ABORTION

SINDHU SEBASTIAN
LECTURER
FMCON

DEFINITION
Abortion is the expulsion or extraction
from its mother of an embryo or fetus
weighing 500gm or less when it is not
capable of independent survival.
WHO

Early Abortion: Before 12 weeks

Late Abortion: From 12-20 weeks

Viability
Survival by Gestational age
Weeks
22
23
24
25
26
27
28

% survival
0
25
55
65
75
90
92

INCIDENCE:

10-20% of all clinical pregnancy

10% Illegal
75% occur before 16wks

CLASSIFICATION
ABORTION
Spontaneous

Isolated

Induced

Recurrent

Legal

Illegal (criminal )

Septic

Threatened

Inevitable

Complete

Incomplete Missed

Septic

ETIOLOGY:
1.Ovular or Fetal factors(60%):
a) Ovo-fetal factors-

Chromosomal abnormality
Gross congenital malformation
Blighted ovum
Hydropic degenaration of villi
Death or Disease of fetus

Contd
b) Interference with circulation-

Knots

Twists
Entanglements
c) Low attachment of placenta
d) Twins or Hydramnios.

2. Unknown

factors

Contd
3. Maternal factors(15%):
Maternal medical illness
-Cyanotic heart diseases
Infections
Maternal hypoxia
Chronic illness
Endocrine and metabolic factors

Contd
Anatomical abnormalities
Cervico-uterine factors-Cervical incompetence
-Congenital malformation of uterus

-Uterine fibroid
-Intrauterine adhesions

-Retroverted uterus

Trauma- Direct
-Psychic Susceptible individual
-Amniocentesis
Toxic agents
4.Blood group incompatibility
5. Premature Rupture of Membranes

6.Environmental factors Smoking,

alcoholism, X-ray, Radiation,
Chemotherapy.
7.Dietic factors
8.Paternal factors:Chromosomal anomaly in
sperm
9.Infections Viral, Bacterial or Parasitic
10. Inherited Thrombophilia

11.Immunological disorder
Autoimmune disease (mother's immune system
will form antibody against her own placenta and
fetus) or
Alloimmune disease ( Paternal antigen which
enters mothers body will produce antibody against it.
Maternal antibody accepts as its own so there will be
decreased foetal-maternal immunologic interaction
and ultimately fetal rejection).

 11. Immunological disorder

Autoimmune disease (mother's immune system
will form antibody against her own placenta and
fetus) or
Alloimmune disease ( Paternal antigen which
enters mothers body will produce antibody against it.
Maternal antibody accepts as its own so there will be
decreased foetal-maternal immunologic interaction
and ultimately fetal rejection).

Common cause
First trimester

Genetic factors -50%

Endocrine disorders
Immunological
Infections
Unexplained (40-60%)

 Second trimester
1.Anatomic abnormalities
a) Cervical incompetence
b) Mullerian fusion defects (Bicornuate uterus, septate
uterus )
c) Uterine synechiae (intra uterine adhesion )

d) Uterine fibroid
2.Maternal medical illness

3.Unexplained

Mechanism of Abortion
Before 8 weeks: Ovum surrounded by the villi with
the decidual coverings is expelled out. Because the
external os fails to dilate the entire mass remains in the
cervix. Called as Cervical Abortion.

8-14 weeks: Expulsion of the fetus commonly occurs

leaving behind the placenta and membranes, so that
there will be bleeding.
Beyond 14th week: Expulsion is similar to that of
mini labour. The fetus is expelled first followed by
expulsion of placenta.

Spontaneous Abortion:
Definition:
It is defined as the involuntary loss of the
products of conception prior to 20 weeks
of gestation.
Incidence:
15% of all confirmed pregnancy
80% occur in first trimester

Causes
1.Abnormal fetal formation due to
-Teratogenic factor
-chromosomal aberration
50-80%of early abortion has structural abnormalities
2.Immunological factors rejection by immune
response

3.Implantation abnormalities Poor implantation result

from
inadequate endometial formation

An inappropriate site of implantation

 improper implantation placental circulation

function affected inadequate fetal nutrition
4.Corpus luteum fails to produce enough progesterone
to maintain the decidua basalis proge therapy is
neeed

5.UTI
7.Ingestion Of Teratogenic Drugs

7.Infections -rubella
syphilis,cytomegalo,toxoplasmosis
Which readily cross the placenta

Changes
Infection
Fetus fails to grow
Estrogen and progesterone production by placenta
fails
Endometrial sloughing

Prostaglandins are released

Uterine contraction expulsion of products of
pregnancy

Cervical dilatation
Expulsion of products of pregnancy

Schematic Diagram of Abortion

Abnormal Fetal
Formation

Immunologic
Factors

Infection
Crosses
placenta

Rejection of the
embryo through
immunologic
response

Fetus fails
to grow
Decrease estrogen
and progesterone
production

Endometrial
sloughing

Miscarriage

Release of
prostaglandin which
causes uterine
contractions and
cervical dilatation

Teratogenic
Factors
(smoking,
alcohol, drugs)

1.Threatened abortion:
It is a clinical entity where the process of
abortion has started but has not
progressed to a state from which
recovery is impossible.

Clinical features
Bleeding per vagina:Slight and bright
red in colour.
Pain: Mild backache or dull pain in
lower abdomen.

Pelvic examination:
a)Speculum examination-bleeding if any,escapes through
the external os.
b)Digital examination-reveals closed
external os.
c)The uterine size corresponds to the period of
amenorrhoea.

Investigation
a)Blood investigation

b)USG
c) Urine for immunological test for pregnancy

Treatment
Rest : 2weeks of bed rest.

Drugs : sedation and analgesics

Phenobarbitone 30mg or
Diazepam 5mg
Advised to preserve vulval pads and anything expelled out per
vaginam for inspection.

To report if bleeding or pain gets aggravated.

Routine note of pulse, temperature and vaginal bleeding.

Advice on discharge
-Limit her activities at least for 2 weeks.
- Avoid heavy work.
-Coitus is contraindicated during this period.
-Follow up after 1month to assess the growth of fetus.

2. INEVITABLE ABORTION

It is the clinical type of abortion where

the changes have progressed to a state
from where continuation of pregnancy
is impossible.

Clinical features
-Increased

vaginal bleeding

-Severe lower abdominal pain- colicky type

-General condition is proportionate to
visible blood loss.

Internal examination
Reveals dilated internal os of the cervix through
which the product of conception are felt.

Management
Principles :
a. To take appropriate measures to look after the
general condition.
b. To accelerate the process of expulsion.
c. To maintain strict asepsis.

Active treatment

Before 12weeks : dilatation and evacuation followed

by curettage of uterine cavity.

After 12weeks :

i. Uterine contraction is accelerated by oxytocin drip

(10 U in 500ml NS) 40-60drops/min.
ii. If the product is expelled and placenta retained, it is
removed by ovum forceps(if lying separate)

Contd
iii. If placenta is not seperated, digital seperation
followed by evacuation under GA.
If bleeding is severe and cervix is closed then
evacuation of uterus is done by Abdominal
hysterectomy.

3. COMPLETE ABORTION

When the products of conception are

completely expelled, it is called
complete abortion.

Clinical features
-There

is history of expulsion of a fleshy

mass per vagina followed by:

-Subsidence of pain

-Vaginal bleeding becomes trace or absent

Cont....

Internal examination reveals:

-Uterus is smaller than the period of amenorrhoea
-Cervical os is closed

-Bleeding is trace
-Examination of the expelled fleshy mass is found
intact.

Management
i. Blood loss should be assessed and treated.
i. If there is doubt about complete expulsion of
products, uterine curettage should be done.
i. Transvaginal sonography is useful to prevent
unnecessary surgical procedure.
i. In case of Rh negative mother antiD gamma
globulin should be given.

4. Incomplete abortion

When the entire products of

conception are not expelled, instead a
part of it is left inside the uterine
cavity, is called incomplete abortion.

Clinical features.
-History of expulsion of fleshy mass per vaginam

followed by:
-Continuation of pain lower abdomen

-Persistence of vaginal bleeding

Internal examination

-Uterus

smaller than the period of

amenorrhoea
-Cervical os may admit the tip of the finger
-Varying amount of bleeding
-On examination,the expelled mass is found
incomplete.

Termination
If the products left behind it leads to

Profuse bleeding
Sepsis
Placental polyp
Choriocarcinoma

Management
The principles to be followed are same as Inevitable
abortion.
Patient may be in a state of shock due to blood loss.,
she should be resuscitated before any active
treatment.

Early abortion: Dilatation and evacuation

Late abortion: Uterus is evacuated under GA and the
products are removed by ovum forcep or by blunt
curette.

5. Missed abortion / Silent

miscarriage or early fetal demise

When the fetus is dead and retained

inside the uterus for a variable
period,it is called as missed abortion
or silent miscarriage.

Pathology
Beyond 12wks: Fetus become macerated or
mummified, liquor amnii get absorbed, placenta
becomes pale,thin and adherent.

Before 12wks: Because of haemorrhage blood will get

collected around ovum called as blood mole".,
water content from the blood gets absorbed and flesh
remains around the ovum called as Fleshy mole or
Carneous mole.

Clinical features
Persistence of brownish vaginal discharge
Subsidence of pregnancy symptoms
Retrogression of breast changes

Non audibility of fetal heart sound even with doppler

Cervix feels firm
Immunological test for pregnancy becomes negative

USG reveals an empty sac

Management

If less than 12wks:

vaginal evacuation by suction
evacuation or slow dilatation of
the cervix by laminaria tent
followed by dilatation and
evacuation of the uterus under GA.

If more than 12wks:

Induction is done
-Oxytocin 10-20U in 500ml NS at
30drops/min. If fails increase dose to
maximum of 200mlU/min
-Prostaglandins:misoprostol tab inserted into
the posterior vaginal fornix
:IM administration of 15methyl PGF2
(carboprost tromethamine)

6. Septic abortion

Any abortion associated with

clinical evidences of infection of
the uterus and its contents.

Criteria
Rise of temperature 100.4*for 24 hrs

Offensive or purulent vaginal discharge

Lower abdominal pain and tenderness

Mode of infection
Usually the micro-organisms present in the
vagina are involved in sepsis when the
resistance power of the mother becomes
low.
Majority of cases the infection occurs
following illegal induced abortion.

Reasons for infection

Proper antiseptic and asepsis are not taken
Incomplete evacuation

Clinical features
Pyrexia associated with chills and rigors.
Purulent vaginal discharge
Shock

Pain abdomen of varying degrees

Internal examination reveals:
-Offensive purulent vaginal discharge
- Tender uterus

Clinical grading
Grade I : Infection localised to uterus
(commonest)
Grade II : infection spreads beyond the
uterus to the tubes and ovaries.
Grade III : Generalised peritonitis / shock /
jaundice or acute renal failure (associated
with illegal induced abortion).

Investigations
Routine investigations :

-Cervical or high vaginal swab for culture and

sensitivity test.
-Blood for haemoglobin, total and differential count,
ABO and Rh grouping.
-Urine analysis including culture
Special investigations :
-USG abdomen and pelvis
-Blood for culture, serum electrolytes, coagulation
profile

Complications
Immediate :

Haemorrhage
Injury to uterus and adjacent
structures
Spread of infection causes Peritonitis
Acute renal failure
Thrombophlebitis

Remote :

Chronic pelvic pain, Backache

Dyspareunia
Ectopic pregnancy
Secondary infertility due to tubal
blockage
Emotional depression.

Prevention
i. Use

family planning method

ii. Encourage to go for legal abortion

Management

Hospitalization
High vaginal or cervical swab
Vaginal examination to note the
state of abortion process

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

Specific management
Drugs : 1.Antibiotics
Gram positive aerobes

a)Aqueous Penicillin G 5million U IV every 6 hours

(b)Ampicillin 0.5-1gm IV every 6 hours.
Gram negative aerobes

(a)Gentamicin 1.5mg/kg IV every 8 hours.

(b)Ceftriaxone 1.5gm IV every 12 hours

For Anaerobes

(a) Metronidazole 500mg IV every 8hours

(b) Clindamycin 600mg IV every 6hours
Grade I
1.Antibiotics
2. Prophylactic anti gas-gangrene

Serum of 8000 U and 3000 U of anti tetanus serum

IM are given.

3. Analgesics and Sedatives

-Blood transfusion
-Evacuation of the uterus within 24hours following
antibiotic therapy

Grade II

Antibiotics
Clinical monitoring- to note pulse, temperature,
urinary output and progress of pain, tenderness and
mass in lower abdomen.

Surgery
i. Evacuation of the Uterus
ii. Posterior colpotomy(pouch of douglas)

Grade III
Antibiotics
Clinical monitoring

Supportive therapy with IV fluids.

Active surgery

-Laparotomy

Recurrent / Spontaneous
miscarriage

Recurrent miscarriage is defined as a

sequence of three or more
consecutive spontaneous abortion
before 20weeks.

Etiology
During 1st trimester
-Genetic factors

-Endocrine and metabolic

-Infection
-Inherited Thrombophiliaintra vascular
coagulation .(protein C-natural inhi-of
coag)
-Immunological cause : Auto & Allo
immunity
-Unexplained

During

nd
2

trimester

Cervical incompetence

Defective mullerian fusion-double uterus,bicornuate

uterus,septate uterus.
Cervical incompetence
Uterine fibroid

Retroverted uterus
Chronic maternal illness
Infection, Unexplained

Investigations
i. History

on previous abortion.
ii. Any chronic illness
iii. Histology of placenta

Diagnostic tests
a. Blood glucose , VDRL , Thyroid
function test, ABO and Rh grouping
b. Autoimmune screening
c. USG
d. Hysterosalpingography
e. Hysteroscopy / Laparoscopy
f. Endocervical swab

Treatment
During Inter conceptional Period

To alleviate anxiety and improve

psychology
Hysteroscopic resection of uterine septate
Uterine unification operation (metroplasty)
for bicornuate uterus.
Genetic counselling if chromosomal
abnormality .
Endocrine dysfunction has to be controlled.
Genital tract infections are treated.

During pregnancy

Reassurance and tender loving care.

Ultrasound

Adequate rest

Avoid strenuous activity

Intercourse

Travelling.

 Luteal phase defect:

Progesterone 100mg as vaginal
suppository TID started 2days after
ovulation. During this time if
pregnancy test is positive continue
treatment 12weeks of pregnancy.
(corpus luteal insufficiency)

Inherited Thrombophilia :

antithrombotic therapy improves the pregnancy

outcome.heparin 5000IUtwice daily.S/C upto 34
weeks
Medical complications : Specific management is
continued.

Unexplained :

Supportive therapy improves pregnancy outcome.

 Circlage operation :non absorbable encircling suture

is placed around the cervix at the level of internal
OS.
Done at 14 weeks of pregnancy or at least two weeks
earlier than the previous pregnancy loss -10th week

Nursing Diagnosis
Risk for fluid volume deficit r/t maternal
bleeding

Nursing Interventions
Report any tachycardia, hypotension, diaphoresis,
or pallor, indicating hemorrhage and shock.
Draw blood for type and screen for possible blood
administration.
Establish and maintain an IV with large-bore
catheter for possible transfusion and large quantities
of fluid replacement.

Nursing Diagnosis
Anticipatory grieving r/t loss of pregnancy, cause of
abortion, future childbearing

Nursing Interventions
Assess the reaction of patient and support person, and
provide information regarding current status, as
needed.
Encourage the patient to discuss feelings about the
loss of the baby include effects on relationship with the
father.
Do not minimize the loss by focusing on future
childbearing; rather acknowledge the loss and allow
grieving.
Providing time alone for the couple to discuss their
feelings.

Nursing Diagnosis
Risk for infection r/t dilated cervix and open uterine
vessels

Nursing Interventions
Evaluate temperature q 4H if normal, and every 2H if
elevated.
Check vaginal drainage for increased amount and
odor, which may indicate infection.
Instruct on and encourage perineal care after each
urination and defecation to prevent contamination.

Nursing Diagnosis
Acute pain r/t uterine cramping and possible
procedures

Nursing Interventions
Instruct patient on the cause of pain to decrease
anxiety.
Instruct and encourage the use of relaxation
techniques to augment analgesics.
Administer pain medication as needed and as
prescribed.

Nursing Diagnosis
Knowledge deficit r/t signs and symptoms of possible
complications

Nursing Interventions
Teach the woman to observe for signs of infection (fever,
pelvic pain, change in character and amount of vaginal
discharge), and advise to report them to provider
immediately.
Deal with clients anxiety. Present information out of
sequence, if necessary, dealing first with material that is most
anxiety producing when the anxiety is interfering with the
clients learning process.
Teach client of the complications for a mother has reason
to be especially worried about her infants health.

Thank you

Induced abortion

Definition

Deliberate termination of
pregnancy before the
viability of the fetus is
called induction of abortion

Elective: if performed for a womans

desires

Therapeutic: if performed for reasons of

maintaining health of the mother

MTP ACT -1971

The continuation of pregnancy would
involve seroius risk of life or grave injury
to the physical and mental health of the
pregnant women
There is a substantial risk of the child
being born with serious physical and
mental abnormalities so as to be
handicapped in life

 When the pregnancy caused by rape ,both in

case of major and minor girl and in mentally
imbalance women
Pregnancy result as a result of contraceptive
failure

Indication
To safe the life of the mother
-Cardiac diseases

-Ch.Glomerulonephritis
-Malignant hypertension
-Hyperemesis gravidarum
-Cervical breast malignancy
-DM with retinopathy

-Epilepsy or psychiatric diaseases with

advice of psychiatrist

 Social indications
-unplanned

pregnancy with low

socioeconomic status
-pregnancy caused by rape or failure of
contraceptive methods

 Eugenic
-Structural-anencephaly

,chromosomal (down syndrome) or

genetic (hemophilia)
-Teratogenic
drugs(warfarrin)radiation exposure more
than 10 rads in early pregnancy
- rubella infection

RECOMMENDATIONS
1.Qualified Registered medical practitioner
a) One has assisted at least 25 MTP in
authorized centre and having certificate
b)6 months house surgeon training in OBG
c)Diploma or degree in OBG

2.Termination can only performed in hospitals

established or maintained by Govt or places approved
by Govt
3.Pregnancy can only terminated on the written consent
of the women. Husband's consent is not required
4.Pregnancy in a minor girl (below the age of 18 years
)can not be terminated without the written consent of
the parent or legal guardian.
5.Termination is permitted up to 20 weeks of pregnancy
When the pregnancy exceeds 12 weeks opinion of two
medical practitioners is required

 The abortion has to be performed

confidentially and to be reported to the
director of health services of state in the
prescribed form

Induced abortion: statistics . . .

1,180,000 abortions 79.7% of women
obtaining abortions
are reported to the
CDC in 1997. This is are unmarried
constant since 1980 21 % of women
obtaining abortions
305 abortions/1000
are younger 19 years
live births
old
National abortion
rate: 20/1000 women 55.2 % are younger
than 24 years old
aged 15-44

Contd

88% of women who

abort are in the first
trimester of
pregnancy

97% of women
having first trimester
abortions have no
complications or post
abortion complaints

2.5 % have minor

complaints that are
handled in a physicians
office
<0.5% require additional
surgery

Roe vs. Wade

1/22/73

We recognize the right of the individual, married or

single, to be free from unwanted governmental
intrusion into matters so fundamentally affecting a
person as the decision whether to bear or beget a
child. That right necessarily includes the right of a
woman to decide whether or not to terminate her
pregnancy.

Gestational age and procedure

50% of abortion performed 8 weeks or
earlier
12% of abortion performed past 12
weeks
1.4% of abortion performed past 20
weeks

First Trimester Abortion

Early Uterine Evacuation (EUE),

Minisuction
Menstrual Regulation
Suction Abortion
Vacuum Curettage
Medical Abortion

Minisuction
Introduced in 1972 by Karman and Potts

Surgical techniques for abortion

Menstrual aspiration(menstrual regulation )
Aspiration of endometrial cavity using a flexible cannula and syringe within
1-3 weeks after failure to menstruate
Several points at early stage of gestation
Woman not being pregnant
Implanted zygote may be missed by the curette
Failure to recognize an ectopic pregnancy
Infrequently, a uterus can be perforated

Dilatation and curettage (D&C)

Removal of pregnancy
contents by some
mechanical means
Vacuum most
commonly used
12-13 weeks is the
upper limit of
gestational age

Usually performed in
free standing clinics

Medical Abortion

Mifepristone (RU486)
Analogue of progestin norethindrone
Strong affinity for the progesterone
receptor, acting as an antagonist
A single oral dose given to women 5
weeks or less produces abortion in
85% of cases

Mifepristone protocol
Women less than 49 days LMP with
confirmed b-hCG
600mg mifepristone on day 1
On day three, return for prostaglandin,
Misoprostil 400 mcg orally
Patient remain in clinic four hours, during
which time expulsion of pregnancy
usually occurs

Medical

Surgical

Private
More sense of
autonomy
More natural
Earlier intervention
unwanted pregnancy

Longer process with

unclear endpoint
More pain
More bleeding
Anxiety regarding
abortion off site

Medical

Surgical

Less skill needed to

provide
Methotrexate also treats
ectopic pregnancy

Increased anxiety re: off site

management
More unscheduled care: calls,
ER visits
Need to guard against
unnecessary intervention
Limited to 49 days LMP

Second Trimester Termination

Dilatation and evacuation (D&E)

Intrauterine injection of
abortifacients
Prostaglandin vaginal suppositories
High dose oxytocin
Hysterotomy

D&E

Mechanical and suction removal of

formed pregnancy after cervical dilation
Technically more difficult than earlier
suction procedures
Associated with fewer complications than
instillation and suppository methods
General anesthesia is not required

 Picture of laminaria

Intrauterine injection of
abortifacients
Prostaglandin, hypertonic saline,
hypertonic urea are introduced by
amniocentesis
Fetus and placenta are aborted vaginally
Osmotic dilators are used to decrease time
to delivery and decrease complications

Prostaglandin suppositories
20 mg suppositories of PGE2 typically given
q 3 hours

Prostaglandin F2alpha 250 mg IM q 2 hours

Mean time to
Mean time to
induction 13.4 hours,
abortion 15-17 hours,
with 90% aborting by
with 80% aborting by
24 hours
24 hours
GI side effects: 39%
GI side effects: 83%
vomiting, 25% diarrhea
vomiting, 71% diarrhea
Fever: temperature
Misoprostil (PGE1
elevation of 1 degree c

High Dose Oxytocin

As effective as PGE2 when used in

appropriate doses
Risk of water intoxication

Hysterotomy

Surgical method to remove pregnancy

abdominally (mini-cesarean section)
Other methods are preferred

Complications - rates
Varies as a function of the gestational age
they are performed

Major complications:
0.25% < 7 weeks
1% < 12 weeks
2% over 12 weeks

Complications - Immediate

Complications of local anesthetic

Cervical shock
Cervical lacerations
Uterine perforation
Hemorrhage
Post abortal syndrome

Complications - Delayed

Bleeding
Retained products

Infection
Continued pregnancy
Ectopic
Intrauterine

Thank you