CASE STUDY #1

ABORTION

GROUP 2
Introduction
 The majority of women who enter pregnancy in good health expect to complete a pregnancy and birth
without complications. In a few women, however, for reasons that usually are unclear, unexpected deviations
or complications from the course of normal pregnancy occur. Abortion is the medical term for any
interruption of a pregnancy before a fetus is viable (able to survive outside the uterus if born at that time). A
viable fetus is usually defined as a fetus of more than 20 to 24 weeks of gestation or one that weighs at least
500 g. A fetus born before this point is considered a miscarriage or premature or immature birth (Cootauco &
Althaus, 2007). Spontaneous miscarriage occurs in 15% to 30% of all pregnancies and arises from natural
causes (Uzelac & Garmel, 2007).The most frequent cause of miscarriage in the first trimester of pregnancy is
abnormal fetal development, due either to a teratogenic factor or to a chromosomal aberration. Between 50%
and 80% of fetuses aborted early have structural abnormalities (Crombleholme, 2009). In other miscarriages,
immunologic factors may be present or rejection of the embryo through an immune response may occur.
Another common cause of early miscarriage involves implantation abnormalities, as up to 50% of zygotes
probably never implant securely because of inadequate endometrial formation or from an inappropriate site of
implantation. And systemic infection in a woman may be yet another cause of miscarriage. Miscarriage can
occur from so many causes and because the cause is unlikely to be determined with an early miscarriage, this
may have difficulty in understanding why this happens
OBJECTIVES
General Objectives:
At the end of case presentation, the participants and the audience will be educated about abortion,
its nursing care management, and acquire proper knowledge, skills and attitude in providing
holistic care to the patient.

Specific Objectives:
KNOWLEDGE
1. Be able to define abortion and discuss its different types.
2. To know the causes, risks factors, and complications of abortion.
3. Be able to explain the anatomy and physiology of the Female Internal Reproductive System.
4. Students will be able to know the diagnostic procedures to confirm abortion.
5. Be able to formulate nursing care plan based on the patient’s need.

SKILLS
1. Be able to provide proper nursing care to the patient based on the nursing care plan.

ATTITUDE
1. Recognize patient’s needs using holistic approach.
2. Establish rapport with the patient and the members of the family.
 01
What is the definition of Abortion?
An abortion is a medical or surgical procedure that deliberately
ends a pregnancy before an embryo or fetus is born. It is also an
expulsion of a fetus from the uterus before it has reached the
stage of viability (in human beings, usually about the 20th week
of gestation). An abortion may occur spontaneously, in which
case it is also called a miscarriage, or it may be brought on
purposefully, in which case it is often called an induced abortion.
 02
Discuss the different types of Abortion.
● Threatened Abortion A threatened abortion is minimal bright red vaginal bleeding or spotting
that occurs in the first 20 weeks of pregnancy. There is a presence of slight minimal abdominal
cramping but no cervical dilatation is present (Cervix is closed). These symptoms indicate that a
miscarriage is possible, which is why the condition is known as a threatened abortion. The exact
cause of a threatened abortion usually isn’t known. However, it’s more common among women
who have previously had a miscarriage.

● Inevitable Abortion Inevitable abortion is an early pregnancy with vaginal bleeding and
dilatation of the cervix. Typically, the vaginal bleeding is worse than with a threatened abortion,
and more cramping is present. No tissue has passed yet. On ultrasound, the products of
conception are located in the lower uterine segment or the cervical canal.

● Incomplete Abortion Incomplete abortion is a pregnancy that is associated with vaginal

bleeding, dilatation of the cervical canal, and product of conception out but remains in the
vagina (Ping-Pong ball). Usually, the cramps are intense, and the vaginal bleeding is heavy.
Patients may describe passage of tissue, or the examiner may observe evidence of tissue
passage within the vagina. Ultrasound may show that some of the products of conception are
still present in the uterus.
● Complete Abortion Complete abortion is a complete expulsion of conceptus, no more signs
of pregnancy. Typically, a history of vaginal bleeding, abdominal pain, and passage of tissue
exists. After the tissue passes, the patient notes that the pain subsides, the vaginal bleeding
significantly diminishes, and the cervix closes. The examination reveals some blood in the
vagina and no tenderness of the cervix, uterus, or abdomen. The ultrasound demonstrates an
empty uterus.

● Missed Abortion A missed abortion, also known as a missed miscarriage, occurs when a
fetus is no longer alive and dies during the first half of pregnancy, but the body does not
recognize the pregnancy loss or expel the pregnancy tissue. As a result, the placenta may
continue to release hormones, so you may continue to experience signs of pregnancy.

● Induced Abortion An abortion that is brought about intentionally. Also called an artificial or
therapeutic abortion. Therapeutic abortions are those induced to safeguard the health of the
mother and in cases of genetic disease and anomalies in the fetus that could endanger the life
of the mother.
 03
What are the causes and risk  factors for Abortion?
 Various factors increase the risk of miscarriage, including:

• Age. Women older than age 35 have a higher risk of miscarriage than do younger women. At age 35,
you have about a 20 percent risk. At age 40, the risk is about 40 percent. And at age 45, it's about 80
percent.
• Previous miscarriages. Women who have had two or more consecutive miscarriages are at higher
risk of miscarriage.
• Chronic conditions. Women who have a chronic condition, such as uncontrolled diabetes, have a
higher risk of miscarriage.
• Uterine or cervical problems. Certain uterine conditions or weak cervical tissues (incompetent
cervix) might increase the risk of miscarriage.
• Smoking, alcohol and illicit drugs. Women who smoke during pregnancy have a greater risk of
miscarriage than do nonsmokers. Heavy alcohol use and illicit drug use also increase the risk of
miscarriage.
• Weight. Being underweight or being overweight has been linked with an increased risk of
miscarriage.
• Invasive prenatal tests. Some invasive prenatal genetic tests, such as chorionic villus sampling and
amniocentesis, carry a slight risk of miscarriage
 04
What are the symptoms of Abortion?
 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 dilated 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 the product 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 contraction felt by the mother

• Uterine contraction can be false or true, but either of the two could be alarming during the
early stages of pregnancy because it could expel the content of the uterus thereby leading to
abortion.
 05
What are the diagnostic procedures done to confirm
Abortion?
Diagnosis of abortion is possible based on clinical criteria and a positive urine
pregnancy test. Usually, ultrasonography and quantitative beta subunit of Human
chorionic Gonadotropin (beta - HCGT are conducted to confirm abortion. The
health care provider might order some tests like:

- Pelvic examination to check if the cervix has begun to dilate

- Blood test to check HCG level in the blood
- Tissue test to confirm the expelled products
- Ultrasound to check for fetal well-being
- Chromosomal test to determine chromosomal compatibility to determine
chromosomal compatibility factors
- Transvaginal ultrasonography
 06
Explain the anatomy and physiology of Female
Internal Reproductive Organ.
1. Vagina - The vagina is a muscular canal lined with nerves and mucus membranes.
 
 The vagina has 3 main functions: provides a passageway for blood and mucosal tissue from the uterus during a woman's monthly
period. receives the penis during sexual intercourse and holds the sperm until they pass into the uterus. provides a passageway for
childbirth.

1. Cervix - cervix, lowest region of the uterus; it attaches the uterus to the vagina and provides a passage between the vaginal cavity and
the uterine cavity.
 
 acts as the opening point into the uterus where sperm can travel to reach eggs and potentially lead to fertilization." The cervix makes up
the lower third of the uterus and connects to the vaginal canal.

 
 The cervical os is part of the female reproductive system and is located in the pelvis. It is part of the
cervix, which is in the lower part of the uterus.
 The internal os of the cervix is the opening of the cervix that joins the uterus.
 The external os of the cervix is the junction between the cervix and the vagina.

During labor, the internal os will undergo effacement, while the external os will undergo dilation.
1. Uterus - The uterus is a hollow muscular organ located in the female pelvis between the bladder and rectum.
also known as the womb, is a female reproductive organ that is responsible for many functions in the
processes of implantation, gestation, menstruation, and labor. The uterus is a thick-walled muscular organ
capable of expansion to accommodate a growing fetus.
The uterus is a secondary sex organ. Secondary sex organs are components of the reproductive tract that mature
during puberty under the influence of sex hormones produced from primary sex organs.
 
 The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be
fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the
developing fetus prior to birth.
 
The thick wall of the uterus has 3 layers:

 The endometrium is the inner layer that lines the uterus. It is made up of glandular cells that
make secretions.
 The myometrium is the middle and thickest layer of the uterus wall. It is made up mostly of
smooth muscle.
 The perimetrium is the outer serous layer of the uterus. The serous layer secretes a lubricating
fluid that helps to reduce friction. The perimetrium is also part of the peritoneum that covers
some of the organs of the pelvis.
 
 The uterus has three parts;

 Fundus – top of the uterus, above the entry point of the uterine tubes.
 Body – usual site for implantation of the blastocyst.
 Cervix – lower part of uterus linking it with the vagina. This part is structurally and functionally different to
the rest of the uterus. See here for more information about the cervix.
 
1. Fallopian Tube - The uterine tubes (or fallopian tubes, oviducts, salpinx) are muscular ‘J-shaped’ tubes,
found in the female reproductive tract.
 
The main function of the uterine tubes is to assist in the transfer and transport of the ovum from the ovary, to
the uterus. The ultra-structure of the uterine tubes facilitates the movement of the female gamete:
 
 The inner mucosa is lined with ciliated columnar epithelial cells and peg cells (non-ciliated secretory cells).
They waft the ovum towards the uterus and supply it with nutrients.
 
 Smooth muscle layer contracts to assist with transportation of the ova and sperm. Muscle is sensitive to
sex steroids, and thus peristalsis is greatest when estrogen levels are high.
 
 
ANATOMICAL STRUCTURE
 The fallopian tube is described as having four parts (lateral to medial);
 Fimbriae – finger-like, ciliated projections which capture the ovum from the surface of the
ovary.
 Infundibulum – funnel-shaped opening near the ovary to which fimbriae are attached.
 Ampulla – widest section of the uterine tubes. Fertilization usually occurs here.
 Isthmus – narrow section of the uterine tubes connecting the ampulla to the uterine cavity.
 
5. Ovary – The ovaries are small, oval-shaped glands that are located on either side of the
uterus. The ovaries are paired, oval organs attached to the posterior surface of the broad
ligament of the uterus by the mesovarium.
 
The main functions of the ovaries are:
 To produce oocytes (female gametes) in preparation for fertilisation.
 To produce the sex steroid hormones oestrogen and progesterone, in response to pituitary
gonadotrophins (LH and FSH).
 
Components of the Ovary
 The ovary has three main histological features:
 Surface – formed by simple cuboidal epithelium (known as germinal
epithelium). Underlying this layer is a dense connective tissue capsule.
 Cortex – comprised of a connective tissue stroma and numerous
ovarian follicles. Each follicle contains an oocyte, surrounded by a single
layer of follicular cells.
 Medulla – formed by loose connective tissue and a rich neurovascular
network, which enters via the hilum of the ovary.
 07
Identify at least 2 Nursing Diagnosis and formulate a
Nursing Care Plan.
Defining characteristics Nursing Outcome Nursing Intervention Rationale Evaluation
Diagnosis Identification
Subjective: Acute pain Short term: Independent: • Maintains optimal Goals met as
Chief complaints of abdominal related to muscle After 4 hours of • Place woman flat in bed placental and evidenced
cramping and heavy vaginal contraction nursing on her side. renal function. by:
bleeding with blood clots. associated with interventions, the • Monitor uterine • Assess whether
heavy vaginal patient will verbalize contractions and fetal labor is present • Scanty
Objective: bleeding relief of control of heart rate by external and fetal status; amount of
VS reveal: pain and vaginal monitor. external system vaginal
- BP: 100/60 mmhg bleeding will be • Omit vaginal examination avoids cervical bleeding
- Hear Rate: 83 beats/min Rationale: minimized. • Withhold oral fluid. trauma. • Absence
- 02 Sat 100% on room air Acute pain is • Measure intake and • Prevents tearing of
- Lungs were clear on defined as an output of placenta previa abdomina
auscultation in all fields. unpleasant Long term: • Assess vital signs is cause of l cramps
- Abdomen was slightly emotional and (pulse,respirations, and bleeding. and
distended, and tenderness sensory After 7 das of blood pressure every 15 • Anticipates need vaginal
was present over the lower experience nursing min; apply pulse pulse for emergency bleeding
pelvic area. resulting from an interventions, the oximeter and automatic surgery
- Pelvic examination shows actual or patient will blood pressure cuff as • Enables
moderate active bleeding potential damage demonstrate relief of necessary assessment of
withbthe cervical os open. of a body tissue. pain as evidenced • Measure maternal blood renal function
- Blood clots noted on the by the absence of loss by weighing perineal • Provides baseline
perineal pad. abdominal cramps pads; save any tissue data on maternal
- Transvaginal ultrasonography and vaginal passed. response to blood
showed abnormal abdominal bleeding. loss.
sac within the cervical canal.
Findings suggestive of
threatened abortion progress.
- Patient was • Assist with ultrasound • Provides objective
diagnosed with examination. evidence amount of
incomplete • Maintain a positive bleeding. Saturating
spontaneous attitude about fetal a sanitary pad in
abortion in the outcome. less than 1 hour is
past. • Support’s woman’s heavy blood loss;
self-esteem; provide tissue may be
emotional support to abnormal
woman and her trophoblast tissue.
support person. • Supplies information
• Assist with placement on placental and
of central venous fetal well-being.
pressure or pulmonary • Supports mother-
artery catheter and child bonding.
blood determinations. • Assist problem
solving which is
Dependent: lessened by poor
- Begin intravenous fluid self-esteem.
of 1LPNSS as ordered. • Provides more
accurate data on
maternal
hemodynamic state.
• Established if blood
replacement will be
needed.
Defining Nursing Outcome Nursing Intervention Rationale Evaluation
Characteristics Diagnosis Identification

Subjective: Risk for Disturbed Short Term: Independent:   Goals met as

Chief complaints of
abdominal cramping and
heavy vaginal bleeding
with blood clots.
 
Objective:
VS reveal:
- BP: 100/60 mm/hg
- Heart Rate: 83
beats/min
- Respiratory rate: 18
breaths/min.
- O2 Sat 100% on room
air
- Temperature: 37.1 C
- Lungs were clear on
auscultation in all fields.
- Abdomen was slightly
distended, and mild
tenderness was present
over lower pelvic area.
- Pelvic examination
shows moderate active
bleeding with the cervical
os open.
- Blood clots noted on
the perineal pad.
- Patient was diagnosed
with Incomplete
Spontaneous Abortion in
the past.
Maternal-Fetal Patient will evidenced by:
Dyad related to verbalize  Review history of previous  To check for presence of • Patient
open cervical os understanding of pregnancies. complications. verbalized
  individual risk understandin
  factors or  Obtain history about prenatal  Lack of prenatal care can g of individual
Rationale: conditions that screening and amount and place both mother and fetus risk factors or
Risk for Disturbed may impact timing of care. at risk. conditions
Maternal-Fetal pregnancy. that may
Dyad is the risk    Provide information and  Detects presence of impact
for the disruption   assist in ultrasonography as complications that may pregnancy.
in the symbiotic Long Term: indicated. affect pregnancy.  
maternal/fetal Patient will  
dyad as a result of display fetal  Screen for abuse during  Prenatal abuse is correlated  
comorbid or growth within pregnancy. with preterm delivery and Goals met as
pregnancy-related normal limits and evidenced by:
conditions carry pregnancy premature dilation of cervix.  
 Encourage modified or
to term. Patient
complete bed rest as • Activity level may need
displays fetal
indicated. modification, depending on growth within
symptoms of uterine activity normal limits
 Emphasize normalcy of and cervical changes. and carry
pregnancy, focus on pregnancy to
pregnancy milestones,  Promotes sense of hope that term.
“countdown to birth”. modifications or restrictions  
serve a worthwhile purpose.
Dependent:
Pre-pregnancy treatment for
Review medication regimen maternal conditions may require
alteration for maternal and fetal
safety.
 08
Make a Drug Study of all the drugs administered to
the patient.
 -
Drug Name Classifications and Indications and Side effects and Special Nursing
Mechanism of Contraindications Adverse effects Precautions Responsibilities
Actions

Generic Name: Classifications: Indications: • Nausea Avoid use in • Inform patient

Methylergonovine Ergot Alkaloids controls bleeding patients who have of its effects
and helps shrink • Vomiting diabetes, high
Trade/Brand Mechanism of the uterus to its cholesterol, or are • If any effects
Name: Methergine Actions: control normal size • Stomach pain overweight persist or
bleeding after a worsen, tell
Dosage: 1 tablet spontaneous or Contraindications: • Diarrhea the patient to
0.2 mg induced abortions. patients with inform the
peripheral doctor
Route: Oral route hypertension
• Record the
Frequency: Three medication
times a day (Tid) given, dosage,
for 3 days time, any
complaints or
Timing: assessments
 -+ Indications and
Drug Name Classifications and Contraindications Side effects and Special Nursing
Mechanism of Adverse effects Precautions Responsibilities
Actions

Generic name: Classification: Indications: For the • Dizziness Avoid use in • Check doctor’s
Ibuprofen Nonsteroidal anti- treatment of primary • Stomach and patient with order
inflammatory drugs dysmenorrhea Abdominal pain moderate or
Brand Name: Motrin (NSAIDs) severe hepatic • Explain purpose
Contraindications: Adverse Effects: impairment of giving
Dosage: 1 tablet Mechanism of Ibuprofen should not Upset stomach, medication to the
200mg Actions: For relief of be given to patients nausea, vomiting, client
mild to moderate who have headache, diarrhea,
Route: Oral route pain experienced constipation, dizziness, • Record the
asthma, or allergic- medication given,
or drowsiness may
Frequency: q 6 type reactions after dosage, time, any
hours PRN for pain taking aspirin. occur. If any of complaints or
(every 6 hours if in these effects persist or assessments
pain) worsen, tell your doctor
or pharmacist promptly.
Timing:
 -+Drug Name Classifications Indications and Side effects and Special Nursing
and Mechanism of Contraindications Adverse effects Precautions Responsibilities
Actions
Generic name: Classification: Iron Indications: Ferrous Therapeutic Take ferrous · Should check
Ferrous Sulfate Supplement sulfate is given to doses - dose sulfate on an the doctor’s order
Mechanism of the patient for the related nausea, empty stomach, at
Brand Name: Slow Action: Iron prevention of iron upper abdominal least 1 hour before · Assess the
Fe combines with deficiency anemia pain, constipation or 2 hours after a bowel movement
porphyrin and brought about by or diarrhea meal. Avoid taking
Dosage: 1 tablet globin chains to the pregnancy. antacids or · Assess history
form hemoglobin, Contraindication: antibiotics within 2 of allergies
Route: Oral Route which is critical for Patients with hours before or
oxygen delivery hemochromatosis, after taking ferrous · Administer the
Frequency: qd from the lungs to hemosiderosis or sulfate . right drug in the
(once a day) other tissues. Iron hemolytic anemia, right dose and
deficiency causes hypersensitive to route in right time
Timing: a microcytic iron salts of their
anemia due to the component, other
formation of small anemic conditions
erythrocytes with unless
insufficient accompanied by
hemoglobin. iron deficiency.
Contraindicated
with allergy to any
ingredient: sulphite
allergy
 -+Drug Name Classifications and Indications and Side effects and Special Precautions Nursing
Mechanism of Contraindications Adverse effects Responsibilities
Actions
Generic name: Classifications: Indications: • Nausea, Vitamin C is not • Inform patients
Ascorbic Acid Vitamins, Water- Treatment of vit.C of its effects
Soluble deficiency
vomiting and stored in the
Brand Name: diarrhea. body. If you take • Inform patients
Vitamin C Mechanism of Contraindications: • Heartburn. more than you not to take more
Actions- Helps to Vitamin C • Stomach need, the extra or less than
Dosage:1 tablet provide correct recommended
500mg vitamin C deficiency
supplementation cramps or vitamin C will by the doctor
and increase the is bloating. pass into your
Route: Oral Route intestinal absorption contraindicated • Fatigue and urine. Very large • Record the
of iron in blood
Frequency: qd (once
sleepiness, doses may also medication
a day) disorders or interfere with given,
like thalassemia, sometimes tests for sugar dosage,
Timing: sickle cell insomnia. in diabetics and time, any
disease, and with tests for complaints
hemochromatosi blood in the or
s. stool. assessment
s
 -+Drug Name Classifications and Indications and Side effects and Special Precautions Nursing
Mechanism of Contraindications Adverse effects Responsibilities
Actions

Generic name: Classifications: Indications: Reduces • Nausea Call your doctor • Record the
Tranexamic Acid Antifibrinolytics the duration of
bleeding
right away if you medication
Brand Name: Mechanism of • Diarrhea have shortness given,
Cyklokapron Actions: Works by Contraindications: of dosage,
Hemostan Should not be given • Stomach breath, trouble time, any
slowing the to patients with
Route: Oral Route breakdown of hypersensitivity to pain or breathing, chest complaints
blood clots, tranexamic acid discomfort tightness, or
Frequency: PRN which helps to flushing of the assessment
Timing: prevent • Vomiting face, trouble s
prolonged swallowing, or
• Inform patients
bleeding. • Chills any swelling of of its effects
your hands,
face, or mouth • If any effects
while you are persist or
worsen, tell the
using this patient to inform
medicine. the doctor
 09
What is the treatment of choice for Incomplete
Abortion? Explain.
Mrs. J.M is diagnosed with incomplete spontaneous abortion and the
treatment of choice is dilatation and curettage . Dilation and curettage
(D&C) is a surgical procedure in which the cervix is opened (dilated) and a
thin instrument is inserted into the uterus. This instrument is used to remove
tissue from the inside of the uterus (curettage). it is used to diagnose and
treat many conditions that affect the uterus, such as abnormal bleeding. A
D&C also may be done after a miscarriage
 10
What will be the Going Home Instructions that should
given.
1. Monitor the amount and odor of vaginal discharge
2. Encourage perineal care every after defecation and
urination.
3. Observe for any signs and symptoms of hemorrhage
4. Take a nutritious and balanced diet
 
 11
What are the complications of Abortion?
Complications of abortion are the following:

1. Damage to the womb or cervix – multiple abortion procedures may result

in the pregnancy complications such as incompetent cervix that
could lead to preterm birth.
2. Excessive bleeding
3. Incomplete abortion – fetal tissue or other products of pregnancy may not
be completely expelled from the uterus. When this occurs, heavy
or irregular bleeding and infection may result and often requires
dilatation and curettage.
4. Infection of the uterus of fallopian tube – bacteria from the vagina can
enter dilated cervix and from there, go upward into the uterus and
fallopian tubes. Antibiotics are often given at the time of abortion to
prevent potential infections
7. Uterine perforation – medical instrument used in the abortion procedure can
go through the wall of the uterus. Depending on the location of
the injury and the depth of the perforation, there may be bleeding or
injury to the surrounding organs.
8. Death