Abortion
Abortion: Excerpt from Professional Guide to Diseases (Eighth Edition)
Abortion is the spontaneous or induced (therapeutic) expulsion of the products of conception from the uterus. Up to 15% of all pregnancies and approximately 30% of first pregnancies end in spontaneous abortion (miscarriage). At least 75% of miscarriages occur during the first trimester. (See Types of spontaneous abortion.)
Causes
Spontaneous abortion may result from fetal, placental, or maternal factors. Fetal factors, which usually cause such abortions at up to 12 weeks’gestation, include the following:
❑ 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 between the 11th and 19th week of gestation and include:
❑ maternal infection, abnormalities of the reproductive organs (especially an incompetent cervix, in which the cervix dilates painlessly in the second trimester)
❑ endocrine problems, such as thyroid dysfunction or a luteal phase defect
❑ trauma
❑ phospholipid antibody disorder
❑ blood group incompatibility
❑ drug ingestion (particularly uterotonic agents).
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 may 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 (hCG) in the blood or urine confirms pregnancy; decreased hCG levels suggest spontaneous abortion or tubal pregnancy. Pelvic examination determines the uterus’size and whether this size is consistent with the pregnancy’s length. Tissue histology indicates evidence of products of conception. Laboratory tests reflect decreased hemoglobin levels and hematocrit due to blood loss. However, blood loss is rarely excessive in spontaneous abortion. It’s critical that ectopic pregnancy be ruled out in a woman who’s pregnant with vaginal bleeding.
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, except possibly in cases caused by an incompetent cervix. The patient must be hospitalized to control severe hemorrhage. 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 given above 20 weeks’gestation — receptors are absent before this gestational age). If any remnants remain in the uterus, dilatation and curettage or dilatation and evacuation (D & E) should be performed.
D & E is also performed in first- and second-trimester therapeutic abortions. In second-trimester therapeutic abortions, the insertion of a prostaglandin vaginal suppository induces labor and the expulsion of uterine contents. When performed competently, second-trimester D & E is a very safe procedure and allows for termination of pregnancy without the need for a lengthy induction of labor. Early first-trimester abortion may also be accomplished pharmacologically with mifepristone (RU-486) an antiprogestin, followed by a dose of a prostaglandin analogue 2 days later, or surgically, using vacuum aspiration.
After an abortion, spontaneous or induced, an Rh-negative female with a negative indirect Coombs’test should receive Rho(D) immune globulin (human) to prevent future Rh isoimmunization.
In a habitual aborter, spontaneous abortion can result from an incompetent cervix (a clinical retrospective diagnosis suggested by a history of previous second-trimester losses accompanied by membrane rupture or painless cervical dilation). Treatment involves surgical reinforcement of the cervix (cerclage) 12 to 24 weeks after the last menstrual period. A few weeks before the estimated delivery date, the sutures are removed, and the patient awaits the onset of labor. An alternative procedure is to leave the sutures in place and to deliver the infant by cesarean birth. Cerclage hasn’t been shown to be more effective than bed rest.
Special considerations
Elective abortion is a controversial issue. The decision to have an elective abortion is a personal decision that requires competent counseling. Many women believe they can’t share their feelings with others, therefore it’s important for a woman contemplating an abortion to examine her existing support system and identify those people capable of helping her through a difficult time. A reputable provider or clinic where the woman can obtain adequate counseling regarding all options for pregnancy resolution, have the procedure performed, and obtain support and follow-up care should be identified ahead during the decision-making process.
Before possible abortion:
❑ Be sure to inform the patient who desires an elective abortion of all the 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. Be sure to ascertain whether the patient is comfortable with her decision to have an elective abortion.
❑ The patient shouldn’t have bathroom privileges, because she may expel uterine contents without knowing it. After she uses the bedpan, inspect the contents carefully for intrauterine material.
After spontaneous or elective abortion:
❑ Note the amount, color, and odor of vaginal bleeding. Save all the pads the patient uses, for evaluation.
❑ Administer analgesics and oxytocin, as ordered.
❑ Provide good perineal care.
❑ Obtain vital signs as indicated.
❑ Monitor urine output.
Care of the patient who has had a spontaneous abortion includes emotional support and counseling during the grieving process. Stress to the patient that she isn’t responsible for a spontaneous abortion, as this generally can’t be prevented. Encourage the patient and her partner to express their feelings. Some couples may want to talk to a clergy member 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. If you identify an inappropriate coping response, refer the patient for professional counseling.
To prepare the patient for discharge:
❑ Tell the patient to expect vaginal bleeding or spotting and to report bleeding that lasts longer than 8 to 10 days or excessive, bright-red blood immediately.
❑ 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 gradual increase of daily activities to include whatever tasks the patient feels comfortable doing, as long as these activities don’t increase vaginal bleeding or cause fatigue. Most patients return to work after 24 hours.
❑ Urge 1 to 2 weeks’ abstinence from intercourse, and encourage the use of a contraceptive.
❑ Instruct the patient to avoid using tampons for 1 to 2 weeks.
❑ Tell the patient to see her physician in 2 to 4 weeks for a follow-up examination.
To help prevent future elective abortions, medical and nursing personnel need to make contraceptive information available. An educated population motivated to utilize contraception would have less need for elective abortion.
To minimize the risk of future spontaneous abortions, 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 habitual 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.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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