Abortion - A Comprehensive Guide PDF

# ABORTION Abortion is termination or loss of a pregnancy before 24 weeks of gestation. Abortion is the commonest cause of bleeding in early pregnancy and is one of the major causes of maternal deaths worldwide. ## Incidence: - Worldwide, an average of 35 in 1000 women of childbearing age (15-4...

# ABORTION Abortion is termination or loss of a pregnancy before 24 weeks of gestation. Abortion is the commonest cause of bleeding in early pregnancy and is one of the major causes of maternal deaths worldwide. ## Incidence: - Worldwide, an average of 35 in 1000 women of childbearing age (15-49 years) have an abortion each year. - However, this rate ranges from 10 per 1000 women in some countries to around 80 per 1000 women in others. - Despite variations in the legal statues of abortion in developed and developing countries, overall rates are quite similar for both. - Globally, of the approximately 210 million pregnancies that occur each year, estimated 38% are unplanned and 22% result in abortions. - In Developing countries, Nigeria inclusive, 182 million pregnancies occur yearly, with an estimated 36% unplanned and 20% ending in abortions. - In Nigeria, it is estimated that 40% of maternal deaths are from abortion and its complications. The gestational age at which pregnancy is usually terminated is 6/20 6-12 week. The proportion of pregnancies ended by abortion is greatest at the beginning and at the end of a woman’s childbearing life. Abortion can lead to death contributing about 29% of cases in maternal mortality as well as maternal morbidity e.g reproductive health infections and infertility. The provision of quality post-abortion care and counseling will contribute immensely to the reduction of maternal mortality. ## Causes of Abortion ### Maternal Causes 1. Maternal ill-health, such as malaria, anemia, diarrhea/dysentery, tuberculosis, pyelonephritis, hepatoerosion, diabetes, etc. 2. Hormonal imbalance. 3. Uterine malformation e.g bicornuate uterus. 4. Uterine infections e.g endometritis. 5. Submucous fibroids. 6. Cervical incompetence. 7. Exposure to teratogenic chemicals. 8. Effect of certain drugs e.g oxytocin, prostaglandin. 9. Emotional disturbance or extremes of emotions such as grief or fright. 10. Violence - Violent exercises. ### Fetal causes 1. Gross fetal malformation/Maldevelopment. 2. Chromosomal abnormalities. ### Social conditions 1. Teenage pregnancy or unwanted pregnancy. 2. Unmet family needs. 3. Rape etc. ## Signs and Symptoms of Abortion 1. History of missed period precedes vaginal bleeding: The cardinal sign is bleeding per vaginam—this may be slight or profuse depending on the nature or type of the abortion. 2. Pains—Patient may complain of backache and intermittent lower abdominal pain. 3. Membranes may rupture and part of the products of conception may protrude through the dilating cervical os (in inevitable abortion). 4. Bleeding may be profuse and products retained in incomplete abortion. 5. Reddish brown/yellowish green foul smelling vaginal discharge (in septic abortion). 6. On abdominal palpation, there is localized or generalized rebound tenderness. If it is complicated with septicemia, patient looks toxic and jaundiced, and stock. 7. Excessive blood loss will lead to anemia and shock. 8. Signs of shock: cold clammy skin extremities rapid feeble pulse, and lowered blood pressure, and hunger respiration. The general condition of the patient depends on the amount of blood loss and type of abortion. ## Classifications of Abortion Abortion can occur early or late - **Early** - Abortion before 12 weeks of gestation. - **Late** - Abortion between 12 and 24 weeks of gestation. ## Classification & Specific Management of Abortion ### Abortion can either occur spontaneously or may be induced. ### A. Spontaneous Abortion This is the loss of pregnancy before 24 weeks of pregnancy (It is termed as miscarriage). It usually occurs naturally on its own without any interference or may result due to disease or accident. #### Stages of spontaneous abortion #### 1. Threatened Abortion: This may progress to term or cannot be saved and become inevitable. #### Signs & Symptoms of threatened abortion 1. Light bleeding and cramping. 2. Closed cervix. 3. Uterus corresponds to dates. #### Management 1. Woman usually managed in the clinic. 2. Advise to avoid hard work and intercourse. 3. Do not give hormones or tocolytics e.g indomethacin. 4. If bleeding does not stop, refer immediately (may be ectopic pregnancy, twins or molar preg). #### 2. Inevitable Abortion: The abortion is imminent and the pregnancy cannot be saved. #### Signs & Symptoms 1. Heavy bleeding. 2. Progressive dilation of the cervix. 3. Uterus smaller than or corresponds to date. #### Management 1. If pregnancy is less than 16 weeks, perform Manual Vacuum Aspiration (MVA). 2. If MVA is not available, stabilize and refer immediately. 3. Give ergometrine 0.5mg IM (repeat after 15 mins) or misoprostol 400 µg (Micrograms) orally (repeat once after 4 hours, if necessary) 4. If pregnancy is greater than 16 weeks; Avant spontaneous expulsion, infuse oxytocin 5 units in 1 litre of normal saline or Ringers lactate, run at Hod/m. 5. Perform MVA to remove any remaining products of conception. ### 2. Induced Abortion: This is a purposeful or deliberate termination of pregnancy either by the woman herself or someone else with the aim or intention of other than liveborn infants or to remove a dead foetus. Pregnancy may be induced for therapeutic or criminal purposes. Induced abortion may be therapeutic or criminal as follows; **Therapeutic abortion** This is carried out by a qualified medical practitioner in the interest of the mother’s life or her total well being. It is performed for medical reasons. #### Reasons or indications for therapeutic abortion 1. The mother’s life is in danger if she continues with the pregnancy e.g in cardiac failure/dx. 2. The woman needs treatment such as chemotherapy that cannot be performed while she is pregnant. 3. There is risk of severe physical or mental harm to the woman if the pregnancy continues. 4. Fatal foetal abnormality has been detected that will result in miscarriage, stillbirth, or death soon after birth. 5. The foetus has a serious abnormality. 6. Selective reduction of multiple pregnancies may be performed if continuing to carry all of the foetuses would be too risky. For the above medications, it is a very personal choice of the mother. **Criminal/unsafe abortion** This is illegal procurement of abortion, usually performed by unqualified persons (quacks) or persons lacking necessary skills or in an environment lacking minimal infection prevention standard or both and having little regard for the consequences. ### 3. Septic Abortion: Septic abortion is an abortion complicated by infection. Usually sequel of incomplete abortion that is criminally induced. Criminal or unsafe abortion is responsible for about 40% of maternal mortality in Nigeria. #### Signs & symptoms 1. Fever/chills. 2. Foul smelling vaginal discharge. 3. Tender uterus. #### Management 1. Immediately give Ampicillin 2g IV every 6 hours plus Gentamicin 5mg/kg body weight IV every 24 hours plus Metronidazole 500mg IV every 8 hours until woman is fever-free for 48 hours. 2. Prior to 16 weeks, if MVA is available, perform. 3. If after 16 weeks and MVA is not available, give antibiotics and refer immediately. 4. Refer immediately. ## Nursing management of a patient with Abortion **NB** The rule is that the slightest case of vaginal bleeding in pregnancy must be reported by the patient. 1. Reassure patient and relative(s). 2. Take history of last menstrual period (if conscious) to determine the gestational age of the pregnancy. 3. Show empathy. 4. Do not perform vaginal examination. 5. Treat for shock if in shock - place patient in position & elevate foot of bed. 6. Give oxygen 6 – 8 liters per minute if necessary. 7. Keep patient warm. 8. Check vital signs - temperature, pulse, respiration and blood pressure, even oxygen concentration. 9. Prevent hypovolemia by giving rectal fluid (Normal Saline 0.9% in 500mls at Hod/m). 10. If patient is bleeding with clots or products of conception. ### 3. Incomplete abortion: The products of conception are not completely expelled. Usually the foetus is expelled but the placenta and membranes are retained. #### Signs & symptoms 1. Persistent heavy bleeding. 2. Dilated cervix. 3. Uterus smaller than date. #### Management **A. If bleeding is light to moderate and preg. is less than 16 weeks, use ring forceps (if available) to remove Products of conception protruding through the cervix.** 1. Give ergometrine 0.5mg IM (repeat after 15 minutes) or misoprostol 400 µg by mouth (repeat once after 4 hours if necessary). **B. If bleeding is heavy and preg. less than 16 weeks** 1. If MVA is available, perform MVA. 2. If MVA is not available, perform curettage. 3. If MVA and curettage are not available, stabilize with infusion and refer urgently. **C. If bleeding is heavy and preg. is greater than 16 weeks:** 1. If MVA is available infuse oxytocin 10 units in normal saline or Ringers lactate at 40 drops per minute until expulsion of products of conception occurs. 2. If necessary, give misoprostol 200µg vaginally every 4 hours until expulsion (do not give more than 800 µg). 3. Perform MVA to remove any remaining products of conception. 4. Refer urgently (if necessary) ### 4. Complete Abortion: The whole product of conception is expelled completely. It is commoner before the 8th week of pregnancy. #### Signs & symptoms 1. Light bleeding. 2. Closed cervix. 3. Uterus smaller than date. 4. Uterus softer than normal. #### Management 1. Observe for heavy bleeding. 2. Give ergometrine 0.5mg or misoprostol 400µg orally. 3. Refer immediately if bleeding does not stop or is sustained. There is pale brownish vaginal discharge. ### 5. Missed Abortion The foetus dies and is retained. There is painless brownish vaginal discharge. #### Signs & Symptoms 1. Painless brownish vaginal discharge 2. No sign of life in the foetus. 3. The cervix is completely closed. 4. The foetus is likely to be retained in the uterus for some time unless there is an intervention in a specialised or highest available health facility. #### Management 1. Immediately give Ampicillin 2g IV every 6 hours plus Gentamicin 5mg/kg body weight IV every 24 hours plus Metronidazole 500mg IV every 8 hours until woman has taken it for 48 hours. 2. Prior to 16 weeks, if MVA is available, perform; 3. If after 16 weeks and MVA is not available, give antibiotics and refer immediately. 6. Habitual or recurrent abortion: This is when there have been three or more consecutive spontaneous abortions. #### Management 1. Patient is admitted and confined to bed as soon as pregnancy is confirmed. 2. Shirôdkar stitches may be applied at a fixed time by the obstetrician to keep the pregnancy till term and removed before she falls into labour. ## Of Conception 1. Attempt to remove the placenta/retained products of conception. 2. If patient is having painful contraction give analgesics e.g fortwin 30mg intramuscularly. 3. If conscious, give paracetamol 2 tabs (1gm) thrice daily for 3 days, start antibiotics e.g Ampicillin 500mg stat, then 250mg 6 hourly for 5 days. 4. Give sedative e.g valium 10mg orally. 5. Put patient on complete bed rest. 6. Continuous close observation of vital signs. 7. Check abdomen for contraction & vagina for blood loss and offensive vaginal discharge. 8. Check for evidence of attempted intervention. 9. Perform manual vacuum aspiration (MVA) if available. If MVA not available and pain persists or patient’s condition does not stabilize within 24 hours of nursing intervention. 10. Refer immediately for higher medical management. 11. If discharged, counsel for family planning. 12. Counsel on safer sexual activities if septic abortion.