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Chapter: Medical Surgical Nursing: Assessment and Management of Female Physiologic Processes

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Abortion - Management of Normal and Altered Female Reproductive Function

Interruption of pregnancy or expulsion of the product of con-ception before the fetus is viable is called abortion.

ABORTION

 

Interruption of pregnancy or expulsion of the product of con-ception before the fetus is viable is called abortion. The fetus is generally considered to be viable any time after the fifth to sixth month of gestation. The term “premature labor” is used when a woman experiences labor after this point in the pregnancy.

 

Spontaneous Abortion

 

It is estimated that 1 of every 5 to 10 conceptions results in spon-taneous abortion. Most of these occur because an abnormality in the fetus makes survival impossible. Other causes may include systemic diseases, hormonal imbalance, or anatomic abnormali-ties. If a pregnant woman experiences bleeding and cramping, a threatened abortion is diagnosed because an actual abortion is usually imminent. Spontaneous abortion occurs most commonly in the second or third month of gestation.

 

There are various kinds of spontaneous abortion, depending on the nature of the process (threatened, inevitable, incomplete, or complete). In a threatened abortion, the cervix does not dilate. With bed rest and conservative treatment, the abortion may be prevented. If it cannot, an abortion is imminent. If only some of the tissue is passed, the abortion is referred to as incomplete. If the fetus and all related tissue are spontaneously evacuated, the abortion is complete.

 

HABITUAL ABORTION

 

Habitual or recurrent abortion is defined as successive, repeated, spontaneous abortions of unknown cause. As many as 60% of abortions may result from chromosomal anomalies. After two consecutive abortions, patients are referred for genetic counseling and testing, and other possible causes are explored. If bleeding oc-curs in these patients, conservative measures, such as bed rest and administering progesterone to support the endometrium, are tried in an attempt to save the pregnancy. Supportive counseling is crucial in this stressful condition. Bed rest, sexual abstinence, a light diet, and no straining on defecation are recommended in an effort to prevent spontaneous abortion. If infection is suspected, antibiotics may be prescribed.

In the condition known as incompetent or dysfunctional cervix, the cervix dilates painlessly in the second trimester of pregnancy, often resulting in a spontaneous abortion. In such cases, a surgi-cal procedure called cervical cerclage may be used to prevent the cervix from dilating prematurely. The procedure involves placing a purse-string suture around the cervix at the level of the internal os. Bed rest is usually advised to keep the weight of the uterus off the cervix.

 

The patient and her health care providers must be informed that such a suture is in place in this high-risk pregnancy. About 2 to 3 weeks before term or the onset of labor, the suture is cut. Delivery is usually by cesarean section.

 

MEDICAL MANAGEMENT

 

After a spontaneous abortion, all tissue passed vaginally is saved for examination. The patient and all personnel caring for her are alerted to save any discharged material. In the rare case of heavy bleeding, the patient may require blood component transfusions and fluid replacement. An estimate of the bleeding volume can be determined by recording the number of perineal pads and the degree of saturation over 24 hours. When an incomplete abor-tion occurs, oxytocin may be prescribed to cause uterine con-tractions before dilation and evacuation (D & E) or uterine suctioning.

 

NURSING MANAGEMENT

 

Because patients experience loss and anxiety, emotional support and understanding are important aspects of nursing care. The response of the woman who desperately wants a baby is very dif-ferent from that of the woman who does not want to be preg-nant but may be frightened by the possible consequences of an abortion.

 

The nurse must be aware that the woman having a sponta-neous abortion often experiences a grieving period. The grieving may be delayed and may cause other problems until resolved. The many reasons for a delayed grief reaction include the following: friends may not have known the woman was pregnant; the woman may not have seen the lost fetus and can only imagine the gender, size, and characteristics of the child who never developed; there is usually no burial service; and those who know about the loss (fam-ily, friends, caregivers) may encourage denial by rarely talking about the loss or by discouraging the woman from crying.

 

Providing opportunities for the patient to talk and express her emotions helps and also provides clues for the nurse in planning more specific care. Those closest to the woman are encouraged to give emotional support and to allow her to talk and freely express her grief. Unresolved grief may manifest itself in persistent vivid memories of the events surrounding the loss, persistent sadness or anger, and episodes of overwhelming emotion when recalling the loss. Dysfunctional grief may require the assistance of a skilled therapist.

Elective Abortion

A voluntary induced termination of pregnancy is called an elective abortion and is usually performed by skilled health care providers. In 1973, the U.S. Supreme Court in Roe v. Wade ruled that de-cisions about abortion reside with a woman and her physician in the first trimester. During the second trimester, the state may reg-ulate practice in the interest of a woman’s health and during the final weeks of pregnancy may choose to protect the life of the fetus, except when necessary to preserve the life or health of the woman.Legislation has been passed to increase access to abortion clinics and to prevent violence toward those who work in such facilities.

 

The rate of abortion, steady from 1980 to 1990, decreased 15% from 1990 to 1995. Rates since then have been the lowest since 1975 (Zapka, Lemon, Peerson et al., 2001). However, the rate has increased among the following groups of females: un-married Caucasian girls under age 15, unmarried non-Caucasian girls ages 15 to 19, and married non-Caucasian women ages 20 to 24. The U.S. rates of abortion are among the highest in the industrialized Western world. These numbers point out the need for nurses to provide contraceptive education and counseling. Elective abortions may be carried out in many different ways (Chart 46-16).


 

MEDICAL MANAGEMENT

 

Before the procedure is performed, a nurse or counselor trained in pregnancy counseling explores with the patient her fears, feelings, and options. After the patient’s choice is identified (ie, continuing pregnancy and parenthood; continuing pregnancy followed by adoption; or terminating pregnancy by abortion), a pelvic exami-nation is performed to determine uterine size. Laboratory studies before an abortion must include a pregnancy test to confirm the pregnancy, hematocrit to rule out anemia, Rh determination, and an STD screen. A patient with anemia may need an iron supple-ment, and an Rh-negative patient may require RhoGAM to pre-vent isoimmunization. Before the procedure, all patients should be screened for STDs to prevent introducing pathogens upward through the cervix during the procedure.

NURSING MANAGEMENT

 

Patient teaching is an important aspect of care for women who elect to terminate a pregnancy. A woman undergoing elective abortion is informed about what the procedure entails and the ex-pected course after the procedure. The patient is scheduled for a follow-up appointment 2 weeks after the procedure and is in-structed in recognizing and reporting signs and symptoms of complications (ie, fever, heavy bleeding, or pain).

 

Available contraceptive methods are reviewed with the patient at this time. Effectiveness depends on the method used and the extent to which the woman and her partner follow the instruc-tions for use. The woman who has used any method of birth con-trol should be assessed for her understanding of the method and its potential side effects and her satisfaction with the method. If the patient was not using contraception, the nurse explains all methods and their benefits and risks and assists the patient in making a contraceptive choice for use after abortion. An increas-ingly important related teaching issue is the need to use barrier contraceptive devices (ie, condoms) for protection against trans-mission of STDs and HIV infection.

 

Psychological support is another important aspect of nursing care. Nurses need to be aware that women terminate pregnancies for many reasons. Some women terminate pregnancies because of severe genetic defects. Many women who have been raped or impregnated in incestuous relationships or by an abusive partner elect to terminate their pregnancies. Infertility patients may elect to undergo selective termination if they become pregnant with multiple fetuses. In pregnancies with multiple gestation, adverse outcomes are directly proportional to the number of fetuses in the uterus. Such multifetal reductions are specialized procedures that are stressful and difficult for the parents; therefore, psychological support and understanding are required. The care of women un-dergoing termination of pregnancy is stressful, and assistance needs to be provided in a safe and nonjudgmental way. Nurses have the right to refuse to participate in a procedure that is against their religious beliefs but are professionally obligated not to im-pose their beliefs or judgments on their patients.

Patients may opt for a type of abortion that ends a pregnancy by using medication rather than surgery. Mifepristone (RU-486, Mifeprex) is used only in early pregnancy (up to 49 days from the last menstrual period). It works by blocking progesterone. Cramping and bleeding similar to a heavy menstrual period will occur. This method requires three visits to a health care provider. The first visit consists of counseling and consent. A sonogram may be used to confirm the pregnancy. Mifepristone will then be administered. The second visit consists of a pelvic examination and possible sonogram to check if the pregnancy has been termi-nated. A third visit 12 days later is to make sure that the pelvic examination is normal and that the pregnancy has been terminated. If the pregnancy persists, options will be discussed, in-cluding surgical abortion (ACOG Practice Bulletin #26, 2001).

 

Infertility

 

Infertility is defined as a couple’s inability to achieve pregnancy after 1 year of unprotected intercourse. Primary infertility refers to a couple who has never had a child. Secondary infertility means that at least one conception has occurred, but currently the cou-ple cannot achieve a pregnancy. In the United States, infertility is a major medical and social problem, affecting 10% to 15% of the reproductive-age population. In 20%, the infertility is unex-plained. The remaining 80% involve medical causes equally dis-tributed between men and women (ACOG Technical Bulletin #125, 2001; Compendium, 2000). Women’s infertility may be related to anovulation, uterine or cervical factors, blocked fallo-pian tubes, or endometriosis, while men’s infertility is related to sperm quality or sperm production. For infertile women who wish to bear children, infertility may have a profound emotional toll (Gonzalez, 2000; Hart, 2002).

 

Pathophysiology

 

Possible causes of infertility include uterine displacement by tumors, congenital anomalies, and inflammation. For an ovum to become fertilized, the vagina, fallopian tubes, cervix, and uterus must be patent and the mucosal secretions of the cervix must be receptive to sperm. Semen and cervical secretions are alkaline, whereas normal vaginal secretions are acidic. Often more than one factor is responsible for the problem. Identify-ing the causes may require the services of a gynecologist, urolo-gist, and endocrinologist.

 

Assessment and Diagnostic Findings

 

Careful evaluation includes physical examination, endocrinologic investigation, and consideration of psychosocial factors. Three complete histories (one of each partner and one of the couple), physical examination, and laboratory studies are performed on both partners to rule out such causative factors as previous STDs, anomalies, injuries, tuberculosis, mumps orchitis, impaired sperm production, endometriosis, DES exposure, or antisperm anti-bodies. Five factors are considered basic to infertility: ovarian, tubal, cervical, uterine, and semen conditions.

 

OVARIAN FACTORS

 

Studies performed to determine if there is regular ovulation and if progestational endometrium is adequate for implantation may in-clude a basal body temperature chart for at least four cycles, an en-dometrial biopsy, serum progesterone level, and ovulation index. The ovulation index involves a urine-stick test that determines if the surge in LH that precedes follicular rupture has occurred.

 

TUBAL FACTORS

 

Hysterosalpingography is used to rule out uterine or tubal ab-normalities. Laparoscopy permits direct visualization of the tubes and other pelvic structures and can assist in identifying condi-tions that may interfere with fertility (eg, endometriosis).

 

CERVICAL FACTORS

 

The cervical mucus can be examined at ovulation and after in-tercourse to determine whether proper changes occur that pro-mote sperm penetration and survival. A postcoital cervical mucus test (Sims-Huhner test) is performed 2 to 8 hours after inter-course. Cervical mucus is aspirated with a medicine dropper–like instrument. Aspirated material is placed on a slide and examined under the microscope for the presence and viability of sperm cells. The woman is instructed not to bathe or douche between coitus and the examination.

 

UTERINE FACTORS

 

Fibroids, polyps, and congenital malformations are possible con-ditions in this category. Their presence may be determined by pelvic examination, hysteroscopy, saline sonogram (a variation of a sonogram), and hysterosalpingography.

 

SEMEN FACTORS

 

After 2 to 3 days of sexual abstinence, a specimen of ejaculate is collected in a clean container, kept warm, and examined within 1 hour for the number of sperm (density), percentage of moving forms, quality of forward movement (forward progression), and morphology (shape and form). From 2 to 6 mL of watery alkaline semen is normal; a normal count is 60 million to 100 million sperm/mL, although the incidence of impregnation is lessened only when the count drops below 20 million sperm/mL. A nor-mal semen analysis should show the following (Angard, 1999):

 

·      Volume: more than 1 mL

 

·       Concentration: more than 20 million/mL

 

·       Motility: more than 50% of the forms should be moving

 

·      Morphology: more than 60% of sperm should have normal forms

 

·      No sperm clumping, significant red or white blood cells, or thickening of seminal fluid (hyperviscosity)

 

MISCELLANEOUS FACTORS

 

Men may also be affected by varicoceles, varicose veins around the testicle, which decrease semen quality by increasing testicular temperature. Retrograde ejaculation or ejaculation into the blad-der is assessed by urinalysis after ejaculation.

 

Blood tests for male partners may include measuring testos-terone; FSH and LH (both of which are involved in maintaining testicular function); and prolactin levels and antisperm antibod-ies (treated with corticosteroids).

 

Immunologic factors also are being investigated. Some cases of recurrent early pregnancy loss or recurrent natural abortion are the result of an abnormal response by the woman to antigens on fetal or placental tissues. Some women have been treated with infusions of their partner’s lymphocytes with some success, but this treatment remains experimental and the long-term effects are unknown.

 

Medical Management

 

Infertility is often difficult to treat because it frequently results from a combination of factors. Couples undergoing an infertility evaluation may conceive without the cause of infertility ever iden-tified. Likewise, although some couples undergo all tests, the cause of the problem may remain undiscovered and infertility persists. Between these extremes, many problems, both simple and complex, can be discovered and corrected. Patients may need assisted reproductive technology to conceive; the methods are de-scribed below. Therapy may require surgery to correct a mal-function or anomaly, hormonal supplements, attention to proper timing, and recognition and correction of psychological or emo-tional factors.

PHARMACOLOGIC THERAPY

 

Pharmacologically induced ovulation is undertaken when women do not ovulate on their own or ovulate irregularly. Various med-ications are used, depending on the primary cause of infertility (Chart 46-17). Clomiphene citrate (Clomid) is the most com-mon medication used. Although Clomid’s precise action is un-known, it enhances the release of pituitary gonadotropins, resulting in follicular rupture or ovulation.


 

Another mode of pharmacotherapy for anovulatory women includes the use of pulsatile gonadotropin-releasing hormone (GnRH). The woman wears an infusion pump attached to an in-travenous or subcutaneous catheter for up to 21 days. Adminis-tration of GnRH can result in ovulation in some women with low hormone levels. This option can reduce cycle monitoring and the incidence of multiple gestation (ACOG Technical Bulletin #197, ACOG Compendium, 2001).

 

Human menopausal gonadotropin may also be used as it stim-ulates the ovaries to produce eggs. Blood tests and ultrasounds are used to monitor ovulation. Multiple pregnancies may occur with these medications. Ovarian hyperstimulation syndrome (OHSS) may also occur. This condition is characterized by enlarged mul-ticystic ovaries and is complicated by a shift of fluid from the intra-vascular space into the abdominal cavity. It is iatrogenic and preventable and develops after ovarian stimulation. The fluid shift can result in ascites, pleural effusion, and edema; hypo-volemia may also result. Risk factors include younger age, history of polycystic ovarian syndrome, high serum estradiol levels, a larger number of follicles, and pregnancy. If the woman is preg-nant, she is producing human chorionic gonadotropin, which can worsen OHSS. Symptoms include abdominal discomfort, distention, weight gain, and ovarian enlargement. This condition may be moderate, severe, or critical. Severe OHSS may result in acute respiratory distress syndrome (ARDS). It is prevented by careful monitoring and adjustment of medication dosage.

 

Management in mild and moderate cases of OHSS consists of decreased activity, monitoring of urine output, and frequent office visits as designated by the reproductive endocrinologist. The patient with severe OHSS is hospitalized for monitoring and treatment. Severe OHSS is characterized by clinical ascites, hypovolemia, oliguria, hemoconcentration, electrolyte imbal-ance, and ovarian size greater than 10 cm. Treatment of severe OHSS includes use of an indwelling catheter for strict monitor-ing of fluid intake and output and daily measurements of weight and abdominal circumference. Intravenous fluids and heparin are administered as prescribed. The patient is permitted to ambulate as tolerated. Critical OHSS is life-threatening and is characterized by tense ascites that may be accompanied by hydrothorax, renal failure, and ARDS. Volume expanders, di-uretic agents, hemodialysis, and intubation may be required (Copeland, 2000).

 

ARTIFICIAL INSEMINATION

 

Depositing semen into the female genital tract by artificial means is called artificial insemination. If the sperm cannot penetrate the cervical canal normally, artificial insemination using the partner’s semen (AIH, or artificial insemination with sperm from the husband or partner) may be considered. In azoosper-mia (lack of sperm in the semen), semen from carefully selected donors may be used (AID, or artificial insemination with sperm from donor).

 

Indications for using artificial insemination include: (1) the man’s inability to deposit semen in the vagina, which may be due to premature ejaculation, pronounced hypospadias (a displaced male urethra), or dyspareunia (painful intercourse experienced by the woman), (2) inability of semen to be transported from the vagina to the uterine cavity (this is usually due to faulty chemical conditions and may occur with an abnormal cervical discharge), and (3) a single woman’s desire to have a child.

 

The woman may have received clomiphene (Clomid) and menotropins (Pergonal) to stimulate ovulation before insemina-tion. Ultrasounds and blood studies of varying hormone levels are used to pinpoint the best time for insemination and to monitor for OHSS. The recipient is placed in the lithotomy position on the ex-amination table, a speculum is inserted, and the vagina and cervix are swabbed with a cotton-tipped applicator to remove any excess secretions. Semen is drawn into a sterile syringe, and a cannula is attached. The semen is then directed to the external os. Semen may also be placed into the uterine cavity (intrauterine insemination). In this procedure, the sperm are washed before insertion to remove biochemicals and to select the most active sperm. This is indicated when mucus is inadequate, when antibodies are present, or when the sperm count is low. After careful withdrawal of the cannula, the patient remains in a supine position for 30 minutes.

 

The success rate for artificial insemination varies. Three to six inseminations may be required over 2 to 4 months. Because arti-ficial insemination is likely to be a stressful and difficult situation for couples, nursing support and strategies to promote coping are crucial.

 

Cannula With Partner’s Semen. 

Certain conditions need to beestablished before semen is transferred to the vagina. The woman must have no abnormalities of the genital system, the fallopian tubes must be patent, and ova must be available. In the male, sperm need to be normal in shape, amount, motility, and en-durance. The time of ovulation should be determined as accu-rately as possible so that the 2 or 3 days during which fertilization is possible each month can be targeted for treatment. Fertilization seldom occurs from a single insemination. Usually, insemination is attempted between days 10 and 17 of the cycle; three different attempts may be made during one cycle. Semen is collected by masturbation; alternatively, a perforated sheath is worn over the penis during intercourse by couples who object to masturbation. Withdrawal and using condoms for sperm collection are consid-ered unsatisfactory by many infertility specialists because some sperm may be lost or adversely affected.

 

Insemination With Donor Semen. 

When the sperm of thewoman’s partner is defective or absent or when there is a risk of transmitting a genetic disease, donor sperm may be used. Safe-guards are put in place to address legal, ethical, emotional, and religious issues. Written consent is obtained to protect all parties involved, including the woman, the donor, and the resulting child. The donor’s semen is frozen and the donor is evaluated to ensure that he is free of genetic disorders and STDs, including HIV infection.

 

IN VITRO FERTILIZATION

 

In vitro fertilization (IVF) involves ovarian stimulation, egg re-trieval, fertilization, and embryo transfer. This procedure is ac-complished by first stimulating the ovary to produce multiple eggs or ova, usually with medications, because success rates are greater with more than one early embryo. Many different proto-cols exist for inducing ovulation with one or more agents. Pa-tients are carefully selected and evaluated, and cycles are carefully monitored using ultrasound and estradiol levels. At the appro-priate time, the ova are recovered by transvaginal ultrasound re-trieval. Sperm and eggs are coincubated for up to 36 hours, and the embryos are transferred about 48 hours after retrieval. Im-plantation should occur in 3 to 5 days.

Gamete intrafallopian transfer (GIFT), a variation of IVF, is the treatment of choice for patients with ovarian failure. Success rates vary from 20% to 30%. The ovaries are stimulated with go-nadotropin derivatives, and follicles are observed with vaginal ultrasound. Once the oocyte is mature, it is retrieved by laparoscopy or transvaginally with ultrasound guidance. The oocyte (unfertilized egg) is removed and drawn into a catheter, where it is mixed with sperm that was obtained shortly before the oocyte retrieval. The most motile fraction of sperm is selected by a washing process. The oocyte and sperm are then inserted into the fallopian tube, where fertilization occurs. The latter method avoids anesthesia. GIFT is the technique of choice for nontubal causes of infertility and for older infertile women.

 

Zygote intrafallopian transfer (ZIFT) consists of oocyte re-trieval and fertilization in vitro; the zygotes are placed into the fal-lopian tubes via laparoscopy.

 

The most common indications for IVF and GIFT are ir-reparable tubal damage, endometriosis, immunologic problems, unexplained infertility, inadequate sperm, and exposure to DES.

 

OTHER ASSISTED REPRODUCTIVE TECHNOLOGIES

 

In intracytoplasmic sperm injection (ICSI), an ovum is retrieved as described previously, and a single sperm is injected through the zona pellucida, through the egg membrane, and into the cyto-plasm of the oocyte. The fertilized egg is then transferred back to the donor. ICSI is the treatment of choice in severe male factor infertility.

 

Women who cannot produce their own eggs (ie, premature ovarian failure) have the option of using the eggs of a donor after stimulation of the donor’s ovaries. The recipient also receives hor-mones in preparation for these procedures. Couples may also choose this modality if the female partner has a genetic disorder that may be passed on to children.

 

Nursing Management

 

Nursing interventions appropriate when working with couples during infertility evaluations include the following: assist in re-ducing stress in the relationship, encourage cooperation, protect privacy, foster understanding, and refer the couple to appropri-ate resources when necessary. Because infertility workups are expensive, time-consuming, invasive, stressful, and not always successful, couples need support in working together to deal with this endeavor.

 

Resolve, Inc., a nonprofit self-help group that provides infor-mation and support for infertile patients, was founded by a nurse who experienced difficulty conceiving. The literature on infertil-ity that is produced by this group is an important resource for pa-tients and professionals. Most areas across the country have local support groups. More information can be obtained by writing to Resolve, Inc..

 

Smoking is strongly discouraged because it has an adverse ef-fect on the success of assisted reproduction. Diet, exercise, stress reduction techniques, health maintenance, and disease preven-tion are being emphasized in many infertility programs.

 

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