Abortion and Causes, Types of Abortion

Abortion

This is bleeding or expulsion of the fetus before 24th week of gestation or viability or less than 500g of weight (WHO). Abortion may be spontaneous or induced.

Incidence: 15% of pregnancies abort spontaneously with peak period of 6-10 weeks – This may not be unconnected with low progesterone secretion (About 65% occurs at this period) 80% happens in the 1st trimester. Bleeding in the 2nd& 3rd trimester carries a greater risk to the mother & child because the placenta is already firmly attached.

Causes

Fetal causes:

·              In about 60% of cases the cause is multiple resulting from chromosomal abnormalities of the conceptus.

·              Mal-development

·              Defective implantation

Maternal Causes;

·              Infection – Acute fevers, rubella, syphilis, Chroni c Nephritis, thyroid dysfunction

·              Environmental factors – Effect of drugs, cigarette  and alcohol,

·              ABO incompatibility, High blood lead, Diabetes, Hormonal imbalance, High parity, Local disorders of genital tract, retroverted or Bicornuate uterus, Cervical incompetence, Environmental stress. Local Causes :

·              Conditions that interfere with embedding and nutrition of the ovum (anemia), Trauma and Fibroid tumors.

Social Causes:

Teenage pregnancy, unmet needs, failed family planning, rape conception.

Types of Abortion

Abortion is classified into the following clinical types

1.           Threatened Abortion

2.           Inevitable Abortion

3.           Incomplete Abortion

4.           Complete Abortion

5.           Missed Abortion

1. Threatened Abortion

Vaginal bleeding during the first 20 weeks of pregnancy, whether the bleeding is associated with uterine contraction or not.

It can be distinguished from implantation bleeding which is usually bright red colour and stops quickly.

Signs and Symptoms

·              Slight bleeding

·              Os is closed and not effacement

·              Slight uterine contraction

·              Slight abdominal discomfort & cramping with backache

·              On speculum examinations cervix is closed and membranes intact

·              Ultrasound scan

Treatment

·              Admission in the hospital

·              Reassure client

·              Assess general condition – history, vital signs etc .

·              Routine Observation bid or 4hrly

·              No Vaginal Examination and enema

·              Save all discharges – Pads, soiled clothing, linens  etc.

Blood Test: Grouping and Gross matching, Hb, Rh factor, plasma Human placenta lactogen level – helps to determine prognosis as low level indicate that pregnancy will terminate (inevitable abortion)

Drugs

Valium 5mg tds

Amylobarbitone sodium (sodium Amytal) 200mg nocte Pethidine 50-100mg to relief pain of uterine contractions, Morphine 15mg.

Speculum examination to rule out bleeding from local lesion.

Monitor fetal condition – FH by sonicaid/Dipltone

Do pregnancy test.

Allow up and about after bleeding has stopped for 3 days

Nutritious diet and personal hygiene Prognosis: 70-80% - continue with pregnancy

Prognosis is better if bleeding becomes brownish from bright red-only about 10% will abot, while initial brown blood becomes red 66% will abort. If accompanied with severe uterine contraction there is increased possibility of abortion.

Advice on Discharge

Rest, less activities, no lifting, or coitus for 2-3 weeks, she should report any case of bleeding.

2. Inevitable Abortion

Definition: Abortion is inevitable when bleeding is accompanied with uterine contractions, bleeding becomes severe and dilatation of the cervix. It is impossible for the pregnancy to continue. It may end up complete or incomplete.

Signs & Symptoms

·              Slight or severe vaginal bleeding

·              Increase contraction of the uterus – Pain

·              Dilatation of the cervix

·              Membranes may or may not be ruptured, it may bulge through the Os or in the vagina

·              Shock may be present

·              Product may protrude through the cervical Os or in the vagina

Treatment

Treat as threatened abortion until Dr’s arrival. If bleeding is severe, give 0.5mg ergometrine or 1ml syntometrine ,keep all blood loss for Dr’s inspection.

Give analgesics – Pethidine 100mg or Morphine 15mg .

Oxytocin drip is given or prostaglandin E2 if it is after 16 weeks.

Evacuate the uterus under G.A.

Blood transfusion if necessary.

3. Complete Abortion

When the entire products of conception are passed, abortion is considered complete. It occurs usually before the 8th week. Bleeding is reduced to mere staining.

There are signs of pregnancy regresses.

4. Incomplete Abortion

The fetus has been expelled but parts of the placenta and membranes are retained in-utero. Lochia is heavy, bleeding may be profuse, pain may or may not be present .Os is partly closed – cervix patulous, there is sub -involution.

Treatment

In the District

Send for medical Aid

Give syntometrine 1ml or 0.5mg ergometrine 1m and can be repeated 5-10 minute later if bleeding is profuse, Pethidine 100mg if there is pain,

Resulscitate if in shock,

5-10 units of oxytocin in 5% glucose

Accompany to nearby Hospital and give post abortion care.

In Hospital

Give syntometrine or ergometrine 0.5mg. Take blood for grouping and cross matching. Take high vaginal swab, evacuation of the uterus is done.

If in Shock

Receive into a warm bed, elevate foot of the bed, give ergometrine- i.v.

Infusion 5% dextrose with Ringers lactate, syntocinon 10unit may be added to drip. Observe vital signs – pulse every 5 minutes B/P – every 30 minutes.

When condition improves – evacuate under G.A.

Treat for anemia if present.

Antibiotic coverage.

Discharge on the 5th day.

5. Missed Abortion

This term is applied when the fetus is dead and is retained with it’s placenta in the uterus. Death usually occurs before 8 weeks though mother may not know. Ultrasound may diagnose it even before the woman notices it.

Treatment

·              Some obstetrician will prefer to leave it as spontaneous expulsion will take place: this may cause anxiety and distress to the mother.

·              Protaglandin E2 may be given to induce labour in conjunction with i.v oxytocin

·              Mannual Vacuum aspiration of the content may be performed

·              Blood coagulation disorder may develop if up to 6-8 weeks

·              Plasma fibrinogen estimate weekly

·              If several weeks have elapsed between death and expulsion of the conceptus give fresh compatible blood.

6. Habitual Abortion

Abortion is said to be habitual if it has occurred spontaneously for at least three or more consecutive occasions. The risk of further abortion with subsequent pregnancies is high. Occurrence is about 1% of all pregnancies and in the early weeks of pregnancy if pregnancy continues till mid – trimester there is r isk of threatened abortion or premature labor.

Causes

Most time unknown occurs more with incompetent cervix Local causes: fibroid, displacement of the uterus medical

condition include diabetes mellitus, nephritis, and tuberculosis.

Treatment

Early booking ,no coitus, hospitalization may be imperative

Shirodker stitches – (cervical serclage) at about 1 4th  â€“16 th week complete bed rest - ventolin tablets 2-4mg bid or daily

7. Septic Abortion

Most common complication of induced or incomplete abortion. It is due to ascending infection.

Signs & Symptoms

Anemia, Signs of Miscarriage, Feeling unwell, lower abdominal pain, headache, vomiting, Pyrexia, rapid pulse, lochia are profuse and offensive.

May be localized or as generalized septicemia with peritonitis

Treatment

V. antibiotic for a start, followed by broad spectrum antibiotic that is effective against anaerobic infection.