Abortion

Prepared by:
Aashma Bidari
M.Sc. Nursing, 1st year
KUSMS
• Abortion is defined as expulsion of the
fetus either spontaneously (also called
miscarriage) or by induction before it
result in the birth of child.
• World Health Organization (WHO) define
abortion as pregnancy termination prior
to 20 weeks' gestation or a fetus born
weighing less than 500 g. (before viability)
• Induced abortions are carried out
surgically or medically, safely or unsafely
 Classification
 SPONTANEOUS  INDUCED
(SPORADIC/RECURRENT) • LEGAL
• THREATENED (MTP)
• INEVITABLE • ILLEGAL
• COMPLETE
• INCOMPLETE
• MISSED
• SEPTIC
 Etiology
• Fetal Factors
• Genetic
- 50% of early miscarriage is due to chromosomal
abnormalities
- Numerical defects like Trisomy, Monosomy
- Structural defects like translocation, deletion,
inversion
 Multiple Pregnancies 
 Maternal Factors
• ENDOCRINE AND METABOLIC FACTORS
(10–15%):
- Luteal Phase Defect
- Thyroid abnormalities
- Diabetes mellitus
• Anatomical abnormalities (10–15%)
Cervicouterine factors
- Cervical incompetence & insufficiency
- Congenital malformation of the uterus
- Uterine Fibroid
- Intrauterine adhesions
• Infections (5%)
- Viral: rubella, cytomegalo, HIV,
- Parasitic: toxoplasma, malaria,
- Bacterial: chlamydia

• Immunological disorders (5–10%)

- Autoimmune disease
•  Environmental Factors
- Cigarette smoking
- Alcohol consumption
- Contraceptive agents
• Maternal medical illness
- Cyanotic heart disease
- Hemoglobinopathies
• Unexplained (40-60%) – In majority, the exact
cause is not known.
 Threatened Abortion
• Condition in which miscarriage has started
but has not progressed to a state from which
recovery is impossible
 Clinical features
• The patient, having amenorrhea,
complains of:
(1)Slight bleeding per vagina
(2)Pain: Usually painless; there may be
mild backache or dull pain in lower
abdomen
• The uterus and cervix feel soft.
• Digital examination reveals closed external os
• Differential diagnosis includes
- cervical ectopy
- polyps or carcinoma
- ectopic pregnancy
- molar pregnancy
• Ultrasound is diagnostic; Pelvic examination is
avoided when USG is available
 Management & Prognosis
• Rest: Patient should be in bed for few days until
bleeding stops
• Relief of pain: Diazepam 5 mg BD
• 80% of pregnancies with threatened abortions go
on until term
• If a live fetus is seen on USG, pregnancy is likely
to continue in over 95% cases.
• If pregnancy continues, there is increased
frequency of preterm labor, placenta previa &
IUGR
 Inevitable Abortion
• It is the clinical type of abortion where the
changes have progressed to a state from
where continuation of pregnancy is
impossible.
 Clinical features
• The patient, having the features of threatened
miscarriage, presents with
- vaginal bleeding
- Aggravation of colicky pain in the lower
abdomen
• Sometimes, the features may develop quickly
without prior clinical evidence of threatened
miscarriage
• Internal examination reveals dilated internal os
through which the products of conception are felt
 Management
• Management is aimed:
- To accelerate the process of expulsion
- To maintain strict asepsis
• If pregnancy < 12 weeks, suction evacuation is done
• If pregnancy > 12 weeks, expulsion by oxytocin
infusion
• General measures:
- Excessive bleeding is controlled by administering
methergin 0.2 mg
- Blood loss is corrected by IV fluid therapy and blood
transfusion
 Incomplete abortion
• The process of abortion has already taken
place, but the entire products of conception
are not expelled & a part of it is left inside
the uterine cavity
 Clinical features
• History of expulsion of a fleshy mass per vagina
- Continuation of pain in lower abdomen
- Persistence of vaginal bleeding
• Internal examination reveals
- Uterus smaller than the period of amenorrhea
- Open internal os
- Varying amount of bleeding
• On examination, the expelled mass is found
incomplete
• Complications:
- The retained products may cause:
(a) bleeding
(b) sepsis
(c) placental polyp.
 Management
• Evacuation of the retained products of conception
(ERCP)
• Early abortion: Dilatation and evacuation under
analgesia or general anesthesia is to be done.
• Late abortion: Uterus is evacuated under general
anesthesia and the products are removed by ovum
forceps or by blunt curette.
• In late cases, D&C is to be done to remove the
bits of tissues left behind.
• Prophylactic antibiotics are given; removed
materials are subjected to a histological
examination.
• Medical management - Tab. Misoprostol 200
μg is used vaginally every 4 hours
 Complete Abortion
• When the products of conception are
completely expelled from the uterus, it is
called complete miscarriage.
 Clinical features
• There is history of expulsion of a fleshy mass per
vagina followed by
- Subsidence of abdominal pain
- Vaginal bleeding becomes trace or absent
• Internal examination reveals:
- Uterus smaller than the period of amenorrhea –
Cervical os is closed
- Bleeding is trace.
• Transvaginal sonography confirms that uterus is
empty
 Missed Abortion
• The fetus is dead and retained passively
inside the uterus for a variable period
• It is diagnosed when there is a fetus with a
crown rump length of 5mm without a fetal
heart.
 Clinical features

• The patient usually presents with features of

threatened miscarriage followed by:
- Subsidence of pregnancy symptoms
- Uterus becomes smaller in size
- Cervix feels firm with closed internal os
- Nonaudibility of the fetal heart sound even with
Doppler ultrasound
• Complications
- Retaining the products for long time can
lead to sepsis
- DIC [Disseminated Intravascular
Coagulation] (very rare) in gestations
exceeding 16 weeks
 Management
• Uterus is less than 12 weeks:
- Prostaglandin E1 (Misoprostol) 800 mg is
given vaginally and repeated after 24 hours
if needed. Expulsion usually occurs within
48 hours
- Suction evacuation is done when the
medical method fails Uterus more than 12
weeks
- Antibiotics are given
 Septic Abortion
• Any abortion associated with clinical
evidences of infection of the uterus and its
contents
• Most common cause – Attempt at induced
abortion by an untrained person without
the use of aseptic precautions
 Clinical Grading
• Grade–I: The infection is localized in the
uterus.
• Grade–II: The infection spreads beyond the
uterus to the perimetrium, tubes and ovaries
or pelvic peritoneum.
• Grade–III: Generalized peritonitis and/or
endotoxic shock or acute renal failure.
• Grade-I is the commonest and is usually
associated with spontaneous abortion
 Clinical Features
• Fever, abdominal pain and vomiting or
diarrhoea
• A rising pulse rate of 100–120/min or more is a
significant finding than even pyrexia. It
indicates spread of infection beyond the uterus.
• Examination shows abdominal tenderness,
rigidity
• Internal examination reveals:
- offensive purulent vaginal discharge
- tender uterus usually with patulous os or
a boggy feel
- Soft cervix with open internal os
 Investigations
• CBC ,Serum urea, creatinine, electrolytes
• High vaginal swab
• Blood culture in suspected septicaemia
• Pelvic USG to detect retained products of
conception
• X-ray abdomen in suspected bowel injury
• X-ray chest if there is difficulty in respiration
 Management
• Mild cases: Start broad spectrum antibiotics and
uterus is evacuated
• Severe Cases
- Vigorous IV infusion with crystalloid
- Oxygen given by nasal catheter
- Broad spectrum antibiotics
- combination of ampicillin, gentamicin,
metronidazole is started
- Uterus is evacuated in 4-6 hrs of commencing
therapy.
 Abortion law provisions in
Nepal
• Government of Nepal allowed first time to provide
safe abortion services with certain condition Nepal
Criminal Code (muluki Ain) on 6th march 2002 and
royal assent was given to it on 27th September
2002.
• GoN developed and approved “safe motherhood
and Reproductive health rights Act, 2018, which
has revised the previous law provisions
 (According to reproductive health
rights 2018 (2075))
15) To perform safe abortion: A pregnant woman
shall have the right to get safe abortion performed
in any of the following circumstances:
a) Fetus (gestation) up to twelve weeks, with the
consent of pregnant women
b) Fetus (gestation) up to twenty-eight weeks, as
per the consent of such women, after the opinion
of the licensed doctor that there may be danger
upon the life of the pregnant women
c) Fetus (gestation) remained due to rape or
incest, gestation up to twenty eight weeks with
the consent of the pregnant women
d) Gestation up to twenty eight weeks with the
consent of the women who is suffering from
HIV or other incurable disease of such nature
e) Gestation up to twenty eight weeks with the
consent of the women, that damage may occur
in the womb due to defects in fetus, or there is
such defect in the fetus that it cannot live even
after birth, genetic defect or any other cause
16)Not to get abortion conducted forcefully:
a) Except in condition in section 15, no one shall
conduct or get abortion.
b) No one shall get the abortion conducted by
coercing a pregnant woman, threatening or tempting
her.
c) While conducting abortion, in case the abortion
does not occur instantly but a living infant is born,
and if the infant, which is born as a result of such an
act dies immediately, it shall be deemed to have got
the abortion conducted for the purposes of this
section
17) Not to commit abortion upon
identifying sex:
a) No one shall commit or cause to be
committed an act to identify the sex of the
fetus in the womb.
b) A pregnant woman shall not be pressurized
or compelled or intimidated or coerced or
enticed or entrapped in undue influence to
identify the sex of the fetus
18. Safe abortion service:
a) The licensed health worker who has fulfilled
the prescribed standards and qualification shall
have to provide the pregnant woman with safe
abortion services in the liscensed health
institution
b) Appropriate technology and process of the
service to be provided
c) Pregnant women who wants to obtain the safe
abortion services shall have to give consent in
the prescribed format.
d) In case of insane, who is not in condition
to give consent or who has not completed the
age of 18 years, her guardian or curator shall
have to give consent.
e) In case of a women who is below the age
of 18 years, safe abortion service shall have
to be provided by considering her best
interest.
19) To maintain confidentiality:
a) The health institution or health worker shall
have to keep confidential all records,
information, documents related to
reproductive health of the pregnant woman
and counseling and services provided to her
Comprehensive Abortion Care
(CAC)
• Safe abortion is often called Comprehensive
Abortion Care (CAC). It is not only method but
it is an approach of providing safe abortion
services.
• CAC focuses mainly on:
- Provide safe, high-quality services, including
abortion, post abortion care & family planning.
- Address the needs of women in the second
trimester of pregnancy (at or after 13 weeks of
gestation) by providing services or refering
- Understand each woman’s particular social
circumstances and individual needs and
tailor her care accordingly
- Address the needs of young women
- Identify and serve women with other sexual
or reproductive health needs
- Refer women to.
 a. Medical Abortion

• As per government guidelines, Medical

abortion services (Mifepristone 200 mg and
misoprostol 800 mcg) is providing up to 10
weeks from last menstrual period through
SBA or IUCD trained ANMs.
 Regimen of MA is as follows

Medicine Dose Route Time

Mifepristone 200mg Orally First day

Misoprostol 800mcg Sublingual or After 24 to 48

buccal or hours of using
vaginal Mifepristone
 Surgical abortion
• Manual Vacuum Aspiration (MVA):
• It is a method by which the contents of the
uterus are evacuated through a plastic or metal
cannula that is attached to a vacuum source.
• This method is used up to 12 weeks of
gestation
 Dilation and Evacuation (D&E)
• After 12 weeks, D&E and Misoprostol-based
medical methods (mifepristone plus
misoprostol or misoprostol only).
• It requires cervix preparation using
pharmacological agents prior to evacuation
of uterus using MVA and specialized forceps
• According to NDHS 2016, 72% used MA
services and about 17% percent used MVA
service. D&E technique for 2nd trimester is
used by 7 % of married women
 MVA
• It is safe effective method of abortion that
involves evacuation of uterine contents by
use of hand-held plastic aspirator

• Compared to sharp-curettage method of

abortion, use of MVA requires less cervical
dilatation and is associated with less blood
loss
Instrument
Steps of performing Manual Vacuum
Aspiration (MVA)
Step 1: prepare the aspirator
• Position the plunger all the
way inside the cylinder
• Have collar stop in place
with tabs in cylinder holes
• Push valve buttons down and
forward until they lock (1)
• Pull plunger back until arms
snap outward and catch on
cylinder base (2)
Step 2: Prepare the patient
• Administer pain medication to have
maximum effect when procedure begins
• Give prophylactic antibiotics to all women,
and therapeutic antibiotics if indicated
• Ask the woman to empty bladder.
• Conduct a bimanual exam to confirm
uterine size and position.
• Insert speculum and observe for signs of
infection, bleeding or incomplete abortion
Step 3: Perform Cervical
antiseptic prep
• Use antiseptic soaked
sponge to clean cervical
os. Start at os and spiral
outward without
retracing areas. Continue
until os has been
completely covered by
antiseptic
Step 4: Perform
Paracervical block
• Paracervical block is
recommended when
mechanical dilatation is
required with MVA
• Administer paracervical
block and place tenaculum
• Use lowest anesthetic dose
possible to avoid toxicity –
if using lidocaine, the
recommended dose is less
than 200 mg
Step 5: Dilate Cervix
• Observe no-touch technique when dilating
the cervix and during aspiration.
• Instruments that enter the uterine cavity
should not touch your gloved hands, the
patient’s skin, the woman’s vaginal walls, or
unsterile parts of the instrument tray before
entering the cervix.
Step 6: Insert Cannula
• While applying
traction to
tenaculum, insert
cannula through the
cervix, just past the
os and into the
uterine cavity until it
touches the fundus,
and then withdraw it
slightly
Step7: Suction Uterine
Contents
• Attach the prepared
aspirator to the cannula.
• Release the vacuum by
pressing the buttons.
• Evacuate the contents of
the uterus by gently and
slowly rotating the
cannula 180° in each
direction
• When the procedure is finished, depress
the buttons and disconnect the cannula
from the aspirator
Step 8: Inspect Tissue
• Empty the contents of the
aspirator into a container.
• Strain material, float in water or
vinegar and view with a light
from beneath.
• Inspect tissue for products of
conception, complete evacuation
and molar pregnancy.
• If inspection is inconclusive,
reaspiration or other evaluation
may be necessary.
Step Nine: Perform Any Concurrent
Procedures
• When procedure is complete, proceed with
contraception or other procedures, such as
IUD insertion or cervical tear repair.

Step Ten: Process Instruments

• Immediately process or discard all
instruments, according to local protocols.
Post Abortion Care Services
(PAC)
• MoHP, Family Health Division has set goal
to make available of quality PAC services
in all district of Nepal
• First initiated in maternal hospital in
Kathmandu in 1995.
• By the end of 2005, it has been expanded
to 65 health facilities of 43 district
• According to National medical Standard for
reproductive health services
Comprehensive Post Abortion Care
includes:
Good Interpersonal Services
Emergency treatment
Family planning services
Reproductive Health Services
Community partnership approach
• Family Health division has approved providing
PAC service by nurses with using MVA
equipment under following circumstances:
- The nurse has successfully completed MVA
training and is certified to conduct PAC
services.
- The nurse will provide PAC services as an
emergency intervention in life saving
situations.
- The nurse works under the supervision of a
physician in a health facility.
• Painless vaginal bleeding in which type of
abortion
a. Complete abortion c. Threatened abortion
b. Incomplete abortion d. Inevitable abortion
• WHO defines abortion as “pregnancy termination
prior to”
a. 20 WOG c. 24 WOG
b. 22 WOG d. 28 WOG
• According to reproductive health rights 2018
(2075), abortion legalized for rape or incest
a. 22 weeks c. 26 weeks
b. 24 weeks d. 28 weeks