Abortion Information - Types of Abortion, Causes, Sign & Symptoms And Treatment of Abortion

Abortion is the spontaneous or induced (therapeutic) expulsion of the products of conception from the uterus before 20 weeks gestation. Up to 15% of all pregnancies and approximately 30% of first pregnancies end in spontaneous abortion (miscarriage). About 85% of miscarriages occur during the first trimester.

Causes

Spontaneous abortion may result fro fetal, placental, or maternal factors.
Fetal factors, which usually cause such abortions at up to 12 week's gestation, includes:

• defective embryologic development resulting from abnormal chromosome division (most common cause of fetal death)
• faulty implantation of the fertilized ovum (such as ectopic pregnancy).
• failure of the endometrium to accept the fertilized ovum.

Placental factors usually cause abortion around the 14th week of gestation, when the placenta takes over the hormone production necessary 10 maintain the pregnancy. These factors include:

• premature separation of the normally implanted placenta (also known, as abruptio placentae).
• abnormal placental implantation (also known, as placenta previa).

Maternal factors usually cause abortion between the 11th and 19th week of gestation and include:

• maternal infection or abnormalities of the reproductive organs (especially an incompetent cervix, in which the cervix dilates painlessly in the second trimester).
• endocrine problems, such as thyroid dysfunction or a luteal phase defect.
• trauma
• antiphospholipid antibody syndrome.
• blood group incompatibility
• drug ingestion (particularly uterotonic agents).

The goal of therapeutic abortion is to preserve the mother's mental or physical health in cases of rape, unplanned pregnancy, or medical conditions, such as moderate or severe cardiac dysfunction.

Types of spontaneous abortion

Types of spontaneous abortion include:

• threatened abortion: Bloody vaginal discharge occurs during the first half of pregnancy. Approximately 20% of pregnant women have vaginal spotting or actual bleeding early in pregnancy; of these, about 50% abort.
• inevitable abortion: Membranes rupture and the cervix dilates. As labor continues, the uterus expels the products of conception.
• incomplete abortion: Uterus retains part or all of the placenta. Before the 10th week of gestation, the fetus and placenta usually are expelled together; after the 10th week, separately. Because part of the placenta may adhere to the uterine wall, bleeding continues. Hemorrhage is possible because the uterus doesn't contract and seal the large vessels that fed the placenta.
• complete abortion: Uterus passes all the products of conception. Minimal bleeding usually accompanies complete abortion because the uterus contracts and compresses maternal blood vessels that fed the placenta.
• missed abortion: Uterus retains the products of conception for 2 months or more after the death of the fetus. Uterine growth ceases; uterine size may even seem to de­crease. Prolonged retention of the dead products of conception may cause coagulation defects, such as disseminated intra vascular coagulation.
• habitual abortion: Spontaneous loss of three or more consecutive pregnancies constitutes habitual abortion.
• septic abortion: Infection accompanies abortion. This may occur with spontaneous abortion but usually results from an illegal abortion. It's usually related to any remaining fetal or placental tissue in the uterus.

Signs and symptoms

Prodromal signs of spontaneous abortion may include a pink discharge for several days or a scant brown discharge for several weeks before the onset of cramps and increased vaginal bleeding. For a few hours, the cramps intensify and occur more frequently; then the cervix dilates to expel uterine contents. If the entire contents are expelled cramps and bleeding subside. However, if any contents remain, cramps and bleeding continue. Infection and sepsis may occur if these contents aren't removed.

Diagnosis

Diagnosis of spontaneous abortion is based on clinical evidence of expulsion of uterine contents, pelvic examination, and laboratory studies. The presence of human chorionic gonadotropin (bCG) in the blood or urine confirms pregnancy; decreased hCG levels suggest spontaneous abortion. Pelvic examination determines the size of the uterus and whether this size is consistent with the length of the pregnancy. Ultrasound visualizes evidence of a gestational sac, size of the fetus, and presence of a heartbeat. Tissue histology indicates evidence of products of conception. Laboratory tests may reflect decreased hemoglobin levels and hematocrit due to blood loss. However, blood loss is rarely excessive in spontaneous abortion.

Treatment

An accurate evaluation of uterine contents is necessary before a treatment plan can be formulated. The progression of spontaneous abortion can't be prevented, except in some cases caused by an incompetent cervix. For those cases where the progression of spotaneous abortion can't be stopped, the patient must be hospitalized to control severe hemorrhage. If bleeding is severe, a transfusion with packed red blood cells or whole blood is required. Initially, the patient receives oxytocin I.V., which stimulates uterine contractions (if given after 20 weeks gestation because receptors are absent before this gestational age). If any remnants remain in the uterus, dilatation alld curettage or dilatation and evacuation (D&E) should be performed to dilate the cervix and remove any and

D&E is also performed in first all second-trimester therapeutic abortions. In second-trimester therapeutic abortions, the insertion of a prosta glandin vaginal suppository induces labor and the expulsion of uterine contents.

D&E is also performed in first all second-trimester therapeutic abortions. In second-trimester therapeutic abortions, the insertion of a prosta glandin vaginal suppository induces labor and the expulsion of uterine contents.

Special considerations

Before induced or therapeutic abortion:

• Explain all procedures thoroughly.
• The patient should not have bathroom privileges because she may expel uterine contents without knowing it. After she uses the bedpan, inspect the contents carefully for intrauterine material.

After spontaneous or elective abortion:

• Note the amount, color, and odor of vaginal bleeding. Save and evaluate all the pertineal pads the patient uses.
• Administer analgesics and oxytocin, as appropriate.
• Provide perineal care.
• Monitor vital signs.
• Monitor urine output.

Care of the patient who has had a spontaneous abortion includes pro­viding emotional support and counseling during the grieving process. Encourage the patient and her partner to express their feelings. Some couples may want to talk to a member of the clergy or, depending on their religion, may wish to have the fetus baptized.

The patient who has had a therapeutic abortion also benefits from emotional support and counseling. Encourage her and her partner to verbalize their feelings. Remember, she may feel ambivalent about the procedure; intellectual and emotional acceptance of abortion aren't the same. Refer her for counseling, if necessary.

To prepare the patient for discharge:

• Tell the patient to expect vaginal bleeding or spotting and to immediately report any bleeding that lasts longer than 8 to 10 days or that's excessive and bright red.
• Advise the patient to watch for signs of infection, such as a temperature higher than 100.5°F (38°C) or foul-smelling vaginal discharge.
• Encourage the gradual increase of daily activities to include whatever tasks the patient feels comfortable doing, as long as these activities don't increase vaginal bleeding or cause fatigue. Most patients are able to return to work after 24 hours.
• Urge 1 to 2 weeks abstinence from sexual intercourse, and encourage use of an effective contraceptive method thereafter.
• Instruct the patient to avoid using tampons or douching for 1 to 2 weeks.