Abortion
Subtopic:
Threatened & inevitable abortion
Threatened abortion is diagnosed when there’s an indication of potential pregnancy loss before the 28th week of gestation. This condition arises when the body shows signs suggesting expulsion of the pregnancy, but these disturbances are not severe enough to inevitably cause miscarriage. Importantly, in cases of threatened abortion, there’s still a possibility for the pregnancy to progress successfully to full term.
Clinical Features of Threatened Abortion
Symptoms:
Absent Menstruation History: The patient typically reports a history of missed periods (amenorrhea), suggesting a potential pregnancy.
Painless Vaginal Bleeding: The primary symptom is bleeding from the vagina which is usually not accompanied by pain.
Mild Abdominal Discomfort or Absence of Pain: Abdominal pain is either absent or very mild. Some women may describe a general feeling of discomfort rather than sharp pain.
Possible Backache and Pelvic Unease: Patients might report experiencing back pain and a general feeling of unease or discomfort in the lower abdomen.
Examination (Signs):
Stable General Condition: The patient’s overall health status appears normal and stable.
Closed Cervical Os on Vaginal Exam: Upon internal examination, the cervical opening (OS) is found to be closed.
Absence of Uterine Contractions: There are no signs of rhythmic tightening of the uterus (contractions), which are characteristic of labor or miscarriage in progress.
Intact Membranes: The amniotic sac (membranes) surrounding the fetus remains unbroken.
Minimal Vaginal Bleeding: There is slight bleeding observed from the vagina.
Positive Pregnancy Indicators: Clinical signs that typically confirm pregnancy, such as changes in the breasts or skin, are present.
Uterine Size Consistent with Gestational Age: The size of the uterus when assessed corresponds appropriately to the expected gestational age based on the duration of missed periods.
Fundal Height Matches Gestational Period: When the abdomen is palpated, the height of the top of the uterus (fundus) is generally in line with the calculated weeks of pregnancy.
Important Note: Routine vaginal examinations should be avoided unless the vaginal bleeding becomes heavy and is accompanied by blood clots. In such cases, examination is warranted to assess the situation more thoroughly.
Management of Threatened Abortion
Maternity Setting:
Patient Admission & Rest: Admit the patient and ensure they are placed on strict bed rest. This minimizes physical strain.
History Collection: Obtain thorough personal and pregnancy histories, specifically noting the date of the last normal menstrual period (LNMP) to estimate gestational age.
Vital Signs Monitoring: Regularly check and record vital signs, including temperature, pulse rate, respiratory rate, and blood pressure. These are indicators of overall health.
General Physical Check-up: Perform a general physical examination to identify and rule out conditions like anemia, dehydration, and jaundice.
Basic Investigations: Request blood smear test for malaria parasites and urine sample for urinalysis to check for common infections.
Aseptic Vulval Care: Carry out aseptic cleaning of the vulval area. Provide a sterile sanitary pad and instruct to save all used pads for monitoring blood loss.
Sedative Administration: Administer Phenobarbital tablets at a dose of 30mg – 60 mg every 8 hours, as prescribed, to promote rest.
Observation Period: Closely observe the patient for 4-6 hours to monitor the progression of symptoms.
Pain Relief: Administer Paracetamol 1 gram every 6-8 hours as needed (prn) for pain relief, continue for up to 5 days.
Stool Softener: Prescribe lubricants like liquid paraffin (30 ml) to ease bowel movements and prevent straining.
Avoid Enemas: Do not administer enemas as they can stimulate uterine activity.
Pad Changes and Blood Loss Assessment: Regularly change vulval pads and examine each used pad to assess and quantify vaginal bleeding.
Blood Loss Documentation: Record the amount of vaginal bleeding, noting the presence of blood clots and any tissue that appears to be membranes.
Hygiene Maintenance: Ensure daily bathing and consistent oral hygiene for patient comfort and to prevent infection.
Bladder and Bowel Monitoring: Pay close attention to bladder function, ensuring the patient urinates regularly. Also, monitor for bowel movements.
If Bleeding Stops: If vaginal bleeding ceases, advise the patient to avoid strenuous activities and abstain from sexual intercourse for a minimum of 14 days.
Follow-up Appointment: Schedule a follow-up appointment at the Antenatal Clinic (ANC) in 2 days for reassessment.
Referral if Bleeding Continues: If vaginal bleeding persists, immediately refer the patient to a hospital for further management.
Hospital Setting:
Hospital Admission & Bed Rest: Admit the patient to the gynecology ward and enforce complete bed rest to minimize physical exertion.
History Recapture: Re-obtain detailed personal and pregnancy histories, emphasizing the date of the last normal menstrual period (LNMP).
Vital Signs Surveillance: Continuously monitor vital signs: temperature, pulse, respiration, and blood pressure, documenting any changes.
Comprehensive Examination: Perform a thorough general physical examination to rule out anemia, dehydration, and jaundice, as well as any other underlying issues.
Detailed Investigations: Order blood tests including hemoglobin (HB) level, blood grouping and cross-matching. Also, request blood smear for malaria parasites and urine for urinalysis.
Emotional Support: Reassure and calm the patient, providing emotional support to alleviate anxiety.
Vaginal Examination and Care: Perform a gentle vaginal inspection. Clean the vulva with normal saline solution and apply a fresh, sterile pad.
Promote Regular Urination: Encourage frequent urination to prevent urinary retention.
Dietary Fiber Encouragement: Provide diet rich in roughage to prevent constipation.
Nutritious Diet Provision: Ensure the patient receives a highly nutritious and balanced diet to support recovery.
Mild Sedatives (If Needed): Administer prescribed mild sedatives if the patient is experiencing restlessness or significant anxiety.
Treat Underlying Causes: Address and treat any identified underlying cause of the threatened abortion, for example, treating malaria if diagnosed.
Sedative Medication: Administer Phenobarbital tablets at 30mg – 60 mg every 8 hours as prescribed.
Observation Duration: Maintain observation for 4-6 hours to assess the patient’s condition and response to treatment.
Pain Management: Provide Paracetamol 1 gram every 6-8 hours as needed (prn) for pain relief, for up to 5 days as prescribed.
Lubricant for Bowels: Administer lubricants such as liquid paraffin (30 ml) to prevent constipation.
No Enemas: Avoid giving enemas.
Pad Monitoring and Blood Loss Recording: Regularly change vulval pads, examine them for blood loss, and record the amount of blood loss, including clots and membranes.
Hygiene Practices: Ensure daily bathing and oral hygiene are maintained.
Bladder and Bowel Habit Attention: Closely monitor bladder function to ensure regular urination, and track bowel movements.
Hygiene and Comfort Maintenance: Maintain a hygienic environment by changing soiled linen, providing bed baths as needed, and ensuring oral hygiene.
Clean Clothing Provision: Provide clean clothing to the patient for comfort and hygiene.
Discharge Advice:
Continued Home Rest: Continue bed rest at home for optimal recovery.
Sexual Abstinence: Avoid sexual intercourse for 3-6 weeks to allow for healing and reduce risk.
Avoid Heavy Lifting: Refrain from heavy work, especially lifting heavy objects, which can strain the body.
Prompt Reporting of Bleeding Recurrence: Instruct to report immediately if vaginal bleeding restarts or increases.
Antenatal Clinic Attendance: Emphasize the importance of attending scheduled antenatal clinic appointments for ongoing pregnancy care.
Medication Adherence: Advise to take only prescribed medications and as directed.
Important Note: Failure to properly manage a threatened abortion can progress to an inevitable abortion (miscarriage). Therefore, diligent care and monitoring are crucial.
INEVITABLE ABORTION
Inevitable abortion occurs when pregnancy loss is unavoidable and will proceed despite any intervention. This signifies a point where the pregnancy cannot continue to term.
Causes of Inevitable Abortion
Maternal Infections: Infections in the mother, especially syphilis during the second trimester, significantly elevate the risk. Syphilis-related issues can negatively impact fetal development and the pregnancy’s health, leading to unavoidable loss.
Fetal Congenital Anomalies: Birth defects in the fetus, possibly due to genetic or environmental factors, can contribute. These abnormalities can compromise the fetus’s ability to survive and develop, making pregnancy loss unavoidable.
Prior Induced Abortion History: A history of intentionally terminated pregnancies can increase the risk in subsequent pregnancies. Scarring or damage to the uterus from previous procedures may raise the likelihood of future pregnancy loss.
Cervical Incompetence: Also known as cervical insufficiency, this is when the cervix opens prematurely during pregnancy. A weak cervix cannot support the growing pregnancy, leading to early dilation and loss of the pregnancy.
Uterine Structural Issues: Abnormalities in the uterus’s shape, such as a septate or bicornuate uterus, can predispose to inevitable abortion. These structural problems can interfere with proper implantation and fetal growth, increasing the risk of pregnancy loss.
Hormonal Imbalances: Variations in hormone levels, notably progesterone, can disrupt pregnancy maintenance. Inadequate hormonal support for the developing fetus can be a contributing factor to inevitable abortion.
Clinical Features of Inevitable Abortion
History of Missed Period: Typically, there is a reported absence of menstruation indicating a possible pregnancy.
Lower Abdominal Pain and Back Discomfort: Pain in the lower abdomen and backache are common symptoms.
Heavy Vaginal Bleeding with Clots: Significant vaginal bleeding, often containing blood clots, is a key sign.
Cervical Dilation: The cervix is found to be open or dilated upon examination.
Painful Uterine Contractions: The patient experiences cramping or painful tightening of the uterus.
Membrane Rupture with Amniotic Fluid Leakage: The amniotic sac may break, resulting in the visible leakage of amniotic fluid (liquor), especially after 16 weeks of gestation.
Protrusion of Products of Conception: During a speculum exam, fetal membranes or other pregnancy tissues may be seen bulging through the cervix or in the vagina.
Signs of Maternal Shock: The mother may exhibit symptoms indicating shock, such as rapid pulse, low blood pressure, or dizziness.
Uterine Size Discrepancy: The size of the uterus felt upon palpation may be smaller than expected for the gestational age.
Note: Inevitable abortion can be classified as either complete (all pregnancy tissue expelled) or incomplete (some tissue remains).
Management of Inevitable Abortion
In the Maternity Center:
Emergency Status: Recognize as a gynecological emergency requiring immediate action.
Admission and Reassurance: Admit the patient and offer emotional support and reassurance.
History Taking: Gather patient history, focusing on current complaints and symptoms.
Physical Assessment: Conduct a physical exam, including vital signs and general health assessment.
Shock Evaluation: Check for and rule out any signs of shock.
Fundal Height Assessment: Determine the fundal height to estimate gestational age.
Speculum Examination (Above 12 Weeks): For pregnancies beyond 12 weeks, perform a speculum exam to remove blood clots or any visible fetal tissue.
Uterotonics for Heavy Bleeding: If bleeding is excessive, administer ergometrine 0.5mg IM or oxytocin IV to stimulate uterine contractions and aid in expelling pregnancy tissue.
Pain Relief: Administer pethidine injection 100 mg if blood pressure is 100/80 mm/Hg or higher for pain management.
IV Fluids: Start intravenous fluids to prevent or manage shock.
Post-Expulsion Uterine Check: After the apparent expulsion of pregnancy products, assess the uterus to ensure it is contracting adequately.
Blood Loss Monitoring: Accurately measure and document all blood loss and observations.
Rest and Comfort: Ensure the mother is allowed to rest comfortably.
Complete vs. Incomplete Abortion Assessment: Evaluate whether the abortion is complete or incomplete and manage accordingly (often referral for further management of incomplete abortion).
In the Hospital:
Admission to Gynecology Ward: Admit the patient to a well-resourced gynecology unit.
Detailed History: Obtain a comprehensive history, focusing on bleeding onset, amount, and any history of infection or illness.
Patient and Family Support: Reassure both the patient and her family members.
Brief General Examination: Conduct a quick general examination to assess maternal condition and check for anemia, dehydration, and shock.
Abdominal Palpation for Gestation: Palpate the abdomen to estimate the gestational age in weeks.
Baseline Vitals: Record initial vital sign measurements.
Vulval Care and Sterile Pad: Clean the vulva, prepare for vaginal examination, and apply a sterile sanitary pad.
Tissue Removal Attempt: Attempt to gently remove any placenta or fetal parts visible at the cervical opening or in the vagina.
Doctor Notification: Inform the attending physician immediately.
Doctor-Ordered Investigations: Carry out investigations as requested by the doctor (e.g., blood tests, ultrasound).
Doctor’s Treatment Plan: Physician-directed treatment may include:
IV Oxytocin (≤ 16 Weeks Gestation): Intravenous oxytocin for pregnancies at or below 16 weeks.
Bleeding Control: Medications like oxytocin/ergometrine injections to control bleeding.
Blood Transfusion (If Needed): Possible blood transfusion depending on lab results and blood loss.
Intravenous Fluids: Continued IV fluids to prevent or treat shock.
Supportive Care: Prescribe pain relievers (analgesics), iron supplements (haematinics), and emphasize good hygiene.
Nutritious Diet: Provide a diet rich in nutrients.
Prevention of Inevitable Abortion
Consistent Prenatal Care: Regular antenatal clinic visits are vital for early detection and management of potential risk factors. Routine check-ups enable close pregnancy monitoring and timely intervention for emerging issues.
Prompt Symptom Reporting: Early recognition of symptoms, such as bleeding, is key. Individuals experiencing any concerning signs should immediately visit maternity centers for evaluation and care.
Timely Medical Consultation: Seeking medical advice and treatment quickly when symptoms or risk factors arise is crucial. Prompt intervention can help manage complications and support a healthier pregnancy.
Healthy Lifestyle Choices: Adopting a healthy lifestyle with proper nutrition, regular physical activity, and avoidance of harmful substances can lower the risk. Maintaining a healthy weight and managing pre-existing conditions are also beneficial.
Management of Pre-existing Conditions: Effectively managing pre-existing conditions like diabetes, hypertension, and thyroid issues through medical care and lifestyle changes can minimize risk.
Genetic Counseling Consideration: For those with a history of genetic issues or recurrent pregnancy loss, genetic counseling can offer insights and guidance on family planning, prenatal testing, and risk reduction.
Complications of Inevitable Abortion
Hemorrhagic Shock: Excessive blood loss can cause hemorrhagic shock, a life-threatening condition with inadequate blood flow to organs. Symptoms include rapid heartbeat, low blood pressure, and organ dysfunction.
Anemia: Prolonged or heavy bleeding can lead to anemia, a deficiency in red blood cells. This results in fatigue, weakness, and shortness of breath.
Dehydration: Significant blood loss can cause dehydration, potentially leading to electrolyte imbalances and organ dysfunction. Manifestations include dizziness, dry mouth, and reduced urine output.
Infection: Incomplete removal of pregnancy tissue can increase the risk of uterine infection. Symptoms include fever, pelvic pain, and abnormal vaginal discharge, requiring immediate medical attention.
Psychological Distress: Dealing with pregnancy loss can cause psychological distress, including grief, guilt, and anxiety. Emotional support and counseling are essential.
Uterine Perforation (Rare): Rarely, procedures during inevitable abortion can cause uterine perforation, a serious complication requiring immediate medical intervention.
Long-Term Reproductive Issues: In some cases, inevitable abortion may be linked to long-term reproductive health problems, such as uterine scarring, which can impact future pregnancies.
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