Abortion is the spontaneous or induced (therapeutic) expulsion of the products of conception from the uterus before fetal viability (fetal weight < 500 g [17 5/8 oz] or gestation < 20 weeks). Up to 15% of all pregnancies & approximately 30% of all first pregnancies end in spontaneous abortion (miscarriage). At least 75% of miscarriages occur during the first trimester.

reason of abortion

Spontaneous abortion may result from fetal, placental, or maternal factors. Fetal factors, which usually cause such abortions between the 9th & 12th week of gestation, include the following:

defective embryologic development resulting from abnormal chromosome division (most common cause of fetal death)
faulty implantation of the fertilized ovum
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 to maintain the pregnancy. These factors include:

premature separation of the normally implanted placenta
abnormal placental implantation.
Maternal factors usually cause abortion between the II th & 19th week of gestation & include:
maternal infection, severe malnutrition, & abnormalities of the reproductive organs (especially an incompetent cervix, in which the cervix dilates painlessly & bloodlessly in the second trimester)
endocrine problems, such as thyroid dysfunction or a luteal phase defect
trauma, including any surgery that requires manipulation of the pelvic organs
phospholipid antibody disorder
blood group incompatibility
drug ingestion.

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

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 & 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 & 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 & 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 & 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

Signs & symptoms of abortion

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 & increased vaginal bleeding. For a few hours, the cramps intensify & occur more frequently; then the cervix dilates to expel uterine contents. If the entire contents are expelled, cramps & bleeding subside. However, if any contents remain, cramps & bleeding continue.

Diagnosis of abortion

Diagnosis of spontaneous abortion is based on clinical evidence of expulsion of uterine contents, pelvic examination, & laboratory studies. Human chorionic gonadotropin (HCG) in the blood or urine confirms pregnancy; decreased HCG levels suggest spontaneous abortion.

CLINICAL TIP Spontaneous abortion may result from a decrease in serum progesterone. Levels should be checked every 7 to 10 days. HCG levels should be checked every 48 hours & should be double in comparison with the previous level

Pelvic examination determines the size of the uterus & whether this size is consistent with the length of the pregnancy. Tissue cytology indicates evidence of products of conception. Laboratory tests reflect decreased hemoglobin levels & hematocrit due to blood loss

Treatment & cure of abortion

An accurate evaluation of uterine contents is necessary before a plan of treatment can be formulated. The progression of spontaneous abortion can't be prevented, except in cases caused by an incompetent cervix. 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, I. V. administration of oxytocin stimulates uterine contractions. If any remnants remain in the uterus, dilatation & curettage or dilatation & evacuation (D&E) should be performed.

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

After an abortion, spontaneous or induced, an Rhnegative female with a negative indirect Coombs' test should receive Rho(D) immune globulin (human) to prevent further Rh isoimmunization.

In a habitual aborter, spontaneous abortion can result from an incompetent cervix. Treatment involves surgical reinforcement of the cervix (McDonald or Shirodkar-Barter procedure) 12 to 14 weeks after the last menses. A few weeks before the estimated delivery date, the sutures are removed & the patient awaits the onset of labor. An alternative procedure, especially for the woman who wants to have more children, is to leave the sutures in place & to deliver the infant by cesarean section.

Special considerations

Before possible 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, & odor of vaginal bleeding. Save all the pads the patient uses, for evaluation.
Administer oxytocin & analgesics, as ordered.
Give good perineal care.
Obtain vital signs every 4 hours for 24 hours.
Monitor urine output.

Care of the patient who has had a spontaneous abortion includes emotional support & counseling during the grieving process. Encourage the patient & 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 support. Encourage her to verbalize her feelings. Remember, she may feel ambivalent about the procedure; intellectual & 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 & to report excessive bright-red blood immediately or any bleeding that lasts longer than 10 days.
Advise the patient to watch for signs of infection, such as a temperature higher than 100.5° F (38° C) & 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 return to work within 1 to 4 weeks.
Urge 1 to 2 weeks abstinence from intercourse, & encourage use of a contraceptive when intercourse is resumed.
Instruct the patient to avoid using tampons for 1 to 2 weeks.
Be sure to inform the patient who desires an elective abortion of all the available alternatives. She needs to know what the procedure involves, what the risks are, & what to expect during & after the procedure, both emotionally & physically. Be sure to ascertain whether the patient is comfortable with her decision to have an elective abortion. Encourage her to verbalize her thoughts both when the procedure is performed & at a follow-up visit, usually 2 weeks later. If you identify an inappropriate coping response, refer the patient for professional counseling.
To help prevent elective abortion, medical & nursing personnel need to make contraceptive information available. An educated population motivated to utilize contraception would have little need for elective abortion.
Tell the patient to see her doctor in 2 to 4 weeks for a follow-up examination.

To minimize the risk of future spontaneous abortions, emphasize to the pregnant woman the importance of good nutrition & the need to avoid alcohol, cigarettes, & drugs. Most clinicians recommend that the couple wait two or three normal menstrual cycles after a spontaneous abortion has occurred before attempting conception. If the patient has a history of spontaneous abortions, suggest that she & her partner have thorough examinations. For the woman, this includes premenstrual endometrial biopsy, a hormone assessment (estrogen, progesterone, & thyroid, follicle-stimulating, & luteinizing hormones), & hysterosalpingography & laparoscopy to detect anatomic abnormalities. Genetic counseling may also be indicated.

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