CAUSES OF SPONTANEOUS ABORTION

• MATERNAL FACTORS there are congenital or acquired conditions of the mother, including environmental factors that can cause abortion. It is less common causes of abortion but is treatable.

• Abortion increases with advancing maternal age, esp. after 35 yrs old– below 35 yrs old 15% miscarriage rate– Between 35-39 yrs old 20-25% miscarriage rate– Between 40-42 yrs old about 35% miscarriage rate– About 42 yrs old about 50% miscarriage rateStructural abnormalities of the reproductive tract such as

congenital uterine defects particularly uterine sputumfibroidscervical incompetence

Inadequate progesterone production (corpus luteum or placenta) is a definite but probably infrequent causes.

• 4. Maternal infection: Rubella virus, cytomegalovirus, Lysteria infection, taxoplasmosis

• 5. Chronic and systemic maternal diseases– Polycystic ovary syndrome– Poorly controlled DM– Renal diseases– Systemic Lupus erythematosus (SLE)– Untreated thyroid diseases– Severe hypertension6. Exogeneous factors include the following

tobaccoalcoholcocainecaffeine (high doses)radiation

• FREQUENCY• In the past 15-20% of recognized pregnancies result in miscarriage.With

the availability of sensitive beta-human chorionic gonadotropin serum essays , early pregnanciesare detected before the date of menstruation formerly were written off as simple abnormal prolongation of the menstrual cycle.Bacause of these earlier methods of detecting pregnancies, it is estimated today that more pregnancies, about 60% to 70% are lost spontaneously than are actually carried to term.

• The frequency of spontaneous abortion increases further with maternal age

• Late implantation, those occurring 8-10 days after fertilization, is also associated with a higher incidence of abortion

• More abortions, about 80%, occur within the first trimester. The frequency of miscarriage decreases with an increasing gestational age

• A woman who has history of abortion has a higher chance, about 5-20% of having another abortion than a woman who has not had abortion

COMPLICATIONS OF ABORTION

• HEMORRHAGE more common with late abortions.Continued heavy bleeding indicates retained tissue(incomplete abortion)

• Infection or septic abortion is often a complication of criminally induced abortion

• Disseminated intravascular coagulation(DIC) may occur if a missed abortion is retained beyond one month. This complication is common in late abortion.

TYPES OF SPONTANEOUS ABORTION

• Spontaneous abortion is a process that can be divided into 4 stages--- threatened, inevitable, incomplete, and complete. A threatened abortion may either be rescued or end in inevitable abortion while inevitable abortion may lead to an incomplete abortion, a complete abortion or missed abortion. Sometimes , abortion may be complicated by infection before or after the complete expulsion of the dead embryo or fetus.

THREATENED ABORTION• Threatened abortion refers to the possible loss of the products of

conception. All vaginal bleeding in early pregnancy without cervical changes is considered a threatened .About 25-30% of all pregnancies have some bleeding during the pregnancy but only less than half proceed to a complete abortion or miscarriage

• Signs and symptoms– Light vaginal bleeding – None to mild uterine cramping.More severe cramps may lead to an inevitable

abortion.Management: A.Assess for:

1.Ask LMP as management for pregnancy bleeding will vary according to the age of gestation. If the woman is more than 20 wks gestation, the bleeding can be placenta previa and not abortion, do not do internal examination2.Instruct the clients to save all the pads for examination. Examining the passed material help clarify the type of abortion occurring.

• 3. Ask for presence of clots. The presence of blood clots suggest heavy bleeding.Vesicles of H-mole and fetal tissues may be mistaken by client as blood clots.This is why it is important to instruct the client to save pads.

• 4. Abdominal pain is the next common complaint of women suffering from abortion next to vaginal bleeding.The pain usually is in the suprapubic area , but reports of pain in one or both lower quadrants are not uncommon. The pain may radiate to the lower back, buttocks ,genitalia and perineum.If the pain ispersistently occurring only on one side ,consider an ectopic pregnancyor a ruptured ovarian cyst as a possible cause. Ask the patient when the pain started and stopped if it did. An abdominal pain suggest an ongoing abortion or a concurrent abortion. When the pain subsides ,it usually suggest completion of the abortion.

B.CONSERVATIVE MANAGEMENT• Usually , no other medical theraphy is needed for patients who

experienced threatened abortion. In fact they need not be admitted to the hospital unless the bleeding and cramping worsens. In any mild bleeding episodes that occurs during the first trimester :

• 1. Instruct the patient to have bedrest until 3 days after the bleeding has stopped. In majority of cases, bleeding usually stops within 48 hours. However, if bleeding persist , tissue is passed and the cramps worsen, tell client to come to the hospital, clinic,or contact the health care provider for further evaluation and treatment. No studies have confirmed that bed rest is effective but it seems to lessen bleeding and contraction but it rarely changes the outcome.

• 2. Advise the couple not to engage in coitus up to 2 weeks after bleeding stopped., although no evidence shows that it is harmful, the risk of guilt feelings associated with abortion immediately after intercourse warrants abstention.

• 3. There is no evidence that hormones save pregnancies except in a very few instances, and hormonal theraphy may cause congenital anomalies, particularly transposition of the great vessels of the heart. Also, vaginal cancer and other genital abnormalities in female offspring have been associated with the use of estrogen for threatened abortion.

• C. However parents usually worry that they might have lost the baby or may loose the baby anytime soon after a bleeding episode.

• 1. Nurses are in position to provide these patient with reassurance. An ultrasound showing normal pregnancy can provide the patient with reassurance.

• 2. It is important to be honest to the patient that it is possible to loss the baby but treatment is availablle to try to save the pregnancy if bleeding continues.

INEVITABLE OR IMMINENT ABORTION

• Refers to the loss of the product of conception that cannot be prevented• SIGNS AND SYMPTOMS• 1. moderate to profuse bleeding• 2. moderate to severe uterine cramping• 3. open cervix or dilatation of cervix• 4. ruptures of membranes• 5. no tissue has passed yet• MANAGEMENT:• Because the fetus cannot be saved anymore, the management is directed

toward avoiding the complication of infection or excessive blood loss.• 1. Hospitalization• 2. D&C• 3. Oxytocin after D&C• 4. Sympathetic understanding and emotional support

COMPLETE ABORTION• Refers to the spontaneous expulsion of the products of

conception after the fetus has died in the utero.• SIGNS AND SYPTOMS• 1. Typically , the patient gives a history of vaginal bleeding,

abdominal pain, and apssage of tissue. After the passage of tissue, the patient observed that the pain and vaginal bleeding significantly diminished.

• 2. On examination on the clinic or hospital the ff. is noted:– Light bleeding or some blood in the vaginal vault– No tenderness in the cervix, uterus, or abdomen– Closed cervix– Empty uterus on ultrasound

management• 1. A complete abortion usually needs no further medical or surgical

treatment. No medication is likely needed.Usually, the uterus contract well after expelling the entire contents so that there is no need for methergin or oxytocin. The risk for infection is also minimal.

• 2.The patient must still be observed closely for continued bleeding or signs of infection. These complication indicates that not all fetal tissue has been passed.

• 3.Regular diet. Advice to eat food rich in iron because of blood loss• 4.Instruct the patient to rest for few days up to 2 weeks after the

abortion.Patient may resume their activities when able but should refrain from coitus and douching for approximately 2 weeks.

• 5. Tell patient she may experience intermittent menstrual-like flow and cramps during the following week. The next menstrual usually occurs in 4-5 weeks

• 6. It is impt. That the expelled products of conception are evaluated by a physician and confirmed to be intact and truly products of conception (not a clot) > If the tissues passed by the patient were not examined by the physician or pathologist(if the product were flushed down the toilet) the physician may order ultrasound and examination of her serum HCG level to be followed up weekly until it is less than 5 mlU/ml. In complete abortion, HCG may initially be high but it will decline steadily and ultrasound will show that the uterus is empty. Patients should avoid intercourse or use contraception until the HCG levels have become negative.

• 7. Reassure patient that the next pregnancy is likely to last to term if she is young and has no other risk factors. However, the woman must use family planning as pregnancy is discouraged for the next 3 months after abortion bec. Of the likelihood of having repeat abortion at this time.

• 8.Aside from testing for CBC and HCG level, the woman”s RH factor must also be determined. If she is RH negative and the father’s RH factor is positive or cannot be determined, it is impt. To have Coomb’s test to determine if she has developed antibodies against RH positive blood. If the Coomb’s test is negative, RhoGam is administered within 72 hours after the abortion to prevent isoimmunization.

• 9.Advice the patient to return to emergency dept. if any of the following symptoms occur– Profuse vaginal bleeding– Severe pelvic pain– Temp greater than 100 *f

COMPLETE ABOTION• NO ABDOMINAL DISTENTION• NO REBOUND TENDERNESS• NORMAL BOWEL SOUNDS• NO HEPATOSPLENOMEGALY• ONLY MILD SUPRAPUBIC TENDERNESS• USUALLY,THE UTERUS EITHER IS NOT

PALPABLE ABDOMINALLY OR IS JUST SLIGHTLY ABOVE THE SYMPHYSIS PUBIS

• IE MAY SHOW:– SOME BLOOD IN THE PERINEUM OR VAGINA

BUT LIMITED ACTIVE BLEEDING– CERVIX IS NONTENDER TO MINIMALLY

TENDER– CERVICAL CANAL IS CLOSED FOR COMPLETE

AND THREATENED ABORTION– UTERUS IS SMALLER THAN WHAT IT IS

EXPECTED FOR DATES, AND IT IS NONTENDER TO MILDLY TENDER

INCOMPLETE ABORTION• THERE IS REBOUND TENDERNESS AND/OR A DISTENDED

UTERUS• IE WILL REVEAL:

– CERVIX IS DILATED IN INCOMPLETE AND INEVITABLE ABORTION

– ACTIVE BLEEDING IS PRESENT FROM INTERNAL OS

– CLOTS AND TISSUES MAY ALSO BE PRESENT IN THE VAGINA OR CERVICAL CANAL

– IF CERVICAL MOTION TENDERNESS IS PRESENT, SUSPECT ECTOPIC PREGNANCY

INCOMPLETE ABORTION• Expulsion of some parts and retention of other parts of

conceptus in utero• SIGN AND SYMPTOMS

– 1. heavy vaginal bleeding– 2. severe uterine cramping– 3. open cervix– 4. passage of tissue– 5. ultrasound shows that some of the products of conception

are still inside the uterusMANAGEMENT:The goal of intervention for incomplete abortion is prompt

evacuation of the uterus to prevent hemorrhage or infection.

• 1. D& C– The uterus must be kept contracted after D&C to prevent

bleeding. If the patient is bleeding, the first action is to place patient flat and massage the uterus.Oxytocin is administered as ordered to maintain uterine contractions.

– Inspect the fundus frequently to make sure it is well contracted

– A danger of D&C is uterine perforation. Suspect of uterine perforation if patient complains of unusual symptoms sucha as shoulder pain and significant abdominal pain. Internal bleeding maybe the cause of tachycardia and hypotension in the absence of excessive vaginal bleeding.

• 2. Monitor blood loss in patients who have inevitable and incomplete abortion. These are the types of abortion which involve significant bleeding.– Inspect the patient’s perineal pad to estimate blood loss. A saturated

perineal pad can absorb approximately 60-100ml. Of blood. It is accurate to weigh perineal pad before and after use.

– Monitor vital signs particularly BP and pulse rate.– Monitor the blood studies of the patient’s clotting factors. If the

patient’s v/s show symptoms of shock but the bleeding per vagina is minimal and the uterus is well contracted ,bleeding may be occurring by DIC

– Monitor I and O. Oliguria is a sign of decreased renal perfussion which occurs with shock.

3. Sympathetic understanding and emotional support. The patient lost a baby and will be grieving. Provide sympathetic understanding in the patient’s emotional reaction and encourage verbalization of feelings.

MISSED ABORTION• Retention of all products of conception after the death

of fetus in the uterus.• SIGNS AND SYMPTOMS– Absence of FHT– Signs of pregnancy disappear. Missed abortion should be

suspected when the:• When the uterus fails to enlarge• Fetal heart sounds are not heard at the appropriate time or

disappear after it has been initially heard• A serum or urine test for the subunit of HCG becomes negative

earlier than expected or does not double within 48-72 hours• Ultrasound showing no cardiac activity provides the earliest

diagnosis

MANAGEMENT• 1. Depending on the age of gestation or size of conceptus , the

product of conception has to be removed from the uterus to prevent DIC

• 2. Up to 28 wk gestattion , missed abortion is frequently manage by inserting a 20-mg dinoprostone(prostaglandin E2) suppository into the vagina q 3-4 hrs as necessary to produce contractions. The said drus is not aprroved for use after 28wk. Laminaria are inserted into the cervix to cause softening and dilatation.

• 3.Late missed abortion may be completed with a dilute IV infusion of oxytocin, which causes contraction of the uterus and delivery of the products of conception. After the uterus contracted following the delivery of the fetus,curettage may be needed to remove the fragments of the placenta. Suction curettage is used for pregnancies of up to 18wk. After that, dilatation and evacuation or oxytocic drugs are used

HABITUAL ABORTION• Abortion occurring in 3 or more successive pregnancies. Habitual

abortion requires extensive diagnostic investigation, including genetic and chromosomal studies. The cause of abortion must be identified in order to determine the most effective treatment to achieve a successful pregnancy.

• MANAGEMENT– 1. treating the cause– 2. Specific treatment according to the cause of abortion include:

• CERVICAL CERCLAGE suturing the cervix or application of cervical cerclage is performed if the cause of repeated abortion is a mechanical defect in the cervix or what is called as incompetent cervix

• FERTILITY DRUGS these medication stimulate estrogen and progesterone production to create a better-nourished uterine lining, which is more suitable for implantation of an embryo. Drugs used includes Clomiphene, Pergoral or other injectible fertility drugs

• 3.ASPIRIN OR MINI HEPARIN the first tissue changes that occur in the placenta before the loss of pregnancy is the formation hyaline fibrinogen blood clots within the small blood vessels. Theses blood clots impede normal blood flow, which results in necrotic changes in the placenta and eventual disruption of the normal blood supply to the fetus eventually leading to fetal death and abortion.By giving the mother small doses of either Heparin or Aspirin for several weeks during the early part of pregnancy, formation of blood clots that impede blood flow in the placenta is prevented. In such manner, abortion is prevented.

• 4. LUTEAL PHASE PROGESTERONE SUPPORT fertilization and implantation occurs during the luteal phase of menstrual cycle. Progesterone, the main hormone produced at this time by the corpus luteum maintains the deciduas where the embryo implants., therefore in the maintenance of pregnancy, progesterone is very impt. Sluggish progeaterone secretion of progesterone by corpus luteum is believe to result in early pregnancy losses. This progesterone deficiency can be corrected by administering progesterone to the pregnant woman in the early part of gestation until the placenta is mature enough to produce adequate amount of progesterone.

• 5. Treatment of medical illnesses such as SLE,m DM, hypothyroidism, Hyperthyroidism, sexually transmitted diseases before and during pregnancy to ensure successful gestation

• INFECTED ABORTION infection involving the products of conception and the maternal reproductive organs.

• SEPTIC ABORTION Dissemination of bacteria (and/or their toxins) into the maternal circulatory and organ system. With aseptic abortion, the patient is acutely ill experiencing s/s of infection and of threatened or incomplete abortion. Septic abortion is often associated with induced abortion performed by untrained persons using unsterile techniques or criminal abortion.

• CAUSATIVE ORGANISM– ESCHERICHIA COLI IS THE MOST COMMON PATHOGENIC AGENT– ENTEROBACTER AEROGENES– PROTEUS VULGARIS– HEMOLYTIC STREPTOCOCCI– STAHYLOCOCCISINGS AND SYMPTOMS

1. foul smelling vaginal discharge2. uterine cramping3. fever , chills, and peritonitis4. leukocytosis –WBC count, 16,000-22,000/ul5. critically ill patients may evidence septic or endotoxic shock with vasomotor collapse , hypothermia, hypotensin, oliguria, or anuria, and respiratory distress

MANAGEMENT

• 1. Treat abortion.• 2 High doses of IV antibiotic theraphy: penicillin

for gram negative microorganisms, and clindamycin and tobramycin for gram positive microorganism

• 3. D & C if accompanied by incomplete abortion• 4. Infertility may occur after recovery due to

scarring of uterus and fallopian tubes, scarring can interfere with fertilization and proper implantation.