![COMPLICATIONS
• RETAINING THE PRODUCTS FOR LONG TIME CAN LEAD TO SEPSIS
• DIC [DISSEMINATED INTRAVASCULAR COAGULATION]– (VERY RARE) IN GESTATIONS EXCEEDING 16
WEEKS](https://image.slidesharecdn.com/abortion-240301055930-10f81234/85/Abortion-presentation-of-obstetrics-and-gynecological-nursing-28-320.jpg)
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Abortion presentation of obstetrics and gynecological nursing
- 3. INTRODUCTION •AN ABORTION IS A PROCEDURE TO END A PREGNANCY. IT USES MEDICINE OR SURGERY TO REMOVE THE EMBRYO OR FETUS AND PLACENTA FROM THE UTERUS. THE PROCEDURE IS DONE BY A LICENSED HEALTH CARE PROFESSIONAL.
- 4. DEFINITION •ABORTION IS THE ENDING OF PREGNANCY BY REMOVAL OR EXPULSION OF AN EMBRYO OR FETUS. AN ABORTION THAT OCCURS WITHOUT INTERVENTION IS KNOWN AS A MISCARRIAGE. • 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).
- 6. SPONTANEOUS ABORTION • SPONTANEOUS ABORTION IS NON-INDUCED EMBRYONIC OR FETAL DEATH OR PASSAGE OF PRODUCTS OF CONCEPTION BEFORE 20 WEEKS OF GESTATION. INCIDENCE 10-20% ( 10% ARE INDUCED OR DELEBERATE 75% ABORTIONS OCCUR BEFORE THE 16TH WEEK • RATES VARY WITH MATERNAL AGE; ALSO HIGH IN WOMEN WITH PAST MISCARRIAGE
- 8. ETIOLOGY •FETAL FACTORS • GENETIC – 50% OF EARLY MISCARRIAGE IS DUE TO CHROMOSOMAL ABNORMALITIES – NUMERICAL DEFECTS LIKE TRISOMY, POLYPLOIDY, MONOSOMY – STRUCTURAL DEFECTS LIKE TRANSLOCATION, DELETION, INVERSION • MULTIPLE PREGNANCIES • DEGENERATION OF VILLI • MATERNAL FACTORS • ENDOCRINE AND METABOLIC FACTORS (10–15%): – LUTEAL PHASE DEFECT – THYROID ABNORMALITIES – DIABETES MELLITUS • •ANATOMICAL ABNORMALITIES (10–15%) CERVICOUTERINE FACTORS – CERVICAL INCOMPETENCE & INSUFFICIENCY – CONGENITAL MALFORMATION OF THE UTERUS – UTERINE FIBROID – INTRAUTERINE ADHESIONS
- 10. CAUSES OF FETAL LOSS • REDUCED INTRA UTERINE VOLUME • REDUCED EXPANSILE PROPERTY OF THE UTERUS • REDUCED PLACENTAL VASCULARITY WHEN IMPLANTED ON THE SEPTUM
- 11. • INFECTIONS (5%) – VIRAL: RUBELLA, CYTOMEGALO, HIV,.. – PARASITIC: TOXOPLASMA, MALARIA,.. – BACTERIAL: UREAPLASMA, CHLAMYDIA • IMMUNOLOGICAL DISORDERS (5–10%)— – • AUTOIMMUNE DISEASE – • ALLOIMMUNE DISEASE – • ANTIFETAL ANTIBODIES • ENVIRONMENTAL FACTORS – CIGARETTE SMOKING – ALCOHOL CONSUMPTION – CONTRACEPTIVE AGENTS • MATERNAL MEDICAL ILLNESS – CYANOTIC HEART DISEASE – HEMOGLOBINOPATHIES • UNEXPLAINED (40-60%) – IN MAJORITY, THE EXACT CAUSE IS NOT KNOWN.
- 12. THREATENED ABORTION • • CONDITION IN WHICH MISCARRIAGE HAS STARTED BUT HAS NOT PROGRESSED TO A STATE FROM WHICH RECOVERY IS IMPOSSIBLE
- 13. CLINICAL FEATURES • THE PATIENT, HAVING AMENORRHEA, COMPLAINS OF: (1) SLIGHT BLEEDING PER VAGINAM (2) PAIN: USUALLY PAINLESS; THERE MAY BE MILD BACKACHE OR DULL PAIN IN LOWER ABDOMEN • THE UTERUS AND CERVIX FEEL SOFT. • DIGITAL EXAMINATION REVEALS CLOSED EXTERNAL OS • DIFFERENTIAL DIAGNOSIS INCLUDES – CERVICAL ECTOPY – POLYPS OR CARCINOMA – ECTOPIC PREGNANCY – MOLAR PREGNANCY •
- 14. INVESTIGATIONS • BLOOD • URINE • ULTRASONOGRAPHY (TVS)
- 15. MANAGEMENT & PROGNOSIS • REST: PATIENT SHOULD BE IN BED FOR FEW DAYS UNTIL BLEEDING STOPS • RELIEF OF PAIN: DIAZEPAM 5 MG BD • 80% OF PREGNANCIES WITH THREATENED ABORTIONS GO ON UNTIL TERM • IF A LIVE FETUS IS SEEN ON USG, PREGNANCY IS LIKELY TO CONTINUEIN OVER 95% CASES. • IF PREGNANCY CONTINUES, THERE IS INCREASED FREQUENCY OF PRETERMLABOR, PLACENTA PREVIA & IUGR
- 16. INEVITABLE MISCARRIAGE • IT IS THE CLINICAL TYPE OF ABORTION WHERE THE CHANGES HAVE PROGRESSED TO A STATE FROM WHERE CONTINUATION OF PREGNANCY IS IMPOSSIBLE
- 18. CLINICAL FEATURES • THE PATIENT, HAVING THE FEATURES OF THREATENED MISCARRIAGE, PRESENTS WITH – VAGINAL BLEEDING – AGGRAVATION OF COLICKY PAIN IN THE LOWER ABDOMEN • SOMETIMES, THE FEATURES MAY DEVELOP QUICKLY WITHOUT PRIOR CLINICAL EVIDENCE OF THREATENED MISCARRIAGE • INTERNAL EXAMINATION REVEALS DILATED INTERNAL OS THROUGH WHICH THE PRODUCTS OF CONCEPTION ARE FELT
- 19. MANAGEMENT • TO ACCELERATE THE PROCESS OF EXPULSION– TO MAINTAIN STRICT ASEPSIS • IF PREGNANCY < 12 WEEKS, SUCTION EVACUATION IS DONE • IF PREGNANCY > 12 WEEKS, EXPULSION BY OXYTOCIN INFUSION • GENERAL MEASURES: – EXCESSIVE BLEEDING IS CONTROLLED BY ADMINISTERING METHERGIN 0.2 MG – BLOOD LOSS IS CORRECTED BY IV FLUID THERAPY AND BLOOD TRANSFUSION
- 20. INCOMPLETE ABORTION • THE PROCESS OF ABORTION HAS ALREADY TAKEN PLACE, BUT THE ENTIREPRODUCTS OF CONCEPTION ARE NOT EXPELLED & A PART OF IT IS LEFT INSIDE THE UTERINE CAVITY
- 22. CLINICAL FEATURES • HISTORY OF EXPULSION OF A FLESHY MASS PER VAGINAM;– CONTINUATION OF PAIN IN LOWER ABDOMEN – PERSISTENCE OF VAGINAL BLEEDING • INTERNAL EXAMINATION REVEALS– UTERUS SMALLER THAN THE PERIOD OF AMENORRHEA – OPEN INTERNAL OS – VARYING AMOUNT OF BLEEDING • ON EXAMINATION, THE EXPELLED MASS IS FOUND INCOMPLETE COMPLICATIONS: • THE RETAINED PRODUCTS MAY CAUSE: (A) BLEEDING (B) SEPSIS OR (C) PLACENTAL POLYP.
- 23. MANAGEMENT • EVACUATION OF THE RETAINED PRODUCTS OF CONCEPTION (ERCP) • EARLY ABORTION: DILATATION AND EVACUATION UNDER ANALGESIA OR GENERAL ANESTHESIA IS TO BE DONE. • LATE ABORTION: UTERUS IS EVACUATED UNDER GENERAL ANESTHESIA ANDTHE PRODUCTS ARE REMOVED BY OVUM FORCEPS OR BY BLUNT CURETTE. IN LATE CASES, D&CIS TO BE DONE TO REMOVE THE BITS OF TISSUES LEFT BEHIND. • MEDICAL MANAGEMENT – TAB. MISOPROSTOL 200 ΜG IS USED VAGINALLY EVERY 4 HOURS
- 24. COMPLETE ABORTION • WHEN THE PRODUCTS OF CONCEPTION ARE COMPLETELY EXPELLED FROM THEUTERUS, IT IS CALLED COMPLETE MISCARRIAGE.
- 25. CLINICAL FEATURES • THERE IS HISTORY OF EXPULSION OF A FLESHY MASS PER VAGINAM FOLLOWED BY – SUBSIDENCE OF ABDOMINAL PAIN – VAGINAL BLEEEDING BECOMES TRACE OR ABSENT • INTERNAL EXAMINATION REVEALS: – UTERUS SMALLER THAN THE PERIOD OF AMENORRHEA – CERVICAL OS IS CLOSED – BLEEDING IS TRACE. • TRANSVAGINAL SONOGRAPHY CONFIRMS THAT UTERUS IS EMPTY
- 26. MISSED ABORTION • THE FETUS IS DEAD AND RETAINED PASSIVELY INSIDE THE UTERUS FOR AVARIABLE PERIOD • IT IS DIAGNOSED WHEN THERE IS A FETUS WITH A CROWN RUMP LENGTH OF 5MMWITHOUT A FETAL HEART.
- 27. CLINICAL FEATURES • THE PATIENT USUALLY PRESENTS WITH FEATURES OF THREATENED MISCARRIAGE FOLLOWED BY: – SUBSIDENCE OF PREGNANCY SYMPTOMS– • UTERUS BECOMES SMALLER IN SIZE – • CERVIX FEELS FIRM WITH CLOSED INTERNAL OS • NONAUDIBILITY OF THE FETAL HEART SOUND EVEN WITH DOPPLER ULTRASOUND • IMMUNOLOGICAL TEST FOR PREGNANCY BECOMES NEGATIVE
- 28. COMPLICATIONS • RETAINING THE PRODUCTS FOR LONG TIME CAN LEAD TO SEPSIS • DIC [DISSEMINATED INTRAVASCULAR COAGULATION]– (VERY RARE) IN GESTATIONS EXCEEDING 16 WEEKS
- 29. MANAGEMENT • UTERUS IS LESS THAN 12 WEEKS: • PROSTAGLANDIN E1 (MISOPROSTOL) 800 MG IS GIVEN VAGINALLY AND REPEATED AFTER 24 HOURS IF NEEDED. EXPULSION USUALLY OCCURS WITHIN 48 HOURS • SUCTION EVACUATION IS DONE WHEN THE MEDICAL METHOD FAILS UTERUSMORE THAN 12 WEEKS • 6TH OR 12TH HOURLY MISOPROSTOL TABLETS GIVEN VAGINALLY • IF THIS FAILS, EXTRAAMNIOTIC INSTILLATION OF ETHACRIDINE LACTATE IS USED • ANTIBIOTICS ARE GIVEN
- 30. SEPTIC ABORTION • ANY ABORTION ASSOCIATED WITH CLINICAL EVIDENCES OF INFECTION OFTHE UTERUS AND ITS CONTENTS • MOST COMMON CAUSE – ATTEMPT AT INDUCED ABORTION BY AN UNTRAINED PERSON WITHOUT THE USE OF ASEPTIC PRECAUTIONS
- 31. CLINICAL GRADING • GRADE–I: THE INFECTION IS LOCALIZED IN THE UTERUS. • GRADE–II: THE INFECTION SPREADS BEYOND THE UTERUS TO THE PARAMETRIUM, TUBES AND OVARIES OR PELVIC PERITONEUM. • GRADE–III: GENERALIZED PERITONITIS AND/OR ENDOTOXIC SHOCK OR JAUNDICE OR ACUTE RENAL FAILURE. GRADE-I IS THE COMMONEST AND IS USUALLY ASSOCIATED WITH SPONTANEOUS ABORTION
- 32. CLINICAL FEATURES •FEVER, ABDOMINAL PAIN AND VOMITING OR DIARRHOEA •A RISING PULSE RATE OF 100–120/MIN OR MORE IS A SIGNIFICANT FINDING THAN EVEN PYREXIA. IT INDICATES SPREAD OF INFECTION BEYOND THE UTERUS. • EXAMINATION SHOWS ABDOMINAL TENDERNESS, RIGIDITY •INTERNAL EXAMINATION REVEALS: – OFFENSIVE PURULENT VAGINAL DISCHARGE – TENDER UTERUS USUALLY WITH PATULOUS OS OR A BOGGY FEEL– SOFT CERVIX WITH OPEN INTERNAL OS
- 33. INVESTIGATIONS •CBC • SERUM UREA, CREATININE, ELECTROLYTES •HIGH VAGINAL SWAB • BLOOD CULTURE IN SUSPECTED SEPTICAEMIA •PELVIC USG TO DETECT RETAINED PRODUCTS OF CONCEPTION • X-RAY ABDOMEN IN SUSPECTED BOWEL INJURY •X-RAY CHEST IF THERE IS DIFFICULTY IN RESPIRATION
- 34. COMPLICATIONS •IMMEDIATE: • HEMORRHAGE •INJURY MAY TO UTERUS & ADJACENT STRUCTURES •SPREAD OF INFECTION LEADS TO: – GENERALIZED PERITONITIS – ENDOTOXIC SHOCK—MOSTLY DUE TO E. COLI – ACUTE RENAL FAILURE – THROMBOPHLEBITIS. • ALL THESE LEAD TO INCREASED MATERNAL DEATHS
- 35. MANAGEMENT •MILD CASES – •BROAD SPECTRUM ANTIBIOTICS STARTED – UTERUS IS EVACUATED •SEVERE CASES • OXYGEN GIVEN BY NASAL CATHETER • BROAD SPECTRUM ANTIBIOTICS – COMBINATION OF AMPICILLIN, GENTAMICIN, METRONIDAZOLE IS STARTED – UTERUS IS EVACUATED IN 4-6 HRS OF COMMENCING THERAPY
- 36. RECURRENT MISCARRIAGE •RECURRENT MISCARRIAGE IS DEFINED AS A SEQUENCE OF THREE OR MORE CONSECUTIVE SPONTANEOUS ABORTION • SEEN IN ~ 1% OF ALL WOMEN • RISK INCREASES WITH EACH SUCCESSIVE ABORTION • NO UNDERLYING CAUSE IS FOUND FOR 50% OF RECURRENT PREGNANCY LOSS
- 37. ETIOLOGY •GENETIC FACTORS (3–5%): PARENTAL CHROMOSOMAL ABNORMALITIES THE MOST COMMON ABNORMALITY IS A BALANCED TRANSLOCATION. THIS LEADS TO UNBALANCED TRANSLOCATION IN THE FETUS, CAUSING EARLY MISCARRIAGE OR A LIVE BIRTH WITH CONGENITAL MALFORMATIONS RISK OF MISCARRIAGE IN COUPLES WITH A BALANCED TRANSLOCATION IS > 25%. THIS IS THE MOST COMMON CAUSE FOR 1ST TRIMESTER LOSS
- 38. ETIOLOGY • CONGENITAL – DEVELOPMENTAL WEAKNESS OF CERVIX , FOLLOWING: • (I) D&C OPERATION • (II) INDUCED ABORTION BY D AND E • (III) VAGINAL OPERATIVE DELIVERY THROUGH AN UNDILATED CERVIX • (IV) AMPUTATION OF THE CERVIX OR CONE BIOPSY. • MULTIPLE GESTATIONS, PRIOR PRETERM BIRTH.
- 39. DIAGNOSIS • HISTORY - REPEATED MID TRIMESTER PAINLESS CERVICAL DILATATION AND ESCAPE OF LIQUOR AMNII FOLLOWED BY PAINLESS EXPULSION OF THE PRODUCTS OF CONCEPTION • INTERNAL EXAMINATION: INTERCONCEPTUAL PERIOD: – PASSAGE OF NO. 6–8 HEGAR DILATOR BEYOND THE INTERNAL OS WITHOUT ANY RESISTANCE OR PAIN – FUNNELLING OF INTERNAL OS SEEN IN HYSTEROSALPINGOGRAPHY
- 40. MANAGEMENT •SURGICAL MANAGEMENT – CERVICAL CIRCLAGE • USUSALLY AT 12-14 WEEKS • THE PROCEDURE REINFORCES THE WEAK CERVIX BY A NON- ABSORBABLE TAPE, PLACED AROUND THE CERVIX AT THE LEVEL OF INTERNAL OS. •NORMAL (COMPETENT) CERVIX INCOMPETENT CERVIX WITH HERNIATION OF THE MEMBRANES •COMPETENCY RESTORED AFTER ENCIRCLAGE OPERATION
- 42. INDUCTION OF ABORTION •DELIBERATE TERMINATION OF PREGNANCY EITHER BY MEDICAL OR BY SURGICAL METHOD BEFORE THE VIABILITY OF THE FETUS IS CALLED INDUCTION OF ABORTION.
- 43. MEDICAL TERMINATION OF PREGNANCY (MTP) •SINCE LEGALIZATION OF ABORTION IN INDIA, DELEBERATE INDUCTION OF ABORTION BY REGISTERED MEDICAL PRACTITIONER IN THE INTEREST OF MOTHER’S HEALTH AND LIFE IS PROTECTED UNDER THE MTP ACT.
- 44. •THE FOLLOWING PROVISION ARE LAID DOWN: •THE CONTINUATION OF PREGNANCY WOULD INVOLVE SERIOUS 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 PREGNANCY IS CAUSED BY RAPE, BOTH IN CASE OF MAJOR AND MINOR GIRL AND IN MENTALLY IMBALANCED WOMEN. •PREGNANCY CAUSED AS A RESULT OF FAILURE OF CONTRACEPTIVE.
- 45. INDICATION •TO SAVE THE LIFE OF MOTHER •SOCIAL INDICATION •EUGENICS
- 46. RECOMMENDATION •REGISTERED MEDICAL PRACTITIONER IS QUALIFIED TO PERFORM AN MTP PROVIDED: ONE HAS ASSISTED IN AT LEAST 25 MTP CASES IN AN AUTHORIZED CENTRE AND HAVING A CERTIFICATE. ONE HAS GOT SIX MONTHS HOUSE SURGEON TRAINING IN OBSTETRICS AND GYNECOLOGY. ONE HAS GOT DIPLOMA OR DEGREE IN OBSTETRICS AND GYNECOLOGY. • TERMINATION CAN ONLY BE PERFORMED IN HOSPITALS, ESTABLISHED ORMAINTAINED BY THE GOVERNMENT OR PLACES APPROVED BY THE GOVERNMENT. •PREGNANCY CAN ONLY BE TERMINATED ON THE WRITTEN CONSENT OF THE WOMAN .HUSBAND’S CONSENT IS NOT REQUIRED.
- 47. •PREGNANCY IN A MINOR GIRL (BELOW THE AGE OF 18 YEARS) OR LUNATIC CANNOT BE TERMINATED WITHOUT WRITTEN CONSENT OF THE PARENT OR LEGAL GUARDIANS. • TERMINATION IS PERMITTED UP TO 20 WEEKS OF PREGNANCY •TERMINATION IS PERMITTED UP TO 20 WEEKS OF PREGNANCY. WHEN THE PREGNANCY EXCEEDS 12 WEEKS, OPINION OF TWO MEDICAL PRACTITIONER IS REQUIRED • THE ABORTION HAS TO BE PERFORMED CONFIDENTIALLY AND TO BE REPORTED TO THE DIRECTOR OF HEALTH SERVICES OF THE STATE IN PRESCRIBED FORM.
- 49. SUMMARY