Abortion

References:

1. Dr. RPS Maternal and Newborn Care: A Comprehensive Guide and Source Book for Teaching and Learning, 2nd Edition, ISBN 978-971-98-2265-3, by Rosalinda Parado Salustiano (pp. 175-195)
2. Lecturer (V)

An abortion is the termination of a pregnancy before the age of viability, currently at 20 weeks of gestation. Abortions are generally divided between those that are induced, and those that are spontaneous. Two types of induced abortions are the following:

1. Therapeutic Abortion: AKA Legal Abortion, to save the life of the mother. This may be used in cases such as ectopic pregnancies, and gravido cardia.
2. Non-Therapeutic Abortion: AKA Criminal Abortion, to get rid of unwanted pregnancies. These are commonly performed through “Hilot”, midwives, doctors, then nurses. While the others perform that abortive procedure, nurses often suggest an abortive drug. Cytotec is a commonly used abortifacient. It is an antiulcer drug taken orally or used as a vaginal suppository.
   • When used as a vaginal suppository, cytotec changes the pH balance of the vagina, leading to ascending infection, resulting in chorioamnionitis. The amniotic fluid becomes infected, which the fetus also contracts. The uterus contracts, separating the placenta from the body to prevent infection, resulting in abortion.
   • When used orally (overdose amount), it induces uterine contractions. If underdosed, it may fail to abort the fetus but still result in congenital defects. This commonly results in anencephaly.

A spontaneous abortion occurs without medical or mechanical intervention. An abortion may present with signs of vaginal bleeding or spotting, uterine/abdominal cramps, passage of tissues or products of conception, and signs related to blood loss/shock (pallor, tachycardia, tachypnea, cool clammy skin, restlessness, oliguria, air hunger, and hypotension). There are six types:

flowchart TB
1(Threatened Abortion)-->2
2(Imminent Abortion)-->3
2-->4
3(Incomplete Abortion)-->6
3-->4
4(Complete Abortion)
5(Missed Abortion)-->6
6(Septic Abortion)

1. Threatened Abortion: the only form of abortion where the pregnancy may still be saved. The only presenting signs in a threatened abortion are contractions or abdominal cramping and spotting.
2. Imminent Abortion: progression of threatened abortion to an unrecoverable state. This will result in a complete or incomplete abortion.
3. Complete Abortion: complete expulsion of all the products of conception. The abortion is done, and further care is focused on postpartum care.
4. Incomplete Abortion: a remnant of the products of conception is left in the uterus. This may progress to sepsis.
5. Missed Abortion: intrauterine fetal demise (IUFD); the fetus may remain in the uterus for 4 to 6 weeks without leading into complications (sepsis). The mother often reports that there have been no fetal movements, prompting the nurse to auscultate and find no fetal heart tone. The best diagnostic examination is an ultrasound.
6. Septic Abortion: may result from incomplete or missed abortions. Discharge is foul and brown in color.

(According to Sir V.)

Spontaneous Abortions	Bleeding/ Contractions	Cervical Dilatation	B.O.W.	Tissues Passed	Fever
Threatened	Mild	Closed	(+)	None	No
Inevitable	Moderate – Strong	Open, especially inevitable if >3 cm	(–)	None	No
Complete	Mild – None	Close or partially open if recent	(–)	Complete placenta with fetus	No
Incomplete	Moderate – Strong	Open	(–)	Placenta/ Fragments	No
Missed	None	Closed before infection	(+) before infection	None	No
Septic	Moderate – Strong	Open	(–)	Either; foul discharge	Yes

Spontaneous Abortions	Management	Medication
Threatened	- No Internal Examinations for any type of bleeding, as this causes further irritation and bleeding. - Sex is disallowed. - External fetal monitoring is done. - Complete bed rest. - Watchful waiting; save pads for monitoring discharge.	- Tocolytic - Sedatives, especially for an emotionally distressed patient.
Inevitable	Admission/Hospitalization
Complete	Pericare, etc.	Oxytocic Analgesics Antibiotics
Incomplete	Dilatation and Curettage	Oxytocic Analgesics Antibiotics
Missed	Delivery of abortus Dilatation and Curettage	Oxytocic Analgesics Antibiotics
Septic	Dilatation and Curettage	Oxytocic Analgesics Antibiotics Antipyretics Antiinflammatories
Habitual

(According to Dr. RPS)

Spontaneous Abortions	Bleeding	Abdominal Cramps	Cervical Dilatation	Tissue Passage	Fever
Threatened	Slight	May or may not be present	None	None	No
Inevitable	Moderate	Moderate	Open	None	No
Complete	Small to negative	Moderate	Close or partially open	Complete placenta with fetus	No
Incomplete	Severe (bleeds the most)	Severe	Open with tissue in cervix	Fetal or incomplete placental tissue	No
Missed	None to severe incoagulopathy	None; No FHT with UTZ	None	None	No
Septic	Mild to severe	Severe	Close or open with or without tissue	Possible; foul discharge	Yes

Habitual Abortion

Three or more consecutive abortions can be considered habitual or recurrent. This is most commonly caused by an incompetent cervix, and occurs as any of the types of spontaneous abortions mentioned above. This is often detected in the threatened phase, and cervical closure (cerclage, cervical stitching) is done. If the cause of habitual abortion is not due to an incompetent cervix, determination of the etiology and treatment of the underlying cause is done.

Additional nursing care/management from Dr. RPS for Threatened and Inevitable Abortions

Type	Nursing Care/Management
Threatened Abortion	- Advise complete bedrest for 24 to 48 hours. - Teach to save all blood clots passed and perineal pads used. - Advise prompt reporting to the hospital if bleeding persists or increases. - Prevention of abortion: avoid coitus or orgasm, especially around the normal time of menstrual period.
Inevitable Abortion	- Save or monitor clots, pads, or tissues for a correct diagnosis. - Monitor VS, blood loss, I&O, changes in status, and signs of infection, and refer any deviation. - Institute measures to treat shock as necessary: replace blood, plasma, and fluids as ordered. - Prepare for surgery. - Provide psychological support: non-judgmental attitude, encourage verbalization, reduce anxiety, and allow the patient to cry. - Prevent isoimmunization: administer RhoGAM as ordered if: the mother is Rh negative; the abortus is Rh positive, and Coombs test result is negative.