easy for the students those who want to study abortion in a easy way

1. WELCOMEWELCOME

2. ABORTION

3. Definition
• “Abortion is the expulsion or extraction from its mother of an
embryo or fetus weighing 500 gm or less when it is not capable
of independent survival”
Dutta D. C
• “Abortion is defined as [a] fetus or embryo removed or expelled
from the uterus during the first half of gestation—20 weeks or
less, or in the absence of accurate dating criteria, born weighing
< 500 g."
-The National Center for Health Statistics

4. CLASSIFICATION OF ABORTION
SPONTANEOUS
INDUCED

6. Spontaneous abortion
• Abortion occurring without medical or mechanical means to
empty the uterus is referred to as spontaneous
• Another widely used term is miscarriage
• Pathology
• Hemorrhage into the decidua basalis, followed by necrosis of
tissues adjacent to the bleeding
• If early, the ovum detaches, stimulating uterine contractions
• Gestational sac is opened , fluid surrounding a small
macerated fetus or alternatively no fetus is visible →
blighted ovum

7. Spontaneous abortion
• Pathology
• In later abortion, the retained fetus may undergo maceration
• The skull bones collapse, the abdomen distends with
blood- stained fluid, and the internal organs degenerate
• The skin softens and peels off in utero or at the slightest
tough
• When amniotic fluid is absorbed, the fetus may become
compressed and desiccated →
fetal compressus
• The fetus become so dry and compressed that it resembles
parchment –
a fetus papyraceous

8. Spontaneous abortion
• Etiology
• More than 80 percent of abortions occur in the first
12 weeks of pregnancy
• At least half result from chromosomal anomalies
• After the first trimester, both the abortion rate & the
incidence of chromosomal anomalies decrease

9. Spontaneous abortion
• The exact mechanism responsible for abortion are not
apparent
• In the first 3 months of pregnancy
• Death of the embryo or fetus nearly always precedes
spontaneous expulsion of the ovum
• Finding of the cause of early abortion involves
ascertaining
the cause of fetal death
• In subsequent months
• The fetus frequently does not die before expulsion
− Other explanations for its expulsion should be sought

10. Spontaneous abortion - Fetal
factors
• Abnormal zygotic development
• Early spontaneous abortion commonly display a
developmental abnormality of the zygote, embryo, early fetus,
or placenta
• 1000 spontaneous abortions analyzed by Hertig and Sheldon
• Half demonstrated degenerated or absent embryos, that
is,
blighted ova

11. F9-3

12. Spontaneous abortion - Fetal
factors
• Aneuploid abortion
• Approximately 50 to 60 percent of embryos and early
fetuses
that are spontaneously aborted contain chromosomal
abnor-malities accounting for most of early pregnancy
wastage
• Jacobs and Hassold (1980)
• 95 percent of chromosomal abnormalities
− d/t maternal gametogenesis error
• 5 percent → d/t paternal error

13. Spontaneous abortion - Fetal
factors
• Aneuploid abortion - Autosomal trisomy
• The most frequently identified chromosomal anomaly
associated with first-trimester abortions
• Most trisomies result from isolated nondisjunction , balanced
structural chromosomal rearrangements are present in one
partner in 2 to 4 percent of couples with a history of recurrent
abortions
• Autosomes 13, 16, 18, 21, and 22 – most

14. Spontaneous abortion - Fetal
factors
• Monosomy X
• The second frequent chromosomal abnormality
• Usually results in abortion
• Much less frequently in liveborn female infant (Turner
syndrome)
• Triploidy
• Associated with hydropic placental (molar) degeneration
• Incomplete (partial) hydatidiform moles may contain triploidy
or trisomy for only chromosome 16

15. Spontaneous abortion - Fetal
factors
• Tetraploid abortuses
• Rarely are liveborn and most often are aborted early in
gestation
• Chromosomal structural abnormalities
• Identified only since the development of banding techniques,
infrequently cause abortion

16. Spontaneous abortion - Fetal
factors
• Euploid abortion
• Abort later in gestational than aneuploid
• Three fourths of aneuploid abortions occurred before8 weeks
• Euploid abortions peak at about 13 weeks
• The incidence of euploid abortions increased dramatically
after maternal age exceeded 35 years

17. Spontaneous abortion – Maternal
factors
• Infections
• Uncommon causes of abortion in human
• Listeria monocytogenes
• Clamydia trachomatis
• Mycoplasma hominis
• Ureaplasma urealyticum
• Toxoplasma gondii

18. Spontaneous abortion – Maternal
factors
• Chronic debilitating diseases
• In early pregnancy, fetuses seldom abort secondary to
chronic wasting disease such as tuberculosis or
carcinomatosis

19. Spontaneous abortion – Maternal
factors
• Endocrine abnormalities
• Hypothyroidism
• Iodine deficiency associated with excessive
miscarriages
• Thyroid autoantibodies → incidence of abortion↑
• Diabetes mellitus
• The rates of spontaneous abortion & major congenital
malformations
• Poor glucose control → incidence of abortion↑
• Progesterone deficiency
• Luteal phase defect
• Insufficient progesterone secretion by the corpus
luteum or placenta

20. Contd…
• Nutrition
• Dietary deficiency of any one nutrients → not important cause
• Drug use and environmental factor
• Tobacco
• ↑ Risk for euploid abortion
• More than 14 cigarettes a day → the risk twofold greater ↑
• Alcohol
• Spontaneous abortion & fetal anomalies → result from frequent
alcohol use during the first 8 weeks of pregnancy
• Drinking twice a week → abortion rates doubled ↑
• Drinking daily → abortion rates tripled ↑
• Caffeine
• At least 5 cups of coffee per day → slightly increased risk of
abortion

21. Contd…
• Drug use and environmental factor
• Radiation
• Contraceptives
• When intrauterine devices fail to prevent pregnancy →
abortion↑
• Environmental toxins
• Anesthetic gases : exact fetal risk of chronic maternal exposure
is unknown
• Arsenic, lead, formaldehyde, benzene, ethylene oxide →
abortifacient
• Video display terminal & accompanying electromagnetic fields
short waves & ultrasound do not increase the risk of abortion

22. • Immunological factors – autoimmune factors
• Recurrent pregnancy loss patients : 15%
• Antiphospholipid antibody : most significant
• LCA (lupus anticoagulant), ACA (anticardiolipin Ab)
• Reduce prostacyclin production
→ facilitating thromboxane dominant milieu → thrombosis
• Prostacyclin : produced by vascular endothelial cell
→ potent vasodilator & inhibit platelet aggregation
• Thromboxane A2 : produced by platelets
→ vasoconstrictor & platelet aggregator
• Strong association with
− Decidual vasculopathy , placental infarction, fetal growth
restriction
Early-onset preeclampsia, recurrent abortion, fetal death

23. Spontaneous abortion – Maternal
factors
• Immunological factors – autoimmune factors
• Therapy of anti phopho lipid antibody syndrome
: low dose aspirin, prednisone, heparin, intravenous
Ig
→ affect both immune & coagulation system
→ counteract the adverse action of antibodies

24. Spontaneous abortion – Maternal
factors
• Inherited thrombophilia
• Many studies of aggregated thrombophilias
→ excessive recurrent abortions
• Laparotomy
• Surgery performed during early pregnancy
→ no evidence of tncreased abortion
• Peritonitis increases the likelihood of abortion
• Physical trauma
• Major abdominal trauma → abortion↑

25. • Uterine defects – acquired uterine defects
• Uterine leiomyoma : usually do not cause abortion
• Placental implantation over or in contact with myoma
→ placental abruption, abortion, preterm labor ↑
→ location is more important than size
• Uterine synechiae (Asherman syndrome)
• Partial or complete obliteration of the uterine cavity by
adherence of uterine wall
• Cause : destruction of large areas of endometrium by curettage
→ insufficient endometrium to support implantation &
menstruation
→ recurrent abortion, amenorrhea, hypomenorrhea

26. Spontaneous abortion – Maternal
factors
• Uterine defects – developmental uterine defects
• Consequence of abnormal mullerian duct formation or fusion
• Spontaneously
• Induced by in utero exposure to DES (diethylstilbestrol)
Bi Septate
Bi carnuate

27. • Incompetent cervix
• Painless dilatation of cervix in the 2nd
or early in the 3rd
trimester
→ prolapse & ballooning of membranes into vagina
→ rupture of membrane & expulsion of immature fetus
• Unless effectively treated, tends to repeat in each pregnancy
• Diagnosis in nonpregnant women
• Hysterography
• Pull-through techniques of inflated Foley catheter balloons
• Acceptance without resistance at the internal os of specifically sized
cervical dilators
• The use of trans vaginal ultrasound in pregnant women
• Cervical length - shortening
• Funneling

28. Spontaneous abortion – Maternal
factors
• Incompetent cervix – Cerclage procedures
• Types of operations commonly used
• McDonald
• Modified Shirodkar
→ 85~90% success rate

31. Spontaneous abortion – Paternal
factors
• Little is known in the genesis of spontaneous abortion
• Chromosomal translocations in sperm can lead to
abortion

32. Categories of spontaneous
abortion
• Threatened abortion
• Inevitable abortion
• Complete
• incomplete abortion
• Missed abortion
• Recurrent abortion
• Septic

33. Threatened abortion
• Definition
• Any bloody vaginal discharge or bleeding during 1st
half of
pregnancy
• Bleeding is frequently slight, but may persist for days or weeks
• Frequency
• Extremely common (one out of four or five pregnant women)
• Prognosis
• Approximately ½ will abort
• Risk of preterm delivery, low birthweight, perinatal death↑
Categories of spontaneous abortionCategories of spontaneous abortion

34. Threatened abortion
• Symptoms
• Usually bleeding begins first
• Cramping abdominal pain follows a few hours to several days later
• Presence of bleeding & pain
→ Poor prognosis for pregnancy continuation
• Treatment
• Bed rest & acetaminophen-based analgesia
• Progesterone (IM) or synthetic progestational agent (PO or IM)
• Lack of evidence of effectiveness
• Often results in no more than a missed abortion
• D-negative women with threatened abortion
• Probably should receive anti-D immunoglobulin

35. Threatened abortion
• Treatment : slight bleeding persists for weeks
• Vaginal sonography
• Serial serum quantitative hCG
• Serum progesterone
→ can help ascertain if the fetus is alive & its location
• Vaginal sonography
• Gestational sac(+) & hCG < 1000mIU/ml
→ gestation is not likely to survive
→ If any doubt(+), check the serum hCG level at intervals of 48hrs
→ if not increase more than 65%, almost always hopeless
• Serum progesterone value < 5 ng/ml
→ dead conceptus

36. Threatened abortion
• Treatment : after death of conceptus
• Uterus should be emptied
→ examination of all passed tissue whether the
abortion is complete
• Ectopic pregnancy should be considered if
gestational sac or
fetus are not identified

37. Inevitable abortion
• Gross rupture of membrane, evidenced by leaking amnionic fluid, in the
presence of cervical dilatation, but no tissue passed during 1st
half of
pregnancy
• Placenta (in whole or in part) is retained in the uterus
→ Uterine contractions begin promptly or infection develops
• The gush of fluid is accompanied by bleeding, pain, or fever,
abortion should be considered inevitable

38. Complete or incomplete
abortion
• Complete abortion
• Following complete detachment & expulsion of the conceptus
• The internal cervical os closes
• Incomplete abortion
• Expulsion of some but not all of the products of conception during 1st
half of pregnancy
• The internal cervical os remains open & allows passage of blood
• The fetus & placenta may remain entirely in utero or may partially
extrude through the dilated os
→ Remove retained tissue without delay

39. Missed abortion
• Retention of dead products of conception in utero for several weeks
• Many women have no symptoms except persistent amenorrhea
• Uterus remain stationary in size, but mammary changes usually
regress → uterus become smaller
• Most terminates spontaneously
• Serious coagulation defect occasionally develop after prolonged
retention of fetus

40. Recurrent abortion
• Definition : Three or more consecutive spontaneous abortions
• Clinical investigation of recurrent miscarriage
• Parental cytogenetic analysis
• Lupus anticoagulant & anticardiolipin antibodies assays
• Post conceptional evaluation
• Serial monitoring of ß–hCG from missed menses period
• ß–hCG>1500mIU/ml → USG
• Maternal serum α-fetoprotein assessment (GA16-18wks)
• Amniocentesis → fetal karyotype
• Prognosis
• Depends on potential underlying etiology & number of prior losses

41. Septic abortion
• A septic abortion or septic miscarriage is a form of
miscarriage that is associated with a serious
uterine infection. The infection carries risk of
spreading infection to other parts of the body and
cause septicemia, a grave risk to the life of the
woman
Causes
• A septic abortion can occur when bacteria enters the
uterus. The bacteria may also belong to the vaginal
flora. Also, sexually transmitted infections (STI) such
as chlamydia may also cause septic abortion.

42. Symptoms
• High fever, usually above 101 °F
• Chills
• Severe abdominal pain and/or cramping /or strong
perineal pressure
• Beginning miscarriage symptoms (heavy bleeding
and or cramping) that suddenly stops and does not
resume
• Prolonged or heavy vaginal bleeding
• Foul-smelling vaginal discharge
• Backache or heavy back pressure

43. Managament
• The woman should have intravenous fluids to
maintain blood pressure and urine output.
Broad-spectrum intravenous antibiotics
should be given until the fever is gone.
• Prevention
• Better birth control and legal abortion (to prevent
unsafe abortions) have dramatically reduced the
number of septic abortions. To decrease the risk
further, a woman should be tested for common
sexually transmitted infections in the first trimester of
her pregnancy. If a woman thinks she might be
miscarrying or has miscarried, she should call her
healthcare provider immediately.

44. INDUCED ABORTION

45. Induced abortion
• The medical or surgical termination of pregnancy before
the time of fetal viability
• Therapeutic abortion
• Termination of pregnancy before of fetal viability for
the purpose
of saving the life of the mother

46. Induced abortion
• Indication
• Continuation of pregnancy may threaten the life of women or seriously
impair her health
• Persistent heart disease after cardiac decompensation
• Advanced hypertensive vascular disease
• Invasive carcinoma of the cervix
• Pregnancy resulted from rape or incest
• Continuation of pregnancy is likely to result in the birth of child with
severe physical deformities or mental retardation

47. Induced abortion
• Elective (voluntary) abortion
• Interruption of pregnancy before viability at the request
of the women, but not for reasons of impaired maternal
health or
fetal disease
• Counseling before elective abortion
• Continued pregnancy with its risks & parental responsibilities
• Continued pregnancy with its risks & its responsibilities of
arranged adoption
• The choice of abortion with its risks

48. Surgical techniques for abortion
• Dilatation and curettage
• Performed first by dilating the cervix & evacuating the product of
conception
• Mechanically scraping out of the contents (sharp curettage)
• Vacuum aspiration (suction curettage)
• Both
• Before 14 weeks, D&C or vacuum aspiration should be performed
• After 16 weeks, dilatation & evacuation (D&E) is performed
• Wide cervical dilatation
• Mechanical destruction & evacuation of fetal parts

49. Surgical techniques for abortion
• Hygroscopic dilators
: swell slowly & dilate cervix → cervical trauma can be minimized
• Laminaria tents
: stem of brown seaweed ( Laminaria digitata or japonica)
→ drawing water from proteoglycan complexes of cervix
→ dissociation allow the cervix to soften & dilate
• Insertion technique : tip rests just at the level of internal os
• Usually after 4-6hours, laminaria dilate the cervix sufficiently to
allow easier mechanical dilation & curettage
• May cause cramping pain
→ easily managed with 60 mg codeine every 3-4 hours

53. Surgical techniques for
abortion
• Menstrual aspiration
• Aspiration of endometrial cavity using a flexible cannula and
syringe within 1-3 weeks after failure to menstruate
• Several points at early stage of gestation
• Woman not being pregnant
• Implanted zygote may be missed by the curette
• Failure to recognize an ectopic pregnancy
• Infrequently, a uterus can be perforated

54. Surgical techniques for abortion
• Laparotomy
• Abdominal hysterotomy or hysterectomy
• Indications
• Significant uterine disease
• Failure of medical induction during the 2nd
trimester

55. Medical induction of abortion
• Early abortion
• Outpatient medical abortion is an acceptable alternative
to surgical abortion in women with pregnancies of less
than 49 days’ gestation
• Three medications for early medical abortion
• Antiprogestin mifeprostone
• Antimetabolite methotrexate
• Prostaglandin misoprostol

56. Medical induction of abortion
• Oxytocin
• Successful induction of 2nd
trimester abortion is possible with
high doses of oxytocin administered in small volumes of IV
fluids
• Satisfactory alternatives to PG E2 for midtrimester abortion
• Laminaria tents inserted the night before
• Chance of successful induction is greatly enhanced

57. Prostaglandins
• Used extensively to terminate pregnancies, especially in the 2nd
Trimester
• PG E1, E2, F2α
• Technique
: Can act effectively on the cervix & uterus (86~95% effectiveness)
• Vaginal prostaglandin E2 suppository & prostaglandin E1
(misoprostol)
• As a gel through a catheter into the cervical canal & lowermost
uterus
• Injection into the amnionic sac by amniocentesis
• Parenteral injection
• Oral ingestion

58. Intra-amnionic hyperosmotic
solutions
• 20-25% saline or 30-40% urea injected into amnionic sac
→ stimulate uterine contraction & cervical dilatation
• Action mechanism : prostaglandin mediated
• Complications of hypertonic saline
• Death
• Hyperosmolar crisis (early into maternal circulation)
• Cardiac failure
• Septic shock
• Peritonitis
• Hemorrhage
• DIC
• Water intoxication
− Hyperosmotic urea : less likely to be toxic

59. Resumption of ovulation after
abortion
• Ovulation may resume as early 2 weeks after an
abortion
• Therefore, if pregnancy is to be prevented,
effective contraception should be initiated soon after
abortion

60. Contra indications
• • pregnancy beyond 63 days of gestation
• • suspected ectopic pregnancy
• • evidence of adrenal dysfunction
• • hemorrhagic disorders treated with anti-coagulants
• • where the duration of pregnancy is not known

61. Side effects
• • nausea
• • occasional vomiting
• • malaise
• • faintness
• • headache
• • skin rashes

62. Signs and symptoms of abortion
• Bleeding which progresses from light to heavy
• Severe cramps
• Abdominal pain
• Fever
• Weakness
• Back pain

63. Ultra sound riteria
• Crown-rump length of at least 7 mm and no heartbeat.
• Mean gestational sac diameter of at least 25 mm and no embryo.
• Absence of embryo with heartbeat at least 2 weeks after an
ultrasound scan that showed a gestational sac without a yolk sac.
• Absence of embryo with heartbeat at least 11 days after an
ultrasound scan that showed a gestational sac with a yolk sac.

64. MTP Act
• 1971
• Indications
• Pre requisites
• Performing personnel

65. Post abortion care
• Prevention
• • Treatment
• • Counseling and services

66. Essential elements
• Community and service provider partnerships for prevention (of
unplanned
• pregnancies and unsafe abortion);
• 2. Counseling to identify and respond to women's emotional and
physical health
• needs and other concerns;
• 3. Treatment of incomplete and unsafe abortion and
complications that are
• potentially life-threatening;
• 4. Contraceptive and family planning services to help women
prevent an unplanned pregnancy or practice birth spacing; and
• 5. Reproductive and other health services that are preferably
provided on-site or via referrals to other accessible facilities in
providers' networks.

67. Nursing assessment
• Vaginal bleeding , spotting, clots
• Low abdominal cramping
• Passing of tissue
• Shock – decreased blood pressure, increased heart
rate.
• Fear, anxiety, disappointment, and feeling of guilt.

68. Nursing diagnoses
• Risk for fatal injury
• Risk for fluid volume deficit
• Ineffective air way clearance
• Actual/ risk for aspiration
• Risk for infection
• Ineffective family coping
• Ineffective family process
• Health seeking behavior

69. IMPLEMENTATION
• Observe for vaginal bleeding and cramping pain
• Save expelled tissue and lot for examination
• Monitor vital signs for every 5 minutes to 4 hours according to the maternal
status
• Maintain woman on bed rest
• Observe for signs of shock, and institute treatment measures
• Prepare for dilation and curettage if appropriate
• Assess signs of infection
• Handle every article in a sterile manner
• Provide support but avoid false assurance.

70. Complication
Shock
Infection
Coagulation failure
Thromboembolism
Infertility

71. Thank you friends