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CAUSES OF SPONTANEOUS

ABORTION
• MATERNAL FACTORS there are congenital or acquired
conditions of the mother, including environmental factors that
can cause abortion. It is less common causes of abortion but is
treatable.
• Abortion increases with advancing maternal age, esp. after 35
yrs old
– below 35 yrs old 15% miscarriage rate
– Between 35-39 yrs old 20-25% miscarriage rate
– Between 40-42 yrs old about 35% miscarriage rate
– About 42 yrs old about 50% miscarriage rate
Structural abnormalities of the reproductive tract such as
congenital uterine defects particularly uterine sputum
fibroids
cervical incompetence
Inadequate progesterone production (corpus luteum or placenta) is
a definite but probably infrequent causes.
• 4. Maternal infection: Rubella virus, cytomegalovirus,
Lysteria infection, taxoplasmosis
• 5. Chronic and systemic maternal diseases
– Polycystic ovary syndrome
– Poorly controlled DM
– Renal diseases
– Systemic Lupus erythematosus (SLE)
– Untreated thyroid diseases
– Severe hypertension
6. Exogeneous factors include the following
tobacco
alcohol
cocaine
caffeine (high doses)
radiation
• FREQUENCY
• In the past 15-20% of recognized pregnancies result in
miscarriage.With the availability of sensitive beta-human
chorionic gonadotropin serum essays , early pregnanciesare
detected before the date of menstruation formerly were written
off as simple abnormal prolongation of the menstrual
cycle.Bacause of these earlier methods of detecting pregnancies,
it is estimated today that more pregnancies, about 60% to 70%
are lost spontaneously than are actually carried to term.
• The frequency of spontaneous abortion increases further with
maternal age
• Late implantation, those occurring 8-10 days after fertilization, is
also associated with a higher incidence of abortion
• More abortions, about 80%, occur within the first trimester. The
frequency of miscarriage decreases with an increasing gestational
age
• A woman who has history of abortion has a higher chance, about
5-20% of having another abortion than a woman who has not had
abortion
COMPLICATIONS OF ABORTION

• HEMORRHAGE more common with late


abortions.Continued heavy bleeding indicates
retained tissue(incomplete abortion)
• Infection or septic abortion is often a
complication of criminally induced abortion
• Disseminated intravascular coagulation(DIC)
may occur if a missed abortion is retained
beyond one month. This complication is
common in late abortion.
TYPES OF SPONTANEOUS
ABORTION
• Spontaneous abortion is a process that can be
divided into 4 stages--- threatened, inevitable,
incomplete, and complete. A threatened abortion
may either be rescued or end in inevitable
abortion while inevitable abortion may lead to an
incomplete abortion, a complete abortion or
missed abortion. Sometimes , abortion may be
complicated by infection before or after the
complete expulsion of the dead embryo or fetus.
THREATENED ABORTION
• Threatened abortion refers to the possible loss of the products of
conception. All vaginal bleeding in early pregnancy without cervical
changes is considered a threatened .About 25-30% of all pregnancies
have some bleeding during the pregnancy but only less than half
proceed to a complete abortion or miscarriage
• Signs and symptoms
– Light vaginal bleeding
– None to mild uterine cramping.More severe cramps may lead to an inevitable
abortion.
Management:
A.Assess for:
1.Ask LMP as management for pregnancy bleeding will vary according to the
age of gestation. If the woman is more than 20 wks gestation, the bleeding
can be placenta previa and not abortion, do not do internal examination
2.Instruct the clients to save all the pads for examination. Examining the
passed material help clarify the type of abortion occurring.
• 3. Ask for presence of clots. The presence of blood clots
suggest heavy bleeding.Vesicles of H-mole and fetal tissues
may be mistaken by client as blood clots.This is why it is
important to instruct the client to save pads.
• 4. Abdominal pain is the next common complaint of women
suffering from abortion next to vaginal bleeding.The pain
usually is in the suprapubic area , but reports of pain in one
or both lower quadrants are not uncommon. The pain may
radiate to the lower back, buttocks ,genitalia and
perineum.If the pain ispersistently occurring only on one
side ,consider an ectopic pregnancyor a ruptured ovarian
cyst as a possible cause. Ask the patient when the pain
started and stopped if it did. An abdominal pain suggest an
ongoing abortion or a concurrent abortion. When the pain
subsides ,it usually suggest completion of the abortion.
B.CONSERVATIVE
MANAGEMENT
• Usually , no other medical theraphy is needed for patients who
experienced threatened abortion. In fact they need not be admitted
to the hospital unless the bleeding and cramping worsens. In any
mild bleeding episodes that occurs during the first trimester :
• 1. Instruct the patient to have bedrest until 3 days after the bleeding
has stopped. In majority of cases, bleeding usually stops within 48
hours. However, if bleeding persist , tissue is passed and the cramps
worsen, tell client to come to the hospital, clinic,or contact the health
care provider for further evaluation and treatment. No studies have
confirmed that bed rest is effective but it seems to lessen bleeding
and contraction but it rarely changes the outcome.
• 2. Advise the couple not to engage in coitus up to 2 weeks after
bleeding stopped., although no evidence shows that it is harmful, the
risk of guilt feelings associated with abortion immediately after
intercourse warrants abstention.
• 3. There is no evidence that hormones save pregnancies
except in a very few instances, and hormonal theraphy may
cause congenital anomalies, particularly transposition of the
great vessels of the heart. Also, vaginal cancer and other
genital abnormalities in female offspring have been
associated with the use of estrogen for threatened abortion.
• C. However parents usually worry that they might have lost
the baby or may loose the baby anytime soon after a
bleeding episode.
• 1. Nurses are in position to provide these patient with
reassurance. An ultrasound showing normal pregnancy can
provide the patient with reassurance.
• 2. It is important to be honest to the patient that it is
possible to loss the baby but treatment is availablle to try to
save the pregnancy if bleeding continues.
INEVITABLE OR IMMINENT
ABORTION
• Refers to the loss of the product of conception that cannot be
prevented
• SIGNS AND SYMPTOMS
• 1. moderate to profuse bleeding
• 2. moderate to severe uterine cramping
• 3. open cervix or dilatation of cervix
• 4. ruptures of membranes
• 5. no tissue has passed yet
• MANAGEMENT:
• Because the fetus cannot be saved anymore, the management
is directed toward avoiding the complication of infection or
excessive blood loss.
• 1. Hospitalization
• 2. D&C
• 3. Oxytocin after D&C
• 4. Sympathetic understanding and emotional support
COMPLETE ABORTION
• Refers to the spontaneous expulsion of the products
of conception after the fetus has died in the utero.
• SIGNS AND SYPTOMS
• 1. Typically , the patient gives a history of vaginal
bleeding, abdominal pain, and apssage of tissue. After
the passage of tissue, the patient observed that the
pain and vaginal bleeding significantly diminished.
• 2. On examination on the clinic or hospital the ff. is
noted:
– Light bleeding or some blood in the vaginal vault
– No tenderness in the cervix, uterus, or abdomen
– Closed cervix
– Empty uterus on ultrasound
management
• 1. A complete abortion usually needs no further medical or surgical
treatment. No medication is likely needed.Usually, the uterus
contract well after expelling the entire contents so that there is no
need for methergin or oxytocin. The risk for infection is also
minimal.
• 2.The patient must still be observed closely for continued bleeding
or signs of infection. These complication indicates that not all fetal
tissue has been passed.
• 3.Regular diet. Advice to eat food rich in iron because of blood loss
• 4.Instruct the patient to rest for few days up to 2 weeks after the
abortion.Patient may resume their activities when able but should
refrain from coitus and douching for approximately 2 weeks.
• 5. Tell patient she may experience intermittent menstrual-like flow
and cramps during the following week. The next menstrual usually
occurs in 4-5 weeks
• 6. It is impt. That the expelled products of conception are evaluated by a physician
and confirmed to be intact and truly products of conception (not a clot) > If the
tissues passed by the patient were not examined by the physician or pathologist(if
the product were flushed down the toilet) the physician may order ultrasound and
examination of her serum HCG level to be followed up weekly until it is less than 5
mlU/ml. In complete abortion, HCG may initially be high but it will decline steadily
and ultrasound will show that the uterus is empty. Patients should avoid
intercourse or use contraception until the HCG levels have become negative.
• 7. Reassure patient that the next pregnancy is likely to last to term if she is young
and has no other risk factors. However, the woman must use family planning as
pregnancy is discouraged for the next 3 months after abortion bec. Of the
likelihood of having repeat abortion at this time.
• 8.Aside from testing for CBC and HCG level, the woman”s RH factor must also be
determined. If she is RH negative and the father’s RH factor is positive or cannot be
determined, it is impt. To have Coomb’s test to determine if she has developed
antibodies against RH positive blood. If the Coomb’s test is negative, RhoGam is
administered within 72 hours after the abortion to prevent isoimmunization.
• 9.Advice the patient to return to emergency dept. if any of the following symptoms
occur
– Profuse vaginal bleeding
– Severe pelvic pain
– Temp greater than 100 *f
COMPLETE ABOTION INCOMPLETE ABORTION
• NO ABDOMINAL DISTENTION • THERE IS REBOUND TENDERNESS AND/OR A
DISTENDED UTERUS
• NO REBOUND TENDERNESS
• IE WILL REVEAL:
• NORMAL BOWEL SOUNDS
• NO HEPATOSPLENOMEGALY – CERVIX IS DILATED IN
• ONLY MILD SUPRAPUBIC TENDERNESS INCOMPLETE AND INEVITABLE
• USUALLY,THE UTERUS EITHER IS NOT ABORTION
PALPABLE ABDOMINALLY OR IS JUST – ACTIVE BLEEDING IS PRESENT
SLIGHTLY ABOVE THE SYMPHYSIS PUBIS FROM INTERNAL OS
• IE MAY SHOW:
– SOME BLOOD IN THE PERINEUM OR
– CLOTS AND TISSUES MAY ALSO
VAGINA BUT LIMITED ACTIVE BLEEDING BE PRESENT IN THE VAGINA OR
– CERVIX IS NONTENDER TO MINIMALLY CERVICAL CANAL
TENDER
– CERVICAL CANAL IS CLOSED FOR – IF CERVICAL MOTION
COMPLETE AND THREATENED ABORTION TENDERNESS IS PRESENT,
– UTERUS IS SMALLER THAN WHAT IT IS SUSPECT ECTOPIC PREGNANCY
EXPECTED FOR DATES, AND IT IS
NONTENDER TO MILDLY TENDER
INCOMPLETE ABORTION
• Expulsion of some parts and retention of other
parts of conceptus in utero
• SIGN AND SYMPTOMS
– 1. heavy vaginal bleeding
– 2. severe uterine cramping
– 3. open cervix
– 4. passage of tissue
– 5. ultrasound shows that some of the products of
conception are still inside the uterus
MANAGEMENT:
The goal of intervention for incomplete abortion is
prompt evacuation of the uterus to prevent
hemorrhage or infection.
• 1. D& C
– The uterus must be kept contracted after D&C to
prevent bleeding. If the patient is bleeding, the first
action is to place patient flat and massage the
uterus.Oxytocin is administered as ordered to
maintain uterine contractions.
– Inspect the fundus frequently to make sure it is well
contracted
– A danger of D&C is uterine perforation. Suspect of
uterine perforation if patient complains of unusual
symptoms sucha as shoulder pain and significant
abdominal pain. Internal bleeding maybe the cause
of tachycardia and hypotension in the absence of
excessive vaginal bleeding.
• 2. Monitor blood loss in patients who have inevitable and
incomplete abortion. These are the types of abortion which
involve significant bleeding.
– Inspect the patient’s perineal pad to estimate blood loss. A
saturated perineal pad can absorb approximately 60-100ml.
Of blood. It is accurate to weigh perineal pad before and after
use.
– Monitor vital signs particularly BP and pulse rate.
– Monitor the blood studies of the patient’s clotting factors. If
the patient’s v/s show symptoms of shock but the bleeding
per vagina is minimal and the uterus is well contracted
,bleeding may be occurring by DIC
– Monitor I and O. Oliguria is a sign of decreased renal
perfussion which occurs with shock.
3. Sympathetic understanding and emotional support. The
patient lost a baby and will be grieving. Provide sympathetic
understanding in the patient’s emotional reaction and
encourage verbalization of feelings.
MISSED ABORTION
• Retention of all products of conception after
the death of fetus in the uterus.
• SIGNS AND SYMPTOMS
– Absence of FHT
– Signs of pregnancy disappear. Missed abortion
should be suspected when the:
• When the uterus fails to enlarge
• Fetal heart sounds are not heard at the appropriate
time or disappear after it has been initially heard
• A serum or urine test for the subunit of HCG becomes
negative earlier than expected or does not double
within 48-72 hours
• Ultrasound showing no cardiac activity provides the
earliest diagnosis
MANAGEMENT
• 1. Depending on the age of gestation or size of conceptus , the
product of conception has to be removed from the uterus to
prevent DIC
• 2. Up to 28 wk gestattion , missed abortion is frequently manage
by inserting a 20-mg dinoprostone(prostaglandin E2) suppository
into the vagina q 3-4 hrs as necessary to produce contractions.
The said drus is not aprroved for use after 28wk. Laminaria are
inserted into the cervix to cause softening and dilatation.
• 3.Late missed abortion may be completed with a dilute IV
infusion of oxytocin, which causes contraction of the uterus and
delivery of the products of conception. After the uterus
contracted following the delivery of the fetus,curettage may be
needed to remove the fragments of the placenta. Suction
curettage is used for pregnancies of up to 18wk. After that,
dilatation and evacuation or oxytocic drugs are used
HABITUAL ABORTION
• Abortion occurring in 3 or more successive pregnancies.
Habitual abortion requires extensive diagnostic
investigation, including genetic and chromosomal studies.
The cause of abortion must be identified in order to
determine the most effective treatment to achieve a
successful pregnancy.
• MANAGEMENT
– 1. treating the cause
– 2. Specific treatment according to the cause of abortion
include:
• CERVICAL CERCLAGE suturing the cervix or application of cervical
cerclage is performed if the cause of repeated abortion is a
mechanical defect in the cervix or what is called as incompetent
cervix
• FERTILITY DRUGS these medication stimulate estrogen and
progesterone production to create a better-nourished uterine lining,
which is more suitable for implantation of an embryo. Drugs used
includes Clomiphene, Pergoral or other injectible fertility drugs
• 3.ASPIRIN OR MINI HEPARIN the first tissue changes that occur in the placenta
before the loss of pregnancy is the formation hyaline fibrinogen blood clots
within the small blood vessels. Theses blood clots impede normal blood flow,
which results in necrotic changes in the placenta and eventual disruption of the
normal blood supply to the fetus eventually leading to fetal death and
abortion.By giving the mother small doses of either Heparin or Aspirin for
several weeks during the early part of pregnancy, formation of blood clots that
impede blood flow in the placenta is prevented. In such manner, abortion is
prevented.
• 4. LUTEAL PHASE PROGESTERONE SUPPORT fertilization and implantation
occurs during the luteal phase of menstrual cycle. Progesterone, the main
hormone produced at this time by the corpus luteum maintains the deciduas
where the embryo implants., therefore in the maintenance of pregnancy,
progesterone is very impt. Sluggish progeaterone secretion of progesterone by
corpus luteum is believe to result in early pregnancy losses. This progesterone
deficiency can be corrected by administering progesterone to the pregnant
woman in the early part of gestation until the placenta is mature enough to
produce adequate amount of progesterone.
• 5. Treatment of medical illnesses such as SLE,m DM, hypothyroidism,
Hyperthyroidism, sexually transmitted diseases before and during pregnancy to
ensure successful gestation
• INFECTED ABORTION infection involving the products of conception and the
maternal reproductive organs.
• SEPTIC ABORTION Dissemination of bacteria (and/or their toxins) into the
maternal circulatory and organ system. With aseptic abortion, the patient is
acutely ill experiencing s/s of infection and of threatened or incomplete
abortion. Septic abortion is often associated with induced abortion performed
by untrained persons using unsterile techniques or criminal abortion.
• CAUSATIVE ORGANISM
– ESCHERICHIA COLI IS THE MOST COMMON PATHOGENIC AGENT
– ENTEROBACTER AEROGENES
– PROTEUS VULGARIS
– HEMOLYTIC STREPTOCOCCI
– STAHYLOCOCCI
SINGS AND SYMPTOMS
1. foul smelling vaginal discharge
2. uterine cramping
3. fever , chills, and peritonitis
4. leukocytosis –WBC count, 16,000-22,000/ul
5. critically ill patients may evidence septic or endotoxic shock with vasomotor collapse
, hypothermia, hypotensin, oliguria, or anuria, and respiratory distress
MANAGEMENT
• 1. Treat abortion.
• 2 High doses of IV antibiotic theraphy: penicillin
for gram negative microorganisms, and
clindamycin and tobramycin for gram positive
microorganism
• 3. D & C if accompanied by incomplete abortion
• 4. Infertility may occur after recovery due to
scarring of uterus and fallopian tubes, scarring
can interfere with fertilization and proper
implantation.