Abortion is the termination of pregnancy or expulsion of the fetus either spontaneously or by induction before it reaches viability i.e before 20 weeks of gestation in developed country and 28 weeks of gestation in developing country.
Between 10 and 15% of all pregnancies terminate as spontaneous abortions, and a further 10-60% are terminated by an induced abortion. The majority of spontaneous abortions occur between the 8th and 12th weeks of pregnancy.
The causes of abortion can conveniently be divided in to three groups - ovo-fetal, maternal and paternal.
In the early weeks (0 to 10) of pregnancy, when most abortions occur, ova-fetal factors pre dominant, but in the latter weeks (11 to 19) maternal factors become more common and the fetus is often born fresh and apparently normal, although too immature to survive.
· Chromosomal abnormality or disease of the fertilized ovum may account for 60% of spontaneous, first trimester abortions.
· Malformation of the trophoblast and poor implantation of the blastocyst may result in placental separation with consequent hypoxia and impaired embryonic development.
· Disease- acquired during pregnancy such as rubella or influenza, especially if they are accompanied by acute fever, interfere with transplacental oxygenation and may precipitate abortion.
· Chronic disorders, for example renal disease accompanied by hypertension, may have a similar effect.
· Drugs - large doses of any drug are poisonous and should be avoided
· ABO incompatibility between mother and embryo may result in abortion.
· Psychological factors
· A retroverted uterus which is unable to rise out of the pelvis may occasionally predispose to abortion.
· Developmental defects such as a bicornuate uterus and myomas
· Cervical incompetence
Since the paternal spermatozoon gives to the ovum half of its chromosomes, defects may result in abortions, particularly if both partners share many common HLA antigen sites.
Sign and symptoms- many mothers will speak of a period of uneasiness prior to the onset of specific sign and symptoms. Vaginal bleeding is generally the earliest sign of an impending abortion. The bleeding may consist of a bloodstained discharge, brown spotting or a bright red loss, which may be variable in amount. Pain is usually felt in a central position, low in the abdomen, and is intermittent in character due to uterine contractions. This may be accompanied by backache.
It is presumed that a pregnancy is threatening to abort when vaginal bleeding occurs before the 24th week.
· The bleeding is not usually severe
· The cervical os is found to be closed & no effect
· Uterine cramping and pain; occasionally lower abdominal pain and backache.
· The membrane remains intact and no tissue is passed.
It is essential that the mother is encouraged to rest in bed with the minimum of disturbance. A mild sedative may be prescribed to aid relaxation and analgesia may be given for pain.
All loss per vagina should be observed and recorded. Temperature and pulse should be taken twice between 24 and 48 hours after the bleeding a speculum examination is performed to exclude local lesions and to note the state of the cervical os.
48 hours after the bleeding ceases the mother can commence gentle ambulation and if in hospital, she may return home. Out comes of threatened abortion
· 70-80% of all mothers diagnosed as having threatened abortion in the first trimester will continue with their pregnancies to term.
This is the term applied to the fetus which is died and is retained with its placenta in the uterus. Early ultrasonic scan may identify missed abortion before the mother experiences any symptoms.
· Pain and bleeding may cease but the mother may experience a residual brown vaginal discharge as having an odour of decaying matter and it can be offensive and distressing.
· All other physiological signs of pregnancy will regress, uterine enlargement will cease and a pregnancy test will prove negative.
Some obstetricians prefers not to treat a missed abortion actively as the dead conceptus will be expelled eventually. Alternatively prostaglandin E2 may be given to induce expulsion in conjunction with i.v oxytocin or a vacuum aspiration of the uterine contents may be performed.
Blood coagulation disorders may develop in cases of missed abortion which persists for over 6-8 weeks.
Occasionally a missed abortion will progress to form a blood mole. This is a smooth brownish red mass which is completelysurrounded by the capsular decidua. With in the capsular decidua the fetus and placenta are surrounded by clotted blood. The mole is usually formed before the 12th week and if it is retained in utro for a period of months, the fluid is extracted from the blood and the fleshy, firm, hard mass remaining is known as a carneous mole.
Prostaglandin E2 pessaries will be inserted in to the vagina to soften the collageon fibbers of the cervix and aid dilatation. This will be followed by an intravenous oxytocin infusion administered via a calibrated pump.
Analgesia will be required to relive the pain of induced contractions and the mother will require close observation throughout the whole procedure.
When it is impossible for the pregnancy to continue it is termed as inevitable abortion.
Profuse vaginal bleeding which suggests that a large section of the placenta has separated from the uterine wall.
The abdominal pain becomes more acute and rhythmic in character.
The membranes may have ruptured and amniotic fluid will be seen. Alternatively the fetal sac and its contents, and possibly the placenta, will protrude through the dilating cervical as.
Bleeding and uterine contractions will continue and all or part of the conceptus will be expelled vaginally.
A complete abortion is more likely to occur prior to the 8th week of pregnancy and constitutes the expulsion of the embryo, placenta and intact membranes.
There is relief from pain and the bleeding usually stops.
When the products of conception are only partially evacuated during abortion, the abortion is incomplete. This usually occurs in the second trimester.
Bleeding is profuse but the abdominal pain and back ache may cease.
The cervix will be soft and purplish in color and will be partly closed.
Prolonged retention of the tissues predisposes the woman to infection and immediate medical intervention is needed.
Specific treatment prior to the 12th week will include the administration of ergometrine 0.5mg i.m to expel the uterine contents and reduce bleeding from the placental site followed by evacuation of any tissue retained. The latter procedure is carried out under general anesthesia. After 12 week an oxytocin infusion will be administered using a pump. A dose of ergometrine will be given on completion of surgery. Uterine aspiration is commonly used but where this is not available the uterus will be evacuated digitally or by dilatation and curettage.
This term is applied when a mother has had at least two consecutive spontaneous abortions. The risk of further abortion increases with each successive aborted pregnancy.
The majority of mothers who encounter this problem will loss their babies in the early weeks of pregnancy. If a pregnancy continues following a mid trimester threatened abortion there is a greater risk of preterm labour.
Legal termination of pregnancy is a therapeutic procedure carried out under the acts of abortion. It is important to provide adequate counseling and support prior to and following theoperation. Many mothers do not make the decision to have a pregnancy terminated with out some inner conflict. There are religious, psychological, social and cultural factors, which affect the woman's decision. Important considerations are her economic and marital status, the health and well being of existing children in the family and the presence of an abnormal fetus.
A few may be advised on health grounds to discontinue the pregnancy.
In the United Kingdom the 1967 Abortion act made the following provisions: Two registered medical practitioners should be of the opinion that the pregnancy should be terminated if (myles text book of midwives)
· The continuance of the pregnancy would involve a risk to the life of the pregnant woman or of injury to her physical and mental health.
· The continuance of the pregnancy would be detrimental to the health and well-being of the existing children in the family.
· There is a substantial risk that the child when born would suffer from such physical or mental abnormalities as to be seriously handicapped.
Before the 12th week of pregnancy vacuum aspiration is the chosen method of termination of pregnancy as there is less blood loss. Alternatively dilatation and curettage may be performed.
After the 12th week a prostaglandin preparation will be used either intra- or extra- amniotically to produce abortion with in 48 hours.
All terminations performed after 8 weeks gestation should be carried out in hospital where resuscitation facilities are available. In all instances ergometrine or syntometrine will be administered intravenously to prevent hemorrhage.
A criminal abortion is one performed in contravention of legal abortion. Such procedures are illegal and are punishable by imprisonment. The abortion is attempted by an unqualified, in expert person. Injuries to the birth canal and pelvic organs can occur if implements are inserted. It is usually the subsequent bleeding which causes a mother to seek professional help and care should be given as for threatened abortion until medical assistance arrives.
Infection may occur following any abortion. It may be associated with incomplete abortion but is more commonly found after an induced abortion.
The infection may be limited to the decidual lining of the uterus but virulent organisms may cause the infection to spread and involve the myometrium, fallopian tubes and pelvic organs.
Complaining of feeling unwell
Headache and nausea accompanied by sweating and
shivering and shivering
It looks flushed, her skin will be hot to the touch and it may be clammy.
Spiking pyrexia in excess of 380C
Steadily rising pulse
After 12th week of pregnancy abdominal examination will identify tenderness of the uterus, which will be bulky and soft in texture. The vaginal discharge will have an offensive odor and may be pinkish in color,
Specific investigations will include vaginal and cervical swabs, full blood culture and hematological investigations.
Amoxycillin 500 mg three times daily and metronidazole 200mg 6.hourly is the treatment of choice until bacteriological results are obtained, after which the antibiotic treatment will be more appropriately prescribed.
Dilatation and curettage will be performed preferably after the acute infection subsides.
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