ABORTION/ MISCARRIAGE

ABORTION/ MISCARRIAGEdefinitionA spontaneous or planned interruption of pregnancy in which there is complete expulsion or partial expulsion (incomplete) of the products of conception before the period of viability. Period of gestation is 20 weeks or less, the conceptus will weigh below 500g and will be less than 16.5 cm long. May be caused by the presence of embryonic defects, external mechanical force, or trauma. Types/ clinical findingsThreatened abortionCervix closed, but bleeding, cramping and backache occur; pregnancy may continue uninterruptedImminent or inevitable abortionBleeding and cramping become more severe, cervix dilates, and membranes may ruptureIncomplete abortionAll the products of conception are not expelled after dilation of cervical osComplete abortionAll products of conception expelled within 24 to 48 hoursMissed abortionFetus dies in utero but not expelled; client must be monitored for disseminated intravascular coagulopathyHabitual abortionThree consecutive pregnancies that end in abortion

Threatened abortionVaginal bleeding occurs.Inevitable abortionMembranes rupture, and cervix dilates.Incomplete abortionSome products of conception have been expelled, but some remain.Pathophysiology Spontaneous AbortionCauses/ risk factorsChromosomal abnormalitiesExposure or contact with teratogenic agents, virusesPoor maternal nutritional statusHx of DM, thyroid disease, anticardiolipin antibodies, or lupus erythematosusSmoking or drug abuseImmunologic factorsAbnormal uterine development or structural defect (ex: incompetent cervix)Environmental factors such as drugs, radiation, or trauma

Clinical ManifestationsUterine crampingLow back painVaginal bleeding usually begins as dark spotting, then progresses to frank bleeding as the embryo separates from the uterusB-hCG levels may be elevated for as long as two weeks after loss of the embryo

Diagnostic EvaluationUltrasound evaluation of the gestational sac or embryoVisualization of the cervix, presence of dilation or tissue evaluated

ComplicationsHemorrhageInfectionSeptic abortionIsoimmunizationPowerlessness or Anxiety

ComplicationsHemorrhageInfectionSeptic abortionIsoimmunizationPowerlessness or AnxietyHemorrhageCommon in incomplete abortion or in a woman who develops an accompanying coagulation defect (DIC)A woman needs clear instructions on how much bleeding is abnormal RULE OF THE THUMB: more than one sanitary pad per hour is excessive Oral medication such as methylergonovine maleate (Methergine) is usually prescribed to aid in contraction

Signs of Hypovolemic shockConfusionPallorIncreased pulse/ tachycardiaDecreased blood pressureDecreased cardiac outputFetal bradycardiaPeripheral vasoconstriction (placenta reacts as a peripheral organ)Decreased urinary outputCold extremitiesInfectionTends to occur when women have loss appreciable amounts of bloodSIGNS OF INFECTION: Fever Abdominal pain or tendernessFoul vaginal dischargeEscherichia coli usually the organism responisble for infection Wipe perineal area from front to back after voiding and defecation to prevent the spread of bacteria from the rectal areaAvoid tampons to control vaginal discharge stasis of any body fluid increases the risk for infectionIsoimmunizationWhen some blood from the placental villi (the fetal blood) enters to maternal circulation, if the fetus was Rh positive and the woman is Rh negative, enough Rh-positive fetal blood may enter her circulation to cause Isoimmunization the production of antibodies against Rh-positive blood from her immunologic system. If her next child is Rh-positive, these antibodies would attempt to destroy the red blood cells of the next infant in the utero. Treatment: After miscarriage, all Rh-negative blood should receive Rh (D antigen) immune globulin (RhIG) to prevent the buildup of antibodies in the event the conceptus was Rh positive.Septic abortionIs an abortion that is complicated by infection Infection can happen after a spontaneous miscarriage, but more frequently it occurs in women who have tried to self-abort or were aborted illegally using nonsterile instrument such as a knitting needle SYMPTOMS: fever, crampy abdominal pain, and uterus feels tender on palpationIf untreated can lead to Toxic shock syndrome, septicemia, kidney failure, and deathTreatment: broad-spectrum antibiotic therapy; a combination of penicillin (gram-positive coverage), gentamicin (gram-negative aerobic coverage), and clindamycin (gram-negative anaerobic coverage)Powerlessness or AnxietySadness and grief over the loss or a feeling that a woman has lost control of her life is to be expected. Dont forget to assess a partners feelings as wellNurses can help by emphasizing that most spontaneous abortions occur because of factors or abnormalities that could not be avoided.Anger, disappointment, and sadness are commonly experienced emotions, although the intensity of the feelings may vary.Providing information and simple, brief explanations of what has occurred and what will be done facilitates the familys ability to grieveIt is helpful for the family to realize that grief may last from 6 months to a year, or even longer. Family support, knowledge of the grief process, spiritual counselors, and the support of other bereaved couples may provide needed assistance during this time.Therapeutic interventionsComplete bed restDiagnostic/ therapeutic blood studies: Blood cell countBlood typingRh incompatibilityCross matching with availability of bloodAssessment of serum progesterone or serial beta-hCGDilatation and curettage or vacuum aspiration performed if all products of conception are retainedNursing Care of Clients Experiencing Abortion AssessmentEvaluate the amount of and color of blood that is present: determine the time the bleeding began and any precipitating factors.Determine whether a positive pregnancy test has previously been obtained, also the date of the last menstrual period.Monitor vital signs for indication of complications such as haemorrhage, infectionEvaluate any blood or clot tissue for the presence of fetal membranes, placenta or fetusPainEmotional response to lossAnalysis/ Nursing DiagnosesRisk for fluid volume deficit related to maternal bleedingAnticipatory grieving r/t loss of expected infantPain r/t uterine contractionsRisk for infection related to dilated cervix and open uterine vesselSituational low self-esteem r/t inability to carry pregnancy to termRisk for fluid volume deficit related to maternal bleedingINTERVENTION1. Monitor intake and output. Calculate insensible loses and fluid balance. Note decreased urine in presence of adequate intake. Measure specific gravity and pH to gauge urinary retention2. Weigh daily. Monitor BP and HR 3. Evaluate skin turgor, capillary refill and general condition of mucous membranes- indicators of fluid status/ hydration4. Encourage moderate amount of fluid as indicated - promote urine flow5. Bed rest---Collaborative---6. Administer IV fluids as indicated - maintains fluid and electrolyte balance7. Monitor lab studies8. Administer RBC, platelets, clotting factors - to prevent hemorrhage

Desired OutcomeDemonstrate adequate fluid volume, as evidenced by stable vita signs, palpable pulses, urine output, specific gravity, and pH within normal limitsIdentify individual risk factor and appropriate interventions.Initiate behaviours/ lifestyle changes to prevent development of fluid volume deficitAnticipatory grieving r/t loss of expected infantDATAVerbal expression of distressDenial of lossAltered eating habits, sleep/ dream patternscryingLabile affect, feeling of sorrow, guilt, angerDifficulty expressing loss

INTERVENTIONProvide open environment in which the patient feels free to discuss feelings and concernsAllows patient to talk freely and deal with perceived lossTherapeutic communication skills used: active listening silence, being available and acceptanceIdentify stage of grievingAwareness allows for appropriate choice of interventions as individual handle grief in many different ways (DABDA)Identify and problem-solve solutions to existing physical responses, e.g. eating, sleeping, activity levels and sexual desireMay need additional assistance to deal with the physical aspects of grievingAssess needs of significant other and assists as indicated. ---collaborative---Refer to other resources; e.g. counseling, psychotherapy as indicatedDESIRED OUTCOMEVerbalized sense of progress toward resolution of the grief and hope for the futureFunction at an adequate level, participate in work and ADLsPain r/t uterine contractionsDATAReports of painFacial grimacingMuscle guardingINTERVENTIONAssess pain, noting location, characteristics and severityGives baseline data and monitors effectiveness of interventionKeep at rest Encourage early ambulationPromotes normalization of organ functionProvide diversional activities Refocuses attention, promotes relaxation and may enhance coping abilities---collaborative---Administer analgesics as indicatedPlace ice bag on abdomenSoothes & relieves pain through desensitization of nerve endings.DESIRED OUTCOMEReport pain is relieved/ controlled. Appears relaxed, able to sleepAble to rest appropriately Risk for infection related to dilated cervix and open uterine vessel

INTERVENTIONObserve and report signs of infection such as redness, warmth, discharge, and increased temperature. With the onset of infection the immune system is activated and signs of infection appearEncourage balanced diet, emphasizing protiens to feed the immune systemEncouraged increased fluid intakeHelps replace fluid lossEncourage rest to bolster the immune systemUse of proper handwashing techniques before and after giving care Follow standard precautions and wear gloves during any contact with body fluids. DESIRED OUTCOMERemains free from symptoms of infectionDemonstrates appropriate care of infection on prone site. Use of hygienic measuresMaintains WBC count & differential within normal limitsSituational low self-esteem r/t inability to carry pregnancy to term

DATAVerbalization of inability to carry pregnancy to termFear of rejection/ reaction of othersNegative feeling about the bodyFeeling of helplessnessDepressionSelf-destructive behaviorINTERVENTIONContract with patient regarding time for listening. Encourage discussion of feelings/ concernsEstablishing time enhances trusting relationship. Opportunity to express feelings allows patient to feel more in control of the situationAvoid making moral judgments Judgments from others will further damage self esteemDiscuss recovery expectationsAssess effect of illness on economic factors of patient/ SOFinancial problems may exist bec of loss of pts role functioningOffer diversional activities based on energy levelsEnables patient to use time and energy in constructive ways that enhance self-esteem and minimize anxiety and depression. ---collaborative---Make appropriate referrals for help, as neededDESIRED OUTCOMEIdentify feelings and methods for coping with negative perception of selfVerbalized acceptance of the situationAcknowledge self as worthwhile; be responsible for selfPlanning/ Implementation (general)Institute measures to alleviate fear and anxiety; assist with grieving processPoint out physiologic reality, but encourage client to work through feelings; grieving may last up to 24 months Encourage participation with thanatology services and bereavement groups when appropriateMonitor amount and type of bleeding: Save and count number of padsDistinguished between dark clotted blood and frank bleeding, which is bright redMonitor fundus for firmness after products of conception are expelledPlanning/ Implementation (general)Monitor vital signs for signs of hypovolemia, shock, and infectionMonitor CBC, hemoglobin, and hematocrit; prepare for administration of bloodAdminister oxygen if necessaryMaintain fluid and electrolyte balanceAdminister RhoGAM to Rh-negative client after abortionEducate about necessity for follow-up care and support groupsEvaluation/ Outcomes(refer to desired outcome on previous pagesReferencesMosbys Comprehensive Review of Nursing for NCLEX-RN, 17th Edition, 2003Adele Pillitteri. Maternal & Child Health Nursing: Care of the Childbearing & Childbearing Family. Lippincott Williams & Wilkins. Fifth EditionMATERNAL-CHILD NURSING, Elsevier Saunders, Second Edition. 2005 Doenges, et.al., NURSING CARE PLANS: Guidelines for Planning and Documenting Patient Care. Edition 3