Presented by /

Abd Elmawla Helmy Selim

Presented to/
Dr. Fatima Ibrahim

Suez Canal University

Faculty of nursing
2020/2021
Objectives:
1. Definition of abortion?
2. Classification of abortion?
3. Causes of abortion?
4. Risk factors for abortion?
5. Medical management for abortion?
6. Nursing management for abortion?

Definition of abortion
Is the expulsion of the fetus prior to viability, which is considered to
be 20 weeks gestation or weight of less than 500g?
Abortions are either spontaneous (occurring naturally) or induced
(occurring as a result of surgical or medical means).
Risk factors for abortion
There are several risk factors associated with a higher rate of
pregnancy loss.

Age — advancing maternal age is the most important risk factor for
spontaneous miscarriage in normal women.

Previous miscarriage — past obstetrical history is an important

predictor of subsequent pregnancy outcome.

Gravidity — some studies have shown an increased risk of

miscarriage with increasing gravidity, while others have not.

Smoking — Heavy smoking (greater than 10 cigarettes per day) is

associated with an increased risk of pregnancy loss.

Alcohol — Consumption of more than 30 ounces of alcohol per

month doubled the risk of a miscarriage.

Cocaine — Use of cocaine is associated with preterm birth, and may

also be a risk factor for spontaneous abortion.

Nonsteroidal anti-inflammatory drugs — the use of nonsteroidal

anti-inflammatory drugs (NSAIDs), but not acetaminophen, may be
associated with an increased risk of miscarriage if used around the
time of conception

Caffeine: The major findings of this study were:

More spontaneous abortions occurred in women who ingested at

least 100 mg of caffeine per day than in women who ingested less
than 100 mg per day;

Prolonged ovulation to implantation interval — Early losses have

also been related to a prolonged interval ( >10 days) between
ovulation and implantation. Such delays can result from late timing
of intercourse with fertilization of an older ovum, delayed tubal
transport, or abnormal uterine receptivity.
Low-foliate level — a well-designed, population-based, case-control
study showed low plasma folate levels ( 2.19 ng/mL [4.9
nmol/L]) were associated with an increased risk of spontaneous
abortion at 6 to 12 weeks of gestation

Causes of abortion
The etiology of abortion of chromosomally and structurally normal
embryos/fetuses in apparently healthy women is particularly
unclear.

Chromosomal abnormalities:

Cause at least 80% of early abortions; usually numerical (as

Monosomy X, and Polyploidies) and sometimes structural.

A blighted ovum (also known as ―anembryonic pregnancy‖) is a

condition in which chromosomal anomalies of the fertilized ovum
result in the formation of an empty pregnancy sac.

Congenital anomalies — Exposure to teratogens can lead to

congenital abnormalities and pregnancy loss. Potential teratogens
include maternal disorders (, diabetes mellitus with poor glycemic
control), drugs, physical stresses ( fever), and environmental
chemicals.

Trauma — Invasive intrauterine procedures/trauma, such as

chorionic villus sampling and amniocentesis, increase the risk of
abortion.

Host factors — Pregnancy loss may also be related to the host

environment. For example:

1- Congenital or acquired uterine abnormalities (septum, fibroid,

intrauterine adhesions) can interfere with optimal implantation
and growth.
 2- Acute maternal infection (Toxoplasma Gondi, rubella, herpes
simplex) can lead to abortion from fetal or placental infection.
3- Maternal endocrine patties (thyroid disease, Cushing's
syndrome, polycystic ovary syndrome) also can contribute to a
suboptimal host environment.
4- A hypercoagulable state due to inherited or acquired
thrombophilia
5- Abnormalities of the immune system ( systemic lupus
erythematous, ant phospholipid antibody syndrome) that lead
to immunological rejection or placental damage

classification of abortion:

Abortion

Spontaneous Induced

Isolated recurrent legal Illegal

(Medical termination) (Criminal)

Septic (common)

Threatened inevitable complete incomplete missed

(less common)
A)) Spontaneous abortion (miscarriage)
Definition: is the natural termination of pregnancy during the first
20 weeks of gestation (delivery of between the 21th and 38 th weeks
is considered as premature birth even if the fetus does not survive)
Types of miscarriage include:

Threatened, inevitable, complete, incomplete, and missed.

1-threatened abortion:
Any vaginal blood loss in early pregnancy should be thought of as a
threatened miscarriage until shown otherwise.( The embryo is
usually live)

Clinical manifestaions:
-Blood loss may be scanty with low back pain or cramps like pain;
the pain may resemble dysmenorrhea or period pains.
-The cervix remains closed.
- the uterus is soft , with no tenderness when palpated

-about 50% percent will continue with the pregnancy irrespective of

the method of management.
Therapeutic Management:
The aim of treatment is to try and conserve the
pregnancy by decreasing the uterine contractions.
1-rest in bed if the bleeding is moderate for at least 7 days after
stopping of bleeding.
2-avoid sexual intercourse and travelling.
3-sedatives (as valium) to relieve pain and anxiety.
4-treat the cause as hypertension.
5-Hormonal treatment if there is hormonal deficiency (as
progesterone IM)

Medical management :-
- Uterine relaxants like ritodrine or isoxsuprine hydrochloride .
- Sedatives to prevent uterine contraction as phenobarbital 60
mg.
- Pethidine for pain.
- Human Chorionic Gonatrophin (HCG) injections can also be
prescribed to support the pregnancy.
Progesterone supplements are given if progesterone deficiency is
suspected to be the cause of the threatened abortion
2-Inevitable or imminent abortion
If the treatment of threatened abortion is not adequate or timely, the
abortion may become inevitable.
-is the case of pregnancy that cannot be saved, because of a good
portion of the placenta has been detached and the cervical os is
dilating
-The woman presents with bleeding, often heavy (that the mother is
in a shocked state) with clots or products of conception.
-The cervix is dilated and on examination, the membranes may
rupture products may be seen or protruding through the os
-the uterus if palpable, is smaller than expected and strong uterine
contractions may be felt abdominally.
-the accompanying backache and intermittent lower abdominal pain
are intense.

inevitable miscarriage may end up as one or

other of the following:
a) Incomplete miscarriage:
-Some of the products of conception are retained, most of the
placenta
-heavy and profuse bleeding, because of retained parts.
-there is pain as well as backache.
-the cervical is usually open and the uterus remain bulky.

b) Complete miscarriage:
-all the products of conception are expelled.
-pain subsides and bleeding is slight and gradually diminishes.
-the cervix is found closed or reforming
-The uterus is becomes smaller in size and is firmly contracted on
examination, and an empty cavity is seen on ultrasound.

Therapeutic management of inevitable

abortion:
1-correction of general condition (and shock if it develops)
supportive treatment like IV fluids and blood transfusion may
also become necessary

2-ergometrine 0.5 mg is given by IM or IV route to induce tetanic

uterine contraction and stop bleeding.

o If pregnancy is less than 12 weeks: Termination is done

by vaginal evacuation and curettage or suction
evacuation under general anesthesia.
o If pregnancy is more than 12 weeks:

a-Oxytocin is given by intravenous drip to expel the

uterine contents.

 If the placenta is retained it is removed under

general anesthesia.

b-surgical by abdominal hysterectomy, if more than

14 weeks gestation.
Nursing Management of inevitable abortion
Before D&C or induction

• Measuring vital signs

• Observe amount of bleeding
• Encourage bed rest
• Administer prescribed medication as ,sedative &
analgesics,…..
• Provide comfortable measures as, back rub
• Prepare client physically & emotionally for D&C
• I.V Dextrose 5% + oxytocin for induction as order

Prepare the needed instruments

• After D&C or induction

• Emotional support
• Administer RHIg if indicated
• I.V infusion monitoring
• Administer blood transfusion and antibiotic if prescribed

Teach the client about:

• Family planning methods

Wear comfortable brassier to reduce breast discomfort due to

breast engorgement
3- Recurrent or habitual abortion:
-is defined as the loss of three or more consecutive pregnancies.

factors associated with recurrent miscarriage:

The etiology remains unexplained in about 50% of cases

 Genetic factors
 Structural anomalies :
1- Uterine conditions a uterine malformation is considered to
cause about 15% of recurrent miscarriages. The most
common abnormality is a uterine septum
2- Cervical conditions :incompetent cervical os which results
in midtrimester spontaneous abortion ,usually after 16
weeks gestation or early preterm delivery
*the abortion tends to be rapid, painless and bloodless.
 Infectious causes
including listeriosis, toxoplasmosis, and certain viral infections
(rubella, herpes simplex, measles, cytomegalic virus).
 Thrombophilia
 Endocrine causes
As hypothyroidism , Unrecognized or poorly treated diabetes -
mellitus , and polycystic ovary syndrome
 Immunologic causes as systemic lupus erythematous.
 Environmental causes
The lifestyle of pregnant women appears to affect the
rate of habitual abortion as smoking, alcohol, and heavy coffee
consumption can adversely affect fetal development.
 Ovarian factors: as inadequate luteal phase with insufficient
secretion of progesterone.

Management:
 Prophylactic therapy should be started when the woman is in
a non pregnant state through prevention of its causes.
 Investigations to identify the cause :
 – blood tests for hormonal levels and for infections, blood
glucose level, USG for uterine causes, HSG to identify
cervical incompetence and for uterine causes.
 1-find the cause of habitual abortion and treat it appropriately
and adequately
 2-Hormonal deficiencies and infections are
treated by medicines and bed rest.
 3-cervical cerculage at 14 weeks, which remains in place until
38 weeks or until onset of labor when it is removed

4- Missed Abortion
In missed abortion the fetus dies but the products of
conception are retained for a prolonged period of time (2 or
more weeks).Signs and symptoms of a missed abortion include
the following:
1. Normal early pregnancy without accompanying
presumptive and probable signs of pregnancy
2 .Vaginal spotting or bleeding or lower abdominal or back
pain at the time of death of the fetus (may or may not occur)
3 .Fundal heights not only ceases to increase but after a while
the uterus becomes smaller (due to maceration of the fetus and
absorption of the amniotic fluid)
4. Regression of mammary changes of pregnancy
5. The woman often loses a few pounds in weight
6 .-the woman may report a brownish vaginal discharge .the
cervix is closed
7 .No fetal heart tones when anticipated by dates
8. If the fetus is retained beyond 6 weeks there is potential
development of disseminated intravascular coagulopathy
(DIC).

Therapeutic management:
-When a woman presents with these signs and symptoms,
an ultrasound examination is ordered for confirmation
Of fetal death.
-evacuation to avoid the potential serious complications:
*uterus is less than 12 weeks: dilation and evacuation.
 5-septic abortion:
-infection superimposed on any type of abortion (especially,
missed, incomplete, and therapeutic)

*symptoms of septic abortion:

In a woman with septic abortion, symptoms that are related to the
infection are mainly:

 High fever, usually above 101 °F

 Chills
 Severe abdominal pain and/or cramping /or strong perineal
pressure
 Beginning miscarriage symptoms (heavy bleeding and or
cramping) that suddenly stops and does not resume
 Prolonged or heavy vaginal bleeding
 Foul-smelling vaginal discharge
 Backache or heavy back pressure

A cold or urinary tract infection may mimic many of the symptoms.

As the condition becomes more serious, signs of septic shock may
appear, including:

 Low blood pressure (hypotension)

 Low body temperature (hypothermia)
 Little or no urine output (oliguria)
 Respiratory distress (dyspnea and labored breathing)

Septic shock may lead to kidney failure, bleeding diathesis,

and disseminated intravascular coagulation (DIC). Intestinal organs
may also become infected, potentially causing scar tissue with
chronic pain, intestinal blockage, and infertility.
If the septic abortion is not treated quickly and effectively, the
woman may die.
Risk factors for abortion:
The risk of a septic abortion is increased by mainly the following
factors:

 The fetal membranes surrounding the unborn child have ruptured,

sometimes without being detected
 The woman has a sexually transmitted infection such as
chlamydia
 An intrauterine device (IUD) was left in place during the
pregnancy
 Tissue from the unborn child or placenta is left inside the uterus
after a miscarriage
 Unsafe abortion was made to end the pregnancy
 Insertion of tools, chemicals, or soaps into the uterus

Medical management for abortion

(A)-isolation
1-general measures: fluids, light diet, analgesics and
antipyretics.
2-promotion of drainage:
Fowler's position and ergometrine
3-observation of vital signs and urine output: for diagnosis and
management of septic shock if it develops.
-Soiled pads probably collected & burned
4-antibiotics either:
*combination to cover the spectrum: ampicillin or
cephalosporin+gentamicin+metronidazole
*or treatment is started by ampicillin or cephalosporin, and
then it may be modified according to results of culture and
sensitivity.
5-evacuation:
Within 24 hours from the start of antibiotic therapy, when
infection and fever become controlled .however, with severe
bleeding, evacuation is immediately started under cover of
massive antibiotics
 -evacuation should be done carefully as the infection makes
the uterus very friable and liable to perforation.
-hysterectomy is rarely indicated as perforation and incomplete
response to treatment of septic shock.

B)) induced abortion:

This is deliberate interruption of intact pregnancy.
This could be either legal (medical termination of pregnancy)
Or illegal (criminal)
1- (Illegal) criminal abortion: is abortion illegally
produced.
*Its complications:
 Sepsis
 Uterine perforation
 Conical lacerations and hemorrhage
 Sudden death
 Acute renal failure
 Infertility
2-legal (medical termination of pregnancy):
It is deliberate induction of abortion before 20 weeks gestation by a
registered medical practitioner in the interest of mother's health and
life.
*Indications:

 Deteriorating health due to pulmonary tuberculosis

 Cardiac diseases Grade III and IV with history of
decompensation
 Chronic glomerulonephritis
 Malignant hypertension
 Intractable hyperemesis gravidarum
 Cervical or breast malignancy
 Diabetes mellitus with retinopathy
 Psychiatric illness
General medical management:

**Algorithm for the management of spontaneous pregnancy

loss. (hCG = human chorionic gonadotropin.)

- Expectant management, medical therapy, and surgical

management for women with incomplete spontaneous
abortion. Expectant management proved to be successful, with
no need for surgical intervention in 82 to 96 percent of women.
Average time to completion of the miscarriage was nine days.
- Medical therapy with misoprostol (Cytotec)
-surgical management: Dilatation and curettage is the
traditional treatment for spontaneous abortion; manual vacuum
aspiration is another surgical option. Prompt surgical
evacuation of the uterus is the treatment of choice when the
patient is unstable because of heavy bleeding or has evidence
of a septic abortion.
-A 50-mcg dose of Rho (D) immune globulin should be given
to patients who are Rh-negative and have a threatened abortion
or have completed a spontaneous abortion.
 NURSING CARE for abortion
**Nursing care for patients experiencing a spontaneous abortion varies
depending on the type of abortion. However, the primary nursing intervention
for all types of spontaneous abortion is to ensure patient safety by identifying
and controlling bleeding and hypovolemic shock.

 Monitor for Symptoms of hypovolemic shock include an increased heart rate,

decreased blood pressure, cool and clammy skin, lightheadedness, and
confusion.
 The nurse should anticipate the need for oxygen therapy and fluid and blood
replacement.
 The nurse may also be responsible for administering medications; for example,
oxytocin (Pitocin) may be used to help in expelling the products of conception
or to control bleeding.
 Patients should be blood-typed and cross-matched in case a blood transfusion is
necessary.
 The nurse monitors vital signs, oxygen saturation, intake and output, and
laboratory results according to institutional policies.
 If a patient experiences a threatened abortion but the fetus does not die, the
nurse may be responsible for monitoring fetal heart sounds and the overall well-
being of the fetus depending on gestational age.
 The nurse should administer prescribed Rhogam to Rh-negative patients within
72 hours to prevent isoimmunization.
 The nurse caring for a patient experiencing spontaneous abortion will also need
to help the patient explore her feelings regarding an actual or potential loss.
Many patients feel of guilt are often significant emotional challenges that many
patients must deal with while grieving their loss.
 Similarly, patients who suffer from a threatened abortion and do not lose the
fetus are often afraid that they may still lose the fetus and remain stressed
throughout the remainder of the pregnancy. This affects not only the patient but
also her family, and the nurse should do everything possible to assist the patient
and her family during this time.
 Monitor for signs of (DIC), DIC produces clotting, bleeding, and ischemia that
occur simultaneously. Symptoms include shortness of breath, chest pain and/or
cyanosis that occur suddenly. Bleeding from the nose, gums, and IV sites occur
in the presence of DIC.
  Nurses are responsible for ensuring that patients are adequately prepared to care
for themselves upon discharge from the hospital following treatment or
monitoring for a spontaneous abortion. It is important that patients understand the
warning signs of further complications and the importance of reporting such
signs to their healthcare provider: Warning signs include fever, foul-smelling
vaginal discharge, significant bright red vaginal bleeding, and pelvic pain.
 In addition, patients are encouraged to avoid sexual activity, tampons, or
douches.
 Experiencing a spontaneous abortion is challenging for patients both physically
and emotionally and they need to rest for a few days after discharge.
 Encourage Foods such as liver, green leafy vegetables, dried foods, and eggs
provide needed iron and Additional fluid intake is recommended.
 The patient needs to understand that it is normal for her to go through a grieving
process and that she may grieve for six months to one year
 Woman should be encouraged to allow her body to rest and recover before
attempting another pregnancy and to discuss with her healthcare provider when
the appropriate time to conceive would be.

Complications of spontaneous miscarriages and

therapeutic abortions include the following:
 Complications of anesthesia
 Post abortion triad (pain, bleeding, low-grade fever)
 Hematomata
 Retained products of conception
 Uterine perforation
 Bowel and bladder injury
 Failed abortion
 Septic abortion
 Cervical shock
 Cervical laceration
 Disseminated intravascular coagulation (DIC)