Abortion

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Women are bearers of life. Nurturing human inside the womb for nine months is no small feat, that is why when a woman and her significant others learns about her pregnancy, they always go the extra mile just to make sure that the health and the safety of both the mother and the baby are intact. We, as nurses, also have this primary responsibility to be informed about the dangers to a pregnant woman so we could educate them and protect them too. As part of our holistic care, let us take a peek on how abortion or miscarriage affects a pregnant woman and what we can do to reduce these cases.

Definition

  • Abortion is a medical term for the disruption of a pregnancy before the fetus reaches its viable age of more than 20 to 24 weeks of gestation or weighs at least 500g.

Pathophysiology

  • The most common cause of an abortion is abnormal fetal development, which is either due to a chromosomal aberration or a teratogenic factor.
  • Another common cause is the abnormal implantation of the zygote, where there is inadequate endometrial formation or the zygote was implanted on an inappropriate site.
  • This would cause inadequate development of the placental circulation, leading to poor nutrition of the fetus and eventually, to an abortion.

Risk Factors

There are always precipitating factors for every condition. Here are the risk factors that concerns abortion:

  • Congenital Structural Defect. This structural defect may be due to chromosomal aberration or a serious physical defect.
  • Low Progesterone. Progesterone maintains the decidua basalis. If the corpus luteum fails to produce enough progesterone, it would risk the life of the fetus inside the uterus.
  • Rh Incompatibility. The fetus could get rejected from a mother’s body if they have an incompatible Rh.
  • Undernutrition. Lack of nutrients would cause undernourishment to both the mother and the fetus, leading to abortion.
  • Drugs. There are drugs which are contraindicated for pregnant women. Ingestion might compromise the fetus and lead to abortion.
  • Infection. In infection, the fetus would fail to grow and estrogen and progesterone production would fall. This would lead to endometrial sloughing, then prostaglandins would be released leading to uterine contractions and cervical dilatation along with expulsion of the products of pregnancy.

Types

Several types of abortion are used to classify every case for a pregnant woman. Once a thorough assessment is done, that would be the time that the type of abortion that occurred could be established.

  • Threatened abortion. The embryo is already viable. The products of conception are still intact and the cervix is closed, but there is vaginal bleeding present.
  • Inevitable/Imminent abortion. The embryo is dead with the products of conception either intact or expelled. The cervix is already dilated and there is presence of vaginal bleeding.
  • Complete abortion. All products of conception are expelled and the embryo is dead. The cervix is dilated, and there is mild bleeding.
  • Incomplete abortion. The embryo is dead but some products of conception are still intact. The cervix is already dilated and there is severe vaginal bleeding.
  • Missed abortion. The embryo is already dead while inside the uterus. The products of conception are still intact and the cervix is closed. There are brown vaginal discharges present.
  • Recurrent/Habitual abortion. Abortion becomes recurrent once the woman has had 3 consecutive miscarriages at the same gestational age.

Signs and Symptoms

As nurses, we are tasked with assessing our patient to provide baseline and accurate information to other caregivers. The signs and symptoms of abortion must be identified first before ruling out any other relative causes.

  • Vaginal spotting. Vaginal spotting appears as small brownish to reddish spots of blood coming out of the woman’s vaginal opening. This usually occurs when the cervix slightly dilates because the woman may have tried to lift heavy objects or mild trauma to the abdomen occurred.
  • Vaginal bleeding. Bleeding is a serious occurrence during pregnancy because it might indicate that the cervix has opened and products of conception might be expelled.
  • Cramping/sharp/dull pain in the symphysis pubis. This could occur on both sides and could be caused by trauma or premature contractions that might cause cervical dilation.
  • Uterine contractions felt by the mother. Uterine contractions can be false or true, but either of the two could be alarming during the early stages of pregnancy because it could expel the contents of the uterus thereby leading to abortion.

Diagnostic Tests

  • Pregnancy test. This is to confirm the pregnancy first if vaginal bleeding occurs. If test turns out negative, then the woman would be subjected to other diagnostic tests that could confirm the nature and cause of the vaginal bleeding. If it is positive, then abortion would be considered and it would be classified according to the presenting signs and symptoms.
  • Ultrasound. The safest and confirmatory test for pregnancy, the ultrasound would be able to confirm if the pregnancy is positive, and also confirm if the products of conception are still intact.

Medical Management

Medical interventions should also be incorporated in the patient’s care plan to reinforce his treatment. These are physician’s orders wherein nurses and other caregivers would assist or take into action, thus ensuring the recovery of the patient.

  • Aside from our own nursing management, physicians would also have to order a series of therapeutic management for the pregnant woman.
  • Administration of intravenous fluids. Such as Lactated Ringer’s, IV therapy should be anticipated by the nurse as well as administration of oxygen regulated at 6-10L/minute by a face mask to replace intravascular fluid loss and provide adequate fetal oxygenation.
  • Avoid vaginal examinations. The physician would also avoid further vaginal examinations to avoid disturbing the products of conception or triggering cervical dilatation.
  • The physician might also order an ultrasound examination to glean more information about the fetal and also maternal well-being.

Our role as nurses in these medical interventions would be to assist in every aspect possible, and ensure the wellbeing of both the mother and the fetus. Through our nursing interventions, we could initiate care without needing to run after the physicians and ask for their orders. We should be able to function independently as caregivers and promote their wellness in our own way as nurses. The most vital pieces of information are always handed to us first, so it would be up to us to initiate the first intervention to make or break the condition of the client before a doctor arrives. Nurses are the first line of defense of every hospital, and we should live up to that expectation.

Surgical Management

Aside from the medical interventions ordered by physician, incidences might occur which would lead to a surgical operation.

  • Dilatation and evacuation. This is to make sure that all products of conception would be removed from the uterus. However, before undergoing this intervention, the physician must be sure that no fetal heart sounds could be heard anymore and the ultrasound must show an empty uterus.
  • Dilation and curettage. This is most commonly performed for incomplete abortions to remove the remainder of the products of conception from the uterus. Since the uterus would not be able to contract effectively, the contents might be trapped inside and could cause serious bleeding and infection.

Nursing Management

Nurses must also have their own independent functions to ensure the safety and well-being of the patient. The following are measures that would allow the nurse to act independently.

Nursing Assessment

  • The presenting symptom of an abortion is always vaginal spotting, and once this is noticed by the pregnant woman, she should immediately notify her healthcare provider
  • As nurses, we are always the first to receive the initial information so we should be aware of the guidelines in assessing bleeding during pregnancy.
  • Ask of the pregnant woman’s actions before the spotting or bleeding occurred and identifies the measures she did when she first noticed the bleeding.
  • Inquire of the duration and intensity of the bleeding or pain felt. Lastly, identify the client’s blood type for cases of Rh incompatibility.

Nursing Diagnosis

Nursing Interventions

  • If bleeding is profuse, place the woman flat in bed on her side and monitor uterine contractions and fetal heart rate through an external monitor.
  • Also measure intake and output to establish renal function and assess the woman’s vital signs to establish maternal response to blood loss.
  • Measure the maternal blood loss by saving and weighing the used pads.
  • Save any tissue found in the pads because this might be a part of the products of conception.

Evaluation

  • The aim for evaluation is inclined towards restoring the maternal blood volume and stopping the source of the bleeding.
  • The client’s blood pressure must be maintained above 100/60 mmHg.
  • The pulse rate should be below 100 beats per minute and the fetal heart rate must be at a normal level of 120-160 beats per minute.
  • The client’s urine output should be more than 30 mL/hr, and only minimal bleeding should be apparent for not more than 24 hours.
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