Abortion
Abortion: Excerpt from Handbook of Diseases
Abortion is the spontaneous or induced (therapeutic) expulsion of the products of conception from the uterus before 20 weeks gestation (fetal weight less than 500 g [17½ oz]). Up to 15% of all pregnancies and about 30% of all first pregnancies end in spontaneous abortion (miscarriage). At least 75% of miscarriages occur during the first trimester.
Causes
Spontaneous abortion may result from fetal, placental, or maternal factors. (See Types of spontaneous abortion.) Fetal factors usually cause abortions before the 12th week of gestation and include:
defective embryologic development resulting from abnormal chromosome division (most common cause of fetal death)
faulty implantation of the fertilized ovum
failure of the endometrium to accept the fertilized ovum.
Placental factors usually cause abortion around the 14th week of gestation, when the placenta takes over the hormone production necessary to maintain the pregnancy. These factors include:
premature separation of the normally implanted placenta
abnormal placental implantation.
Maternal factors usually cause abortion during the second trimester and include:
maternal infection, severe malnutrition, and abnormalities of the reproductive organs (especially an incompetent cervix, in which the cervix dilates painlessly and bloodlessly in the second trimester)
endocrine problems, such as thyroid dysfunction or a luteal phase defect
trauma, including any surgery that requires manipulation of the pelvic organs
phospholipid antibody disorder
blood group incompatibility
drug ingestion.
The goal of therapeutic abortion is to preserve the mother’s mental or physical health in cases of rape, unplanned pregnancy, or medical conditions, such as moderate or severe cardiac dysfunction.
Signs and symptoms
Prodromal signs of spontaneous abortion include a pink discharge for several days or a scant brown discharge for several weeks before the onset of cramps and increased vaginal bleeding. For a few hours, the cramps intensify and occur more frequently; then the cervix dilates to expel uterine contents. If the entire contents are expelled, cramps and bleeding subside. However, if any contents remain, cramps and bleeding continue.
Diagnosis
Diagnosis of spontaneous abortion is based on clinical evidence of expulsion of uterine contents, pelvic examination, and laboratory studies. Human chorionic gonadotropin in the blood or urine confirms pregnancy.
CLINICAL TIP: Ectopic pregnancy should be a consideration whenever an intrauterine pregnancy cannot be ruled in.
Pelvic examination determines the size of the uterus and whether this size is consistent with the length of the pregnancy. Tissue pathology indicates evidence of products of conception. Blood loss is rarely significant enough to decrease hemoglobin levels.
Treatment
An accurate evaluation of uterine contents is necessary before a plan of treatment can be formulated. The progression of spontaneous abortion can’t be prevented. If bleeding is severe, a transfusion with packed red blood cells or whole blood is required. Initially, I.V. administration of oxytocin stimulates uterine contractions. If any remnants remain in the uterus, dilatation and curettage or dilatation and evacuation should be performed.
Dilation and evacuation is also performed in first- and second-trimester therapeutic abortions. Medical abortion, using mifepristone (RU-486) and misoprostol (a prostaglandin) is also effective (90% to 97%) for pregnancy termination less than 49 days from the last menses.
After an abortion, spontaneous or induced, an Rh-negative female with a normal indirect Coombs’test result should receive Rho(D) immune globulin (human) to prevent further Rh isoimmunization.
In a patient who has suffered from habitual abortion, spontaneous abortion can result from an incompetent cervix. Treatment involves bed rest and, in some situations, surgical reinforcement of the cervix 12 to 14 weeks after the last menses. A few weeks before the estimated delivery date, the sutures are removed and the patient awaits the onset of labor. An alternative procedure, especially for a woman who wants to have more children, is to leave the sutures in place and to deliver the infant by cesarean birth.
Special considerations
Before an abortion, perform the following:
Thoroughly explain all procedures to the patient.
After the patient uses the bedpan, inspect the contents carefully for intrauterine material. (The patient shouldn’t have bathroom privileges because she may inadvertently expel uterine contents.)
After spontaneous or elective abortion, perform the following:
Note the amount, color, and odor of vaginal bleeding. Save all the pads the patient uses, for evaluation, and provide perineal care.
Administer oxytocin and an analgesic as ordered.
Obtain vital signs every 15 minutes for 1 hour, every 30 minutes for 2 hours, every hour for 2 hours, then every 4 hours for 24 hours.
Monitor urine output.
Caring for a patient who has had a spontaneous abortion includes emotional support and counseling during the grieving process. Encourage the patient and her partner to express their feelings. Some couples may want to talk to a member of the clergy or, depending on their religion, may wish to have the fetus baptized.
The patient who has had a therapeutic abortion also benefits from support. Encourage her to verbalize her feelings. Remember, she may feel ambivalent about the procedure; intellectual and emotional acceptance of abortion aren’t the same. Refer her for counseling, if necessary.
Before the patient is discharged, perform the following:
Tell the patient to expect vaginal bleeding or spotting and to immediately report excessive bright-red blood or bleeding that lasts more than 10 days.
Advise the patient to watch for signs of infection, such as a temperature higher than 100.5° F (38° C) and foul-smelling vaginal discharge.
Encourage the patient to gradually increase her daily activities to include whatever tasks she feels comfortable doing, as long as these activities don’t increase vaginal bleeding or cause fatigue. Many patients return to work within 1 to 2 days.
Urge the patient to abstain from intercourse for 1 to 2 weeks, and encourage her to use a contraceptive when intercourse is resumed.
Instruct the patient to avoid using tampons for 1 to 2 weeks.
Inform the patient who desires an elective abortion of all available alternatives. She needs to know what the procedure involves, what the risks are, and what to expect during and after the procedure, both emotionally and physically. Ascertain whether the patient is comfortable with her decision to have an elective abortion. Encourage her to verbalize her thoughts both when the procedure is performed and at a follow-up visit, usually 2 weeks later. If you identify an inappropriate coping response, refer the patient for professional counseling.
Tell the patient to see her physician in 2 to 4 weeks for a follow-up examination.
Emphasize to the pregnant woman the importance of good nutrition and the need to avoid alcohol, cigarettes, and drugs. If the patient has a history of spontaneous abortions, suggest that she and her partner have thorough examinations. For the woman, this includes premenstrual endometrial biopsy, a hormone assessment (estrogen, progesterone, and thyroid, follicle-stimulating, and luteinizing hormones), and hysterosalpingography and laparoscopy to detect anatomic abnormalities. Genetic counseling may also be indicated.
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Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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