2. ABORTION.pdf

ABORTION
MR NKOLE J
Lecturer- Dept. of Nursing Sciences - LIAS
MR NKOLE J 1

Introduction
 Abortion is the commonest cause of vaginal bleeding in early
pregnancy and is one of the leading causes of maternal
mortality worldwide.
 The term miscarriage is commonly used in some literature to
mean term abortion. In medical terms, whether induced or
spontaneous it is generally called abortion.
 The majority of the abortions occur in the first trimester, or within
the first 12 weeks of pregnancy.
MR NKOLE J 2

General objective
• At the end of the lecture/ discussion, students should be able to
acquire knowledge and skill in the management of a patient
with an abortion
MR NKOLE J 3

Specific objectives
By the end of this lecture / discussion, students
should be able to:
 Define of abortion
 State the causes of abortion
 Explain classifications of abortion
 Explain the different types and management of abortions
MR NKOLE J 4

Definition of terms
 Abortion is the termination or interruption of pregnancy or fetal
growth before the 28th week of pregnancy
 Abortion is loss of pregnancy before the 28th week or loss of
fetus weighing less than 500g (WHO).
 Abortion is the interruption of pregnancy before 28th week,
after which the fetus is said to be viable.
MR NKOLE J 5

• Unsafe Abortion is “a procedure for terminating an unintended
pregnancy that is carried out either by persons lacking
necessary skills or in an environment that does not conform to
minimal medical standards, or both (WHO, 2008).
MR NKOLE J 6

Causes of abortion
• They are divided into two namely maternal and fetal causes;
MATERNAL CAUSES
i. Maternal infections Bacteria, viruses and parasites invade the
placenta and affect the metabolism of the placenta leading to
early degeneration. Toxoplasmosis, cytomegalovirus, syphilis,
Chlamydia and malaria are common causes of abortion
ii. Hormonal imbalance - The hormones responsible for sustaining
the pregnancy might not be sufficient e.g.
Oestrogen/progesterone. The risk increases with advancing
maternal age due to imbalance of hormones..
MR NKOLE J
7

Causes of abortion
iii) Structural abnormalities of the genital tract – Retroversion of
the uterus, bicornuate uterus and fibroids hinder the growth of the
fetus and this leads to abortion.
iv) Incompetent cervix – inability to hold the pregnancy due to
inadequate cervical collagen fibres which makes the cervical os
weak leading to failure of the cervix to contain the weight of the
growing fetus.
v) Maternal chronic conditions – conditions such as anaemia,
hypertension, renal diseases, and cardiac diseases lead to Poor
placental perfusion makes it weaker and eventually starts detaching
MR NKOLE J 8

Causes of abortion
vi) Extreme emotional Stress and anxiety - Cause alterations in the
levels of pituitary hormones and associated hormones which maintain
and sustain the pregnancy. This alteration may affect uterine function
and may cause abortion
vii) Noxious agents (Poisonous substance) e.g. Drugs, chemicals
and radiation. These are embryo toxic and can lead to abortion.
viii) Trauma- External pressure such as assault and strenous activities
may induce an abortion in that it may lead placental detachment.
ix) Nutritional deficiencies - Malnutrition and Lack of folic Acid.
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9

x) Social habits such as Cigarette smoking, nicotine in cigarette
constrict the blood vessels and may lead to hypoxia
• Excessive alcohol intake may lead to reduced food intake and
falls which can lead to abortion.
xi) Blood Incompatibility - ABO incompatibility and Rhesus
incompatibility (Iso-immunisation). The Rhesus antibodies can cross
the placenta and attack the RBC leading to hemolysis.
xii) Abodominal surgery: trauma of surgery may initiate abortion
e.g. myomectomy, appendicitis or peritonitis (laparatomy).
xiii) Multiparity : uterus becomes weak because of having too
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10

• FETAL CAUSES
i. Chromosomal anomalies The malformations and abnormalities
of the conceptus. Any change in the normal structure or number of
chromosomes may lead to malformations and abnormalities of
the conceptus and this may lead to abortion. This accounts for
50% causes of abortion.
ii. Defective Implantation Any defective implantation of the
blastocyst which may not promote fetal growth may lead to an
abortion
MR NKOLE J 11

• Multiple pregnancy - Has an increased tendency to
spontaneous abortions in the sense that the uterus may fail to
accommodate them
• Fetal infections -Fetal infections like Rubella (German measles)
can cause extensive damage to the fetus leading to abortion
MR NKOLE J 12

Classification of Abortions
• There are two (2);
i. Spontaneous abortion
ii. Induced abortion
MR NKOLE J 13

• Spontaneous Abortion is the termination of pregnancy that
occurs without external interference.
• Spontaneous Abortion involuntary loss of product of conception
prior to 28 weeks gestation without any external
interference(Myles,2006)
• Types of Spontaneous Abortions
i. Threatened v) Missed
ii. Inevitable vi) Habitual
iii. Incomplete vii) septic
iv. Complete
MR NKOLE J 14

• Induced abortion is the termination of pregnancy before the
28th weeks of gestation that occurs due to external interference
• Induced abortion is the termination of pregnancy by choice of a
woman prior to 28th weeks gestational age
onwards(Myles,2006)
• Types of Induced Abortion
i. Therapeutic abortion
ii. Criminal abortion
MR NKOLE J 15

ABORTION
SPONTANEOUS ABORTION INDUCED ABORTION
THREATENING
TERM MISEED INERVITABLE THERAPEUTIC CRIMINAL
BLOOD MOLE COMPLETE INCOMPLETE COMPPLTE INCOMPLETE
CARNEOUS HABITUAL SEPTIC SEPTIC
ABORTION TREE
MR J.NKOLE 16

Types of abortion under spontaneous
• Threatened Abortion
• It is a spontaneous type of abortion, in
which a pregnant woman presents with
slight bleeding through the un-dilated
cervix.
• Diagnosed when a pregnant woman
presents with slight bleeding, with or
without low backache and cramp like
pain. There is minor disturbance to the
pregnancy
• The pregnancy may; Go to term ,
Missed or Inevitable
MR NKOLE J 17

• Inevitable abortion
• It a type of abortion in which there is
progressive dilatation of the cervix. The
pregnancy is more advanced < 12
weeks
• Bleeding is heavier and abdominal pain
is more severe, colicky in nature and
situated in the supra pubic area.
• Amniotic membranes may be felt bulging
into the cervical canal or may be
already ruptured and fetal parts
palpable
MR NKOLE J
18

• Complete abortion
• The term “complete abortion” indicates that all products of
conception have been expelled.
• Uterus becomes smaller on palpation
• On vaginal examination cervix is closed
• Patient usually notices expulsion of the tissue or even foetus and
placenta
• Abdominal pain subsides and bleeding may stop or slows down
considerably. MR NKOLE J 19

• Incomplete abortion
• This is when the foetus is expelled
however; the placenta and membranes
are retained (Expulsion of products of
conception is incomplete)
• Abdominal pain continues although may
be less severe
• Bleeding continues and becomes heavier
• Uterus is enlarged, palpable and may
feel boggy.
• Cervix may either be dilated or closed.
MR NKOLE J 20

• There will be signs of shock if severe bleeding
• Placenta and foetus may appear to have been expelled , but
some trophoblastic or placental tissue remain adhering to the
uterine wall causing profuse bleeding.
• Products of conception may be felt or seen.
MR NKOLE J 21

• Missed abortion
• Type of abortion in which the fetus dies
and is retained in utero together with the
placenta and membranes.
• Signs of pregnancy disappear and uterus
does not grow/ ceases to increase
• Brownish vaginal discharge which may be
offensive.
• Cervix is closed and fetal heart cannot be
heard by either fetal-scope or Doppler
• Pregnancy test usually is negative MR NKOLE J 22

• Blood mole
• A missed abortion can occasionally progress to a blood mole
• The foetus dies and retained in uterus, however the decidua
capsularis remains intact.
• The zygote is surrounded by layers of blood, due to bleeding
between the gestational sac and uterine wall.
• The signs of pregnancy disappear and a brownish discharge is
usually present.
MR NKOLE J 23

• Corneous mole
• This is when fluid drains from a blood mole leaving a the fleshy,
firm, hard mass.
• Examination of the mole upon expulsion reveals an embryo in
the centre of the mass
MR NKOLE J 24

• Habitual abortion
• This is when a woman has experienced three or more
consecutive spontaneous abortion, usually at 12weeks gestation
• It can also occur between 22 to 24 weeks gestation.
• In the majority of patients no obvious causes can be found.
• However some of the known causes are chronic illness, such as
diabetes mellitus, and abnormalities such as a septate uterus
and cervical incompetence and they may experience the
following; MR NKOLE J 25

sudden rupture of membranes
expulsion of a fresh abortus
painless dilatation of the internal cervical os.
• These women should always be referred to the hospital
MR NKOLE J 26

• Septic Abortion
• It is an infected abortion or any abortion which is associated
with the presence of pathogenic microbes and may result from
spontaneous incomplete or criminal abortions.
• Septic Abortion is characterized by Fever accompanied by
tachycardia, Headache, offensive lochia, usually profuse.
• The uterus is bulky and very tender
• There is body malaise, nausea and vomiting
MR NKOLE J 27

• Risk factors of septic abortion may include;
retained products of conception
 unsterile instruments or environment
associated injuries to the birth canal
MR NKOLE J 28

Molar pregnancy/ hydatid mole
• An abnormality during pregnancy in
which the chorionic villi around an
aborting embryo degenerate and form
clusters of fluid-filled sacs
• Gross Malformation of trophoblast (of
the developing fetus) in which the
chorionic villi proliferate and become
avascular, the villi are filled with fluid so
that they collectively take an
appearance of a bunch of grape
MR NKOLE J 29

• Blood supply is then cut off
giving it a creamy white
appearance/ snow white
• The fetus receives no more
oxygen and nutrients and dies
out.
MR NKOLE J 30

Types under induced abortion
• It can be either therapeutic or criminal abortion.
• Therapeutic abortion
• This is an abortion in which the uterus is evacuated by a
qualified trained medical Doctor (personal) for a valid medical
reason.
• This procedure must only be performed in the interest of the
mother’s life and the foetal well- being .It is carried out in a
hospital. Haemorrhage can be effectively be controlled and
resuscitative facilities are at hand, and where strict aseptic
measures are always taken. MR NKOLE J 31

• The consent of the medical superintendent of the hospital is
required by law ,as well as the consent of the patient and the
husband or guardian if she is less than 18 years.
MR NKOLE J 32

• Criminal abortion
• This is a type of abortion which is illegally performed. It may be
performed by an unqualified person, possibly under unhygienic
conditions
• Can be done using a variety of methods and places causing
them to become septic abortions, also if qualified personal do
not use aseptic techniques.
MR NKOLE J 33

INVESTIGATIONS
• History- History of being pregnant - ask the woman about her
last menstrual period to confirm pregnancy and its duration.
Ask about the amount of bleeding and how many times she has
changed her pads to rule out haemorrhagic shock.
Severity of the lower abdominal cramping as it can be a sign of
pending abortion.
• Blood tests - Gravindex test confirms pregnancy by presence of
HCG which is used as a basis for pregnancy test.

Investigations cont.
• Blood for culture and sensitivity will confirm the increased
leucocytes, the causative organism and its sensitivity if there is
sepsis.
• Full blood count may show reduced hemoglobin due to
haemorrhage and increased leucocytes count if there is infection.
• Rhesus group should be checked to rule out rhesus iso-
immunization.

Investigations Cont…
Ultra sound examination- this a confirmatory test that will reveal:
Gestational sac which will show that the patient was pregnant or
has products of conception.
 If the gestation sac is empty, it signifies that the patient has an
incomplete abortion.
Absence of fetal heart sounds will signify intrauterine fetal
death as in missed abortion.

Management of abortions
MR NKOLE J 37

 It is a spontaneous type of abortion, in which a pregnant woman
presents with slight bleeding through the un-dilated cervix
 Diagnosed when a pregnant woman presents with slight
bleeding, with or without low backache and cramp like pain
 There is minor disturbance to the pregnancy
 The pregnancy may;
Go to term
Missed
Inevitable
Threatened Abortion
MR J.NKOLE 38

Threatened Abortion
Clinical features
 History of amenorrhea
 Signs of pregnancy present
 Pregnancy test is positive
 Blood loss is scant/ slight per vaginal bleeding
 with or without lower abdominal pain and backache
 cervix closed
 uterus is soft and non tender
Management of abortions
MR J.NKOLE 39

Management
Aim
 To prevent abortion to become inevitable
Threatened Abortion
MR J.NKOLE 40

 Investigations
 History from the patient will reveal amenorrhea
 Urine for Gravindex test will positive
 U/sound scanning will show gestational sac which will show that the
patient has products of conception
 Blood for RPR to rule out syphilis
 FBC for Hb estimation and to ascertain if the patient requires blood
transfusion
 Speculum examination to determine the level of cervical dilatation
 V. E not done but speculum examination to assess cervical opening
Medical management
MR J.NKOLE 41

Medication
 Sedatives such as Diazepam to facilitate rest
 Analgesics such as Panadol for pain management if any
 Folic/ Feso4 for facilitation of blood formation
 Ventolin tab 4mg tds will be given to relax the uterine muscles
(tocholitic)
 Vitamin C may be given as it facilitates absorption of iron
Threatened Abortion
MR J.NKOLE 42

Environment
 The patient will be admitted in Gynae ward. Ensure that the room is well
ventilated and clean.
Psychological care
 Mother maybe agitated with the possible lose of the fetus, be empathetic
 Explain the possible cause of her condition
 Explain the condition of the fetus to herself and significant others
 Explain the possible outcome
 Why she is being admitted
 Need for rest and why the need for restriction of visitors
Nursing care of patient with threatened abortion
MR J.NKOLE 43

Rest
 Bed rest is the most important form of treatment so that the woman has
total physical and mental rest.
 Bed rest increases blood flow to the placenta and reduces pain.
 The patient should remain in bed for 5-7days or for as long as blood is
bright red.
 The environment should be quite and visitors should be restricted to
promote rest.
 All nursing procedures should be done in one block
 Give mild sedatives e.g. Phenobarbitone 60mg 8hourly to enable patient
rest in bed.
Nursing care to patient with threatened abortion
MR J.NKOLE 44

Observations
 Vital signs (TPR +BP)
 Observe P/v bleeding for amount and colour
 Pads should be saved in order to help assess the amount of
blood loss(pad count)
 Report any increase in bleeding like clots and any abnormal
tissue through the vagina which could be the sign of inevitable
abortion.
 Observe for pain and presence of contractions.
Nursing care to patient with threatened abortion
MR J.NKOLE 45

Diet
 Well balanced diet/ Mixed diet
 Carbohydrate
 Proteins
 Vitamins
 Iron rich foods
 Fluids to prevent constipation
 Roughage to prevent constipation
 Should be light and non stimulating to prevent uterine contractions.
MR J.NKOLE 46

Hygiene / Infection Prevention
 Sanitary pads changed when soiled to prevent infections
 Pad count done
 Vulva swabbing done to prevent ascending infection
 Daily baths (assisted or bed baths depending on the condition) for comfort and
promoting blood circulation
 Oral care
 Hair care
 Nail care
 Change of soiled linen
MR J.NKOLE 47

 Ensure aseptic techniques are followed during all the procedures
done on the client
 Use clean and sterile equipment such as speculum, pads
 Hand washing
 Personal protective equipment (Aprons, gloves)
MR J.NKOLE 48

Exercises
 Avoided as bleeding maybe provoked
 Complete bed rest encouraged
 If they should be done then it should to a minimal degree
 Coitus should be avoided until the woman recovers fully as it may
worsen the condition
 Elimination
 Monitor bowel opening and bladder emptying
 Constipation and diarrhoea should be avoided as they may provoke
bleeding
 Constipation is prevented by giving fluids and roughage
MR J.NKOLE 49

Information, Education and Communication
 Importance of taking Medication
 Danger signs e.g. Pv bleeding, spotting, fever
 Review dates
 Antenatal care
 Diet
 Avoidance of coitus
 Hygiene
 Rest (avoid strenuous exercises)
 Avoidance of tampons to prevent cervical excitation
 Avoidance of constipation
Threatened Abortion
MR J.NKOLE 50

 Incomplete abortion is a type of abortion in which the fetus is expelled but
part of the products of conception (placenta, membranes) are retained. It is
an emergency and requires urgent attention.
 Clinical picture
i. Backache and abdominal pains which may be severe
ii. PV bleeding is profuse because the uterus cant contract with retained
products of conceptions
iii. Signs of shock such as cold clammy skin, thready pulse, hypothermia,
hypotension may be seen.
iv. Uterus is bulky (enlarged)
v. Uterus is palpable and may feel boggy
vi. Cervix may either be dilated or closed, but will feel patulous
Management of Incomplete Abortion
MR J.NKOLE 51

• Aims
i. To resuscitate the patient
ii. Remove retained products of conception
iii. To arrest haemorrhage
iv. To prevent complication
MR NKOLE J 52

1. Resuscitation
Call for help
 To assist in resuscitation – mobilize available personnel.
Airway
 Maintain a clear airway
 Supine position and the head tilted on the side or lateral position
 Any secretions should be sucked using a suctioning machine
 Oral pharyngeal airway can also inserted
 Any tight clothing around her neck should be loosened.
MR J.NKOLE 53

Breathing
 Ensure that the patient is breathing well and monitor the respirations
 Humidified oxygen via a face mask or nasal catheter should be
administered at 5L/min
Circulation - commence intravenous infusion of Normal Saline 0.9%
1000mls. Depending on the blood loss patient may get as many litres as
possible to replace lost fluids and to combat shock.
• Urgent haemoglobin, grouping and cross matching for blood transfusion
to restore blood volume.
• Foot end of the bed will be elevated to improve blood supply to the vital
organs. Patient is also covered to prevent hypothermia
MR J.NKOLE 54

2. Evacuation of retained products from the uterus:
• Manual vacuum aspiration (MVA) - This is the surgical method
involved in the treatment of incomplete abortion which is done to
evacuate the remaining products of conception.
• MVA uses suction to remove uterine tissue through a cannula with
minimal scrapping of the uterine walls.
• This procedure is important to minimize bleeding by enhancing
uterine contraction.
Immediate management

If gestation is 16 weeks or more;
• Infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min. until
expulsion of products of conception occurs.
• Evacuate any remaining products of conception from uterus by
dilatation and curettage.
• If necessary, give misoprostol 200 µg vaginally every 4 hours
until expulsion, but do not administer more than 800 µg

• 3. Medical therapy – the following Antibiotics are given such as
to prevent infection:
• Amoxil 500mg tds for 5days
• Metronidazole 400mg tds for 5 days.
• Paracetamol 500mg prn to relief pain.
• Give Ergometrine 0.5mg intramuscularly to prevent further
bleeding.

Aims
 To allay anxiety
 To prevent complications
 To provide post abortal counselling
Nursing Care Following an Abortion
MR J.NKOLE 58

Environment
• Patient will be nursed in Gynae ward . The room should be clean to
prevent infection and warm enough for patients comfort. It should
also have enough lighting for easy observation.
• Psychological care
• These women woman may have feelings of guilt, shame, depression,
worthlessness and she may feel she is no longer capable of
providing her husband with a child
• Explain the possible cause of abortion to the mother and the
significant others and involve the support person in the care
MR J.NKOLE 59

 If the cause is preventable, explain how such can be avoided in the
subsequent pregnancies
 Explain all the procedures being done including the method of uterine
evacuation
 Allow the patient and significant others to ask questions
MR J.NKOLE 60

Rest
 Due to excessive loss of fluids and pain, the woman will be
feeling weak and tired, therefore rest should ensured until
complete recovery
 Maintain the quiet environment by doing the following;
Do the procedures in one block
Restrict visitors
Sedatives
Analgesics
MR J.NKOLE 61

• Observation
• Monitor the vital signs of temp, B.P pulse and respirations every.
• A low B.P may signify post operative bleeding; Low pulse and
respiration rates are suggestive of impending shock.
• A high temp after 48 hrs. may be suggestive of infection.
• Check for other signs shock like cold clammy skin, restlessness and
feeble pulse
• Observe the degree of bleeding by requesting the woman to
keep the pads (pad count) and eventually estimation of the loss
MR NKOLE J 62

• If on IV fluids maintain a fluid balance chart and note the intake
and out put to rule out hypovolemic shock and renal failure.
• Pain Relief
• Give Analgesics like paracetamol 1g tds
• Diversion therapy
MR NKOLE J 63

Hygiene and Infection Prevention
 Sanitary pads changed when soiled to prevent infections
 Vulva swabbing done to prevent ascending infection
 Daily baths (assisted or bed baths depending on the condition)
for comfort and promoting blood circulation)
 Oral care
 Hair care
 Nail care
 Change of soiled linen
MR J.NKOLE 64

 Ensure aseptic techniques are followed during all the
procedures done on the client
 Use clean and sterile equipment such as speculum, pads
 Hand washing
 Personal protective equipment (Aprons, gloves)
MR J.NKOLE 65

Nutrition
 Give a well balanced diet/ Mixed diet containing the following;
 Carbohydrate
 Proteins
 Vitamins
 Iron rich foods
 Fluids to prevent constipation
 Roughage to prevent constipation
 Should be light and non stimulating to prevent uterine contractions.
MR J.NKOLE 66

Exercise
 Complete bed rest encouraged initially
 Exercises are introduced slowly
 Strenuous ones are avoided until full recovery
 Coitus should be avoided until the woman recovers fully
Elimination
 Monitor bowel opening and bladder emptying
 Constipation is prevented by giving fluids and roughage
MR J.NKOLE 67

Post Abortal Counselling
 The main aim of counselling is to ensure that the client is availed with
family planning services to prevent repeated abortions
 This should be done to all women.
 Counselling should be done using profiling system and it can done
individually or in groups whilst upholding the patients confidentiality
 Patients should be referred appropriately to the next level of care if
necessary
 Involve the partner or support person and explain the importance of post
abortal contraception
MR J.NKOLE 68

 Hygiene
 Nutrition
 Rest
 Family planning
 Sexual advice
 Review date
 Medication
 Danger signs e.g. Pv bleeding, spotting, fever
Information, Education, Communication
MR J.NKOLE 69

 Infertility secondary to infection and healing by fibrosis which may block
fallopian tubes
 Shock due to bleeding
 Anaemia due to severe bleeding
 Uterine perforation
 Peritonitis due to perforation of uterus and infection of the peritoneum
 Disseminated intravascular coagulation (DIC) more common in missed
abortion
 Secondary bacterial infections due to use of unsterile instruments to abort
or from an endogenous infective organism
Complications
MR J.NKOLE 70

Septic Abortion
• Septic Abortion
• It is an infected abortion which is associated with the presence of
pathogenic microbes and may result from spontaneous
incomplete or criminal abortions characterized by Fever
accompanied by tachycardia, Headache, offensive lochia,
usually profuse.
MR NKOLE J 71

• Risk factors of septic abortion may include;
retained products of conception
 unsterile instruments or environment
associated injuries to the birth canal
MR NKOLE J 72

i. Severe pain around the supra pubic region.
ii. Uterus bulky and very tender on palpation
iii. Foul smelling vaginal discharge usually profuse.
iv. Cervical OS open and products of conception may be felt in
the cervical canal.
v. Chills and fever signifies serious infection.
vi. There is body malaise, nausea and vomiting
S/S of septic abortion

• Septic abortion is an emergency as delay may result in severe
complications or death.
• Most serious complication of septic abortion is septic shock
characterized by hypotension with tachycardia, normal or
subnormal temperature.
• Therefore the following should be instituted;
• Resuscitate with intravenous fluids in order to replace lost fluids

Management
 Treatment of these patients with septic abortion is an emergency
as delay may result in severe complications or death
 Management is the same as for incomplete abortion.
Septic Abortion
MR J.NKOLE 75

 Isolate the patient
 Resuscitate with intravenous fluids
 Most patients will have fluid deficit from blood loss during
abortion or from poor fluid intake due to ill health or fever
 Evacuation of the uterus should be instituted immediately
resuscitation is complete and antibiotics started
Septic Abortion
MR J.NKOLE 76

 Take a cervical swab for culture and sensitivity before starting antibiotic
treatment
 Give parenteral broad spectrum antibiotics
i. Metronidazole 500mgs TDS
ii. Gentamycin 80mg BD
iii. Ceftriaxone 1g OD
 Blood transfusion can be given in cases of low haemoglobin
 Folic/ Feso4
 Analgesics
Septic Abortion
MR J.NKOLE 77

• Also called recurrent abortion or recurrent pregnancy loss (RPL).
• This is when the patient has experienced 3 or more consecutive
spontaneous abortions, usually after 14weeks of gestation
(Ladewig 1996).
• There is usually no obvious cause but the commonest predisposing
factors are uterine abnormalities and cervical incompetence.
• These women should always be referred to the hospital.
HABITUAL ABORTION

• The abortion occurs in the second trimester between 22-24
weeks.
• There is no warning sign but the woman experiences sudden
rupture of membranes and expulsion of fresh abortus occurs.
• This occurs after gradual painless dilatation of the internal os.
Signs and Symptoms

• Management
• Investigate the woman thoroughly to rule out any systemic
disease like DM, syphilis.
• Evacuate any retain products of conception and allow strict bed
rest
• The woman should refrain from lifting heavy objects once
conceives again.
• Encourage her to book for ANC as soon as pregnancy is
suspected in the subsequent pregnancy.
Habitual abortion cont.

• She should avoid coitus in the 1st and 2nd trimester
• She should not be allowed to travel in the 1st and 2nd trimester
• If she works advise her to take leave so that she can rest at
home.
• To enable the cervix hold the weight of the growing fetus and
ensure sustenance and viability of the pregnancy, the doctor can
insert a Shirodika suture at 10 weeks to 38 weeks.
Habitual abortion cont.

• This occur when the fetus dies and is retained in utero, together
with the placenta and membranes (Ladewig 1996).
• Signs and symptoms
i. History of amenorrhea
ii. Signs of pregnancy disappear
iii. Height of fundus less than expected because the uterus does
not grow.
iv. Brownish vaginal discharge.
v. Cervical OS closed.
MISSED ABORTION

vi) There is no pain.
vii) Fetal heart cannot be heard by either fetoscope or Doppler
viii) Pregnancy test usually is negative

• A uterine evacuation is performed if the patient is less than 16
weeks pregnant.
• If the patient is more than 16 weeks pregnant, an oxytocin or
prostaglandin infusion is erected to expel the fetus.
• If the condition of missed abortion persists for over 6-8 weeks,
disseminated intravascular coagulation (DIC) disorders can
occur, therefore, weekly blood samples are taken so that
estimates of plasma fibrinogen can be made.

• DIC comes about when a dead foetus is retained in utero for
more than 3 to 4 weeks.
• Thromboplastins are released from the dead foetal tissues.
• These enter the maternal circulation and deplete clotting factors.

Blood mole
• This condition arises in cases of missed abortion.
• The ovum dies in utero, and the decidua capsularis remains
intact.
• The zygote is surrounded by layers of blood, due to bleeding
between the gestational sac and the uterine wall.
• It usually occurs before the 12th week of gestation. The signs of
pregnancy disappear and there is a brown discharge present.
• When fluids drain from the blood mole, the fleshy, firm, hard
mass which is left, is known as a carneous mole
MR NKOLE J 86

• An evacuation of the uterus is performed if it is diagnosed
before 12 weeks.
• Oxytocics or prostaglandins are used to abort the mole if the
condition is diagnosed after the 12th week of pregnancy.
• Pethidine 100mg i.m to reduce pain
• Conduct strict observation on the mother.

• It occurs when fluids drain from the blood mole leaving a fresh,
firm and hard mass.
• The examination of the mass after expulsion will reveal an
embryo in the center of the mass.
• Management
• Evacuation of the products if diagnosed at 12 weeks.
• If diagnosed after 12 weeks induction will be done to evacuate
the products.
Carneous Mole

INDUCED ABORTION
• Induced abortion can either be;
• Therapeutic abortion, or
• Criminal abortion.

• A therapeutic abortion is one in which the uterus is evacuated by
a qualified, trained medical doctor, for a valid medical reason
(Sellers 2008).
• Therefore this procedure must only be performed in the interest
of the mother’s life and her total well- being.
• Therapeutic abortion is provided for under the legal abortion
Act of 1972.
THERAPEUTIC ABORTION

• It can also be done if there is increased chance of gross fetal
abnormalities.
• It is only carried out in a hospital where haemorrhage can be
effectively controlled, resuscitative facilities are at hand and
where strict aseptic measures are always taken.
• The consent of the medical superintendent of the hospital is
required by law, as well as the consent of the patient and her
husband or guardian if she is less than 18 years.

• Evacuation of the uterus if pregnancy is less than 16 weeks by
MVA, beware of infection setting in and also haemorrhage.
• If the pregnancy is more than 16 weeks oxytocin and cytotec is
given to expel the products of conception.
• Psychological care is given throughout the procedure to gain
cooperation.
• Complete bed rest is essential.
• Observe the blood loss through pad count to assess the amount of
blood loss to prevent shock. Drugs like Benzylpenicillin, gentamycin
and metronidazole are given to combat and prevent infection

• Introduction
• This is an abortion which is illegally processed (Sellers, 2008).
• This type of abortion is punishable by law.
• It is usually performed by unqualified person, possibly under unhygienic
conditions.
• It may be by the woman herself or any other person.
• Methods Used
• Use of herbal medicine taken orally or inserted in the vagina, drugs
intoxication and use of sharp objects introduced from the vagina to the
uterus with an intention of disturbing the uterine environment to induce
abortion.
CRIMINAL ABORTION

• This type of abortion can lead to incomplete or septic abortions.
• If it is incomplete then it should be treated as incomplete
abortion as described above with an antibiotic cover to combat
infection.
Criminal abortion

• Anaemia due severe bleeding
• Infection
• Cervical laceration which may lead to habitual abortion.
• Acute renal failure due to reduced renal perfusion.
• Secondary infertility
• Uterine perforation
• Shock
Complications of abortions

TOGETHER WE CAN MAKE IT A REALITY
Motherhood … .
.. A dream of every woman
MR NKOLE J 97

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2. ABORTION.pdf