Abortion

- Loss of pregnancy before fetus is viable or capable of living outside the uterus.
- The medical consensus today is that a fetus of less than 20 weeks gestation or one weighing less than 500 g is not viable.
- May be either spontaneous or induced
- Usually called miscarriage
I. SPONTANEOUS ABORTION
- Termination of pregnancy without action taken by the woman or another person.
- Most occur in the first 12 weeks of pregnancy
Etiology and predisposing factors :
1. Parental age
2. Chromosomal abnormalities
3. Endocrine imbalances
- type 1 Dm
- hypothyroidism
- inadequate progesterone
4. Maternal infections
- syphilis
- listeriosis
- toxoplasmosis
- brucellosis
- rubella
- cytomegalovirus
5. Abnormal embryonic development
6. Abnormalities of reproductive tract
SUBGROUPS :
A. THREATENED ABORTION
- Vaginal bleeding occurs, but the products of conception are not expelled
Clinical manifestation
1. Spotting or bleeding in early pregnancy
2. Rhythmic uterine cramping
3. Persistent backache
4. Feelings of pelvic pressure
*Pregnancies complicated w/ early bleeding that do not end w/ a spontaneous abortion are more likely to have further complica tions during late pregnancy such as :
1. Prematurity
2. SGA
3. Abnormal presentation
4. Perinatal asphyxia
Therapeutic management
1. Women must be advised to notify physician or nurse-midwife if brownish or red vaginal bleeding is noted.
2. When woman reports bleeding in early pregnancy, nurse obtains a detailed history that includes :
- length of gestation/LMP
- onset, duration and amount of vaginal bleeding.
3. Accompanying discomfort such as cramping, backache or abdominal pain is noted.
4. Ultrasound and vaginal ultrasound examination
-to verify if embryo or fetus is present and alive
Maternal serum chorionic gonadotropin levels and progesterone levels
- provide information about viability of pregnancy
5. Woman may be advised to limit sexual activity.
6. Woman is instructed to count number of perineal pads used and note quantity and color of blood on pads.
7. Woman look for evidence of tissue passage w/c would indicate progression beyond threatened abortion.

8. Bleeding episodes
9. Nurse should offer accurate results and avoid false reassurance.

B. INEVITABLE ABORTION
- Cannot be stopped when there is rupture of membranes and dilation of cervix
Clinical manifestation
Rupture of membranes
Experienced as a loss of fluid from the vagina and subsequent uterine contractions and active bleeding.
Excessive bleeding or infection
- Can happen if complete evacuation of products of conception does not occur spontaneously.
Therapeutic management
1. Natural expulsion of uterine contents Common in inevitable abortion
2. Vacuum curettage Used to clean out uterus if natural expulsion is ineffective or incomplete
3. Dilation and Curettage If pregnancy is more advanced and or if bleeding is excessive
4. IV sedation or other anesthesia Provides pain management for the procedure

C. INCOMPLETE ABORTION
- Some but not all of the products of conception are expelled from the uterus.
Clinical manifestation
1. Active uterine bleeding
2. Severe abdominal cramping
3. Cervix is open
4. Fetal and placental tissue passed
Therapeutic management
Retained tissue Prevents the uterus from contracting firmly thereby allowing profuse bleeding from uterine blood vessels
1. Initial treatment should focus on stabilizing the woman cardiovascularly.
2. A blood specimen is drawn for blood type and screen or cross-match
3. An IV line is inserted for fluid replacement
4. When the womans condition is stable, a D&C is usually performed to remove the remaining tissue
5. IV administration of Oxytocin and Intramuscular administration of Methylergonovine to contract the uterus and control blee ding

D. COMPLETE ABORTION
- All products of conception are expeeled from the uterus
Clinical manifestation
After passage of all products of conception :
1. Uterine contractions and bleeding subside
2. Cervix closes
3. Symptoms of pregnancy no longer present
Therapeutic management
1. No additional intervention is required unless excessive bleeding or infection develops
2. Woman should be advised to rest and watch for further bleeding, pain or fever

3. Woman should not have intercourse until after a follow-up visit w/ a healthcare provider

E. MISSED ABORTION
- Fetus dies but is retained in the uterus
Clinical manifestation
1. Early symptoms of pregnancy disappear
2. Uterus stops growing and decreases in size reflecting the absorption of amniotic fluid and maceration of fetus
3. Vaginal bleeding of a red or brownish color may or may not occur
Therapeutic management
1. Ultrasound examination confirms fetal death by identifying a gestational sac or fetus that is too small for the presumed gestational age
2. No fetal heart activity can be found
3. Pregnancy tests for hCG should show a decline in placental hormone production
4. D&C For 1st tri ; D&E For 2nd tri
5. Vaginal prostaglandin E2 or Misoprostol (Cytotect) may be needed to induce uterine contractions that expel fetus
2 Major Complications :
1. Infection
If signs of uterine infection exists such as :
- elevated temp
- vaginal discharge w/ foul odor
- abdominal pain
Evacuation of uterus will be delayed until cultures are obtained and antimicrobial therapy is initiated.
2. Disseminated Intravascular Coagulation (DIC)

F. RECURRENT SPONTANEOUS ABORTION

- 3 or more consecutive pregnancies end in spontaneous abortion
Clinical manifestation
Causes :
1. Genetic or chromosomal abnormalities
2. Anomalies of the reproductive tract
3. Inadequate Luteal phase w/ insufficient secretion of progesterone and immunologic factors
4. Systemic diseases
5. Reproductive infections
Therapeutic management
1. Examination of the reproductive system to determine whether anatomic defects are the cause
2. Genetic screening to identify chromosomal factors
3. Additional therapeutic management depends on the cause
4. Cervical incompetence results in painless dilation of cervix in 2nd tri . Cervix may be sutured to keep it from opening (cerclage procedure)
5. Rh immune globulin (RhoGAM)is given to the unsensitized negative woman to prevent development of anti-Rh antibodies