pontaneous Abortion

• Gynecology And Obstetrics Articles • Nov 23, 05

Introduction

Essentials of Diagnosis

• Intrauterine pregnancy at less than 20 weeks.

• Low or falling levels of hCG.
• Bleeding, midline cramping pain.
• Open cervical os.
• Complete or partial expulsion of products of conception.

General Considerations

About three-fourths of spontaneous abortions occur before the 16th week; of these, three-
fourths occur before the eighth week. Almost 20% of all clinically recognized
pregnancies terminate in spontaneous abortion.

More than 60% of spontaneous abortions result from chromosomal defects due to
maternal or paternal factors; about 15% appear to be associated with maternal trauma,
infections, dietary deficiencies, diabetes mellitus, hypothyroidism, or anatomic
malformations. There is no reliable evidence that abortion may be induced by psychic
stimuli such as severe fright, grief, anger, or anxiety. In about one-fourth of cases, the
cause of abortion cannot be determined. There is no evidence that video display terminals
or associated electromagnetic fields are related to an increased risk of spontaneous
abortion.

It is important to distinguish women with a history of incompetent cervix from those with
more typical early abortion and those with premature labor or rupture of the membranes.
Characteristically, incompetent cervix presents as “silent” cervical dilation (ie, with
minimal uterine contractions) between 16 and 28 weeks of gestation. Women with
incompetent cervix often present with significant cervical dilation (2 cm or more) and
minimal symptoms. When the cervix reaches 4 cm or more, active uterine contractions or
rupture of the membranes may occur secondary to the degree of cervical dilation. This
does not change the primary diagnosis. Factors that predispose to incompetent cervix are
a history of incompetent cervix with a previous pregnancy, cervical conization or surgery,
cervical injury, DES exposure, and anatomic abnormalities of the cervix. Prior to
pregnancy or during the first trimester, there are no methods for determining whether the
cervix will eventually be incompetent. After 14-16 weeks, ultrasound may be used to
evaluate the internal anatomy of the lower uterine segment and cervix for the funneling
and shortening abnormalities consistent with cervical incompetence.
Clinical Findings

A. Symptoms and Signs

1. Threatened abortion
Bleeding or cramping occurs, but the pregnancy continues. The cervix is not dilated.

2. Inevitable abortion
The cervix is dilated and the membranes may be ruptured, but passage of the products of
conception has not occurred. Bleeding and cramping persist, and passage of the products
of conception is considered inevitable.

3. Complete abortion
The fetus and placenta are completely expelled. Pain ceases, but spotting may persist.

4. Incomplete abortion
Some portion of the products of conception (usually placental) remain in the uterus. Only
mild cramps are reported, but bleeding is persistent and often excessive.

5. Missed abortion
The pregnancy has ceased to develop, but the conceptus has not been expelled.
Symptoms of pregnancy disappear. There is a brownish vaginal discharge but no free
bleeding. Pain does not develop. The cervix is semifirm and slightly patulous; the uterus
becomes smaller and irregularly softened; the adnexa are normal.

B. Laboratory Findings
Pregnancy tests show low or falling levels of hCG. A complete blood count should be
obtained if bleeding is heavy. Determine Rh type, and give Rho(D) immune globulin if
the type is Rh-negative. All tissue recovered should be assessed by a pathologist and may
be sent for genetic analysis in selected cases.

C. Ultrasonographic Findings
The gestational sac can be identified at 5-6 weeks from the LMP, a fetal pole at 6 weeks,
and fetal cardiac activity at 6-7 weeks. Serial observations are often required to evaluate
changes in size of the embryo. A small, irregular sac without a fetal pole with accurate
dating is diagnostic of an abnormal pregnancy.

Differential Diagnosis

The bleeding that occurs in abortion of a uterine pregnancy must be differentiated from
the abnormal bleeding of an ectopic pregnancy and anovular bleeding in a nonpregnant
woman. The passage of hydropic villi in the bloody discharge is diagnostic of
hydatidiform mole.

Treatment
A. General Measures
1. Threatened abortion
Place the patient at bed rest for 24-48 hours followed by gradual resumption of usual
activities, with abstinence from coitus and douching. Hormonal treatment is
contraindicated. Antibiotics should be used only if there are signs of infection.

2. Missed or inevitable abortion

This calls for counseling regarding the fate of the pregnancy and planning for its elective
termination at a time chosen by the patient and physician. Insertion of a laminaria to
dilate the cervix followed by aspiration is the method of choice for a missed abortion.
Prostaglandin vaginal suppositories are an effective alternative.

B. Surgical Measures
1. Incomplete abortion
Prompt removal of any products of conception remaining within the uterus is required to
stop bleeding and prevent infection. Analgesia and a paracervical block are useful,
followed by uterine exploration with ovum forceps or uterine aspiration.

2. Cerclage and restriction of activities

These are the treatment of choice for incompetent cervix. A variety of suture materials
including a 5-mm Mersilene band can be used to create a purse-string type of stitch
around the cervix, using either the McDonald or Shirodkar method. Cerclage should be
undertaken with caution when there is advanced cervical dilation or when the membranes
are prolapsed into the vagina. Rupture of the membranes and infection are specific
contraindications to cerclage. Cervical cultures for N gonorrhoeae, chlamydia, and group
B streptococci should be obtained before or at the time of cerclage.

George L et al: Plasma folate levels and risk of spontaneous abortion. JAMA
2002;288:1867.

Provided by ArmMed Media

Revision date: December 8, 2007
Last revised: by Mamikon Bozoyan, M.D.

n nursing care plan for abortion definitions for Abortion is: Spontaneous abortion,
miscarriage, or induced abortions, the products of conception are expelled from the uterus
before fetal viability and gestation of less than 20 weeks is achieved.
Causes for Abortion
It’s May result from fetal, placental, or maternal factors:

• Fetal factors usually include defective embryologic development resulting from

abnormal chromosome division (the most common cause of fetal death), faulty
implantation of fertilized ovum, and failure of the endometrium to accept the
fertilized ovum, usually cause such abortions between 9 and 12 weeks of
gestation
 • Placental factors usually include premature separation of the normally implanted
placenta, abnormal placental implantation, and abnormal platelet function.
Usually cause abortion around the 14th week of gestation.
• Maternal factors usually include maternal infection, severe malnutrition, and
abnormalities of the reproductive organs. usually cause abortion between 11 and
19 weeks of gestation

Other maternal factors include endocrine problems, such as thyroid gland dysfunction or
lowered estriol secretion, trauma, including any type of surgery that necessitates
manipulation of the pelvic organs, blood group incompatibility and Rh isoimmunization,
and recreational drug use and environmental toxins.
Therapeutic abortion is performed to preserve the mother's mental or physical health in
cases of unplanned pregnancy, or medical conditions, such as cardiac dysfunction or fetal
abnormality.

Complications that may happen in Nursing Care Plan for Abortion

• Infections in case of the products of conception aren't completely expelled

• Hemorrhage
• Anemia
• Coagulation defects such as disseminated intravascular coagulation

Assessment Nursing Care Plan for Abortion

• Pink discharge for several days or a scant brown discharge for several weeks
• Cramps and increased vaginal bleeding
• If any contents remain, cramps and bleeding continue.

Assess the patient’s emotional status, as well as that of the baby’s father and other family
members. Often this hospital admission is the first one for the patient, and it may cause
anxiety and fear

Diagnostic tests Nursing Care Plan for Abortion

• HCG in the blood or urine confirms

• Decreased HCG level
• Laboratory test results reflect a decreased hemoglobin level
• Ultrasound examination; absence of fetal heart sounds

Nursing diagnosis
Primary Nursing Diagnosis found in Nursing Care Plan for Abortion
Anticipatory grieving related to an unexpected pregnancy outcome
Common nursing diagnosis found in Nursing Care Plan for Abortion
 • Anxiety
• Disabled family coping
• Dysfunctional grieving
• Hopelessness
• Powerlessness
• Risk for infection

Nursing outcomes, Interventions, and Patient teaching Nursing Care Plan for Abortion