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Abortion -is the termination of pregnancy by the removal or expulsion from the uterus of a
Abortion
-is the termination of pregnancy by the
removal or expulsion from the uterus of
a
fetus
or embryo
prior to viability. A
spontaneous abortion (also
miscarriage) occurs on its
called
a
own.
An
induced
abortion
is
the
intentional
termination of a pregnancy and
expulsion of a fetus, whether by surgery
or the administration of pharmaceuticals.
Type of abortions
Type of abortions
Spontaneous Miscarriage  Interruption of a pregnancy before a fetus is viable (more than 20 to
Spontaneous Miscarriage
Interruption of a pregnancy before a fetus
is viable (more than 20 to 24 weeks of
gestation or one that weighs at least 500
g) without outside intervention
Early miscarriage- if it occurs before
16week of pregnancy
Late miscarriage- occurs between
weeks 16 and 24
Causes:  Abnormal fetal formation, due either to a teratogenic factor or to a chromosomal aberration
Causes:
Abnormal fetal formation, due either to a
teratogenic factor or to a chromosomal
aberration
Immunologic factors
Rejection of the embryo through an immune
response
Implantation of abnormalities (50% of zygotes
are probably never implanted
Corpus luteum fails to produce enough
progesterone to maintain the decidua basalis
Infection (rubella, syphilis, poliomyelitis,
cytomegalovirus, and toxoplasmosis and also
UTI)
Ingestion of teratogenic drugs (isotretinoin)
Ingestion of alcohol
Assessment:  Vaginal spotting Intervention:  Depends on the symptoms and the description of the bleeding
Assessment:
Vaginal spotting
Intervention:
Depends on the symptoms and the
description of the bleeding
Threatened Miscarriage  a condition that suggests a miscarriage might take place early--under 16 weeks; late--16
Threatened Miscarriage
a condition that suggests a miscarriage
might take place early--under 16 weeks;
late--16 to 24 weeks
Causes:
Unknown; possibly chromosomal ,uterine
abnormalities
Assessment:  Vaginal bleeding, initially beginning as scant bleeding, and usually bright red  Slight cramping
Assessment:
Vaginal bleeding, initially beginning as
scant bleeding, and usually bright red
Slight cramping
No cervical dilatation
Diagnostic exam:  Sonogram  Beta HCG (quantitative) test over a period of days or weeks
Diagnostic exam:
Sonogram
Beta HCG (quantitative) test over a period
of days or weeks to confirm whether the
pregnancy is continuing
Complete blood count (CBC) to determine
amount of blood loss
Pregnancy test to confirm pregnancy
Progesterone level
White blood count (WBC)
with differentil to rule out infection
Treatment:  (dilation and curettage or D&C)  avoid or restrict some forms of activity for
Treatment:
(dilation and curettage or D&C)
avoid or restrict some forms of activity for
24 to 48 hours
Not having sexual intercourse for 2 weeks
is usually recommended after bleeding
episode to prevent infection and to avoid
inducing further bleeding.
bedrest
Imminent (Inevitable) Miscarriage  A threatened miscarriage becomes an imminent miscarriage if uterine contractions and cervical
Imminent (Inevitable) Miscarriage
A threatened miscarriage becomes an
imminent miscarriage if uterine
contractions and cervical dilation occur.
With cervical dilation, the loss of the
products of conception cannot be halted.
Assessment:
Vaginal spotting
Cramping
Cervical dilatation
Diagnostic exam:  Sonogram Treatment:  Vacuum extraction (dilation and evacuation)  Suction Curettage
Diagnostic exam:
Sonogram
Treatment:
Vacuum extraction (dilation and
evacuation)
Suction Curettage
Complete Miscarriage  In a complete miscarriage, the entire products of conception (fetus, membranes, and placenta)
Complete Miscarriage
In a complete miscarriage, the entire
products of conception (fetus,
membranes, and placenta) are expelled
spontaneously without any assistance
Assessment:  Vaginal spotting  Cramping  Cervical dilatation  Complete expulsion of uterine contents Diagnostic
Assessment:
Vaginal spotting
Cramping
Cervical dilatation
Complete expulsion of uterine contents
Diagnostic exam:
Ultrasound
Treatment:
If there is no fetal tissue left in the womb
(a complete miscarriage), no further
medical treatment is required
Incomplete Miscarriage  Part of the conceptus (usually the fetus) is expelled, but membrane or placenta
Incomplete Miscarriage
Part of the conceptus (usually the fetus) is
expelled, but membrane or placenta is
retained in the uterus.
Assessment:
Vaginal spotting
Cramping
Cervical dilatation
Incomplete expulsion of uterine contents
Diagnostic exam:  Ultrasound Treatment:  Dilation and curettage  Suction curettage
Diagnostic exam:
Ultrasound
Treatment:
Dilation and curettage
Suction curettage
Missed Miscarriage  (early pregnancy failure), the fetus dies in utero but is not expelled. Assessment:
Missed Miscarriage
(early pregnancy failure), the fetus
dies in utero but is not expelled.
Assessment:
Vaginal spotting
Slight cramping
No apparently loss of pregnancy
Embryo died 4 to 6 weeks before the
onset of miscarriage
Diagnostic exam:  Sonogram Treatment:  Dilation and evacuation  Prostaglandin suppository or misoprostol (Cytotec) to
Diagnostic exam:
Sonogram
Treatment:
Dilation and evacuation
Prostaglandin suppository or misoprostol
(Cytotec) to dilate the cervix, followed by
oxytocin stimulation or administration of
mifepristone
Recurrent Pregnancy Loss  In the past, women who had three spontaneous miscarriages that occurred at
Recurrent Pregnancy Loss
In the past, women who had three spontaneous
miscarriages that occurred at the same gestational age
were called ‘habitual aborters.’ today the term recurrent
pregnancy loss is used to described this miscarriage
pattern, and a thorough investigation is done to discover
the cause and the loss and help ensure the outcome of the
future pregnancy.
Causes:
Defective spermatozoa or ova
Endocrine factors such as lowered levels of protein-bound
iodine (BPI), butanol-extractable iodine (BEI), and
globulin-bound protein (GBI), poor thyroid function, or
luteal phase defect
Deviations of the uterus, such as septate or bicornuate
uterus
Infection
Autoimmune disorders such as those involving lupus
anticoagulant and antiphospholipid antibodies
 Treatment:  surgery to correct problems with the shape of the uterus  medication to
Treatment:
surgery to correct problems with the
shape of the uterus
medication to correct immune problems
and hormone imbalances.
Complication of miscarriage  1. hemorrhage- blood loss  2. infection- who have lost appreciable amounts
Complication of miscarriage
1. hemorrhage- blood loss
2. infection- who have lost appreciable
amounts of blood, most likely from the
debilitating effect of blood loss.
3. septic abortion- complicated in infection.
4. Isoimmunization- by spontaneous birth or
D&C at any point in pregnancy, some blood
from the placental villi may enter maternal
circulation. If the fetus was RH positive and
the woman is Rh negative, enough Rh positive
fetal blood may enter her circulation.
5. powerlessness or anxiety- Assess woman’s
adjustment to spontaneous miscarriage.
Elective Termination of Pregnancy (Induced Abortion)  A procedure performed to deliberately end a pregnancy before
Elective Termination of Pregnancy
(Induced Abortion)
A procedure performed to deliberately end a
pregnancy before fetal viability.
Induced abortions are done for a number of reasons:  To end a pregnancy that threatens
Induced abortions are done for a number of
reasons:
To end a pregnancy that threatens a woman’s
life (e.g., pregnancy in a woman with class IV
heart disease)
To end a pregnancy that involves a fetus
found on amniocentesis to have a
chromosomal defect
To end a pregnancy that is unwanted because
it is the result of rape or incest
To terminate the pregnancy of a women who
chooses not to have a child at this time in her
life for such reasons as being too young, not
wanting to be a single parent, wanting no
more children, or having financial difficulties
Medically Induced Abortion Mifepristone (a progesterone antagonist) is a compound that blocks the effect of progesterone,
Medically Induced Abortion
Mifepristone (a progesterone antagonist) is a
compound that blocks the effect of progesterone,
preventing implantation of the fertilized ovum
and therefore causing abortion. The compound is
taken as a single oral dose of 600mg anytime
within 49 days of gestational age. Three days
later, Misoprostol 400 mcg is administered in a
single oral or vaginal dose.
Methotrexate- an antimetabolite that causes
trophoblastic cell death is also be used although
it is not approved for used in medical abortions
*Mifepristone has additional approved applications, such as regression of uterine leiomyomas, induction of labor, and detoxification
*Mifepristone has additional approved
applications, such as regression of uterine
leiomyomas, induction of labor, and
detoxification in cocaine overdose
* Misoprostol can cause nausea, vomiting,
diarrhea, and severe abdominal cramping
Medical abortion is contraindicated under the following circumstances:  Confirmed or suspected ectopic pregnancy  An
Medical abortion is contraindicated under
the following circumstances:
Confirmed or suspected ectopic pregnancy
An intrauterine device is in place
A woman has a serious medical condition
such as chronic adrenal failure
Current long-term systemic corticosteroid
therapy
History of allergy to mifepristone,
misoprostol, or other prostaglandins
Hemorrhagic disorders or concurrent
anticoagulant therapy
Advantages:  Decrease risk of damage to the uterus through instrument insertion  Decrease use of
Advantages:
Decrease risk of damage to the uterus
through instrument insertion
Decrease use of anesthesia necessary for
surgically performed abortions
Complications:
Incomplete abortion
Possibility of prolonged bleeding
 The woman should return for post- procedure ultrasonography or a pregnancy test to ensure that
The woman should return for post-
procedure ultrasonography or a
pregnancy test to ensure that the
pregnancy has ended.
It is important that women receive
contraceptive counseling after the
procedure so they can avoid having to
undergo such a procedure again in the
future
Surgically Induced Abortion  Elective surgical abortions involve a number of techniques, depending on the gestational
Surgically Induced Abortion
Elective surgical abortions involve a number of
techniques, depending on the gestational age at
the time the abortion is performed.
Menstrual Extraction or Suction Evacuation (5-7 weeks after the LMP)  It is performed on an
Menstrual Extraction or Suction Evacuation
(5-7 weeks after the LMP)
It is performed on an ambulatory basis
Procedure:
The woman voids, and her perineum is washed
with an antiseptic
A speculum is then introduced vaginally, the
cervix is stabilized by a tenaculum, and a narrow
polyethylene catheter is introduced through the
vagina into the cervix and uterus
The lining of the uterus that would be shed with
a normal menstrual flow is then suctioned and
removed by means of the vacuum pressure of a
syringe
Post-op Intervention:  The woman should remain supine for about 15 minutes after the procedure until
Post-op Intervention:
The woman should remain supine for about
15 minutes after the procedure until uterine
cramping quiets, to prevent hypotension in
standing
She may be given oral oxytocin to ensure full
uterine contraction after the procedure
Inform to expect some vaginal bleeding,
similar to a normal menstrual flow, for a
week after the procedure; they may have
occasional spotting for up to 2 weeks
Advised, not to douche, use tampons, or
resume coitus until 1 week after the
procedure, to avoid introducing infection
 Return visit after 2 weeks that include pelvic examination and pregnancy test  It is
Return visit after 2 weeks that include
pelvic examination and pregnancy test
It is important that women receive
contraceptive counseling after the
procedure so they can avoid having to
undergo such a procedure again in the
future
Dilatation and Curettage (gestational age of the pregnancy is less than 13 weeks)  This procedure
Dilatation and Curettage
(gestational age of the pregnancy is less than 13
weeks)
This procedure is usually done in an ambulatory
setting using a paracervical anesthetic block
*A paracervical block does not eliminate pain but
limits what the woman experiences to cramping
and a feeling of pressure at her cervix.
Procedure:  The woman voids, the perineum is washed, the anesthetic block is administered, and the
Procedure:
The woman voids, the perineum is washed, the
anesthetic block is administered, and the cervix
is dilated
The uterus is then scraped clean with the
curette, removing the zygote and trophoblast
cells with the uterine lining.
Post-op Intervention:  The woman remains in the hospital or clinic for 1-4 hours with careful
Post-op Intervention:
The woman remains in the hospital or
clinic for 1-4 hours with careful
assessment of v/s and perineal care
She may be given oxytocin to ensure firm
uterine contruction and minimize bleeding
Offer contraceptive counseling to avoid
repeat procedure
Complications:  Uterine perforation from the instruments used and carries increased risk of uterine infection because
Complications:
Uterine perforation from the instruments
used and carries increased risk of uterine
infection because of greater cervical
dilatation
*woman may be given prophylactic
antibiotics to prevent infection
Dilatation and Vacuum Extraction (between 12 and 16 weeks)  Inpatient or an ambulatory procedure Procedure:
Dilatation and Vacuum Extraction
(between 12 and 16 weeks)
Inpatient or an ambulatory procedure
Procedure:
Dilatation of the cervix is begun the day before
the procedure by administration of oral
misoprostol or insertion of a laminaria tent
(seaweed that has been dried and sterilized) into
the cervix under sterile conditions
Over a 24-hour period, gradually, painlessly, and
without trauma, it dilates the cervix enough for a
vacuum extraction tip to be inserted
After either misoprostol or laminaria dilatation or
dilatation by traditional dilators, a narrow suction
tip is specially designed for the incompletely
dilated cervix is introduced into the cervix
 The negative pressure of a suction pump or vacuum container then gently evacuates the uterine
The negative pressure of a suction pump
or vacuum container then gently
evacuates the uterine contents over a 15
minute period
Post-op Intervention:  The woman lies flat for at least 15 mins.  The woman remains
Post-op Intervention:
The woman lies flat for at least 15 mins.
The woman remains in the hospital or clinic
for 1-4 hours with careful assessment of v/s
and perineal care
She usually receives oxytocin to ensure firm
uterine contruction and minimize bleeding
Offer contraceptive counseling
Inform to expect bleeding comparable to a
menstrual flow for the first week afterward,
and spotting for up to 2 or 3 weeks afterward
Cramping may continue for up to 24 to 48
hours
*she can take a mild analgesic such as
acetaminophen or ibuprofen for discomfort
 Advised not to douche, use tampons, or resume coitus until after she returns in 2
Advised not to douche, use tampons, or
resume coitus until after she returns in 2
weeks for a follow-up examination
Complications:
Potential for uterine perforation because a
rigid cannula is used for the procedure
infection
Prostaglandin Saline Induction (between 16 and 24 weeks)  Inpatient or ambulatory procedure Procedure:  The
Prostaglandin Saline Induction
(between 16 and 24 weeks)
Inpatient or ambulatory procedure
Procedure:
The woman is admitted to a same-day surgery
unit and has oral misoprostol or vaginal laminaria
inserted to help prepare the cervix for dilatation
The prostaglandin is then administered
*F2-alpha by injection; E2 by suppository
Labor, which follows the administration of
prostaglandin by several hours, may be
shortened by administration of a dilute
intravenous solution of oxytocin
Nursing Intervention:  If large amounts of oxytocin is necessary to induce labor –observe closely for
Nursing Intervention:
If large amounts of oxytocin is necessary
to induce labor –observe closely for signs
of water intoxication, or body fluid
accumulating in body tissue
*signs of water intoxication are severe
headache, confusion, drowsiness, edema,
and decreased urinary output
If such symptoms occur, the oxytocin drip
should be stopped immediately
*always infuse oxytocin using a piggyback
method during an abortion procedure, the
same as with the woman in term labor
Post-op Intervention:  Examine the products of conception whether the entire conceptus (fetus, placenta and membranes)
Post-op Intervention:
Examine the products of conception
whether the entire conceptus (fetus,
placenta and membranes) has been
delivered
Carefully observed for vaginal
hemorrhage
Complications:
May develop disseminated intravascular
coagulation from trauma because her
blood clotting is compromised
Saline Induction (between 16 and 24 weeks)  Hypertonic (20%) saline causes fluid shifts and sloughing
Saline Induction
(between 16 and 24 weeks)
Hypertonic (20%) saline causes fluid shifts and
sloughing of the placenta and endometrium
Procedure:
Woman voids to reduce the size of her bladder so
it will not be accidentally punctured by the saline
injection
A sterile spinal needle is then inserted into the
uterus through the anesthetized abdominal wall,
into the amniotic fluid
The needle is then withdrawn
Within 12 to 36 hours after the injection, labor
contractions begin
Complications:  Hypernatremia –from accidental injection of the hypertonic saline solution into a blood vessel within
Complications:
Hypernatremia –from accidental injection of the
hypertonic saline solution into a blood vessel
within the uterine cavity
Severe dehydration– due to the presence of
concentrated salt solution in the bloodstream
causing body fluid to shift into the blood vessels
in an attempt to equalize osmotic pressure
Post-op Intervention:  Inform to expect vaginal spotting for as long as 2 weeks  A
Post-op Intervention:
Inform to expect vaginal spotting for as long as 2
weeks
A first menstrual flow usually occurs 2 to 8
weeks after the procedure
Follow-up examination after 2 to 4 weeks
Sexual relations and douching are generally
contraindicated until the time of postabortion
checkup
Hysterotomy: (more than 16 to 18 weeks) This procedure is the same as a cesarean section
Hysterotomy:
(more than 16 to 18 weeks)
This procedure is the same as a cesarean section (in which
the doctor cuts through the abdomen and uterus to deliver
the baby), except that in a hysterotomy, no medical attention
is given to the baby upon delivery to help it survive. Most
often, a wet towel is placed over the baby’s face so it can’t
breathe. Sometimes the baby placed in a bucket of water.
The goal is to have a baby that won’t survive.
Partial Birth Abortion (used during last 3 months of pregnancy)  Surgical technique used if the
Partial Birth Abortion
(used during last 3 months of pregnancy)
Surgical technique used if the fetus had been
discovered to have a congenital anomaly that
would be incompatible with life or would result in
a severely compromised child (e.g.,
encephalocele, high meningocele)
Procedure:  Labor was induced by a combination of oxytocin and cervical ripening  The fetus
Procedure:
Labor was induced by a combination of oxytocin
and cervical ripening
The fetus was turned so that the breech
presented to the birth canal
A clamp was then inserted into the base of a
fetal skull, the head contents were destroyed,
and the head was collapsed and then delivered
When to resume intercourse after abortion? For 2-4 weeks - no sex, no tampons, no douches.
When to resume intercourse after abortion?
For 2-4 weeks - no sex, no tampons, no douches.
After the 2-4 weeks is over, you should NOT have sex
again unless you feel physically recovered, and have
discussed with your partner what you want to do if an
unplanned pregnancy occurs again. Do NOT let yourself
be pressured into having sex again before you are
physically and emotionally ready, and have had a
serious discussion about the course of action for future
unplanned pregnancies. You can get pregnant as soon
as two weeks after an abortion! Your body normally will
go back to it's regular cycle, and release an egg
(ovulation) at 2 weeks post-ab. So once you decide you
are ready to resume sexual intercourse again, make
sure you are using birth control right away.