Lesson plan

On
Abortion
GENERAL OBJECTIVES
At the end of my class students will be able to gain indepth knowledge about Abortion.

SPECIFIC OBJECTIVES

 To define Abortion.

 To explain various types of Abortions.

 To list out etiological factors related to Abortion.

 To discuss the clinical features of Abortion.

 To enumerate the investigations related to Abortion.

 To discuss the treatment related to Abortion.

 To explain the management related to Abortion.

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2 min Black board

INTRODUCTION

Abortion is the ending of pregnancy by removing a fetus or

embryo before it can survive outside the uterus. An abortion
which occurs spontaneously is also known as a miscarriage. An
abortion may be caused purposely and is then called an induced
abortion, or less frequently, "induced miscarriage". The word
abortion is often used to mean only induced abortions. A similar
procedure after the fetus could potentially survive outside the
To define the womb is known as a "late termination of pregnancy".
Abortion. 3 min Lecture Power What is
method point Abortion?
DEFINITION
presentation

1) Expulsion or extraction from its mother of an embryo or

fetus weighing 500gm or less when it is not capable of
independent.

-According to WHO
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2) Abortion is the removal of pregnancy tissue, products of
conception or the fetus and placenta from the uterus. In
general, the terms fetus and placenta are used after
eight weeks of pregnancy. Pregnancy tissue and products
of conception refer to tissue produced by the union of an
egg and sperm before eight weeks.

-According to the text book of Myles

3) Abortion is the termination of a pregnancy by removal or

expulsion of an embryo or fetus. An abortion that occurs
without intervention is known as a miscarriage or
"spontaneous abortion"; these occur in approximately 30%
to 40% of all pregnancies.

-According to the text book of DC Dutta

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To explain TYPES OF ABORTIONS
the different 3 min
types of 1) Spontaneous 2) Induced Lecture Power What are the
Abortions. method point different
presentation types of
 Threatened  Legal Abortions?

 Inevitable  Illegal (criminal)

 Incomplete

 Complete

 Missed

 Septic

To list out
the ETIOLOGY
etiological What are the
factors 5 min Lecture Power etiological
related to  Genetic factors method point factors
Abortions. presentation related to
 Infection
Abortions?
 Endocrine and metabolic factors
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 Immunological
 Anatomical factors
 Others

Threatened Abortion

To discuss Definition : It is a clinical entity where the process of abortion

the 5 min
has started but has not progressed to a state from which
threatened Lecture Power What is
abortion. recovery is impossible. method point threatened
presentation Abortion?
Clinical features :

1. Bleeding per vagina : The bleeding is usually slight and

bright red in colour. On rare occasion, the bleeding may be
brisk and sharp, specially in the second trimester, suggestive of
low implantation of placenta. The bleeding usually stops
spontaneously.

2. Pain : Usually painless, may be mild backache dull pain in

lower abdomen. Pain appears usually following haemorrhage.
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P/V Examination : Usually not done if necessary should be done
as gently as possible.

P/S Examination : Reveals bleeding if any escapes through the

external os.

Investigation :

 Blood for Hb%, ABO and Rh grouping, anti-D

gamma globulin- if Rh negative.
 Urine for Pg test.
 Ultrasonography (TVS/ Abdominal)

Treatment :

1. Rest : When active bleeding present.

2. Drugs : Sedation and relief of pain.

3. General measure : Pulse, Blood Pressure,

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4. Temperature, P/V bleeding.

Inevitable Abortion
To explain 5 min Lecture Power What is
the method point inevitable
inevitable Definition : In this type of abortion where the changes have presentation abortion?
abortion.
progressed to a state from where continuation of pregnancy is
impossible.

Clinical Features :

1. Amenorrhoea

2. P/V bleeding

3. Lower abdominal pain : Aggravation of pain colicky in nature.

4. P/V examination /Bleeding Present (+)or (++) :

P/S: Dilated internal os of the cervix through which the

products of conception are felt.
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Management :

1. Correction of anemia

2. Correction of dehydration

3. To accelerate process of expulsion

4. To maintain strict asepsis (to reduce post abortion

complication).

Treatment :

1. Before 12 weeks : Dilatation, evacuation, curettage Suction

evacuation and curettage Under G/A.

2. After 12 weeks : Oxytocin drip Prostaglandin tablet

To explain 5 min Complete abortion Lecture Power What is

the complete method point complete
abortion. presentation abortion?
Definition : When product of conception are expelled
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completely.

Clinical Features :

1. Amenorrhoea

2. History of expulsion of fleshy mass per vagina.

3. Subsidence abdominal pain.

4. P/V bleeding : Trace or absent

5. P/V examination : Bleeding (+) or absent.

Bimanual examination :

1. Uterus is smaller than the period of amenorrhoea and firm.

2. Cervical Os closed.

3. Bleeding : Trace or absent.

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Management :

1. Correction of anemia if needed.

2. Anti-D gamma globulin-50 microgram or 100 microgram if

patient Rh negative, within 72 hours of abortion.

To discuss 5 min Incomplete abortion Lecture Power What is the

the method point incomplete
incomplete presentation abortion?
Definition : When the entire products of conception are not
abortion.
expelled, instead a part of it is left inside the uterine cavity, it
is called incomplete abortion. Commonest type of abortion
amongst hospital incidence.

Clinical features :

1. Amenorrhoea History of

2. History of Expulsion of product of conception per vagina.

3. Continues lower abdominal colicky pain.

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4. Per vaginal bleeding.(irregular).

5. Internal examination :

a. Uterus smaller than the period of amenorrhoea.

b. Patulous cervical os often admitting tip of the finger.

c. Varying amount of bleeding.(P/V)

Management :

1. Correction of anemia if necessary.

2. Antibiotics.

3. Dilatation and evacuation under G/A.

4. Histopathological examination of product of conception

after removed.
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To explain 5 min Missed abortion Lecture Power What is
the missed method point missed
abortion. presentation abortion?
Definition : Sometimes fetus died in uterus and retained inside
for a variable period is called missed abortion.

Clinical features :

1. Amenorrhoea

2. P/V bleeding / Brownish discharge.

3. Subsidence of pregnancy symptoms.

4. Fetal heart sound not audible with doppler.

5. Cervix feels firm.

6. Pregnancy test negative.

7. USG reveals absent fetal heart movement and fetal motion.

Complication : Blood coagulation disorders.

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Management :

Less than 12 weeks-dilatation, evacuation & curettage.

More than 12 weeks-induction by

1. Oxytocin

2. Prostaglandins

Lecture Power What is

Recurrent (Habitual) Abortion
To explain 5 min method point recurrent
the recurrent presentation abortion?
abortion. Definition :

Three consecutive pregnancies ending in spontaneous abortion

therefore constitute the criterion for the diagnosis of ‘recurrent
abortion’. In practice, however, investigation, if not treatment,
may be justified by a woman’s anxiety over having lost 2
pregnancies.
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Investigation

1. Occurrence of previous abortions

2. Periods of amenorrhoea

3. subsequent bleeding painful and by home

4. Curettings contain chorionic villi on histological examination

Special tests

Between pregnancies

(1) Blood count and uninalysis.

(2) Serological tests for syphilis in wife and husband.

(3) Determination of the blood groups of wife and husband,

with tests for antibodies in the wife.

(4) Glucose tolerance test.

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(5) Estimation of theblood urea level, and renal function tests
where indicated.

(6) Tests of thyroid function.

(7) Hysterography to determine the shape of the fundus and

the competence of the internal os is essential in all cases.
Cervical sphincteric action is beststudied during the luteal
phase.

(8) A formiminoglutamic acid (FIGLU) excretion test and blood

folate assays.

(9) Study of the chromosome patterns of wife and husband.

To discuss 5 min Septic Abortion

the septic Lecture Power What is
abortion. method point septic
Definition: An abortion complicated by infection
presentation abortion?

Signs & Symptoms

 Abdominal pain
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 Fever
 Vaginal discharge (foul smelling)
 Sick looking, febrile or jaundiced
 Tender uterus
 Offensive vaginal discharge or bleeding
 Cervix is usually soft and may be dilated

Complications

 Haemorrhage
 Peritonitis
 Pelvic abscess, endometritis,
 Septicemia
 Septic/haemorrhagic shock
 PID
 Pelvic adhesions
 2° Infertility
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Management

[Link]

2. IV fluids: RL, NS

3. Insert urethral catheter

4. Monitor Input/output

5. Blood grouping & Cross matching

6. Antibiotics: Preferably cephalosporins, if not available

ampicilin and metronidazole

7. Evacuation

8. Haematenic
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5 min COMPLICATIONS
To listout
the Power What are all
1. Haemorrhage
complications Lecture point the
related to 2. Septicaemia method presentation complications
abortions. of abortion?
3. Bacteraemia shock with rigors, nausea, vomiting, diarrhoea,
hypotension, confusion, delirium and coma
4. Renal failure
5. Secondary
6. Infertility
7. Death
Role of midwife during abortion:
To explain 10 Lecture Power What is the
the min method point management
management  The woman with abortion must be admitted to presentation of abortion?
of abortion. gynaecological ward for close observation and treatment
 History taking to obtain possible aetiological factors
together with details of bleeding, pain and products of
conception expelled

 Perform a full physical examination

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 Check and record vital signs i.e. temperature, pulse,
respiration and blood pressure.
 Observe aseptic technique when performing vaginal
examinations .
 Provide pads to observe severity of blood loss.
 Put up intravenous fluids if the woman is bleeding severely
i.e. normal saline, ringers lactate.
 If necessary Check Hb, grouping and cross matching and
arrange for blood donor.
 Give antibiotics to treat infection in case of septic abortion.

Legislation & professional Responsibilities:

I. Abortion in India is legal only up to twenty weeks of

pregnancy under specific conditions and situations which are
broadly defined as:
[Link] continuance of the pregnancy would involve a risk to the
life of the pregnant woman or of grave injury of physical or
mental health, or
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[Link] is a substantial risk that if the child were born, it
would suffer from such physical or mental abnormalities as to
be seriously handicapped.
Recently, the Supreme Court permitted a rape survivor to
terminate her pregnancy at 24 weeks, which is beyond the
permissible 20 weeks limit prescribed under the Medical
Termination of Pregnancy Act, 1971.

[Link] to The Pre-Natal Diagnostic Techniques(Regulation

and Prevention of Misuse) Amendment Act, 2002 the following
are cognisable, non-bailable and non-compoundable offences

 Conducting or associating or helping to conduct Pre-Natal

Diagnostic tests for determining the sex of the foetus.
 Sex selection on a woman or a man or both on any tissue,
embryo, conceptus fluid or gametes derived from either or
both of them
Advertisement or communication in any form in print, by
electronic media or internet by units, medical professionals or
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companies on the availability of sex determination and sex
selection in the form of services, medicines, or any kind of
techniques.
[Link] trimester abortion:
Medical Methods in the first trimester:
[Link] methotrexate
[Link] mifepristone
Surgical methods:
(i) Cervical dilatation followed by evacuation of uterus by:
Curettage /Suction evacuation / vacuum aspiration / Dilatation
and evacuation
(ii) Menstrual aspiration (MR)

[Link] trimester abortion:

Methods of second trimester abortion (13 – 20 week)
Medical methods using drugs like:
[Link] lactate.
[Link]
Surgical methods
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[Link]
[Link]
[Link]

[Link] trimester abortion:

There are at least three medical procedures associated with
late-term abortions:
[Link] and evacuation (D&E)
[Link] labor induction (sometimes called "induction abortion")
[Link] dilation and extraction (IDX or D&X).
Summary

Today we learnt about abortion its definition, types , etiology, causes, manifestations, management, role of midwife during
abortion, Legislations and professional resposibilties, different abortion procedures.

Conclusion

Abortion practices is different in different countries. Hence, a midwife must learn about different practices and legislation
and her responsibilities during abortion to carry out safe midwifery practices.

BIBLIOGRAPHY
1) Women and health: today's evidence, tomorrow's agenda. Geneva: World Health Organization; 2009.

2) Myers JE, Seif MW. Global perspective of legal abortion – trends, analysis and accessibility. Best Practice and Research

Clinical Obstetrics and Gynaecology. 2010;24:457–466.

3) Warriner IK, et al. Can midlevel health-care providers administer early medical abortion as safely and effectively as

doctors? A randomised controlled equivalence trial in Nepal. Lancet. 2011;377:1155–1161.

4) Kishen M, Stedman Y. The role of advanced nurse practitioners in the availability of abortion services. Best Practice and

Research Clinical Obstetrics and Gynaecology. 2010;24:569–578.

5) Jejeebhoy S, et al. Can nurses perform MVA as safely and effectively as physicians Evidence from India. Contraception.

2011;84:615–621.