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 response Implantation of abnormalities (50% of zygotes are probably never implanted Corpus luteum fails to produce enough progesterone to maintain the decidua basalis Infection (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

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 cramping No 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 pregnancy Progesterone level White 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 hours Not 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 spotting Cramping 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 spotting Cramping Cervical dilatation Complete 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 spotting Cramping Cervical dilatation Incomplete expulsion of uterine contents

Diagnostic exam:
Ultrasound

Treatment:
Dilation and curettage Suction curettage

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

Assessment:
Vaginal spotting Slight cramping No apparently loss of pregnancy Embryo died 4 to 6 weeks before the onset of miscarriage

Diagnostic exam:
Sonogram

Treatment:
Dilation and evacuation Prostaglandin 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), butanolextractable 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 miscarriage
1. Hemorrhage - blood loss

2.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 womans 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 womans 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 place A woman has a serious medical condition such as chronic adrenal failure Current long-term systemic corticosteroid therapy

History of allergy to mifepristone, misoprostol, or other prostaglandins Hemorrhagic 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 abortion Possibility of prolonged bleeding

Nursing Intervention: 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 basis

Procedure: The woman voids, and her perineum is washed with an antiseptic A 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 procedure

Procedure: 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 counseling Inform 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 procedure Infection

Prostaglandin Saline Induction (between 16 and 24 weeks) Inpatient or ambulatory procedure

Procedure: 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 suppository Labor, 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 endometrium

Procedure: 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 weeks A first menstrual flow usually occurs 2 to 8 weeks after the procedure Follow-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 which the doctor cuts through the abdomen and uterus to deliver the baby), except that in a hysterotomy, no medical attention

is given to the baby upon delivery to help it survive. Most often, a wet towel is placed over the babys face so it cant breathe. Sometimes the baby placed in a bucket of water. The goal is to have a baby that wont 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 ripening The 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.

Bukidnon State University College of Nursing

ABORTION

Submitted by: Ma. Honey E. Mondoy Vanessa Kristine G. Dagooc Submitted to: Ms. Carina Joanne V. Barosso, RN, MAN