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SPONTANEOUS ABORTION
Definition:-Abortion is the termination of pregnancy
before the period of viability which is considered to
occur at 20th week.
Classification or Varieties:
Threatened abortion
-Inevitable abortion
-Complete abortion
-Incomplete abortion
-missed abortion
-Septic abortion
CONT:
-Maternal illness :
1) Infection: a) Viral Infection specially of
rubella and cytomegalic inclusion disease
produces congenital malformation and
abortion . The viruses of hepatitis, parvovirus,
influenza have got lethal action on the fetus
causing its death and expulsion.
CONT:
CONT:
CONT:-Mid trimester:
(1) Cervical incompetence
(2) Uterine malformation such as bicornuate,
septate or double uterus
(3) Uterine fibroid
(4) Low implantation of placenta
(5) Twins and hydramnios.
MECHANISM OF ABORTION:
-MECHANISM OF ABORTION: in the early weeks,
death of the ovum occurs first, followed by its
expulsion, in the later weeks, maternal
environmental factors are involved leading to
expulsion of the fetus which may have signs of life
but is too small to survive.
THREATENED ABORTION
-DEFINITION: It is a clinical entity where the process of
abortion has started but has not progressed to a state
from which recovery is impossible.
-INVESTIGATIONS:
1)Blood: for estimation, ABO and Rh grouping.
2)Urine: for immunological test of pregnancy. This is
done to confirm the fetal death in cases of continued
bleeding
Special investigation:
(1) A well formed gestation ring.
(2) observation of fetal cardiac motion.
(3) A blighted ovum.
GENERAL MEASURE
(1) the patient is advised to preserve the vulval pads
and anything expelled out per vaginam, for inspection.
(2) to repot if bleeding and / or pain becomes
aggravated.
(3) Routine note of pulse temperature and vaginal
bleeding.
-ADVICE ON DISCHRGE: The patient should limit her
activities for at least two weeks and avoid heavy work,
strenuous exercise and excitement. Coitus is
contraindicated during this period. She should be re
examined after one month to note the growth of the
uterus and advised to consult the physician if bleeding
recurs.
INEVITABLE ABORTION
DEFINITION: It is the clinical type of abortion
where the changes have progressed to a state from
where continuation of pregnancy is impossible.
CLINICAL FEATURES:
(1) increased vaginal bleeding.
(2) aggravation of pain in the lower abdomen
which may be colicky in nature.
(3) the general condition of the patient is
proportionate to the visible blood loss.
(4) Internal examination reveals dilated internal os
of the cervix through which the products of
conception are felt.
ACTIVE TREATMENT
Before 12 weeks :
(1) Dilatation and evacuation followed by curettage
of the uterine cavity by blunt curette under general
anesthesia is quite effective and a safe procedure.
(2) Alternatively suction evacuation followed by
curettage may be employed.
After 12 weeks :
(1) The uterine contraction is accelerated by
oxytocin drip (10 units is 500 ml of 5% dextrose) 4060 drops per minute.
If the fetus is expelled and the placenta is retained,
it is removed by ovum forceps, if lying separated.
CONT:
COMPLETE ABORTION
DEFINITON: When the products of conception are expelled
en masse, it is called complete abortion.
INCOMPLETE ABORTION
-
CONT:(3) Internal examination reveals:(a) uterus smaller than the period of amenorrhea
(b) patulous cervical os often admitting tip of the finger
and
(c) varying amount of bleeding
MANAGEMENT
MANAGEMENT:
-In recent cases The same principles are to be
followed like that to the inevitable abortion.
-Early abortion: Dilatation and evacuation under
general anesthesia is to be done.
-Late abortion: The uterus is explored under
general anesthesia by finger and the products left
behind is either removed by ovum forceps or by
blunt curette.
-In late cases- dilatation and curettage operation is
to be done to remove the bits of tissues left
behind. The removed materials are subjected to a
histological examination.
MISSED ABORTION
-DEFINITION : When the fetus is dead and retained
inside the uterus for more than four weeks, it is
called missed abortion.
-CLINICAL FEATURES: The patient usually presents
with features of threatened aborting followed by:
(1) Persistence of brownish vaginal discharge.
(2) Subsidence of pregnancy symptoms.
(3) Retrogression of breast changes.
(4) Cessation of uterine growth which in fact
becomes smaller in size.
CONT:-MANAGEMENT:
-Uterus less than 12 week: Vaginal evacuation can be
carried out without delay. This can be effectively done by
suction evacuation.
-Uterus more than 12 week: the same principles of the
management protocol as advocated in the intrauterine fetal
death are to be followed.
-Oxytocin to start with 10-20 units of oxytocin in 500 ml of
5% dextrose saline is administered in drip with 30 drops per
minute. If fails, escalating dose of oxytocin to the maximum
of 100 units, in a pint of 5% dextrose saline at a drip rate of
30 drops per minute, may be used with precaution.
SEPTIC ABORTION
-DEFINITION: Any abortion associated with
clinical evidences of infection of the uterus and its
contents, is called septic abortion. Although
clinical criteria vary, abortion is usually considered
septic when there are:
(1) rise of temperature of at least 100.4 F (38 C)
for 24 hours or more
(2) offensive or purulent vaginal discharge and
(3) other evidences of pelvic infection such as
lower abdominal pain and tenderness.
INVESTIGATIONS
(1) Cervical or high vaginal swab is taken prior to
internal examination for:(a) culture in aerobic and anaerobic media to find
out the dominant micro-organisms,
(b) sensitivity of the micro-organisms to antibiotics
(c) smear for Gram stain. Gram negative organisms
are E. coli, pseudomonas, Bacteroides etc.
-Gram positive organisms are Staphylococci,
anaerobic streptococci, Cl. Welchii, cl. Tetani etc.
CONT:Special investigations
(2) X-ray abdomen and pelvis not commonly done
these days.
(3) Blood (a) Culture if associated with spell of
chills and rigors,
(b) Serum electrolytes as an adjunct to the
management protocol of endotoxic shock.
(c) Coagulation profile
CONT:-COMPLICATIONS:
-Immediate: The major complications of septic
abortion are dependent more on the nature of the
abortion in which the sepsis occurs: Practically all
the fatal complications are associated with illegally
induced abortions confined to the grade III types.
-Hemorrhage: related due to abortion process and
also due to the injury inflicted during the
interference.
-Injury: may occur to the uterus and also to the
adjacent structures particularly gut.
CONT:GENERAL MANGEMENT:
-Hospitalization: even with a case of mild infection is
preferable. The patient should be kept in isolation, if
possible.
-To take high vaginal or cervical swab: for culture,
drug sensitivity test and Gram stain.
-Vaginal examination: is then made to note the state
of the abortion process and extension of the
infection. If the products are found loosely lying in
the cervix, they should be removed by sponge holding
forceps.
-Overall assessment of the case: is to be done and
the patient is put in accordance with the clinical
grading.
CONT:-GRADE-I
Drugs : (1) Antibiotics
(2)Prophylactic anti gas-gangrene serum of 8000 units
and 3000 units of antitetanus serum intramuscularly
are given
(3) Blood transfusion
(4) Evacuation of the uterus
-GRADE II
-Antibiotics Mixed infections including gram positive,
gram negative and anaerobic organisms are common.
-For gram positive aerobes: (a) Aqueous penicillin G 5
million units I.V. every 6 hours (b) Ampicillin 0.5 1
gm. I.V. every hours. B. Gram negative aerobes: (a)
Gentamicin 1.5 mg/kg I.V. every 8 hours.
RECURRENT ABORTION
-DEFINITION: Recurrent abortion is defined as a
sequence of three or more consecutive spontaneous
abortions some however, consider two or more as a
standard. It may be primary or secondary (having
previous viable birth)
-ETIOLOGY
-FIRST TRIMESTER ABORTION:
-Genetics a recurring aneuploid abnormality of
the conceptus is probably responsible. It may be a
chance event or related to maternal age. The most
common type of parental chromosomal abnormality
is a balance translocation.
CONT:-Immunological cause:
-Autoimmunity: the association of raised
circulating lupus anticoagulant (LA) and antiphospholipid antibodies (APAS) with recurrent fetal
loss is now well established. APAS positive women
demonstrate a tendency to miscarry at
progressively lower gestational ages.
-INVESTIGATIONS:
-Interconceptional period
(i)Passage no.6-8 Hagar dilator: beyond the
internal os without any resistance and pain and
absence of internal os snap on its withdrawal
specially in premenstrual period indicate
incompetence.
-During pregnancy:
-Ultrasonography findings of cervical length less
than 3 cm and width of internal os more than 1.5
cm in first trimester with or without bulging of the
membranes are suggestive.
-Defective mullerian fusion: such as double
uterus, septate or bicornuate uterus.
-TREATMENT
INTERCONCEPTIONAL PERIOD:
-To alleviate anxiety and to improve the
psychology:
CONT:
-To correct the uterine pathology metroplasty for
double or bicornuate uterus, removal of septum
(hysteroscopically preferred) or myomectomy for
sub mucous fibroid distorting the uterine cavity.
NURSING DIAGNOSIS:
SUMMARY
SUMMARY:- Abortion is the termination of
pregnancy before the period of viability which is
considered to occur at 20th week. Its
Classification are:-Threatened abortion
-Inevitable abortion
-Complete abortion
-Incomplete abortion
-missed abortion
-Septic abortion
BIBLIOGRAPHY: