ABORTION for 2023 cohort (1).pdf

MEDICAL SURGICAL NURSING II DISORDERS OF THE FEMALE REPRODUCTIVE ORGANS  ABORTIONS PRESENTED BY KAREN NSANDU GIVA  SPECIFIC OBJECTIVES By the end of the lesson, learners should be able to: Define abortion Explain the classifications of abortions, their manife...

MEDICAL SURGICAL NURSING II DISORDERS OF THE FEMALE REPRODUCTIVE ORGANS  ABORTIONS PRESENTED BY KAREN NSANDU GIVA  SPECIFIC OBJECTIVES By the end of the lesson, learners should be able to: Define abortion Explain the classifications of abortions, their manifestations and management Explain the aetiology, clinical manifestations and management of abortions according to their classifications  DEFINITION Abortion – Is an interruption or expulsion of the products of conception before the fetus is viable.  The fetus is viable any time after the 5th month of gestation. Abortion is termination of pregnancy by any means before the foetus is sufficient to developed to survive It is the premature expulsion of products of conception from uterus it can be either spontaneous or induced.  DEFINITION Abortion is the expulsion or extraction from its mother of an embryo or foetus weighing 500gm or less when it is not capable of independent survival. (WHO). It can be spontaneous or induced. CLASSIFICATION 1. Mainly based on whether it was induced or spontaneous 2. Within these two main classifications there are others as follows;  CT.. Spontaneous abortion can be; - Threatened abortion - Inevitable - Complete - Incomplete - Missed - Septic CT..  CLASSIFICATIONS OF ABORTION Induced - septic abortion - elective abortion - therapeutic  CLASSIFICATION 1. Spontaneous abortion is non-induced embryonic or foetal death or passage of products of conception before 20 weeks of gestation. Common in the 2nd or 3rd month of gestation. Incidence 10-20% (10% are induced or deliberate 75% abortions occur before the 16th week rates vary with maternal age; also high in women with past miscarriage  ETIOLOGY OF SPONTANEOUS ABORTION 1. Fetal factors Genetic – 50% of early miscarriage is due to chromosomal abnormalities – numerical defects like trisomy- (baby with 47 instead of 46 chromosomes) Multiple gestation-  AETIOLOGY OF SPONTANEOUS ABORTION CT.. 2. Maternal factors - Endocrine and metabolic factors (10–15%): –diabetes mellitus - anatomical abnormalities (10–15%) cervicouterine factors – cervical incompetence & insufficiency – - congenital malformation of the uterus – - uterine fibroid  TYPES OF SPONTANEOUS ABORTIONS AND THEIR MANAGEMENT CT.. 3. Environmentalfactors – cigarette smoking;–the chemicals in tobacco cross the placenta , exposing the fetus to harmful substances, - alcohol consumption- may cause acute or chronic foetal poisoning - maternal medical illness - cyanotic heart disease – hemoglobinopathies  CT.. 4. Unexplained (40-60%) – in majority, the exact cause is not known. Infections (5%) – viral: rubella, cytomegalo, HIV,.. malaria,.. – Bacterial: chlamydia 5. Immunological disorders (5–10%)— – autoimmune disease antifoetal antibodies which reject the foetus  TYPES OF SPONTANEOUS ABORTIONS, THEIR MANIFESTATIONS AND MANAGEMENT CT.. 1. Threatened abortion is a condition in which abortion has started but has not progressed to a state from which recovery is impossible Clinical features of Spontaneous abortion- the patient, having amenorrhea, complains of: (1) slight bleeding per vagina (2) pain: usually painless; but there may be mild backache or dull pain in lower abdomen the uterus and cervix feel soft. Cervix is CLOSED  CLASSIFICATION CT’D.. Management threatened abortion- Rest: patient should be in bed for few days until bleeding, stops, Use of tocolytic drugs that help delay premature labour by relaxing muscles including uterine muscles therefore inhibiting contractions. Give e.g. Salbutamol 4mg tds orally or Nifedipine 10 mg orally bid.  CT.. Patient may also be given pain relief give analgesics: 80% of pregnancies with threatened abortions reach term. If a live foetus is seen on USS, pregnancy is likely to continue in over 95% cases. If pregnancy continues, there is increased frequency of preterm labour, IUGR  CLASSIFICATION CT.. 2. Inevitable abortion - it is the clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible.  CT.. Clinical features – vaginal bleeding, aggravation of colicky pain in the lower abdomen Sometimes, the features may develop quickly without prior clinical evidence of threatened miscarriage VE reveals dilated cervical os through which the products of conception are felt  CT.. Management done to accelerate the process of expulsion– to maintain strict asepsis If pregnancy < 12 weeks, Manual Vacuum Aspiration is done to evacuate the foetus If pregnancy > 12 weeks, expulsion by oxytocin infusion general measures: – excessive bleeding is controlled by the Oxytocin 10IU IM stat Blood loss is corrected by IV fluid therapy and blood transfusion  CT.. 3. Incomplete abortion - the process of abortion has already taken place, but the entire products of conception are not expelled & a part of it is left inside the uterine cavity  CT.. Clinical features history of expulsion of a fleshy mass per vagina; of incomplete abortion- Continuation of pain in lower abdomen Persistence of vaginal bleeding On assessment, uterus is smaller than the period of amenorrhea – open internal os – varying amount of bleeding On VE the expelled mass is found incomplete Complications: the retained products may cause: (a) bleeding (b) sepsis  CT.. MANAGEMENT Evacuation of the retained products of conception (ercp) uterus is evacuated under general anaesthesia. Med Misoprostol 200 μg is used orally or vaginally every 4 hours Due to its ability to induce uterine contractions and expel retained products of conception.  CT.. 4. Septic abortion any abortion associated with clinical evidences of infection of the uterus and its contents Occurs when products of conception become infected. However, most common cause – attempt at induced abortion by an untrained person without the use of aseptic precautions  CT.. Infection maybe localized in uterus, most common usually associated with spontaneous abortion Infection may spread beyond the uterus to the parametrium, tubes and ovaries or pelvic peritoneum. There may be generalized peritonitis and/or endotoxic shock or jaundice or acute renal failure.  CT.. Clinical features: Fever, abdominal pain and vomiting or diarrhoea a rising pulse rate of 100–120/min or more is a significant finding than even pyrexia. It indicates spread of infection beyond the uterus.  CT.. Examination shows abdominal tenderness, rigidity Vaginal examination reveals: – offensive purulent vaginal discharge – tender uterus usually with patulous os or a boggy feel– soft cervix with open internal os  CT.. Investigations in septic abortion Serum urea, creatinine, electrolytes High vaginal swab blood culture in suspected septicaemia Pelvic USS to detect retained products of conception X-ray abdomen in suspected bowel injury X-ray chest if there is difficulty in respiration  CT.. Complications Immediate: haemorrhage , injury to uterus & adjacent structures spread of infection leads to: – generalized peritonitis – endotoxic shock—mostly due to e. Coli – acute renal failure – thrombophlebitis. All these lead to increased maternal deaths  CT.. Management mild cases – broad spectrum antibiotics started – uterus is evacuated Severe cases, oxygen given by nasal catheter Broad spectrum antibiotics – combination of ampicillin, Gentamicin, IV Flagyl is started – uterus is evacuated in 4-6 hrs of commencing therapy  CT.. 5. Complete abortion is when the products of conception are completely expelled from the uterus, it is called complete miscarriage. Clinical features: there is history of expulsion of a fleshy mass per vagina Followed by subsiding abdominal pain – vaginal bleeding becomes trace or absent  CT.. Bimanual examination reveals: – uterus smaller than the period of amenorrhea – cervical os is closed – bleeding is trace. USS confirms that uterus is empty Management; counsel the patient and encourage FP  CT.. 6. Recurrent miscarriage (habitual abortions) is defined as a sequence of three or more consecutive spontaneous abortions Seen in ~ 1% of all women Risk increases with each successive abortion No underlying cause is found for 50% of recurrent pregnancy loss  CT.. Aetiology of Recurrent miscarriage – Abnormality of the foetus, Chromosomal anomalies Systemic diseases such as maternal infections Hormonal imbalances Anatomic abnormalities Drugs Hydatidiform mole  CT.. Aetiology of Recurrent miscarriage – Developmental weakness of cervix, following: (i) Dilatation and Curettage (D&C) operation (ii) Induced abortion (iii) Vaginal operative delivery through an undilated cervix (iv) Amputation of the cervix or cone biopsy. (v) Multiple gestations and prior preterm birth.  CT.. Diagnosis -History - repeated mid trimester painless cervical dilatation and escape of liquor amnii followed by painless expulsion of the products of conception Speculum and bimanual examination: funnelling of internal os seen in hysterosalpingography (X-ray of uterus and Fallopian tubes) Management Surgical management –cervical cerclage usually at 12-14 wks Shirodkar suture is the type of cerclage used in Malawi. A procedure done to prevent premature birth or miscarriage.  CT.. It involves placing stitches by a non- absorbable tape in the cervix through the vagina to help it stay closed. It reinforces the weak cervix, placed around the cervix at the level of internal os. (competent) cervical competency restored after cerclage operation  CT.. Absolute contraindications to cervical cerclage include; Uterine contractions or labor Unexplained vaginal bleeding Intrauterine or vaginal infection Rupture of fetal membranes Intrauterine death (IUD), major foetal anomaly, A gestational age beyond 28 weeks  CONT Management:  Conservative measures : bed rest Progesterone to support the endometrium and save pregnancy. Abstinence Light diet If infection is present, antibiotics  CONT Cervical cerclage the internal os of the cervix is tied surgically in incompetent cervix in second trimester. Shirodkar suture is the type of cerclage used in Malawi.  TYPES OF SPONTANEOUS ABORTIONS,THEIR MANIFESTATIONS AND MANAGEMENT CT.. Induced - septic abortion - elective abortion - therapeutic 1. Septic – details as above  CT.. 2. ELECTIVE ABORTION A voluntary induced termination of pregnancy by a skilled health care provider. Surgical termination :  D & C ( Vacuum Aspiration).  Medical : Misoprostol 200 vaginally  CT.. 3. Therapeutic abortion Therapeutic termination of pregnancy, also known as therapeutic abortion, is performed to end a pregnancy when the mother's life is at risk or when the foetus has severe abnormalities in major organ systems that make survival after birth unlikely. It may also be done by choice in certain situations.  CT.. Nursing management involves provision of comprehensive care and support to women undergoing the procedure, ensuring their physical and emotional well-being before, during, and after the abortion.  1. Pre-Procedure Care: Assessment: Conduct a thorough medical, obstetric, and gynaecological history. Evaluate the gestational age through ultra-sound. Assess for any contraindications to the procedure, such as medical conditions or allergies. Identify risk factors for complications such as previous surgeries, infections, or blood disorders  CT.. Counselling: Provide accurate information about the procedure Offer emotional support and discuss concerns regarding the decision, considering the psychological impact. Ensure informed consent is obtained. Preparation: Administer pre-operative medications if needed (e.g., antibiotics, pain relief).Explain the preoperative steps, such as fasting or the need for accompaniment. Check baseline vital signs and ensure laboratory work (e.g., blood type, Rh status, haemoglobin) is complete  MEDICAL MGNT Before the procedure, counselling Pelvic examination is performed (USS) Hematocrit to rule out anaemia and RH determination. Before procedure screen for STI to prevent introducing pathogens upwards through the cervix during the procedure.  NURSING MANAGEMENT For all types of abortion Manage anxiety Emotional support psychological support Counselling and provision of available contraceptives methods Maintain confidentiality for your clients. POSTABORTION FAMILY PLANNING  OBJECTIVES Define postabortion family planning List importance of postabortion family planning State when a woman can start Contraceptive Methods after Abortion State special considerations  DEFINING Post-abortion family planning is the initiation and use of family planning methods at the time of treatment for an abortion, or before fertility returns after an abortion (within 11- 14 days after the abortion occurred).  IMPORTANCE OF POST- ABORTION FAMILY PLANNING Helps women who have just experienced abortion or who have just been treated for post-abortion not to conceive too early and allows them to regain their normal health.  CT.. Ideally, these services should be integrated with post-abortion care and offered immediately post-abortion, to prevent increasing likelihood that these women could have unintended pregnancy  IMPORTANCE OF POST-ABORTION FAMILY PLANNING CT… Research has shown that return of fertility after an abortion is fast before the woman has recovered physically and psychologically from the effects of abortion A woman receiving post-abortion care may need other reproductive health services. In particular, a provider can help to assess if the woman might have been exposed to sexually transmitted infection  WHEN TO START CONTRACEPTIVE METHODS AFTER ABORTION Methods that can be started immediately Combined oral contraceptives Progestin-only pills Progestin-only injectable Contraceptive implants Male and female condoms  SPECIAL CONSIDERATIONS Methods that can only be started once infection is ruled out or resolved IUCDs Female sterilization  SPECIAL CONSIDERATIONS CT… Methods that can be started once any injury to the genital tract has healed IUCDs Female sterilization Fertility awareness methods  SPECIAL CONSIDERATIONS CT… IUCD insertion could be inserted immediately after an abortion requires a specifically trained provider. Female sterilization Must be decided upon in advance, and not while a woman is sedated, under stress or in pain. Counsel carefully and be sure to mention available reversible methods as another option. QUESTIONS?