Provide open environment in which the patient feels
free to discuss feelings and concerns
o Allows patient to talk freely and deal with perceived loss
o Therapeutic communication skills used: active listening
silence, being available and acceptance

2. Identify stage of grieving

o Awareness allows for appropriate choice of interventions
as individual handle grief in many different ways
(DABDA)

3. Identify and problem-solve solutions to existing

physical responses, e.g. eating, sleeping, activity
levels and sexual desire
o May need additional assistance to deal with the physical
aspects of grieving

4. Assess needs of significant other and assists as

indicated.
---collaborative--5. Refer to other resources; e.g. counseling,
psychotherapy as indicated

Anticipatory grieving r/t loss of expected infant

DESIRED
OUTCOME

Verbalized
sense of
progress
toward
resolution
of the grief
and hope
for the
future
Function at
an adequate
level,
participate
in work and
ADLs

 INTERVENTION
1. Assess pain, noting location, characteristics
and severity
DESIRED

DATA
Reports of
pain
Facial
grimacing
Muscle
guarding

o Gives baseline data and monitors effectiveness

OUTCOME
of intervention
Report pain

2. Keep at rest
3. Encourage early ambulation
o

Promotes normalization of organ function

4. Provide diversional activities

o Refocuses attention, promotes relaxation and
may enhance coping abilities

---collaborative--5. Administer analgesics as indicated

6. Place ice bag on abdomen
o Soothes & relieves pain through
desensitization of nerve endings.

Pain r/t uterine contractions

is relieved/
controlled.
Appears
relaxed,
able to
sleep
Able to rest
appropriatel
y

 INTERVENTION
1. Observe and report signs of infection such as
redness, warmth, discharge, and increased
temperature.
o With the onset of infection the immune system is
activated and signs of infection appear

2. Encourage balanced diet, emphasizing protiens

to feed the immune system
3. Encouraged increased fluid intake
o Helps replace fluid loss

4. Encourage rest to bolster the immune system

5. Use of proper handwashing techniques before
and after giving care
6. Follow standard precautions and wear gloves
during any contact with body fluids.

DESIRED
OUTCOME

Remains free
from symptoms
of infection
Demonstrates
appropriate care
of infection on
prone site. Use
of hygienic
measures
Maintains WBC
count &
differential
within normal
limits

Risk for infection related to dilated cervix and open uterine vessel

 DATA
Verbalization of
inability to
carry pregnancy
to term
Fear of
rejection/
reaction of
others
Negative feeling
about the body
Feeling of
helplessness
Depression
Self-destructive
behavior

INTERVENTION
1. Contract with patient regarding time for listening.
Encourage discussion of feelings/ concerns

DESIRED
OUTCOME

Identify
o Establishing time enhances trusting relationship.
feelings and
Opportunity to express feelings allows patient to feel
methods for
more in control of the situation
coping with
2. Avoid making moral judgments
negative
o Judgments from others will further damage self esteem
perception of
3. Discuss recovery expectations
self
4. Assess effect of illness on economic factors of
Verbalized
patient/ SO
acceptance of
o Financial problems may exist bec of loss of pts role
the situation
functioning
Acknowledg
5. Offer diversional activities based on energy levels
e self as
o Enables patient to use time and energy in constructive
worthwhile;
ways that enhance self-esteem and minimize anxiety and
depression.
be
responsible
---collaborative--for self
5. Make appropriate referrals for help, as needed

Situational low self-esteem r/t inability to carry pregnancy to term

1. Institute measures to alleviate fear and anxiety; assist with

grieving process
2. Point out physiologic reality, but encourage client to work
through feelings; grieving may last up to 24 months
3. Encourage participation with thanatology services and
bereavement groups when appropriate
4. Monitor amount and type of bleeding:
Save and count number of pads
Distinguished between dark clotted blood and frank bleeding,
which is bright red
Monitor fundus for firmness after products of conception are
expelled

Planning/ Implementation (general)

5. Monitor vital signs for signs of hypovolemia, shock,

and infection
6. Monitor CBC, hemoglobin, and hematocrit; prepare
for administration of blood
7. Administer oxygen if necessary
8. Maintain fluid and electrolyte balance
9. Administer RhoGAM to Rh-negative client after
abortion
10. Educate about necessity for follow-up care and
support groups

Planning/ Implementation (general)

(refer to desired outcome on previous pages

Evaluation/ Outcomes

 Mosbys Comprehensive Review of Nursing for NCLEXRN, 17th Edition, 2003

Adele Pillitteri. Maternal & Child Health Nursing: Care
of the Childbearing & Childbearing Family. Lippincott
Williams & Wilkins. Fifth Edition
MATERNAL-CHILD NURSING, Elsevier Saunders,
Second Edition. 2005
Doenges, et.al., NURSING CARE PLANS: Guidelines
for Planning and Documenting Patient Care. Edition 3

References