ABORTION

Introduction
One of the most ethical dilemmas the society is facing for decades is the issue on abortion.
There are many strong arguments about the issue for those who are in favor and against it. Abortion
is defined as pregnancy termination. It could be done intentionally (by choice) or accidentally as in
miscarriage. Abortions caused by rape, incest and possible health concerns to mother or baby
constitute just 7%. Social and personal issues are the cause for rest of the abortions.
Many pregnancies are lost in the early weeks than at any other stage of gesitation. While early
pregnancy losses are often considered to be less important than the loss of the baby in later
pregnancy,the loss of a wanted pregnancy is always distressing to the mother irrespective of the
timing. This is particularly true of recurrent abortions. Abortion is one of the complications of early
pregnancy and can either be spontaneous or induced
Abortion is the termination of pregnancy before the fetus becomes viable. Viability is
usually reached at 28weeks when the fetus weighs slightly more than 1000gms. Viable means
capable o f living a separate existence.

Definition
1. Abortion is confined to the period before the 20 th week of pregnancy or the delivery of a
fetus weighing less than 500gm (about one lb) which is 454gm
Cunningham 1993
2. 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
WHO
Incidence
The incidence of abortion is difficult to work out but probably 10-20% of all clinical
pregnancies end in miscarriage & another optimistic figure of 10% are induced illegally. 75%
abortions occur before the 16th week & of these, about 75% occur before the 8th week of pregnancy.

Classification or varieties

Abortion

Spontaneous Induced

Isolated (Sporadic) Recurrent Legal Illegal (criminal)

Septic common
Threatened Inevitable Complete Incomplete Missed Septic (Less common)
Etiology:
It is often complex & in many obscure
In many cases abortions occur primarily as result of ovum which is not viable & in others as
a result of abnormal uterine activity.
The following are the potential causes
Genetic factors
Majority 50% of early miscarriages are due to chromosomal abnormality in the conceptus.
Autosomal trisomy is the commonest cytogenetic abnormality

Endocrine & metabolic factors

Luteal phase defect (LPD) results in early miscarriage implantation & placentation are
not supported adequately.
Deficient progesterone secretion from corpus luteum or poor endometrial response to
progesterone is the cause
Thyroid abnormalities: overt hypothyroidism or hyperthyroidism are associated with
increased fetal loss
Diabetes mellitus when poorly controlled causes increased miscarriage
Hormonal imbalance, maternal diabetes, hypo & hyper thyroidism, inadequate luteal
phase & inadequate production of progesterone by the placenta may lead to abortion

Anatomical abnormalities
Cervico-uterine factors: these are mostly related to the second trimester abortions
Cervical incompetencies
Congenital malformation of the uterus
Uterine fibroid
Intra uterine adhesions

Infections
Transplacental fetal infections occur with most micro organisms & fetal lossws could be
cause
Viral: rubella, cytomegalo, variola, vaccinia or HIV
Parasitic : toxoplasma, malaria
Bacterial; ureaplasma, Chlamydia, brucella, spirochaete

Immunological disorders
Autoimmune disease-these patients form antibodies against their own tissue & the placenta.
These antibodies ultimately cause rejection of early pregnancy

Alloimmune disease: paternal antigens which are foreign to the mother invoke a protective
blocking antibody response. These blocking antibodies prevent maternal immune cells from
recognizing the fetus as a foreign entity. Therefore, the fetal allograft containing foreign
paternal antigens are not rejected by the mother. Paternal human leukocyte antigen (HLA)
sharing with the mother leads to diminished fetal-maternal immunological interaction &
ultimately fetal rejection

Blood group incompatibility:

Incompatibility ABO group matings may be responsible for early pregnancy wastage & often
recurrent but Rh incompatibility is a rare cause of death of the fetus before 28 th week.
 When the mothers blood group is Rh negative & that of the father id Rh positive the fetal
blood group may be Rh positive & mat therefore haemolysis on account of the immune iso-
antibodies formed in the maternal blood. The haemolysis may causes fetal death & late
abortion. ABO incompatibility may also be an etiological factor

Others
Maternal medical illness: cyanotic heart disease, haemoglobinopathies are
associated with early abortion
Premature rupture of membranes inevitably leads to abortion
Parenteral factors: sperm chromosomal anomaly (translocation) can cause abortion
Inherited thrombophilia causes both early & late miscarriages due to intravascular
coagulation. Protein C resistance is the most common cause.

Environmental factors
Cigarette smoking, alcohol consumption, X-Irradiation & antineoplastic drugs are known to
cause abortion

Various maternal, paternal & fetal causes are responsible for abortion
Foetal factors:
Intrinsic defects of varying degrees in the fertilized ovum
Unsatisfactory uterine environment produces embryonic defects & faculty implantation
Cystic degeneration of the chorionic villi is a common cause producing primary death of the
fertilized ovum & abortion
Hemorrhage into the deciduas is the cause of spontaneous abortion
Infection of the placenta
Placenta praevia, multiple pregnancy, hydramnios in the early months may cause abortion
Umbilical, cord anomalies produce fetal death & abortion occasionally

Maternal factors:
Maternal systematic diseases like maternal acute infections, fevers, HTN, chronic pyelonephritis
Trauma in the early weeks
Effects of drugs
Stress leads to instability or excitability of the autonomic nervous system is the causation of
abortion
Psychogenic trauma may precipitate an abortion

Uterine causes:
Congenital anomalies of the uterus. Fibroid tumours of the uterus.
Cervical incompetence either congenital or acquired as a result of obstetric or surgical
trauma
Retroversion of the uterus
Ovarian tumours complicating early pregnancy may produce abortion especially in the
torsion of the tumour

Common cause of abortion

First trimester: Genetic factors
Endocrine factors
Immunological disorders
Infection
Second trimester: Anatomic abnormalities- cervical incompetence, mullerian fusion defects,
uterine synechiae, uterine fibroid
Maternal medical illness
Mechanism of abortion
In the early weeks, death of the ovum occurs first, followed by its expulsion. In the later weeks,
maternal environmental factors are involved leading to expulsion of the fetus which may have signs
of life but is too small to survive.
Before 8 weeks: the ovum, surrounded by the villi with the decidual coverings, is expelled
out intact. Sometimes, the external os fails to dilate so that the entire mass is accommodated
in the dilated cervical canal & is called cervical abortion
8-14 weeks: expulsion of the fetus commonly occurs leaving behind the placenta & the
membranes. A part of it may be partially separated with brisk haemorrhage or remains
totally attached to the uterine wall.
Beyond 14th week; the process of expulsion is similar to that of a mini labour. The fetus is
expelled first followed by expulsion of the placenta after a varying interval

Signs & symptoms

Pain due to uterine contractions
Haemorrhage as the result of separation of the ovum
Dilatation of the cervix due to uterine contractions
Expulsion of a part of or the entire ovum
Depending upon the signs & symptoms the following types of abortions may be recognized

1. Spontaneous abortion;
The process starts of its own accord through natural causes. It is defined as the involuntary
loss of the products of conception prior to 24 weeks gestation

Incidence
15% of all confirmed pregnancies are said to result in a miscarriage, some 80% of which
happen in the first trimester

Etiology: the cause in most instances remain unknown

Foetal causes: 50% are due to chromosomal abnormalities of the conceptus. Genetic &
structural abnormalities cause pregnancy loss

Maternal causes: structural abnormalities of the genital tract such as retroversion of

uterus, bicornuate uterus & fibroids.
Infections such as rubella, gonorrhea & Chlamydia
Maternal diseases such as diabetes, renal diseases & thyroid dysfunction
Environmental factors: excessive consumption of alcohol & cigarette smoking
Multigravidae are more at risk than primigravidae

Types of spontaneous abortion

Threatened
Inevitable
Complete
Incomplete
Missed
Septic
TYPE OF BLEEDING PAIN CERVICAL DILATION TISSUE PASSAGE
ABORTION
Threatened Slight Mild cramping No No
Inevitable Moderate Moderate cramping Yes No
Incomplete Heavy Severe cramping Yes Yes
Complete Decreased; slight Mild cramping No Yes
Missed None; slight None No No

Threatened abortion:
In this condition after a period of amenorrhoea, the mother complaints of slight coliky pain in the
lower abdomen associated perhaps with backache, frequency of micturation & slight bleeding per
vaginum. The cervix found softened, uterus enlarged & more or less globular size depending on the
period of pregnancy. The os is generally closed. There is no actual sign suggestive of death or
expulsion of a portion of the ovum. 70-80% of all mothers, diagnosed as having a threatened
miscarriage in the first trimester continue with their pregnancies to term. If the bleeding settles &
the pregnancy continues, subsequently management should take account of the possibility of intra-
uterine growth retardation due to poor placental function. There is also an increased risk of a
preterm labour.
If the loss persists, the pain may become rhythmical & the uterus contracts to expel its
contents as the miscarriage becomes inevitable.

Definition:
Threatened abortion is a clinical entity where the process of abortion has started but has not
progressed to a state from which recovery is impossible

Clinical features:
The patient, having symptoms suggestive of pregnancy, complains of:
1. Bleeding per vaginum: -slightly bright red in colour.
2. Pain-usually painless bleeding, but there may be mild backache or dull pain in lower abdomen.
Pain appears usually following haemorrhage

Pelvic examination should be done gently(avoided if USG available)

Speculum examination reveals-bleeding.(if escapes through external os)
Digital examination-revarls closed external os
The uterine sixe xorresponds to the period of amenorrhoea
The uterine & cervix feel soft

Investigations:
Routine investigations:
1. Blood-hemoglobin, hematocrit, ABO & Rh grouping
2. Urine for immunological test of pregnancy
3. USG: reveals a well formed gestation ring with central echoes from the embryo indicating
healthy fetus.
4. Observation of fetal cardiac motion
5. A blighted ovum evidenced by loss of definition of the gestation sac, smaller mean
gestational sac diameter, absent fetal echoes & absent fetal cardiac movements
Treatment:
Rest-for few days
Drugs- sedation & relief of pain phenobarbitone 30mg or diazepam 5mg given twice daily.

Inevitable abortion:
Vaginal bleeding is heavy, with clots or products of conception. Blood loss may be heavy &
the mother is in a shocked state. The uterus may be smaller than expected the membranes
ruptures, cervix dilates & products may be seen in the vagina. Blood loss may be excessive & if
bleeding to be controlled by syntocinon 20 units intravenously or ergometrine 0.5mg
intravenously or intramuscularly can be given.
The pain experienced by the mother may be intense so adequate analgesia can be given.

Definition
Inevitable abortion is the clinical type of abortion where the changes have progressed to a state
from where continuation of pregnancy is possible.

Clinical features
Increased vaginal bleeding
Aggravation of pain in the lower abdomen which may be colicky in nature
Internal examination reveals dilated internal os of the cervix through which the products of
conception are felt

Management:
General measures:
Excessive bleeding should be promptly controlled by administering Methergin 0.2mg if the cervix is
dilated & the size of the uterus is less than 12 weeks. The shock is corrected by intravenous fluid
therapy & blood transfusion

Active treatment:
Before 12 weeks:
- Dilatation & evacuation followed by curettage of the uterine cavity blunt
curette under general anaesthesia
- Alternatively, suction evacuation followed by curettage is done
After 12 weeks:
- Uterine contraction is accelerated by oxytocin drip (10 units in 500 ml of
normal saline) 40-60 drops per minute.
- If bleeding is profuse with the cervix closed-evacuation of the uterus may
have to be done by abdominal hysterectomy.

Complete abortion:
The conceptus, placenta & membranes are expelled completely from the uterus. Once this
has occurred, pain subsides & bleeding decreases. The uterus on palpation, is firmly contracted &
is empty. Cervical canal may be closed. No further medical intervention is required, although
support to the mother is required.

Definition
When the products of conception are expelled, it is called complete abortion
Clinical features:
Subsidence of abdominal pain
Vaginal bleeding becomes trace or absent
Internal examination reveals
- Uterus smaller than the period of amenorrhoea & a little firmer
- Cervical os is closer
- Bleeding is trace
- Examination of the expelled fleshy mass is found intact

Management:
The effect of blood loss, if any, should be assessed & treated
Transvaginal sonography is useful to prevent unnecessary surgical procedure

Incomplete Abortion:
When only a part of the products of conception has been expelled, it is termed incomplete
abortion. Remnants of placenta remain within the uterine cavity contributing to the degree of
bleeding which may be heavy & profuse. Intravenous or intramuscular ergometrine 0.5 mg may be
given to control the loss. Evacuation under general anesthesia to remove any retained tissue should
be done, once the mother is in a stable condition.

Definition
When the entire products of conception are not expelled, instead a part of it is left inside the
uterine cavity, it is called incomplete abortion

Clinical features:
History of expulsion of a fleshy mass per vaginum followed by
Continuation of pain lower abdomen, colicky in nature
Persistence of vaginal bleeding varying magnitude
Internal examination reveals-
- Uterus smaller than the period of amenorrhoea,
- patulous cervical os often admitting tip of the finger,
- varying amount of bleeding,
- on examination the expelled mass is found incomplete

Termination
The products left behind may lead to
a. profuse bleeding
b. sepsis
c. placental polyps
d. rarely choriocarcinoma

Management:
Early abortion: dilatation & evacuation under general anesthesia
Late abortion- the uterus is evacuated under general anesthesia & the products are removed by
ovum forceps or by blunt curette

Missed abortion:
 When the fetus has died but is retained, the products of conception are often spontaneously
expelled within 4-5weeks of fetal death. In this condition, the symptoms of abortion occur but
subside later, without any part of the ovum being expelled. A brown loss originating from the
degeneration of placental tissue may present. There is a reduction & then cessation of the
symptoms of pregnancy. Uterine growth stops. Treatment of missed abortion is evacuation of the
uterus by dilatation & curettage under general anesthesia.
During D & C procedure the cervical canal is gently dilated to allow a small curette to be
introduced into the uterine cavity. The curette is used to remove any retained products.

Septic abortion
This condition is most commonly a complication of induced or incomplete abortion & is due
to ascending infection. In addition to the signs of miscarriage, the mother complaints of feeling
unwell & may have headache, nausea, pyrexia. There is a localized infection in the uterine tubes &
the uterine cavity or as generalized septicemia with peritonitis.
Blood culture & vaginal swabs should be taken to identify the cause of the infection.
Intravenous 7 antibiotics should be given to control infection.

RECURRENT ABORTION
This term refers to any case in which there is have been three or more consecutive
spontaneous miscarriages.
Unless each successive abortion occurred about the same time and in a similar fashion it
should not be assumed that there is a common underlying cause.
Approximately 1-4% are habitual aborters
There is increased risk of abortion after a previous abortion.
Repeated midtrimester abortions may result from cervical in competence.

Abortion Types Characteristics Management

occurring before the 20th week 1. Bedrest
Threatened of gestation 2. No coitus up to 2 weeks after
Abortion characterized by cramping and bleeding stopped
vaginal bleeding with no cervical
dilation.
it may subside or an incomplete
abortion may follow.
Imminent or membranes rupture and the 1. Hospitalization
Inevitable cervix dilates 2. D and C
Abortion characterized by lower 3. Oxytocin after D and C
abdominal cramping and 4. Sympathetic
bleeding. 5. Understanding and emotional
support
Incomplete is characterized by expulsion of 1. D and C
Abortion only part of the products of 2. Oxytocin after D and C
conception (usually the fetus). 3. Sympathetic
severe uterine cramping 4. Understanding and emotional
bleeding occur with cervical support
dilation.
characterized by complete 1. There is no treatment other than
Complete Abortion expulsion of all products of
conception
light bleeding
mild uterine cramping
passage of tissue
closed cervix
Missed Abortion intrauterine pregnancy is
present but is no longer
developing normally
the cervix is closed, and the
client may report dark brown
vaginal discharge.
pregnancy test findings are
negative.
rest is usually needed.
2. All of the tissues that came out
should be saved for examination by
a doctor to make sure that the
abortion is complete.
3. The laboratory examination of the
saved tissue may determine the
cause of abortion.
1. Usually treated by induction of
labor by dilation (or dilatation) and
curettage (D & C).

Recurrent characterized by spontaneous 1. Trace the cause of recurrent

orHabitual abortion of three or more abortion
Abortion consecutive pregnancies

Septic Abortion abortion complicated by 1. Antibiotics as prescribed by your

infection Obstetrician
foul smelling vaginal discharge
uterine cramping
fever

Management
General management:
Hospitalization
Vaginal /cervical swab for culture
Vaginal examination
Overall assessment
Investigation protocol

Grade-I
Antibiotics
Prophylactic anti gas gangrene of 8000 units & 3000 units of antitetanus serum
intramuscularly
Analgesics & sedatives
Blood transfusion
Evacuation of the uterus

Grade-II
 Antibiotics
Surgery- evacuation of the uterus
Posterior colpotomy

Grade-III
Antibiotics
Clinical monitoring
Supportive therapy

Medical diagnosis & prognosis:

Determining the cause of vaginal bleeding in early pregnancy is essential for accurate
diagnosis.
The vagina & cervix is carefully inspected for cause of possible bleeding. Ultrasound used
todifferentiate between a live fetus & pregnancy loss.

Medical management:
The pregnant mother should contact obstetrician immediately whenever bleeding occur.
Mother may be kept at home bedrest & sexual abstinence may be prescribed. Occasionally
sedatives are ordered to promote relaxation.
If bleeding becomes copious & is accompanied by pains or uterine contractions, immediate
hospitalization, IV therapy for fluid replacement or blood transfusions if necessary.

INDUCTION OF ABORTION
Deliberate termination of pregnancy before the viability of the fetus is alled induction of abortion
The induced abortion may be legal or illegal
In India , the abortion was legalized by medical Termination of Pregnancy Act of 1971, & has
been enforced in the year April 1972. The provisions of the act have been revised in 1975.

MEDICAL TERMINATION OF PREGNANCY

MTP is Medical Termination of Pregnancy. It also called induced abortion. It is the medical way of
getting rid of unwanted pregnancy. Any qualified gynecologist (MD/DGO) can perform MTP. Any
MBBS Doctor, who has obtained training in MTP, is allowed to perform this procedure. However,
MTP should always be performed at a place recognized by government authorities.

Following are the Indications for Medical Termination of Pregnancy

Medical Termination of Pregnancy is legally permitted up to 20 weeks of gestation. Pregnancy
termination performed in first trimester is safer than in second trimester since it has fewer
complications. It is illegal to perform MTP after determining sex of the child as Government of
India has banned sex determination.

Complications of Medically Terminated Pregnancy

Medical Termination of Pregnancy(MTP) is a procedure that is carried out under anesthesia &
increases the risk for the procedure. Patient can have lot of bleeding during & after the procedure.
There are high chances of patient having recurrent abortions. Rarely, patient may not conceive
again if infection sets in.

When pregnancies may be terminated by registered medical practitioners-

(1)Notwithstanding anything contained in the Indian Penal Code (45 of 1860), a registered medical
practitioner shall not be guilty of any offence under that Code or under any other law for the time
being in force, if any pregnancy is terminated by him in accordance with the provisions of this Act.
(2)Subject to the provisions of sub-section (4), a pregnancy may be terminated by a registered
medical practitioner, -
(a) here the length of the pregnancy does not exceed twelve weeks if such medical practitioner is, or
(b) Where the length of the pregnancy exceeds twelve weeks but does not exceed twenty weeks, if
not less than two registered medical practitioner are, of opinion, formed in good faith, that -
(i) the continuance of the pregnancy would involve a risk to the life of the pregnant woman or of
grave injury to her physical or mental health; or

(ii)there is a substantial risk that if the child were born, it would suffer from such physical or mental
abnormalities to be seriously handicapped.

(4)(a)No pregnancy of a woman, who has not attained the age of eighteen years, or, who, having
attained the age of eighteen years, is a lunatic, shall be terminated except with the consent in
writing of her guardian.

(b)Save as otherwise provided in clause (a), no pregnancy shall be terminated except with the
consent of the pregnant woman.

4. Place where pregnancy may be terminated- No termination of pregnancy shall be made in

accordance with this Act at any place other than -
(a) a hospital established or maintained by Government, or
(b) a place for the time being approved for the purpose of this Act by Government.

Nursing management
Nursing assessment:
The nurse must obtain a detailed accurate history including length of gestation, onset,
durtation & intensity of the bleeding episode. Describe the quantity of bleeding in amounts.
Observe presence, nature & location of pains.
Assess blood loss i.e. weighing perineal pads before & after use & then substracting to find
the difference.
Observe pads for any tissues to ascertain whether the abortion is complete.
Observe for signs of shock, syncope.

Nursing Diagnosis:
Anxiety related to uncertainty of pregnancy outcome
Fluid volume deficit related to excessive blood loss from spontaneous abortion
Anticipatory grieving related to actual or threatened loss of pregnancy
Pain related to uterine contractions
Risk for infection related to retained products of conception
Situational low self esteem related to inability to carry pregnancy to term successfully.

Nursing interventions are based on the type of abortion, prognosis & identified nursing diagnosis
Complete bed rest & restriction of activities
Well balanced diet
Inspection of perineal pads
Explanations to mother regarding prognosis
Monitor mothers status i.e. vital signs, amount of bleeding, comfort level, facilitate
diagnostic tests.
Psychosocial support
She may express guilt & blame. So verbalization o
 1. Nursing Diagnosis : Risk for fluid volume deficit r/t maternal bleeding
Nursing Interventions
Report any tachycardia, hypotension, diaphoresis, or pallor, indicating hemorrhage and
shock.
Draw blood for type and screen for possible blood administration.
Establish and maintain an IV with large-bore catheter for possible transfusion and large
quantities of fluid replacement.

2. Nursing Diagnosis : Anticipatory grieving r/t loss of pregnancy, cause of abortion, future
childbearing
Nursing Interventions
Assess the reaction of patient and support person, and provide information regarding
current status, as needed.
Encourage the patient to discuss feelings about the loss of the baby include effects on
relationship with the father.
Do not minimize the loss by focusing on future childbearing; rather acknowledge the loss
and allow grieving.
Providing time alone for the couple to discuss their feelings.

3. Nursing Diagnosis : Risk for infection r/t dilated cervix and open uterine vessels
Nursing Interventions
Evaluate temperature q 4H if normal, and every 2H if elevated.
Check vaginal drainage for increased amount and odor, which may indicate infection.
Instruct on and encourage perineal care after each urination and defecation to prevent
contamination.

4. Nursing Diagnosis : Acute pain r/t uterine cramping and possible procedures
Nursing Interventions
Instruct patient on the cause of pain to decrease anxiety.
Instruct and encourage the use of relaxation techniques to augment analgesics.
Administer pain medication as needed and as prescribed.

5. Nursing Diagnosis : Knowledge deficit r/t signs and symptoms of possible complications
Nursing Interventions
Teach the woman to observe for signs of infection (fever, pelvic pain, change in character
and amount of vaginal discharge), and advise to report them to provider immediately.
Deal with clients anxiety.
Present information out of sequence, if necessary, dealing first with material that is most
anxiety producing when the anxiety is interfering with the clients learning process.
Teach client of the complications for a mother has reason to be especially worried about her
infants health.