ABORTION

Abenojar, Bea A. Abinales, Jerome A. Adriano, Hannah Angeline I. Agbannawag, Jamie D. BSN 4A1

ABORTION

An abortion is the medical term for any interruption of a pregnancy before a fetus is viable (able to survive outside the uterus if born at that time). A viable fetus is usually defined as a fetus of more than 20 to 24 weeks of gestation. A fetus born before this point is considered a premature or immature birth.

 Spontaneous Miscarriage
A spontaneous miscarriage is an early miscarriage if it occurs before week 16 of pregnancy and a late miscarriage if it occurs between weeks 16 and 24. Bleeding before week 6 is rarely severe; bleeding after week 12 can be profuse because the placenta is implanted deeply. For some women, the stage of attachment between weeks 6 and 12 can lead to the most severe, even life-threatening bleeding.

CAUSES:
Abnormal fetal formation: due to teratogenic factor or to a chromosomal aberration Implantation abnormalities: poor implantation may result from inadequate endometrial formation or from an inappropriate site of implantation The corpus luteum fails to produce enough progesterone to maintain the deciduas basalis. Infection: Rubella, syphilis, poliomyelitis, cytomegalovirus, and toxoplasmosis infections can cross the placenta causing fetal death. Urinary tract infection may cause an incidence of miscarriage. Ingestion of teratogenic drugs

ASSESSMENT:

The presenting symptom is almost always vaginal spotting.

TYPES OF ABORTION
1. Threatened Miscarriage

threatened miscarriage is manifested by: Vaginal bleeding Scant bleeding (bright red) Slight cramping NO CERVICAL DILATATION 50% of women with a threatened miscarriage continue the pregnancy; 50% changes to immenent or inevitable miscarriage. If it stops, usually it does within 24 to 48 hours. She can gradually resume to normal activities.

MANAGEMENT: Avoid strenuous activity within 24 to 48 hours Bed rest Obtain human chorionic gonadotropin hormone (hCG) at the start of bleeding and again in 48 hours Avoid coitus for 2 weeks after bleeding

Imminent (Inevitable) Miscarriage Manifested by uterine contraction and cervical dilatation. Loss of the products of conception cannot be halted. MANAGEMENT: If no fetal heart sounds or sonogram reveals an empty uterus or nonviable fetus, physician may perform vacuum extraction ( Dilatation & Evacuation: D&E) Inform patient that pregnancy was already lost and that all procedure are to clean the uterus and prevent further complications Save any tissue fragments to examine for any abnormalities Assess vaginal bleeding by recording the number of pad she uses.

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3. Complete Miscarriage The entire products of conception (fetus, membranes, and placenta) are expelled spontaneously without any assistance. The bleeding usually slows within 2 hours and then ceases within a few days after passage of the products of conception.

4. Incomplete Miscarriage Part of the conceptus (usually the fetus) is expelled, but membrane or placenta is retained in the uterus. There is a danger of maternal hemorrhage as long as part of the conceptus is retained in the uterus because the uterus cannot contract effectively in this condition. Dilatation & Curettage (D&C) or suction curettage is usually performed to evacuate the remainder of the pregnancy from the uterus. Inform patient that pregnancy was already lost and that all procedure are to clean the uterus and prevent further complications.

5. Missed Miscarriage Also known as early pregnancy failure wherein the fetus dies inside the utero but is not expelled. It is usually discovered at a prenatal examination when the fundal height is measured and no increase in size can be demonstrated, or previously heard fetal heart sounds cannot be heard. A sonogram can establish the fetus is dead. Often the embryo actually died 4 to 6 weeks before the onset of miscarriage symptoms and failure of growth was noted. Disseminated intravascular coagulation (DIC) may result if fetus remains too long in the utero.

MANAGEMENT: D&E is most commonly done. If the pregnancy is over 14 weeks, labor may be induced by a prostaglandin suppository or misopristol (Cytotec) to dilate the cervix, followed by oxytoxin stimulation or administration of mifepristone.

6. Recurrent Pregnancy Loss It is when a women had three spontaneous miscarriages that occurred at the same time gestational age. They were formerly termed as habitual aborters. A thorough investigation is done to discover the cause of the loss and help ensure outcome of a future pregnancy. Although many occur for unknown reasons, possible causes include:

 Defective spermatozoa or ova Endocrine factors such as lowered levels of proteinbound iodine (PBI), butanol-extractable iodine (BEI), and globuline-bound iodine (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

Complications of spontaneous miscarriages and therapeutic abortions include the following:

Local anesthesia: Paracervical block is a common method of anesthesia for therapeutic abortion. Accidental intravascular injection of anesthetic is a potentially lifethreatening complication of this method that could lead to seizure, cardiopulmonary arrest, and death. General anesthesia: Complications with general anesthesia may lead to uterine atony with severe hemorrhage. Cervical shock: Vasovagal syncope produced by stimulation of the cervical canal during dilatation may occur. Rapid recovery usually follows. Postabortion triad: Pain, bleeding, and low-grade fevers are the most common presenting complaints. Postabortion triad usually is caused by retained products of conception.

 Hemorrhage: Excessive hemorrhage during or after abortion may signify uterine atony, cervical laceration, uterine perforation, cervical pregnancy, a more advanced gestational age than anticipated, or coagulopathy. Hematometra: Also known as post abortion syndrome, this is the result of retained products of conception or uterine atony for other causes. The endometrium is distended with blood, and the uterus is unable to contract to expel the contents. Patients usually present with increasing lower midline abdominal pain, absent or decreased vaginal bleeding, and, at times, hemodynamic compromise. This may develop immediately after miscarriage or abortion, or it may develop insidiously.

 Perforation: Patients with uterine perforation missed during the procedure usually present to the ED with increased abdominal pain, bleeding (possibly ranging from very mild to absent), and fever. If perforation results in injury to major blood vessels, patients may present in hemorrhagic shock. Bowel injury: This may accompany uterine perforation. If initially unrecognized, patients present with abdominal pain, fever, blood in the stool, nausea, and vomiting. Bladder injury: This occurs as a result of uterine or cervical perforation. Patients present with suprapubic pain and hematuria. Septic abortion: This is endometritis. Patients present with fever, chills, abdominal pain, vaginal discharge, vaginal bleeding, and history of recent pregnancy.

 Failed abortion (continued intrauterine or ectopic pregnancy): Failure to terminate the pregnancy is relatively common with very early abortions (< 6 wk gestational age). Such patients may present to the ED with symptoms of continuing pregnancy such as hyperemesis, increased abdominal girth, and breast engorgement. In addition, an unrecognized ectopic pregnancy in the postabortion period presents in the usual manner. Disseminated intravascular coagulation: Suspect DIC in all patients who present with severe postabortion bleeding, especially after midtrimester abortions. Incidence is approximately 200 cases per 100,000 abortions; this rate is even higher for saline instillation techniques (660 per 100,000 abortions).

DRUG STUDY Methergin

NAME OF DRUG

CLASSIFICATIO N AND ACTION

INDICATION

CONTRAINDICATION

SIDE EFFECTS AND ADVERSE REACTION Common: Abdominal pain with large doses, hypertension, headache, skin eruptions. Uncommon: Dizziness, nausea, vomiting, convulsions, sweating, chest pain, hypotension. Rare: Bradycardia, tachycardia, palpitations, arterial spasm.

NURSING RESPONSIBILITIES

Generic Name:
Methylergo metrine maleate Brand Name: Methergin

Classification: Genitourinary drugs Action: Act directly at the uterine smooth muscles to stimulate rate, tone and amplitude of contractions . It reduces rapid, sustained titanic uterotonic effects that shortens the third stage of labor and reduce blood loss.

Active manageme nt of the third stage of labor, interior hemorrhag e following separation of placenta and uterine atony, subinvoluti on of iochometra , caesarian section, menorrhagi a, metrorrhag ia. Postpartum and postaboital uterine bleeding.

1st and 2nd stage of labor before crowning of the head, primary and secondary uterine inertia. Patients with severe hypertension, preeclampsia, eclampsia, severe or persistent sepsis, vascular disease, impaired renal or renal function. Hypersensitivity to ergot alkaloids.

Assess calcium level before administering therapy. Hypocalcemia must be corrected to increase drug effectiveness. Assess and document fundal tone, nonphasic contractions, and check for relaxation or severe cramping. Monitor vital signs and note for changes that may indicate hemorrhage. Assess respiration rate, rhythm, and depth. Assess for ergotism (overdose): nausea, vomiting, weakness, muscular pain, insensitivity to cold and paresthesia to determine dose adjustments or drug withdrawal. Advice patient to take only as prescribed and no to exceed dose.

DISCHARGE PLAN
Medications: Teach client about the home medications ordered by the physician.

Exercise:

Light physical activity

Treatment Maintain adequate nutrition and medications Health teaching Encourage patient to increase fluid intake Instruct client to avoid rapid position changes Bed rest

OPD follow up Diet Adequate fluid intake and nutrition DAT diet Assess clients grieving