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CNE WAD TINGKAT 3 Siti Shazwani binti Zulkaflee RN Ba. Health Sciences (honor) Nursing, USM.

Abortions Threatened Abortion Missed Abortion Incomplete Abortion Complete Abortion Inevitable Abortion Septic Abortion

Expulsion of conception product/fetus weighing <500gm or less than 22/52 gestations (WHO) Types of abortion 1. Spontaneous 2. Induced

Spring 2005

Con Law II

Spring 2005

Con Law II

About 80% of all abortions occur in the first trimester The rate of clinical abortion is fairly stable each week until 12 weeks, then falls off If conception occurs prior to 3 months after a delivery the incidence of abortion is increased

If the prior pregnancy ended in an abortion the subsequent pregnancy is at higher risk to abort (20%) Prior pregnancy successful only 5% abort If all prior pregnancies were successful then only 3% abort

A subchorionic bleed does not increase the risk of spontaneous abortion if fetal viability is confirmed If a women has multiple abortions they tend to abort at the same time

Fetal cause 70% of spontaneous abortion has abnormal karyotypes Uterine cause congenital anomalies, sub mucous fibroids, uterine septum, cervical incompetence Maternal disease Uncontrolled DM, thyroid disorders, renal failures Trauma post surgery, psychosocial Immunological cause Infection Drugs cytotoxic agents Lifestyle cigarettes, alcohol Radiation/radiotherapy

Sign and symptoms

Features Missed Incomplete Threatened Inevitable PV Nil/ Fresh Fresh Fresh/nil Bleeding spotting Abdominal Nil + Nil + Pain Passing out Nil + Nil Nil POC Cervix/OS Close Open Close Open Uterine Size <date <date = date = date

Management and Treatment

Missed Abortion
Definition: Pregnancy failure before the expulsion of POC 1. History taking 2. VE/Speculum 3. Ultrasound = fetus visualized but no fetal heart heard. If doubt, to repeat scan in 1-2/52 4. Large bore branulla, IV fluid if necessary. 5. Ix: UPT, FBC, GSH 6. Surgical tx: ERPOC INFORMED CONSENT, OT LIST Keep pt NBM at least 4 hours before procedure. [6 AM] Skin preparation Uterus < 14/52 for Cervagem 1mg insertion at least 2 hours before procedure [4 AM] Uterus >14/52 for Cervagem insertion 4 hourly till abortion. (Max 3x/day) [6 AM, 10 AM, 2 PM]

Ultrasound finding: Missed Abortion

No cardiac activity when CRL >5mm endovaginally. Gestational sac too large for menstrual age. Gestational sac >13mm without yolk sac. Gestational sac >18mm without embryo. Distorted, irregular, sac with cremated inner aspect. Choriodecidual reaction that is irregular, discontinuous or thin (2mm). No double decidual reaction. Low sac position. Subchorionic collection.

U/S image : Missed Abortion

Nurses role
Vital signs 4hourly inform if : BP<90/60mmHg PR >120bpm Pain Score >3 SOB, tachypnea Pt looked Pale/Sweating or c/o dizziness Pad charting inform if : 2 pads soaked in 1hour blood clots Pt passing out POC Prepare for Scan / VE & Speculum / Emergency OT

Product Of Conception
A medical term used to identify any tissues that develop from a pregnancy. It is commonly used by doctors because it includes not only the fetus but also the placenta and any other tissues that may result from a fertilized egg. (About.com) Common point of view: perut ikan, meaty look alike blood clots, blood clots with membrane

Gemeprost (Prostaglandin E1 Synthetic Analogue) 1mg/supp Indication: Cervical priming/dilatation. Inducing abortion in the first trimester Dosage: 1mg 3 hourly before surgery to a max of 5 pessaries in 24 hours. Adverse effects: vaginal bleeding Mild to severe uterine pain Gastrointestinal disturbance Headache Muscle weakness Dizziness Flushing Chills, Backache Dyspnea, chest pain Palpitations Mild pyrexia Anaphilactic reactions are rare

Cervagem Pessary
Precautions: Obstructive airway disease Elevated intraoccular pressure Cercitis/vaginitis Ulceratice collitis Cardiovascular disease Renal or hepatic disease. Hypertension/hypotension Contraindications: Hypersensitivity to prostaglandin Acute pelvic inflammatory disease Uterine scars

(Source: Drug Formulary, 2012 Edition, HTF)

Incomplete Abortion
Definition: incomplete expulsion of POC and retained in the uterine. Need surgical intervention 1. History taking; assessed the degree of vaginal bleeding and resus accordingly. 2. Large bore branulla. IV fluids if necessary. 3. VE/Speculum; Os open, continued bleeding and abdominal pain. 4. Remove POC if possible. 5. IM Syntometrine 1ml (1 ampoule) STAT 6. Ultrasound; No need if clinically suggestive of incomplete abortion. 7. Ix: UPT, FBC, GSH 8. Surgical tx: ERPOC INFORMED CONSENT, OT LIST Confirm patients last meal. Keep pt NBM STAT and at least 4 hours before procedure. Skin preparation

Ultrasound Finding: Incomplete Abortion

Retained products of conception (chorionic villi = placental tissue and trophoblastic = fetal tissue remaining within the uterus). Clinical signs:
Prolonged bleeding. Infection.
Finding Gestational sac/collection Gestational sac + dead fetus Endometrium >5mm thick Endometrium 2-5mm thick Endometrium <2mm thick Retained Products 100% 100% 100% 43% 14%

U/S Image: Incomplete Abortion

U/S Image: Incomplete Abortion

Vital signs 4hourly / according to situation inform if : BP<90/60mmHg PR >120bpm Pain Score >3 SOB, tachypnea Pt looked Pale/Sweating or c/o dizziness Pad charting inform if : 2 pads soaked in 1hour blood clots Pt passing out POC Prepare for VE & Speculum; Assist in removing POC if at OS Prepare for Scan / Emergency OT

Nurses Role

Operative procedure Patient under GA Positioned in lithotomy position Perineum area cleaned and draped Bladder catheterized Vaginal examination done vulva and vagina normal, os closed, position of uterus > anteverted/retroverted Sims speculum inserted for visualization of cervix Anterior lip of cervix grasped with Volsellum forcep Cervical os dilated with Hegar dilator until size ___ (eg: size 9) Uterine sound inserted and cervicouterine length measured ___ (eg: 10cm). Suction done with Karman curette size 8 until gritty sensation felt/ Curette used sponge forcep to remove any remaining POC Check for any active bleeding from external os, lip of cervix and from internal os.
If present active bleeding, compress with gauze > if still bleed, suture Fill in form for POC sent for HPE Swabs and instrument counts

Nursing Care Plan

Post-operative plan Monitor vital signs hourly, then once stable, 4 hourly. Monitor pad chart, inform if excessive bleeding Encourage orally and ambulation Off IVD once tolerating orally

Discharge plan TCA stat if increase PV bleeding, persistent abdominal pain, fever, foul smelly vaginal discharge. Inform PV bleeding normally will continue and decreasing till 2 weeks. Advice for contraceptives for 3/12 before next pregnancy. MC if working (refer policy)