Spontaneous Abortion: Types and Causes

Spontaneous Abortion

• Also known as a miscarriage.
• Pregnancy interruption that happens before a fetus is "viable".
• Affects fetuses of more than 20-24 weeks gestation or weighing less than 500g.
• Occurs in 15-30% of all pregnancies.
• Can be an early or late miscarriage.

Causes of Spontaneous Abortion

• Chromosomal abnormalities.
• Implantation abnormalities.
• Inadequate progesterone from the corpus luteum.
• Maternal and intra-abdominal infections.
• Endocrine disorders.
• Reproductive system abnormalities (uterus/cervix).
• Teratogenic drugs.
• Ingestion of alcohol.

Types of Spontaneous Abortion

• Threatened: Unexplained spotting or light bleeding, mild uterine clamping/backache, pelvic pressure, bleeding for days, closed cervix.
  • Advised to evaluate for h.mole or ectopic pregnancy.
  • Once bleeding stops, resume normal activity gradually.
  • Avoid sex to prevent infection and further bleeding for two weeks after resolution.
  • Half of women will continue the pregnancy, but in the other half, the threatened miscarriage will become imminent or inevitable.
• Imminent: Bleeding (moderate to heavy), cramping (mild to severe), dilated cervical os, membranes may rupture.
  • No Fetal Heart Tones may be auscultated, and ultrasound may reveal an empty uterus or nonviable fetus.
  • Vacuum extraction (dilation and evacuation) ensures all conception products are removed.
  • Suction curettage cleans the uterus, preventing infection.
• Complete: All products of conception spontaneously expelled without assistance, a contracted uterus.
  • Cervical os may close after the products of conception are passed.
  • Bleeding usually slows within 2 hours and ceases within a few days.
• Incomplete: Some of the products of conception are retained.
  • Causes active uterine bleeding and severe abdominal cramping, potentially with a slightly dilated internal cervical os.
  • Poses a maternal hemorrhage risk because the uterus cannot effectively contract.
  • Dilation and curettage (D&C) or suction curettage evacuate pregnancy remnants.
• Missed: Fetus dies in utero but is not expelled.
  • Uterine growth stops, breast changes regress, brownish vaginal discharge.
  • Diagnosed by ultrasonic examination.
• Recurrent/Habitual: Three or more consecutive pregnancy losses occur.
  • Thorough investigation to discover the cause.
  • Possible causes may include resistance to uterine artery blood flow, chorioamnionitis/uterine infection, autoimmune disorders, or defective spermatozoa/ova.
• Septic: Occurs with self-abortion or illegal abortions using non-sterile instruments, such as knitting needles.
  • Infectious organisms grow rapidly in uterus, which becomes warm, moist, and dark.
  • Necrotic membranes are also present.

Complications of Spontaneous Abortions

• Hemorrhage: Complete spontaneous miscarriage rarely causes serious or fatal hemorrhage.
  • Incomplete miscarriage can develop a coagulation defect, possibly DIC.
  • Monitor vital signs to detect hypovolemic shock.
  • If excessive vaginal bleeding occurs - Position patient flat and massage uterine fundus to aid contraction.
  • D&C or suction curettage needed to empty uterus.
  • A transfusion replaces blood loss.
  • Bleeding is abnormal if it changes to dark, then serous fluid.
  • Oral methylergonovine maleate (Methergine) aids uterine contractions.
  • Repression helps deal with anger or grief.
• Infection: Minimal over a short time.
  • Bleeding is self-limiting, and instrumentation is limited.
  • Watch for fever, abdominal pain/tenderness, and foul vaginal discharge.
  • Temperatures higher than 100.4° F (38.0° C) needs evaluation.
  • Endometritis, peritonitis, thrombophlebitis, and septicemia can develop.
• Isoimmunization: Can occur when the placenta is dislodged.
  • Blood from the placental villi may enter the mother's circulation during spontaneous birth or D&C.
• Powerlessness or anxiety: Assess the woman's adjustment to spontaneous miscarriage.
  • Expect sadness and grief; assess partner's feelings.
  • Spontaneous miscarriage is particularly heartbreaking for older women due to limited childbearing years.

Assessment and Nursing Management

• Assess maternal vital signs, urine output, amount and appearance of bleeding, comfort level, and general physical health.
• Assess for pelvic cramping and backache.
• Use ultrasound scanning and hemoglobin/hematocrit levels for diagnosis.
• Check for pregnancy confirmation, length, duration, intensity, description, frequency, associated symptoms, and blood type.
• Assess vital signs and monitor urine contractions and FHR.
• Measure maternal blood loss by weighing perineal pads, saving any tissue passed.
• Outpatient evaluation often occurs during the first trimester with cramping/spotting.
• Analgesics relieve pain if cramps are severe.

Placenta Previa

• A high-risk pregnancy complication that occurs when placement of the placenta affects the cervix.
• Placenta implanted in the lower uterus.
• Unknown cause, but thought to occur when the placenta must spread out to find an adequate exchange surface in the uterine cavity.

Causes of Placenta Previa

• Increased parity.
• Advanced maternal age.
• History of cesarean births, uterine curettage.
• Multiple gestation.
• Male fetus.

Assessment and Care

• Assess the duration of pregnancy, time bleeding began, and whether there was accompanying pain.
• Immediate care measures include placing pregnant person in bed rest immediately in side-lying position.
• Estimate the present rate of blood loss.
• Obtain baseline maternal vital signs; assess BP every 5-15 minutes.
• PREVIA mnemonic helps provide care:
  • Painless bright red bleeding
  • Replace blood loss
  • Evident in lower segment
  • Vitals indicate shock
  • Inspect FHR
  • Avoid vaginal exam

Abruptio Plancenta

• Occurs when the placenta separates from the inner wall of the uterus before the baby is born.
• The separation occurs late in pregnancy/as late as during the first or second stage of labor.
• Placental abruption can deprive a fetus of oxygen/nutrients and causes heavy maternal bleeding.
  • Early delivery is may be needed.

Predisposing factors

• High parity.
• Advanced maternal age.
• Short umbilical cord.
• Chronic or pregnancy-induced hypertension.
• Direct trauma.
• Vasoconstriction due to cocaine or cigarette use.

Symptoms

• Most likely to occur in the last trimester of pregnancy, including:
• Vaginal bleeding.
• Abdominal pain, back pain.
• Uterine tenderness or rigidity.
• Uterine contractions.

Characteristics of Placental Abruption Mnemonic

• A: Abdominal pain (acute).
• B: Bleeding - Variable.
• R: Rigid abdomen.
• U: Uncomfortable patient.
• P: Palpable tenderness (uterus).
• T: Tense (contractions).

Therapeutic Management

• Assess maternal history, physical exam, and possible causes of bleeding during late pregnancy.
• Assess maternal hemodynamic status, fetal well-being, and uterine resting-tone and contractions.
• Anticipate lab tests: CBC, type and crossmatch, coagulation studies, Apt test, and Kleihauer-Betke test.
• Administer supplemental Oxygen.
• Stop oxytocin administration during induction.
• Monitor blood loss, fetal response, and maternal status.
• Anticipate blood replacement therapy, or vasoactive drug therapy.
• There should be medical evaluation for route and timing of delivery.

Premature Rupture of Membrane (PROM)

• Also known as pre-labor rupture of membranes when the rupture occurs beyond 37 weeks gestation.
• PPROM, or preterm premature rupture of membrane is a rupture prior to 37 weeks gestation.

Complications

• Potter-like Syndrome occurs when fetal development has been disrupted due to oligohydramnios.
• Cord Prolapse is the extension of the cord out of the uterine cavity and into the vagina.

Pathophysiology

• Amniotic fluid continues to leak out, leading to oligohydramnios.
• Compression of the fetus occurs, which decreases cushioning needed for fetal growth.
• Potter facies, limb contractures and wrinkled sin may develop.
• Cord compression leads to cord prolapse.
• Blood flow impairment occurs and placental insufficiency and fetal is possible, leading to stillbirth.

Potter Sequence Definition

P - Pulmonary Hypoplasia O - Oligohydramnios T - Twisted Skin T - Twisted Face E - Extremities Defect

Considerations for PROM

• Diagnosed by the identification of alkaline fluid pooling in posterior vaginal fornix.
• Point-of-care tests identify membrane rupture.
• Sudden gush of clear or pale fluid signals water breaking.
• Complications include umbilical cord compression or prolapse.
• Nitrazine paper uses alkaline fluid from the uterus while a normal vaginal pH ranges from 3.5 to 4.5, giving a blue result.
• Fern tests must observe the mother for signs and/or symptoms of infection.

Maternal Implications of PROMs

• Infection: Can lead to chorioamnionitis, endometritis, or sepsis.
• Late separation of the placenta.
• More frequently occurs in pregnant people with PROM.

Risk Factors for PROMs

• Trauma.
• Incompetent Cervix.
• Bleeding during pregnancy, multiple pregnancy.
• Smoking or substance abuse.
• Connective tissue disorders, lower socioeconomic status.
• Infection (cervicitis, or UTI).
• Previous history of PROM.
• Amniocentesis.

PROM Assessment

• Determine the duration of membrane rupture and gestational age.
• Observe mother for signs and symptoms of infection: WBC count, temperature, PR, or character of amniotic fluid.
• Sterile vaginal speculum exam identifies fluid with a fern test or nitrazine test.
• Assess baby's fetal well-being via heart rate, biophysical profile, and gestational age.

Nursing Management

• Focus on pregnant person, partner, and baby including signs of infections.
• Vaginal exams are not done unless absolutely necessary.
• Monitor foul or strong odor and cloudy or yellow appearance in vaginal discharge.
• Monitor the frequency/intensity of contractions and changes in character.
• Promote left side rest and provide comfort measures.
• Maintain hydration and monitor temperature and FHR every four hours.
• Avoid temperature higher than 38°C (100.4° F).

Educative Care

• Pregnant people should avoid breast stimulation, vaginal exams/suppositories, intercourse, and tub bathing/douching.
• Maintain activity restrictions, understand PROM implications and all treatment methods.
• Assure the couple amniotic membrane fluid is still produced despite rupture.
• Provide psychological support to reduce anxiety.

Pregnancy Induced Hypertension (PIH)

• High blood pressure, formerly known as toxemia.
• Begins after 20 weeks of pregnancy and ends shortly after the baby's born.
• It happens in about 6% to 8% of pregnancies.
• A condition in which vasospasms occur during pregnancy in both large and small arteries.
• Gestational hypertension is different from other types because it goes away after childbirth.

What is HELLP Syndrome

• HELLP Syndrome:
  • Hemolysis (rupture of RBCs).
  • Elevated Liver enzymes.
  • Low Platelets.

PIH Classifications

• Gestational Hypertension: At least 140/90 mmHg blood pressure with no proteinuria or edema.
• Mild Preeclampsia: At least 140/90 mmHg blood pressure, proteinuria, and edema.
• Severe Preeclampsia: At least 160/110 blood pressure, marked proteinuria, extreme edema, epigastric pain, nausea and vomiting, oliguria, headache, blurring of vision, hyperreflexia and possible cerebral edema.
• Eclampsia: Most severe classification, with a triad of symptoms including seizures, coma, elevated temperature, blurred vision and hyperactive reflexes with rapid changes in blood pressure.

HELLP Syndrome Role of the Nurse

• Administer calcium gluconate as anti-dote for for magnesium toxicity,.
• Administer Magnesium sulfate as prevention for seizures, report any feeling warm or flushing.
• Monitor respirations; report less <12, and any deep tendon decrease.
• Monitor urinary output <30 cc/hr, and any EKG changes.

PIH Risk Factors

• Multiple Pregnancy in patient.
• Women from low socio-economic backgrounds.
• Primiparas <20 years of age or older than 40 years old.
• Multigravida and history of essential hypertension.
• Heart disease, diabetes with vessel or renal involvement.

Nursing interventions

• Watch for:
  • High Blood Pressure; take two separate (at least 4-6 hours apart) recordings
  • Swelling face ,face eyes or extremities.
  • Fetal distress/restriction of growth.
  • Decreased/Absent Deep Muscle tone or change with EKG.
  • Headache, with vision change or reflex.
  • Bleeding won't stop, platelet, liver and liver enzyme changes.

General Nursing Care

• Perform strict monitoring of intake and output.
• Watch the salt intake.
• Side-lying bed rest with fetal monitoring.
• Assess for neurological status, vision changes and headache, for seizure.
• Monitor urinary output.
• Provide protein rich diet.

Explore the causes, types, and treatments for spontaneous abortion (miscarriage). Spontaneous abortion is pregnancy interruption before a fetus is viable, typically before 20-24 weeks gestation. Understand the risk factors and management strategies.