ABORTION

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                                ABORTIONS


GENERAL OBJECTIVES.

At the end of the discussion the student should be able to demonstrate an understanding on the management of a woman who had an abortion.

SPECIFIC OBJECTIVES

1.    Define

2.    Discuss the causes of abortion.

3.    Outline the types of abortion.

4.    State the signs and symptoms of abortion.

5.    Discuss the management of abortion.

6.    Discuss the IEC you give to a woman after abortion.

Definition.

This is an interruption of pregnancy before 26th week of gestation and the fetus is not viable.

WHO-expulsion or extraction from its mother of an embryo or fetus weighing 500g or less If it shows signs of life register as a birth.

 

CAUSES

Fetal causes

·       Malformations.

·       Disease of the fertilized ovum.

·       chromosomal anomalies

·       genetic

 

Maternal causes

·       Infection like rubella and chlamydia.

·       Any other infections like those that causes acute febrile conditions e.g malaria.

·       Diseases like chronic nephritis, dm,Thyriod dysfunction.

·       Effects of drugs in large doses.

·       Maternal social life.

·       Endocrine dysfunction.

·       ABO incompatibility.

·       Maternal age.

·       Abnormal in maternal uterine structure.

·       Stress.

 

Local conditions.

·       Trauma

·       Fibroids

·       Incompetent cervix

·       Uterine malformation

 

Investigations.

·       Ultrasound-will show if fetus is in uterus and is viable-if doubt repeat a week later

·       HCG beta unit-doubles by 50% in 48 hours in normal pregnancy

·       Hb

·       Rhesus group should be checked.

·       History from the patient.

 

General signs and symptoms.

Though this depends on the type of abortion there are some which common in all the types.

·       PV bleeding due to partial detachment of the embedded ovum.

·       Pain lower abdominal pains intermittent in character and often accompanied by backache due to uterine contractions.

·       Dilatation of the os present when abortion is inevitable

 

TYPES OF ABORTIONS.

There are two main types of abortions:

·       Spontaneous abortion.

·       Criminal abortion

1.    Threatened abortion

       Definition.

This is the type of abortion in which the disturbance is slight, pregnancy may go to normal.

     Signs and symptoms.

 

·        Amenorrhea followed by slight PVB

·       No pain or in few instances pain can be there.

·       Uterine size correct for dates

·       Cervix is closed

·       Membranes are intact.

·       Avoidance of vaginal procedures and coitus.

 

 NOTE: Bed rest has no role in management.

 

Outcome.

·       Pregnancy may go to term. If s/s subsides.

·       Pregnancy may be inevitable when bleeding and contractions continues.

·       Pregnancy may be missed. 

 

Treatment.

·       Put patient on bed rest

·       Quick assessment is done.

·       Observations Bp, temperature, pulse and Respiration.

 

Investigations.

·       Maternal placental lactogen assessed to predict when bleeding stops.

·       Gently do speculum examination to rule out cervical lesions.

·       Pap smear is done to detect cancers cells.

·       Blood for Hb x-match and grouping  

·       The outcome by radio immunoassay, if low abortion may be inevitable.

·       An ultra-sonic may be made to detect a blighted ovum.

·       HCG levels when you do pregnancy test.

 

 

 

Nursing Care.

   Psychological Care.

·       Reassure the woman that the end result may be that the pregnancy may go to term.

Observations.

·       Observe that TPR and blood pressure are done every 15 minutes (that is in intensive phase) then when condition improves it can be done twice daily.

·       All vaginal discharges, pads, stained clothes and linen are kept to help in estimation of amount of bleeding .Vaginal examination is not done but a specular examination is done.

Hygiene

·       Vaginal swabbing should be done twice a day to prevent infection.

·       Pads should be changed whenever soiled and showed to the midwives or care giver to assess the amount of discharge and colour.

 

   Nutrition.

·       Increased fibre prevents constipation.

·       Increase proteins (balanced diet).

·       Iron supplements

·       Increase fluid intake

 

  Treatment.

·       Analgesics e.g. paracetamol, pethidine to relief the pain.

·       Iron tablets

·       Sedatives-salbutamol 4mg tds given to relaxe the muscles.

·       Antibiotics given to prevent infection.

·       Encourage rest if bleeding

 

     IEC

·       Enough rest should be encouraged.

·       Restrict her activities within reasonable limits and to avoid heavy lifting, strenuous exercises fatigue and excitement.

·       Coitus is contra-indicated for 2-3 weeks.

·       If bleeding starts again, she should see her doctor.

·       Keep soiled linen, pads and stained clothes for Dr’s inspection.

 

 

 

 

 

2.    INEVITABLE ABORTION

 

Definition.

This is when a pregnancy is aborted no matter what you do.

 

Signs and symptoms.

·       Bleeding with clots.

·       Intermittent uterine contractions accompanied by pain.

·       Membranes rupture

·       Os dilated, some parts of conception and protrude through os.

·       Ovum protrudes through the dilating cervical os, clumping with backache.

·       Placenta has separated

 

Outcome

·       Complete abortion.

·       incomplete abortion

 

Treatment.

·       Should be treated like threatened abortion unless where bleeding is very much.

·       If the bleeding is too much, give ergometrine 0.5ml i.m.

·       Give antibiotics.

·       Give analgesics.

·       Oxytocin can be given but if not successful, the uterus is evacuated by suction.

·       Blood Transfusion if bleeding was profuse.

 

 Nursing care.

Observations.

·       Blood pressure, TPR done to act as baseline data, if Bp is low by this indicates bleeding.

·       Pads soiled with blood should be inspected and recorded to assess blood loss.

·       If bleeding is severe, give ergometrine 0.5ml i.m.

 

 Psychological Care.

·       Tell the expectant mother all the findings.

·       Tell her that she has lost the pregnancy and if the cause has been known, tell her the cause.

·       Explain any other possible procedures e.g. MVA to allay anxiety and get consent from her.

·       After 20 weeks milk may come out if so a firm uplift bra should be worn.

 

   IEC

·       Hygiene at home. Change soiled pants.

·       Nutrition-iron rich foods

·       Avoid lifting heavy weights/objects. Avoid strenuous exercises for a month.

·       family planning

·       review dates

·       avoid coitus for a month

·       Report to nearest Health Centre if bleeding re-occurs.

 

  Investigations

·       Blood for Hb grouping and cross-match.

·       Pregnancy test

·       ultra-sound scanning

 

 

 

3.    COMPLETE ABORTION

Definition

This is a type of abortion in which all the products of conception are expelled out. This is more likely to occur before 8 weeks.

 

Signs and Symptoms

·       bleeding is reduced to a mere staining

·       pain ceases

·       os is closed

·       Involution of uterus takes place.

·       if pregnant, more than 20/40 milk may be expressed

 

Nursing Care

Observations

·       TPR is done.

·       BP done

·       Observe the amount of bleeding by inspecting the pads.

·       nutrition

·       firm bra if pregnancy 20/40 and more

 

Psychological care

·       reassure client

·       Reason to rest for 5/12 without getting pregnant.

·       Reasons for known abortion.

 

IEC

·       Family planning

·       hygiene

·       diet

 

Outcome

·       habitual

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.    INCOMPLETE ABORTION

 

Definition

This is a type of abortion in which the fetus has been expelled but the whole or part of the placenta and membranes has remained in utero. usualy at more than 12wks because placenta is firmly embedded and slender cord breaks.

 

Signs and symptoms.

·       The lochia continues and bleeding may be profuse.

·       Lower abdominal pain may or may not be present.

·       Os is partly closed but not complete.

·       Cervix is patulous.

·       Involution does not take place.

 

Outcome.

·       Complete abortion.

·       Septic abortion.

 

Treatment

 

·       Give Ergometrine if no doctor.

·       Alternatively oxytocin can be given.

·       Resuscitate woman with plasma expanders.

·       Blood transfusion can be done depending on the Hb results.

·       Pain killers are given e.g. pethedine.

·       Triple antibiotics are given.

·       Prepare for evacuation.

 

Nursing care

·       Admit for mo. to examine and confirm diagnosis.

·       If in shock manage accordingly.

·       Put up IV fluids to resuscitate the woman.

·       Blood for investigations is taken that is for: Hb, grouping and x match.

·       A high vaginal swab is taken for m/s.

 

Psychological care.

·       Explain the disease process to the woman and her relatives if any.

·       Explain the procedures done.

·       Obtain a signed consent for MVA.

 

IEC

·       Hygiene.

·       Family planning.

·       Nutrition.

·       High fluids intake.

·       Drug compliance.

·       Review dates.

 

5.    MISSEDABORTION.

Definition

Term used when a fetus died in utero.

 

Signs and symptoms.

·       Woman presents with signs of threatened abortion and these later subsides

·       Uterus stops increasing in size, breast size changes reduces.

·       Woman reports brown discharge with no abdominal pains.

Management

·       Abortion must be induced as soon as possible with prostaglandin or oxytocin infusion.

·       Prolonged retention in utero for more than 6/52 may lead to profuse bleeding due to hypofibrinogneumia.

·       There is need to estimate fibrinogen levels weekly.

 

6.    HABITUAL/RECCURENT ABORTION.

Definition.

This is a term used to describe women who had three or more conservative spontaneous abortion whose cause is unknown.

 

Management.

·       Investigate to establish the cause and treat accordingly.

·       Advise woman to improve her general health by improving her diet.

·       As soon as she fails pregnant she should report to the clinic.

·       If the cause is due to incompetence cervix the sloodic suture is inserted before 16/52 and removed at 38/52 or as soon as a woman goes into premature labour to allow vaginal delivery.

 

IEC

·       Inform her when to come review or removal of the suture to prevent complication like ruptured uterus.

 

 

 

 

 

 

 

 

 

 

 

 

 

REFERENCES

 

•        Fraser, D.M eta l (2006): MYLES TEXTBOOK FOR MIDWIVES, African ed. Churchill Livingstone. Sydney

•        General Nursing Council of Zambia (2010): PROCEDURE MANNUAL FOR THE ENROLLED MIDWIFERY PROGRAM

•        Pauline McCALL Sellers Juta and Co,Lt(2008)Midwifery Volume 1,South Africa

      

                THE END

                                   THANK YOU!!!!!!!!! 

 

 

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