ABORTION

Introduction

Pregnancy is ususlly uncomplicated experience. In some cases, however, problem arise during the pregnancy that place the woman and her unborn child at risk. Regular prenatal care serves to detect these potential complications quickly so that effective care can be provided.

SPONTANEOUS ABORTION ( MISCARRIAGE)

Definition

Abortion is the termination of pregnancy before the period of viability which is considered to occur at 28^th week.

Incidence

75%  abortions occur before the 16^th week and of these, about 75% occur before the 8^th week of pregnancy.

Classification or varieties

                                               Abortion

 

       Spontaneous                                                            Induced

 

Isolated                   Recurrent                                  Legal                       Illegal

                                                                                                                   Septic -- common

  

Threatened    Inevitable  Complete  Incomplete  Missed   Septic

Etiology

The causes of abortion are usually divided into:

1.      Ovular or fetal

2.      Maternal environment

3.      Paternal factor

4.      Unknown

I.          Ovo – fetal factors ( 60%)

a)      The ovo – fetal factors usually operate  in early fetal wastage. Meticulous histological and cytogenic study of the abortus reveals gross defects in the ovum or the fetus. The defects include

·   Chromosomal abnormality ( autosomal trisomy, monosomy)

·   Gross congenital malformation

·   Blighted ovum ( ovum without embryo)

·   Hydropic degeneration of the villi

b)     Interference with the circulation, in the umbilical cord by knots, twists or entanglements may cause death of the fetus and its expulsion.

c)      Low attachment of the placenta or faulty placental formation ( circumvallate) may interfere with the placental circulation

d)     Twins or hydramnios ( acute) by ra;idly stretching the myometrium may cause abortion.

II.          Maternal factors( 15%)

Maternal factors usually operate in late abortion leading sometimes to expulsion of the living fetus which ofcourse is too small to survive.

1. Maternal illness

• Infection: viral infection specially rubella and cytomegalic inclusion disease produces congenital malformation and abortion if contracted in early weeks of pregnanacy. The viruses of hepatitis, parvovirus, influenza have got lethal action on the fetus causing its death and expulsion. Parasitic( malaria) and protozoal infection ( Toxoplasmosis) may produce abortion  if contracted in early pregnanacy.  Spirochates hardly produce abortion before 20^th week because of effective thickness of the placental barrier. Hyperpyrexia may precipitate abortion by increasing uterine irritability.
• Maternal hypoxia and shock: Acute or chronic respiratory diseases, heart failure, severe anemia or anaesthetic complications may produce anoxic state which may precipitate abortion. Severe gastroenteritis or cholera which is prevalent in the tropics is often an important cause.
• Chronic illness : Hypertension, chronic nephritis and chronic wasting disease are responsible for late abortion by producing placental infarction resulting in fetal anoxia.
• Endocrine factors: An Increased association of abortion is found in conditions of hypothyroidism, hyperthyroidism and diabetes mellitus.

2. Trauma

·        Direct trauma on the abdominal wall by blow or fall may be related to abortion.

·        Psychic: emotional upset or change in environment may lead to abortion by affecting the uterine activity

·        In susceptible individual, even a minor trauma in the form of journey along rough road, internal examination in the early months or eliciting Hegar’s sign or sexual intercourse in early months is enough to excite abortion.

·        Amniocentesis, chorion villus sampling or abdominal surgery in early months may cause abortion.

3. Toxic agents

Environmental toxins like lead, arsenic, anaesthetic gases, tobacco, caffine, alcohol, radiation in excess amount increases the risk of abortion.

4. Cervico – uterine factors

These are related to the second trimester abortions

·        Cervical incompetence

·        Congenital malformation of the uterus – bicournate or septate uterus

·        Uterine tumour- distortion of the uterine activity and increased uterine irritability

·        Retroverted uterus

5. Immunological : presence of autoimmune factors like lupus anticoagulant and antiphospholipid antibodies increases the risk of abortion
6. Blood group incompatibility :  incompatible ABO group matings may be responsible for early pregnancy wastage and often recurrent but Rh incompatibility is a rare cause of death of fetus before 28^th week. Couple with group A husband and group O wife have got higher incidence of abortion.
7. Premature rupture of membranes inevitably leads to abortion
8. Dietetic factors : deficiency of folic acid or Vitamin E is often held responsible

III.          Paternal factors

Defective sperm, contributing half of the  number of the chromosomes to the ovum, may result in abortion

IV.          Unknown ( 25%)

Inspite of the numerous factors mentioned, it is indeed difficult in a majority to pinpoint the cause of abortion in clinical practice.

THREATENED ABORTION

DEFINITION

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

The patient, having symptoms suggestive of pregnancy, complains of:

Bleeding per vaginam: the bleeding is usually slight and bright red in colour. On rare occasion, the bleeding may be brisk and sharp, specially in the late second trimester, suggestive of low implantation of placenta. The bleeding either stops spontaneously or continues with change of colour to brown or dark remains as bright red.

Pain : bleeding is usually painless but there may be mild back ache or dull pain in lower abdomen. Pain appears usually following haemorrhage.

Pelvic examination should be done as gently as possible

·        Speculum examination reveals – bleeding if any, escapes through the external os.

_ any local lesion in the cervix may co – exist

·        Digital examination reveals the closed external os. In multiparae, external os may be patulous but the internal os must be closed. The uterine size corresponds to the period of amennorhoea. The uterus and the cervix fell soft.

Investigations

Routine investigations include:

Blood :  for haemoglobin estimation, ABO and Rh grouping. Blood transfusion may be required urgently if abortion becomes inevitable and anti – D  gamma globulin has to be given in Rh negative non – immunized women.

Urine for immunological test of pregnancy. This is done to confirm  the fetal death in case of  continued bleeding. The test remains positive for a variable period even after the fetal death.

Special investigation

The ultrasonographic ( transvaginal) findings may be:

 A well formed gestation ring with central echoes from the embryo indicating healthy fetus.

Observation of fetal cardiac motion. With this there is 98% chance of continuation of pregnancy.

 A blighted ovum is evidenced by loss of definition of the gestation sac, smaller mean gestational sac diameter, absent fetal echoes and absent fetal cardiac movements.

Serum progesterone value of 25 ng \ ml or more generally indicates a viable pregnancy in about 95% of cases. Serial serum chorionic gonadotrophin ( hCG) level is helpful to assess the fetal well being. Normally quantitative value of hCG should double by every 48 hours.

Treatment

 Bed rest:  the patient should be in bed for few days until bleeding stops. Prolonged restriction of activity has got no therapeutic value. However, with history of  previous early pregnancy wastage, the period of rest should be extended to about two weeks beyond the period at which the previous wastage occurred.

Drugs: sedation and relief  of pain may be ensured by phenobarbitone 30mg or diazepam 5 mg tablet twice daily. Bowel should be left alone for 48 hours. Mild laxative ( milk of magnesia) 4 teaspoons at bed time may be prescribed later on, if required. Enema should not be given.

There is no evidence that treatment with natural progesterone or synthetic progestins  improves the prognosis. Even some of the progestins structurally related to testosterone may result in virilization of the female fetus. Initial study suggests that use of hCG  improves pregnancy outcome. There is also no valid reason to use tocolytic agents.

General measures

The patient is advised to preserve the vulval pads and anything expelled out per vaginam , for inspection

To report if bleeding and or pain becomes aggravated

Routine note of pulse, temperature and vaginal  bleeding

Advice on discharge

The patient should limit her activities for atleast two weeks and avoid heavy work, strenuous exercise and excitement. Coitus is contraindicated during this period.

She should be re -examined after one month to note the growth of the uterus and advised to consult the physician if bleeding recurs.

Prognosis

The prognosis is very unpredictable whatever method of treatment is employed either in the hospital or at home. In isolated spontaneous threatened abortion, the following events may occur:

In about two  - third, the pregnancy continues beyond 28 weeks.

In the rest, it terminates either in inevitable or missed abortion. If the pregnancy continues, there is increased frequency of preterm labour, placenta praevia, intrauterine growth retardation of the fetus and fetal anomalies.

Blighted ovum

It is a sonographic diagnosis. There is absence of fetal pole in a gestational sac with diameter of 3cm or more. Uterus is to be evacuated once the diagnosis made.

NURSING DIAGNOSES

• Anxiety related to outcome of pregnanacy
• Acute pain ( lower abdomen) related to abdominal cramping secondary to threatened abortion
• Activity intolerance related fatigue
• Risk for fluid volume deficit related to vomiting
• Risk for complications related to threatened abortion

BIBLIOGRAPHY

·        Fraser DM, Cooper MA. Myles textbook for midwives. 14th edition. London: Churchill  Livingstone; 2003

·        Dutta DC. Textbook of obstetrics. 6th edition. Kolkata: New Central Book Agency; 2004

·        Jacob Annamma . A Comprehensive Textbook of Midwifery . 2nd edition . New Delhi : Jaypee

  Brothers Medical Publishers Pvt Ltd ;2008

·        Elizabeth Marie. Midwifery For Nurses. 1^st edition. New Delhi: CBS publishers. 2010.