1

CHAPTER 2

2

ABORTION

3

DEFINITION OF ABORTION/SPONTANEOUS MISCARRIAGE

• Spontaneous abortion, miscarriage or early pregnancy loss is defined as the spontaneous termination of pregnancy before 20 weeks.
• Abortion is the extraction or expulsion from the mother of an embryo or fetus weighing 500 gm or less when it is not capable of independent survival (WHO).

4

CLINICAL TYPES OF ABORTION

5

6

ETIOLOGY

7

8

9

THREATENED ABORTION

In this the process of abortion has started but not reached a state where recovery is impossible .

DEFINITION:

10

CLINICAL FEATURES:

​

• Vaginal Bleeding
• Pain
• Per abdominally:The uterus is felt soft and enlarged. The uterine size corresponds to the period of amenorrhea.
• Per vaginal:Per vaginal examination is avoided, but if done the cervix will be soft with a closed internal os.

11

INVESTIGATION:

12

MANAGEMENT

• Rest: The patient should stay in bed until the bleeding stops.There is no evidence that prolonged restriction of activity has any therapeutic value.
• Reassurance: A sympathetic attitude by health care providers is essential.
• Hormone therapy:Natural progesterone is sometimes given on an empirical basis, but there is no evidence that it supports the continuation of pregnancy.

13

Continue….

• Blood transfusion: Blood transfusion may be required if abortion becomes inevitable.
• Anti-D: Anti-D is given if the pregnancy is more than 12 weeks and the mother is Rh negative.
• If anembryonic pregnancy is confirmed, the uterus is to be evacuated once the diagnosis is made.

14

NURSING MANAGEMENT

• If the bleeding decreases or stops explain the facts to the woman.
• Reassure the mother and advise her to get her vitals checked regularly.
• Advise her to avoid strenuous exercise/work and to avoid sexual intercourse.
• Advise her to take bed rest.

15

• Advise the patient to preserve the vulval pads and anything expelled out per vaginam for examination
• Advise her to report if pain or bleeding becomes aggravated.

Continue….

16

INEVITABLE ABORTION

​

It is a type of abortion where changes have progressed to a state where the continuation of pregnancy is impossible.

DEFINITION

17

Features of inevitable abortion start rapidly without any prior symptoms.

• Bleeding: Profuse vaginal bleeding.
• Pain: More pain in the lower abdomen, which is colicky.
• General condition: It is similar to the amount of blood loss. If the blood loss is profuse, the patient may be in shock.

CLINICAL FEATURES

18

Per vaginal:

• Internal examination reveals dilated internal os of the cervix.
• Products of conception can be felt with dilated os.
• If it is in 2nd trimester, then membranes may rupture with abdominal pain (mini labor).

Continue…..

19

​

The management is the immediate evacuation of the uterus.

Management principles are:

• To maintain strict asepsis to prevent infection.
• To speed up the expulsion process.
• To look after the mother's general condition.

MANAGEMENT

20

• If the patient is in shock, then immediate resuscitation with intravenous fluids and blood transfusion.
• Anti-D is given if the mother is Rh-negative.
• The products are sent for histopathological examination to exclude a molar pregnancy.
• Prophylactic antibiotics are given.

General Management

21

• Before 12 weeks:

a) Manual vacuum Aspiration can be done.

b)Dilatation and evacuation followed by curettage of the uterine cavity by blunt curettage using analgesia.

• After 12 weeks, Oxytocin infusion is started, and the expulsion process is hastened. Start 10-20 U of Oxytocin in 500 ml NS/RL @ 40-60 drops/min
• If the products of conception are expelled out and the placenta is retained.

Actual Management

22

COMPLETE ABORTION

​

In this type of abortion, the products of conception would have been completely expelled from the uterus, and the cavity would be empty.

DEFINITION

23

History of vaginal bleeding and lower abdominal pain with expulsion of products of conception per vaginam with the following features:

• Abdominal pain: Decrease in the abdominal pain.
• Minor vaginal bleeding
• P/V examination:

⁃Internal OS is closed.

-The uterus is less than a period of amenorrhoea.

⁃Minimal vaginal bleeding.

CLINICAL FEATURES

24

• Per abdomen: Abdominal examination shows a softer-than usual uterus, and the fundal height is less than the gestation period.
• Ultrasound findings: Ultrasound confirms that miscarriage is complete and the uterus is empty.Transvaginal ultrasound confirms whether the uterine cavity is empty or not.

Continue….

25

​

Management is conservative.

Observe the woman for 4-6 hours.

The effect of blood loss should be evaluated, and treatment can be initiated accordingly.

Anti-D: A Rh-negative woman should be given Anti-D gamma globulin intramuscularly within 72 hours.

MANAGEMENT

26

INCOMPLETE ABORTION

​

In this type of abortion, the process of abortion has already been stated, but the products are only partly expelled.

DEFINITION

27

CLINICAL FEATURES

• Vaginal Bleeding
• Abdominal pain: The presence of abdominal pain, which is colicky.
• Per vaginal examination:Uterus smaller than a period of amenorrhoea and varying amount of bleeding.
• Abdominal examination:Presence of uterine tenderness and the fundal height is less than the gestation period.
• Ultrasonography reveals the presence of products of conception inside the uterine cavity.

28

MANAGEMENT

General Measures

• Look for complications such as profuse bleeding,sepsis or placental polyp.
• The same principles of management are to befollowed for inevitable abortion
• If the patient is in a state of shock due to blood loss,management for shock is to be done first, followed by evacuation of the uterus.

29

For less than 14 weeks:

Medical management:

If the patient is hemodynamically stable and os is closed,misoprostol 600 μg orally or 400 μg sublingually or 400–800 μg vaginally can be used to hasten the process of expulsion.

Surgical management:

• Vacuum aspiration
• Dilatation and evacuation under analgesia or general anaesthesia are to be done.

30

For more than 14 weeks:

Medical management:

Use of repeat doses of 400 μg misoprostol administered sublingually,vaginally or buccally every 3 hours.

Surgical management:

• The uterus is evacuated under general anaesthesia
• Dilatation and curettage (D&C).

31

• Prophylactic antibiotics are given.
• Products are sent for histopathological examination.
• Anti–D is given to Rh-negative women.

32

MISSED ABORTION/SILENT MISCARRIAGE

DEFINITION

In this abortion, there is intrauterine death of the embryo or fetus, and it is retained inside the uterus for a variable time.

33

PATHOLOGY

​

• Before 12 weeks of gestation, the ovum is surrounded by chorionic villi, making the pathological process challenging to understand.
• After 12 weeks, the retained fetus becomes mummified or macerated.
• The liquor amnii gets absorbed, and the placenta becomes pale and thin and may be adherent.

34

CLINICAL FEATURES

• Presence of brown colour vaginal bleeding.
• Signs and symptoms of pregnancy slowly disappear.
• Retrogression of the breast changes.
• Uterine growth stops or becomes smaller in size.
• Non-audibility of fetal heart rate if it was audible earlier.
• Pregnancy tests may be harmful.
• The cervix becomes firm.

35

• Immunological test for pregnancy negative.
• Ultrasonography

INVESTIGATION

36

COMPLICATIONS

• Sepsis
• Disseminated intravascular coagulation
• Psychological trauma

37

MANAGEMENT

Uterus less than 12 weeks:

• Medical management:

Prostaglandin E1, i.e.,Misoprostol tablet 800 μg vaginally every 3 hrs (X2 doses) or 600 μg sublingually every 3 hrs (X 2doses) usually results in spontaneous expulsion without the need for surgical intervention.

• Surgical management: Dilatation and evacuation are done as a definitive treatment or if medical treatment fails.

38

Medical management:

• Use of 200 mg mifepristone administered orally, followed 1–2 days later by repeat doses of 400 μg misoprostol administered sublingually or vaginally every 4–6 hours. The minimum recommended interval between use of mifepristone and misoprostol is 24 hours.
• Oxytocin: 10-20 units of Oxytocin in 500 ml of normal saline at 30 drops per minute. If this fails, increase the dose slowly by proper monitoring.

Uterus more than 12 weeks:

39

Surgical management:

If medical treatment fails, then surgical methods are adopted:

• Dilatation and evacuation are done after the cervix becomes softer using PGE1.

40

NURSING MANAGEMENT

• The woman should be asked to come for a follow-up after one month.
• Emotional support should be provided.
• Counseling for contraceptives is to be given.
• At follow-up, discuss the particular cause, if present and the prognosis.

41

DEFINITION

SEPTIC ABORTION

Any abortion that occurs with clinical evidence of infection of the uterus and its contents is called septic abortion.

42

Abortion is usually considered septic when there are:

• Rise of temperature of at least 100.4°F (38°C) for 24 hours or more
• Offensive or purulent vaginal discharge.
• Other evidence of pelvic infection is lower abdominal pain and tenderness.

43

• Anaerobic: Bacteroides group (fragilis), anaerobic Streptococci.
• Aerobic: Escherichia coli (E. coli), Klebsiella,Staphylococcus, methicillin-resistant Staphylococcus aureus(MRSA).
• Mixed infection is more common.

MODE OF INFECTION

44

• The woman looks sick and anxious.
• Temperature: >38°C.
• Chills and rigours (suggest-bacteremia).
• Persistent tachycardia ≥90 bpm (spreading infection).
• Hypothermia (endotoxic shock) <36°C.
• Abdominal or chest pain.
• Tachypnea (RR) >20/min.
• Impaired mental state.
• Diarrhea and vomiting.

CLINICAL FEATURES

45

Grade I: The infection is localised in the uterus(Commonest and associated with spontaneous abortion).

Grade II: The infection spreads beyond the uterus to the parametrium, tubes, ovaries, or pelvic peritoneum.

Grade III: Generalized peritonitis and endotoxic shock or jaundice or acute renal failure (associated

with induced illegal abortion).

CLINICAL GRADING

46

• Routine investigations include:
• Cervical or high vaginal swab
• Blood Test.
• Urine analysis, including culture.
• Ultrasonography of the pelvis and abdomen
• Plain X-ray—(a) Abdomen—in suspected cases of bowel injury

(b) Chest—for cases with pulmonary

complications (atelectasis)

INVESTIGATION

47

COMPLICATIONS

• Hemorrhage
• Generalized peritonitis
• Endotoxic shock
• Hemorrhage
• Acute renal failure
• Thrombophlebitis

• Chronic debility
• Chronic pelvic pain and backache
• Dyspareunia
• Ectopic pregnancy
• Secondary infertility due to tubal blockage
• Emotional depression

Immediate

Remote Complications

48

MANAGEMENT

• Principles of management are as follow:
• To control sepsis.
• To remove the source of infection.
• To give supportive therapy to bring back the normal homeostatic and cellular metabolism.
• To assess the response to treatment.

49

MANAGEMENT

General Management

Police notification is essential if a criminal abortion is suspected.

Hospitalisation is necessary for all cases of septic abortion.

Oxygen is given by nasal catheter.

Vigorous intravenous infusion with crystalloids.

The patient is kept in isolation.

50

Grade I

• Antibiotics drugs:
• Piperacillin-tazobactam and carbapenems
• Clindamycin
• Gentamycin
• Metronidazole
• Analgesics and sedatives
• Blood transfusion
• Evacuation of the uterus

51

Grade II

• Antibiotics: Same as mentioned for grade I.
• Analgesic, AGS and ATS are given as required in Grade I.
• Blood transfusion is more often needed.
• Surgery:
• Evacuation of the uterus
• Posterior colpotomy

​

52

Grade III

• Antibiotics: Same as mentioned for grade I.
• Supportive therapy is directed to treat generalised peritonitis by gastric suction and intravenous crystalloid infusion.
• The patient may need intensive care unit management.
• Management of endotoxic shock or renal failure.
• Surgery:
• Evacuation of the uterus
• Posterior colpotomy

​

53

SEPTIC ABORTION

DEFINITION

Recurrent miscarriage is traditionally defined as three or more consecutive spontaneous abortions before 20 weeks of gestation.

54

ETIOLOGY

• First Trimester Abortion
• Unknown cause
• Chromosomal abnormalities
• Endocrine and metabolic cause

• Second Trimester Abortion
• Uterine Causes
• Mullerian abnormalities
• Intrauterine adhesions
• Leiomyomas

• Cervical Insufficiency

55

INVESTIGATION

• History and Examinations
• Etiology Wise Investigations
• For chromosomal abnormalities, The RCOG recommends karyotyping the products of conception after the third miscarriage by array-based comparative genomic hybridisation to reduce maternal contamination.
• For Mullerian abnormalities, transvaginal ultrasound in the secretory phase is beneficial for diagnosing uterine anomalies
• Non-pregnant state: The internal os may allow the passage of a No. 8 Hegar cervical dilator without resistance. Hysterosalpingography may show typical funnelling of the internal os.

​

​

​

56

​

• Ultrasound in pregnancy: Transvaginal ultrasound is the ideal method to follow up and detect early insufficiency

• Physical examination in pregnancy: Cervical dilatation and membranes visible at or beyond the internal os on speculum examination in the absence of overt infection or significant uterine contractions are also diagnostic. This is termed acute cervical insufficiency.

• For infections: Tests for bacterial vaginosis and VDRL for syphilis
• For LPD: Endometrial biopsy and progesterone levels.
• For hypothyroidism: TSH levels.

57

• During Interconceptional Period

MANAGEMENT

• Alleviate anxiety and improve psychology
• Management for congenital malformation:Hysteroscopic resection of uterine septa,synechiae and submucous myomas.Uterine unification operation (metroplasty) is done for cases with bicornuate uterus.

​

• Chromosomal anomalies:Genetic counselling, Karyotyping, preimplantation genetic diagnosis.
• Treatment for endocrine disorders.
• Treatment of genital infections:Empirical therapy .

58

• During Pregnancy

• Psychological support
• Early pregnancy scan
• Rest
• Progesterone therapy
• Folic acid supplementation
• Antenatal care
• Cervical Cerclage Operations

59

INDUCTION OF ABORTION

Induced abortion is the deliberate termination of pregnancy before the period of viability.

DEFINITION

60

NURSING MANAGEMENT

Assessment

• History:
• Pregnancy history: LMP, Previous pregnancies, pregnancy losses.
• Ask for the history of pain
• Physical examination: Vital signs, speculum vaginal examination, ultrasonography.
• Laboratory tests: Hb, CBC.

61

Diagnosis

• Fluid volume deficiency is related to active fluid volume loss secondary to hemorrhage.
• Anxiety related to loss of pregnancy and future child being born.
• Acute pain related to uterine cramping.
• Risk for infection related to vaginal bleeding secondary to dilated cervical os.
• Risk for complications related to disease condition.

62

Goals

• To maintain fluid volume.
• To relieve anxiety.
• To reduce pain.
• To prevent infection.
• To prevent complications.

63

Nursing Interventions

• To maintain fluid volume:
• Assess vital signs and physical signs of shock.
• The nurse should estimate fluid losses—the lady’s pads.
• Nurses should assess causative factors (pregnancy test), retain fetal/placental parts and review laboratory data.
• Administer IV fluids, blood products/plasma expanders as ordered.
• Limit activity for those with threatened abortion.

64

• To relieve anxiety:

•

• Assess the anxiety of mothers and family members from their facial expressions.
• Reassure the mother in case of threatened abortion so that pregnancy can be continued.
• Reassure the mother by providing psychological support when she is grieving for her lost baby.

65

• To reduce pain:
• Assess the level of pain with the help of a pain scale.
• Provide a comfortable position for the mother and advise her to rest in bed.
• Provide diversional therapy to the lady.
• Administer analgesics as prescribed by the doctor.
• Tell the lady to report immediately if the pain worsens.

66

• To prevent infection:
• Assess for signs of infection like fever,tachycardia, redness, burning on urination, etc.
• Teach the lady to maintain personal hygiene.
• Advise her to use sterile pads and change them frequently.
• Administer antibiotics as prescribed in case of septic abortion.
• Advise the lady to report if the amount of bleeding increases

67

• To prevent complications:
• Teach the lady about complications in future pregnancies.
• Advise her for follow-up visits for 1-3 weeks.
• Advise her to seek medical attention as soon as possible if any complications arise.

68

Health Education

• Clean the perineum after each voiding or bowel movement and change the perineal pad often.
• Avoid tub baths for two weeks.
• Avoid tampon use, douching, and vaginal intercourse for two weeks.
• Notify the physician if an elevated temperature or foul-smelling vaginal discharge develops.
• Eat foods high in iron and protein to promote tissue repair and blood cell replacement.
• Seek help from a support group or professional counselling as needed.

69

ECTOPIC PREGNANCY

70

INTRODUCTION

• An ectopic pregnancy is one where implantation occurs at a site other than the uterine cavity.
• Sites can be in the tube, ovary, cervix and the abdomen.

71

DEFINITION

If the fertilised ovum implants in an area other than the endometrial lining of the uterus, it is termed an ectopic pregnancy.

72

CLASSIFICATION

73

TUBAL PREGNANCY

The fertilised ovum may lodge in any tube portion, giving rise to ampullary, isthmic and interstitial tubal pregnancies. Because the tube lacks a sub-mucosal layer, the fertilised ovum promptly burrows through the epithelium, and the zygote lies within the muscular wall.

74

ABDOMINAL PREGNANCY

After tubal rupture or abortion, if the fetus is still alive, it can very rarely result in a secondary abdominal pregnancy or a secondary intraligamentous pregnancy.

75

Management

• Once the diagnosis is made, the urgent laparotomy is irrespective of the period of gestation because there are risks of continuation of pregnancy, like fetal death and increased fetal malformation.
• During this period, the patient should be in the hospital.

76

OVARIAN PREGNANCY

Pregnancy implanted in the ovary is very rare. The usual consequence is rupture at an early stage. The management is by surgery, and usually, ovariotomy will have to be done. The pathologist usually makes the diagnosis because many ovarian pregnancies are mistaken for a ruptured corpus luteum.

77

INTERSTITIAL PREGNANCY

Interstitial pregnancy is defined as implantation in the proximal interstitial part of the fallopian tube. Risk factors are the same as described for tubal pregnancy.

An additional and specific risk factor is previous ipsilateral salpingectomy.

78

Management

• Laparoscopy or laparotomy
• Cornual resection involves resecting the pregnancy
• Another option is colostomy, which involves incision of the cornua and suction or instrument evacuation of the pregnancy.
• Multidose systemic methotrexate is an option if diagnosed early. Elective caesarean section is recommended in the future.

79

CORNUAL PREGNANCY

Cornual pregnancy is defined as pregnancy in a rudimentary horn of a bicornuate uterus. The horn will usually be noncommunicating. If diagnosed in the early stages, excision of the rudimentary horn and tube of the affected side can be done. It should be remembered that renal anomalies can coexist with uterine anomalies. If not diagnosed early, rupture is inevitable at around 12- 20 weeks with massive intraperitoneal hemorrhage.

80

Management

At laparoscopy/laparotomy, it may be confused with an interstitial pregnancy. The round ligament will be attached laterally to the sac in a rudimentary horn.

In an interstitial pregnancy, the round ligament will be medical to the sac. The rudimentary horn should be exercised.

81

ANGULAR PREGNANCY

This is defined as intrauterine implantation in one of the lateral angles of the uterus and medical to the uterotubal junction and round ligament. This distinction is vital because these pregnancies can go up to term. However, there is a risk of abnormal placentation and bleeding

82

CERVICAL PREGNANCY

Occurs in the endocervical canal below the internal os, accounting for less than 1%. The usual predisposing factors are a previous dilatation, curettage, or caesarean section.

83

Management

• Previously, it was done by hysterectomy due to the profuse bleeding during evacuation.
• Medical treatment with a multiple dose of methotrexate is a perfect option and usually the first choice in ectopic pregnancy.
• If medical treatment fails, radiological uterine artery embolisation is an option, followed by evacuation.

84

SITES OF ECTOPIC PREGNANCY

85

ETIOLOGY

• Pelvic inflammatory disease
• Congenital factors
• Salpingitis isthmica nodosa
• Previous surgery on the tube
• Assisted reproductive technology (ART)
• Intrauterine devices

• Cigarette smoking
• Previous ectopic pregnancy
• Abortion
• Infertility
• Zygote abnormalities
• Ovarian factors

86

CLINICAL FEATURES

Triad of ectopic pregnancy

87

• Amenorrhea
• Lower abdominal pain
• Vaginal bleeding
• Dysuria
• Frequency or retention of urine
• Rise in temperature
• Vaginal bleeding is slight, dark-coloured and usually continuous.
• The feeling of nausea, vomiting, and fainting attacks, even to the extent of syncope, may be present.
• Shoulder pain may also be present.

88

DIAGNOSIS

• Blood examination
• Culdocentesis
• Transvaginal ultrasound:
• Estimating hCG:
• Curettage
• Laparoscopy
• Serum progesterone

89

MANAGEMENT

90

VESICULAR MOLE/ HYDATIDIFORM MOLE/

MOLAR PREGNANCY/GESTATIONAL

TROPHOBLASTIC DISEASE (GTD)

91

DEFINITION

It is an abnormal placenta condition with partly degenerative and partly proliferative changes in the young chorionic villi. These result in the formation of clusters of small cysts of varying sizes. Because of its superficial resemblance to a hydatid cyst, it is named a hydatidiform mole.

92

ETIOLOGY

• The cause is not known
• Women over 35 years of age.
• Teenage pregnancie
• Faulty nutrition caused by inadequate protein and animal fat intake
• Disturbed maternal immune mechanisms
• Cytogenetic abnormality—complete moles generally have a 46XX karyotype (85%),

93

CLINICAL FEATURES

Symptoms

• Vaginal bleeding
• The blood may be mixed with a gelatinous fluid from ruptured cysts, giving the appearance of discharge “white currant in red currant juice”
• Varying degrees of lower abdominal pain
• Vomiting of pregnancy becomes excessive to the stage of hyperemesis
• Breathlessness

94

• Expulsion of grape-like vesicles per vaginam is diagnostic of vesicular mole.

95

Signs:

• The patient looks more ill than can be accounted for.
• Pallor is present
• Features of preeclampsia
• The size of the uterus is more than that expected.

96

INVESTIGATION

• Full blood count
• ABO and Rh grouping
• Hepatic, renal and thyroid function tests are carried out.
• Sonography
• Quantitative estimation of chorionic gonadotropin
• Plain X-ray abdomen
• CT and MRI

97

Complications of Molar Pregnancy

• Hemorrhage and shock
• Sepsis
• Perforation of the uterus
• Preeclampsia with convulsion on rare occasion.
• Coagulation failure is caused by the pulmonary embolisation of trophoblastic cells, which causes fibrin and platelets to deposition within the vascular tree.
• The development of choriocarcinoma

98

MANAGEMENT

• Ultrasonography and sensitive hCG testing
• The principles in the management are:

A)Suction evacuation (SE) of the uterus as early as the diagnosis made.

B) Supportive therapy: Correction of anaemia and infection, if there is any.

C) Counseling for regular follow-up.

• The patients are grouped into two groups: Group A: The mole is in the expulsion process—less common—and Group B: The uterus remains inert (early diagnosis with ultrasonography)

99

Supportive Therapy

• The patient usually presents with a variable amount of bleeding, and often, they are anaemic and associated with infection.
• IV infusion with Ringer’s solution is started.
• A blood transfusion is given if the patient is frail.
• A parenteral antibiotic is given if there is an associated infection.
• Blood is kept reserved during the evacuation as there is a risk of bleeding.

100

Definitive Therapy

Suction evacuation (SE) is the treatment method. It is safe, rapid, and effective in almost all cases.

Group A: Cervix is Favourable

• The preferred method is suction evacuation. A negative pressure is applied up to 200–250 mm Hg.
• Alternatively, conventional dilatation of the cervix followed by evacuation is done.
• Digital exploration and removal of the mole by ovum forceps under general anaesthesia.

101

Group B: Cervix is Tubular and Closed

Prior slow dilatation of the cervix is done by introducing a laminaria tent followed by suction and evacuation. Alternatively, vaginal misoprostol (PGE1) 400 µg, 3 hours before surgery, may be used.

• Hysterectomy
• Curettage following vaginal evacuation
• Prophylactic chemotherapy
• Regimes: Methotrexate, 1 mg/kg/day IV or IM
• Combined oral pills
• Barrier methods of contraception
• Surgical sterilisation

Thank you