PPT-OBG-ABORTION.MANAGEMENT PRESENTATION
- 1. B.Sc (BASIC)NURSING DEGREE Midwifery & Obstetrical Nursing UNIT VII – High Risk Pregnancy ABORTION PREPARED BY : Mrs. Mohana M.Sc(N) PROFESSOR KVCN
- 2. OBJECTIVES The students will be able to define abortion Identify the difference between various types of abortion Perform medical induction for abortion Describe various surgical techniques used for abortion Detect the consequences that occur by abortion and provide appropriate care
- 3. CONTENT OVERVIEW Definition Types of abortion- Spontaneous, Induced, Complete abortion, Incomplete abortion, Missed abortion, Recurrent abortion, Induced abortion Risk factors, etiology, mechanism, clinical manifestations of each type Management – medical & surgical Nursing management
- 4. INTRODUCTION Abortion or pregnancy loss is accounts to spontaneous events or through legal termination. The first large scale study on abortions and unintended pregnancies conducted by The Lancet in 2017 said one in three of the 48.1 million pregnancies in India end in an abortion with 15.6 million taking place in 2015.
- 5. DEFINITION Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing 500 gm or less when it is not capable of independent survival -WHO
- 6. DEFINITION …contd The 500gm of fetal development is attained approximately at 22 weeks(154 days of gestation). The expelled embryo or fetus is called abortus Abortion is the cause for bleeding in early pregn
- 9. SPONTANEOUS ABORTION Abortion occurring without medical or mechanical means to empty the uterus is referred to as spontaneous Another widely used term is miscarriage
- 10. INCIDENCE (INDIA) 10-20% of cases of all clinical pregnancies end in miscarriage. About 75%miscarriages –before 16th week About 80% occur –before 12th week of pregnancy.
- 11. RISK FACTORS Increases with parity Increased maternal and paternal age The frequency of abortion increases from 12% in women younger than 20 years to 26% in those older than 40 years Women conceiving within 3 months following a term birth, have a higher incidence of abortion
- 12. ETIOLOGY The exact mechanism responsible for abortion are not apparent Factors responsible for abortion Maternal Fetal
- 13. FETAL FACTORS 1.Abnormal zygotic development Developmental abnormality of the zygote, embryo, early fetus, or placenta Degenerated or absent embryos or fetal pole with diameter of 3cm or more or blighted ova/Silent miscarriage. 2.Aneuploid abortion Chromosomal abnormalities - Maternal gametogenesis error -Paternal error
- 14. BLIGHTED OVUM - Anembryonic Gestational sac - Positive HCG test as placenta secretes HCG and stops later - Presents in first few weeks of pregnancy - Removal through medical or surgical induction
- 15. BLIGHTED OVUM
- 16. MATERNAL FACTORS CONTRIBUTING TO ABORTION 1. INFECTIONS 2.CHRONIC ILLNESSES 3.ENDOCRINE ABNORMALITIES 4. DRUGS 5. NUTRITION 6. IMMUNOLOGICAL FACTORS 7.UTERINE/CERVICAL DEFECTS
- 17. INFECTIONS - Uncommon causes of abortion in human • Listeria monocytogenes • Clamydia trachomatis • Mycoplasma hominis • Ureaplasma urealyticum • Toxoplasma gondii CHRONIC DEBILITATING DISEASES – Diabetes mellitus – Celiac sprue • Cause both male and female infertility and recurrent abortions
- 18. ENDOCRINE ABNORMALITIES – Hypothyroidism • Thyroid autoantibodies → incidence of abortion is high – Diabetes mellitus • Poor glucose control → incidence of abortion increased – Progesterone deficiency • Luteal phase defect • Insufficient progesterone secretion by the corpus luteum or placenta
- 19. DRUG USE AND ENVIRONMENTAL FACTORS • At least 5 cups of coffee per day → slightly increased risk of abortion Caffeine • Arsenic, lead, formaldehyde, benzene, ethylene oxide in sufficient doses → abortifacient Radiation/ exposure to metals • When intrauterine devices fail to prevent pregnancy → abortion↑ Contraceptives • Anesthetic gases : exact fetal risk of chronic maternal exposure is unknown Environmental toxins • ↑ Risk for euploid abortion • More than 14 cigarettes a day → the risk twofold greater ↑ Tobacco • Spontaneous abortion & fetal anomalies → result from frequent alcohol use during the first 8 weeks of pregnancy Alcohol
- 20. IMMUNOLOGICAL FACTORS – AUTOIMMUNE FACTORS – Recurrent pregnancy loss patients : 15% – Antiphospholipid antibody : most significant • LCA (lupus anticoagulant), ACA (anticardiolipin Ab) ALLOIMMUNE FACTORS - Inherited thrombophilia
- 21. UTERINE DEFECTS – ACQUIRED UTERINE DEFECTS Uterine synechiae (Asherman syndrome) Partial or complete obliteration of the uterine cavity by adherence of uterine wall
- 22. INCOMPETENT CERVIX The retention power of the cervix(Internal os) may be impaired functionally and or anatomically in an incompetent cervix
- 23. INCOMPETENT CERVIX Painless dilatation of cervix Prolapse & ballooning of membranes into vagina Rupture of membranes & expulsion of immature fetus Unless effectively treated, tends to repeat in each pregnancy
- 24. INCOMPETENT CERVIX Diagnosis in nonpregnant women Hysterography Pull-through techniques of inflated Foley catheter balloons Specifically sized cervical dilators Transvaginal ultrasound in pregnant women • Cervical length - shortening • Funneling Etiology – Previous trauma to the cervix • Dilatation & curettage • Conization • Cauterization – Abnormal cervical development • Exposure to DES in utero
- 25. MANAGEMENT OF INCOMPETENT CERVIX Prophylactic surgery performed between 12 & 16weeks Delayed until after 14 weeks’ gestation for other factors to be elicited The more advanced the pregnancy, the more likely the risk that surgical intervention stimulate preterm labor or membrane rupture Usually do not perform after about 23 weeks
- 26. CERVICAL ENCIRCLAGE SURGERY Reinforcement of weak cervix by purse string suture or banding Types of operations commonly used – McDonald – Modified Shirodkar 85~90% success rate is achieved
- 27. PREOPERATIVE EVALUATION – Sonography : Confirm living fetus & exclude major fetal anomalies – Cervical cytology – Cultures for gonorrhea, chlamydia, group B streptococci • Obvious cervical infections → treatment is given • For at least a week before & after surgery → sexual intercourse should be restricted
- 28. NUTRITION • Dietary deficiency of vitamins, iron and folic acid • Not a major cause PATERNAL FACTORS -Little is known in the genesis of spontaneous abortion -Chromosomal translocations in sperm can lead to abortion OTHER FACTORS -Laparotomy Physical trauma
- 29. Mechanism of Miscarriage In Earlier Weeks Death of the ovum occurs first Its Expulsion In Later weeks Maternal environment factors are involved Expulsion of the fetus which may have signs of life but it is small to survive
- 31. CATEGORIES OF SPONTANEOUS ABORTION Threatened abortion Inevitable abortion Complete or incomplete abortion Missed abortion septic abortion
- 32. THREATENED ABORTION Definition It is a clinical entity where the process of miscarriage has started but has not progressed to a state from which recovery is possible. -Any bloody vaginal discharge or bleeding during 1st half of pregnancy -Bleeding is frequently slight, but may persist for days or weeks
- 33. Frequency • Extremely common (one out of four or five pregnant women) Prognosis • Approximately 50% will abort • Risk of preterm delivery, low birthweight, perinatal death • Risk of malformed infant does not appear to be increased Symptoms • Usually bleeding begins first • Cramping abdominal pain follows a few hours to several days later • Presence of bleeding & pain • Poor prognosis for pregnancy continuation
- 34. DIAGNOSIS BIOCHEMICAL TESTS • Serial serum quantitative hCG • Serum progesterone • ( can help ascertain if the fetus is alive & its location) • Serum progesterone value < 5 ng/ml→ dead conceptus • VAGINAL SONOGRAPHY • Gestational sac(+) & hCG < 1000mIU/ml • → gestation is not likely to survive • → In case of doubt of survival, check the serum hCG level at intervals of 48hrs • → if no increase more than 65%, almost always hopeless
- 35. TREATMENT – Bed rest & acetaminophen-based analgesia – Progesterone (IM) or synthetic progestational agent (PO or IM) – D-negative women with threatened abortion • should receive anti-D immunoglobulin 50 mcg IM After Death of Conceptus – Uterus should be emptied, examination of all passed tissue whether the abortion is complete – Ectopic pregnancy should be considered if gestational sac or fetus are not identified
- 36. INEVITABLE ABORTION DEFINITION Inevitable Abortion It is the clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible MANIFESTATIONS Increased Vaginal Bleeding -Aggravation of pain in the lower abdomen which may be colicky in nature -Internal Examination-dilated IO of the cervix which the products of conception are felt DIAGNOSIS Blood-Hb,Hematocrit,ABO and Rh grouping MANAGEMENT IV therapy Oxytocic drugs -Before 12 weeks- D&E,D&C -After 12 Weeks-Induction of Labour
- 37. MISSED MISCARRIAGE/ EARLY FETAL DEMISE Definition When the fetus is dead and retained inside the uterus for a variable period Manifestations -Persistence of brownish vaginal discharge -Subsidence of pregnancy symptoms -Retrogression of breast changes -cessation of uterine growth -Non audiability of FHR Diagnosis Blood-Hb,Hematocrit,ABO and Rh grouping USG Management Before 12 weeks – Prostoglandin E1-800mg-vaginally Suction and Evacuation Complications IUD
- 39. COMPLETE ABORTION When the products of conception are expelled enmasse - Vaginal Bleeding becomes trace or Absent -Subsidence of abdominal pain -Uterus is smaller than the period of amenorrhea -Cervical os is closed Blood- Hb,Hematocrit,A BO and Rh grouping Conservative care ANTI D administration
- 40. INCOMPLETE ABORTION When the entire products of conception are not expelled ,instead a part of it is left inside the uterine cavity -Persistence of Vaginal bleeding -Continuation of pain in lower abdomen - Internal Examination- - Uterus is smaller than the period of amenorrhea -Patulous cervical os often admitting tip of the finger. -Varying amount of bleeding Blood- Hb,Hematocrit, ABO and Rh grouping USG Management Misoprostol 200 micro gm- vaginally every 4 hrs Surgical Management -ERCP -MVA
- 42. SEPTIC ABORTION • Looks sick and anxious • -T >38◦ C • -Chills and Rigorous • -Persistent Tachycardia > 90 bpm • -Hypothermia(Endo toxic shock)<36◦ C • - Abdominal or Chest pain • -Tachypnea (RR) >20/mt • -Impaired Mental state • -Diarrhea and/or Vomitting • -Renal Angle Tenderness Any abortion associated with clinical evidences of infections of the uterus and its contents Blood-Hb,Hematocrit,ABO and Rh grouping, • -Cervical or high vaginal swab • -USG • -Plain Xray DIAGNOSIS
- 43. MANAGEMENT Grade-I-The Infection is localized in the uterus • Antibiotics • -Antigas gangrene serum of 8000 units,and 3000 units of Antitetanus • Analgesics and sedatives • -Evacuation of the Uterus Grade-II- The Infection spreads beyond the uterus to the parametrium,tubes and ovaries or pelvic peritoneum-Same the treatment of Grade 1 • Posterior Colpotomy Grade-III- Generalised peritonitis and/or endotoxic shock or jaundice or acute renal failure - Intensive care treatment
- 44. RECURRENT ABORTION Definition : Three or more consecutive spontaneous abortions before 20 weeks Clinical investigation of recurrent miscarriage – Parental cytogenetic analysis – Lupus anticoagulant & anticardiolipin antibodies assays
- 45. Postconceptional evaluation – Serial monitoring of ß–hCG from missed mens period • ß–hCG>1500mIU/ml → USG – Maternal serum α-fetoprotein assessment (GA16-18wks) – Amniocentesis → fetal karyotype Prognosis – Depends on potential underlying etiology & number of prior losses
- 46. MANAGEMENT 1. Adequate rest 2. Appropriate diet 3. Anemia correction 4. Treatment of systemic illness 5. Reassurance and tender loving care 6. Surgical management of incompetent cervix
- 47. INDUCED ABORTION The medical or surgical termination of pregnancy before the time of fetal viability Therapeutic abortion – Termination of pregnancy before of fetal viability for the purpose of saving the life of the mother due to – Invasive carcinoma of the cervix – Pregnancy resulted from rape or incest – Continuation of pregnancy is likely to result in the birth of child with severe physical deformities or mental retardation
- 48. TYPES Elective (voluntary) abortion – Interruption of pregnancy before viability at the request of the women, but not for reasons of impaired maternal health or fetal disease Counseling before elective abortion – Continued pregnancy with its risks & parental responsibilities – Continued pregnancy with its risks & its responsibilities of arranged adoption – The choice of abortion with its risks
- 49. MEDICAL INDUCTION Early abortion – Outpatient medical abortion is an acceptable alternative to surgical abortion in women with pregnancies of less than 49 days’ gestation (ACOG, 2001b) – Three medications for early medical abortion • Antiprogestin mifepristone • Antimetabolite methotrexate • Prostaglandin misoprostol
- 56. POST ABORTION MANAGEMENT Support the woman Anti D administration counselling Use of contraceptives Follow up care
- 58. KEY FEATURES Detailed the composition and tenure of the DLC Abortion sites approved for - A – upto 12 weeks - B- 12 – 20 weeks , facilities and equipments required Need for registered medical practitioner and referral hospitals
- 60. NURSING CARE PLAN 1. Anxiety 2. Acute pain 3. Fluid volume deficit 4. Deficient knowledge 5. Risk for complications 6. Situational Self Esteem
- 61. REFERENCES 1. Myles, M. F., Bennett, V. R., & Brown, L. K. (1993). Myles textbook for midwives. Edinburgh: Churchill Livingstone. 2. Reeder, S. J., Martin, L. L., & Koniak, D. (1997). Maternity nursing: Family, newborn, and women's health care. Philadelphia: Lippincott. 3. Dutta, D. and Konar, H., 2013. DC Dutta's Textbook Of Obstetrics. 7th ed. New Delhi: Jaypee Brothers Medical Publishers 4. Orshan (2009). Maternity Nursing. LWW 5. Ricci(2009). Essentials of maternity nursing, Lippincotts 6. Lowdermilk(2008). Maternity Nursing,Elsevier
- 62. THANK YOU