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Spontaneous Abortion Case Study

Spontaneous abortion (SAB) is defined as the termination of pregnancy from natural causes before the fetus is viable. Viability is defined as 20 to 24 weeks’ gestation or a fetal weight of
more than 500 g. SABs are a common occurrence in human reproduction, occurring in approximately 15% to 22% of all pregnancies. If the abortion occurs very early in the gestational
period, the ovum detaches and stimulates uterine contractions that result in its expulsion. Hemorrhage into the decidua basalis, followed by necrosis of tissue adjacent to the bleeding, usually accompanies the abortion. If the abortion occurs later in the gestation, maceration of the fetus occurs; the skull bones collapse, the abdomen distends with blood-stained fluid, and the internal organs degenerate. In addition, if the amniotic fluid is absorbed, the fetus becomes compressed and desiccated.

There are five types of SABs, classified according to symptoms: threatened,
inevitable, incomplete, complete, and missed. A threatened abortion occurs when there is slight
bleeding and cramping very early in the pregnancy; about 50% of women in this category abort.
An inevitable abortion occurs when the membranes rupture, the cervix dilates, and bleeding
increases. An incomplete abortion occurs when the uterus retains parts of the products of conception and the placenta. Sometimes, the fetus and placenta are expelled, but part of the placenta may adhere to the wall of the uterus and lead to continued bleeding. A complete abortion occurs when all the products of conception are passed through the cervix. A missed abortion occurs when the products of conception are retained for 2 months or more after the death of the fetus. Signs and symptoms of these five types of abortion involve varying degrees of vaginal bleeding, cervical dilatation, and uterine cramping.

CAUSES
The majority of SABs are caused by chromosomal abnormalities that are incompatible with life;
the majority also have autosomal trisomies. Maternal infections, such as Mycoplasma hominis, Ureaplasma urealyticum, syphilis, HIV, group B streptococci, and second trimester bacterial vaginosis, increase the risk for an SAB. Inherited disorders or abnormal embryonic development
resulting from environmental factors (teratogens) may also play a role. Patients who are classified as habitual aborters (three or more consecutive SABs) usually have an incompetent cervix— that is, a situation in which the cervix is weak and does not stay closed to maintain the pregnancy. Occupation may also be a consideration if the woman is exposed to teratogens.

GENETIC CONSIDERATIONS
It is estimated that 50% or more of fetuses spontaneously aborted during the first trimester have significant chromosomal abnormalities. Slightly more than 50% of these are trisomies, 19% are monosomy X, and 23% are polypoloidies (multiples of the usual number of chromosomes).
About 9% of aborted fetuses and 2.5% of stillbirths are due to trisomies 13, 18, or 21. Infants born with trisomy 13 or 18 rarely survive the perinatal period.

GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS
More than 80% of abortions occur in the first 12 weeks of pregnancy. SABs are more common
in teens (12%), elderly primigravidas (26%), and those women who engage in high-risk behaviors, such as drug and alcohol use or multiple sex partners. The incidence of abortion increases if a woman conceives within 3 months of term delivery. Surveillance data for pregnancy-related deaths between 1987 and 1990 demonstrated that more black mothers died after ectopic pregnancies and abortions, both spontaneous (14%) and induced (7%), than white mothers (8% and 4%, respectively).

ASSESSMENT
Obtain a complete obstetric history. Determine the date of the last menstrual period
to calculate the fetus’s gestational age. Vaginal bleeding is usually the first symptom that signals
the onset of a spontaneous abortion. Question the patient as to the onset and amount of bleeding.
Inquire further about a small gush of fluid, which indicates a rupture of membranes, although at
this early point in gestation, there is only a small amount of amniotic fluid expelled. Ask the
patient to describe the duration, location, and intensity of her pain. Pain varies from a mild cramping to severe abdominal pain, depending on the type of abortion; pain can also occur as a backache or pelvic pressure. Although it is a sensitive topic, ask the patient about the passage of fetal tissue. If possible, the patient should bring the tissue passed at home into the hospital because sometimes laboratory pathological analysis can reveal the cause of the abortion. With a missed abortion, early signs of pregnancy cease; thus, inquire about nausea, vomiting, breast tenderness, urinary frequency, and leukorrhea (white or yellow mucous discharge from the vagina).

PHYSICAL EXAMINATION
Temperature is elevated above 100.4°F if a maternal infection is present. In addition, pallor, cool and clammy skin, and changes in the level of consciousness are symptoms of shock. Examine the patient’s peripad for blood loss, and determine if any tissue has been expelled. Sometimes tissue can be observed at the introitus, but do not perform a vaginal examination if that situation occurs.

PSYCHOSOCIAL
Assess the patient’s emotional status, as well as that of the baby’s father and other family members. Often this hospital admission is the first one for the patient, and it may cause anxiety and fear. The father may withhold expressing his grief, feeling he needs to “be strong” for the mother.

PRIMARY NURSING DIAGNOSIS
Anticipatory grieving related to an unexpected pregnancy outcome

OUTCOMES. Grief resolution

INTERVENTIONS. Grief work facilitation; Active listening; Presence; Truth telling; Support group

PLANNING AND IMPLEMENTATION

MEDICAL. Threatened abortions are treated conservatively with bedrest at home, although there is no evidence to support bedrest as altering the course of a threatened abortion. Acetaminophen is prescribed for mild pain. Patients are instructed to abstain from intercourse for at least 2 weeks following the cessation of bleeding. Approximately 50% of patients who are diagnosed with a threatened abortion carry their pregnancies to term. Inevitable and incomplete abortions are considered obstetric emergencies. Intravenous (IV) fluids are started immediately for fluid replacement, and narcotic analgesics are administered to decrease the pain. Oxytocics, when given IV, help decrease the bleeding. With any type of abortion, it is critical to determine the patient’s blood Rh status. Any patient who is Rh-negative is given an injection of an Rho(D) immune globulin (rhoGAM) to prevent Rh isoimmunization in future pregnancies. To determine the patient’s response to treatment, monitor the patient’s vital signs, color, level of consciousness, and response to fluid replacement.

SURGICAL. A dilation and curettage (D&C) is usually indicated. This procedure involves dilating the cervix and scraping the products of conception out of the uterus with a curette. The nurse’s role in this procedure is to explain the procedure to the patient and family, assist the patient to the lithotomy position in the operating room, perform the surgical prep, and support the patient during the procedure. A D&C is not indicated in the case of a complete abortion, since the patient has passed all tissue. Bleeding and cramping are minimal. Monitor the patient for complications, such as excessive bleeding and infection. With a missed abortion, the physician can wait for up to 1 month for the products of conception to pass independently; however, disseminated intravascular coagulation (DIC) or sepsis may occur during the wait. Clotting factors and white blood cell (WBC) counts should be monitored during this waiting time. The physician can remove the products of conception if an SAB does not occur.

PHARMACOLOGIC TREATMENT
Oxytocin (Pitocin), 10–20 U IV after passage of tissue, Stimulates uterine contractions to decrease postpartum bleeding

RhD immunoglobulin (RhoGAM), 120 mg (prepared by blood bank), Prevents Rh isoimmunizations in future pregnancies; given if mother is Rh negative and infant is Rh positive

DISCHARGE AND HOME HEALTHCARE GUIDELINES
PREVENTION. Use extreme caution not to make the patient feel guilty about the cause of the SAB; however, it is important that she be made aware of factors that might contribute to the occurrence of an SAB (such as cigarette smoking; alcohol and drug usage; exposure to x-rays or environmental teratogens). Preconceptual care should be encouraged, should the patient decide to become pregnant again.

COMPLICATIONS. Teach the patient to notify the physician of an increase in bleeding, return of painful uterine cramping, malodorous vaginal discharge, temperature greater than 100.4°F, or persistent feelings of depression.

HOME CARE. Teach the patient to avoid strenuous activities for a few days. Encourage the patient to use peripads instead of tampons for light vaginal discharge to decrease the likelihood of an infection. Explain that the patient should avoid intercourse for at least 1 week and then use some method of birth control until a future pregnancy can be discussed with the physician. Follow-up is suggested. A phone call to the patient on her due date will demonstrate support and provide an outlet for her to express her grief.
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