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Abortion

Abortion is the ending of pregnancy by removing an embryo or fetus before it can survive outside the uterus. An abortion that occurs spontaneously is also known as a miscarriage.

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Abortion

  1. 1. Abortion Nursing Path www.drjayeshpatidar.blogspot.com
  2. 2. The Supreme Court’s Wisdom “ . . . we need not resolve the difficult question of when life begins. When those trained in the respective disciplines of medicine, philosophy, and theology are unable to arrive at any consensus, the judiciary, at this point in the development of man’s knowledge, is not in a position to speculate as to the answer.” 5/18/2018 2www.drjayeshpatidar.blogspot.com
  3. 3. Early “Life”  Intercourse  Fertilization  Implantation  Pre-embryo  Embryo  Fetus  Viability  Birth 5/18/2018 3www.drjayeshpatidar.blogspot.com
  4. 4. 5/18/2018 4www.drjayeshpatidar.blogspot.com
  5. 5. 5/18/2018 5www.drjayeshpatidar.blogspot.com
  6. 6. Fertilization complex process which takes 24 hours after penetration of the oocyte (egg) by the sperm occurs in fallopian tube complete when pronuclei (23 chromosomes) of sperm and oocyte fuse to form a new cell called a zygote (46 chromosomes) 5/18/2018 6www.drjayeshpatidar.blogspot.com
  7. 7. 5/18/2018 7www.drjayeshpatidar.blogspot.com
  8. 8. Stages of the pre-embryo . . . Zygote: one cell Blastomere: 2-8 cells, it takes 20 hours for the first cell division Morula: 8-16 cells. The morula travels out of the fallopian tube and reaches the endometrial cavity Blastocyst: multicellular mass of cells with a fluid filled center 5/18/2018 8www.drjayeshpatidar.blogspot.com
  9. 9. Implantation  Process of blastocyst adhering to the uterine wall. Slow process occurring 5 - 9 days after the beginning of fertilization.  Three cell layers are formed: – Ectoderm • brain, nerves, skin – Mesoderm • cartilage, muscle, blood vessels, heart, kidneys – Endoderm: • digestive tract, respiratory tree, liver, pancreas 5/18/2018 9www.drjayeshpatidar.blogspot.com
  10. 10. Embryo and Fetus  Embryo – 16 days after the beginning of fertilization until 8 weeks after after fertilization. – Organogenesis is complete  Fetus – Completion of organogenesis until delivery 5/18/2018 10www.drjayeshpatidar.blogspot.com
  11. 11. Pregnancy Dating Days, weeks LMP – Human gestation – Conception – Trimesters 5/18/2018 11www.drjayeshpatidar.blogspot.com
  12. 12. Viability Survival by Gestational age at DHMC – Weeks % survival 22 0 23 25 24 55 25 65 26 75 27 90 28 92 5/18/2018 12www.drjayeshpatidar.blogspot.com
  13. 13. Definitions  Abortion  Complete Abortion  Incomplete Abortion  Threatened Abortion  Inevitable Abortion  Missed Abortion  Septic Abortion  Induced 5/18/2018 13www.drjayeshpatidar.blogspot.com
  14. 14. Abortion Termination of pregnancy before 20 weeks gestation calculated from date of onset of last menses – Early Abortion: before 12 weeks – Late Abortion: from 12-20 weeks Delivery of a fetus of weight less than 500 grams 5/18/2018 14www.drjayeshpatidar.blogspot.com
  15. 15. Definitions . . . Induced Abortion: intentional medical or surgical termination of a pregnancy – Elective: if performed for a woman’s desires – Therapeutic: if performed for reasons of maintaining health of the mother 5/18/2018 15www.drjayeshpatidar.blogspot.com
  16. 16. Induced abortion: statistics . . .  1,180,000 abortions are reported to the CDC in 1997. This is constant since 1980  305 abortions/1000 live births  National abortion rate: 20/1000 women aged 15-44  79.7% of women obtaining abortions are unmarried  21 % of women obtaining abortions are younger 19 years old  55.2 % are younger than 24 years old 5/18/2018 16www.drjayeshpatidar.blogspot.com
  17. 17. Statistics, continued  53% of women in the United States having abortions have never had one before  88% of women who abort are in the first trimester of pregnancy  97% of women having first trimester abortions have no complications or post abortion complaints  2.5 % have minor complaints that are handled in a physicians office  <0.5% require additional surgery 5/18/2018 17www.drjayeshpatidar.blogspot.com
  18. 18. Induced abortion: safety Risk of death from a legal abortion is 0.4/100,000 Risk of death from a term pregnancy is 9/100,000 5/18/2018 18www.drjayeshpatidar.blogspot.com
  19. 19. Induced Abortion: safety Risk of death for being an abortion provider 20/100,000 5/18/2018 19www.drjayeshpatidar.blogspot.com
  20. 20. Historical Perspective “(T)here is every indication that abortion is an absolutely universal phenomenon, and that it is impossible even to construct an imaginary social system in which no woman would ever feel at least compelled to abort” Devereux G. A typological study of abortion in 350 primitive, ancient, and pre-industrial societies. 5/18/2018 20www.drjayeshpatidar.blogspot.com
  21. 21. Historical perspective cont . . . Abortion legal in US from Puritan settlement till mid 1800’s 1840: Eastman Everett Act, State of Maine – 1 year in jail, $1000, loss of license 1846: abortion illegal nationally 5/18/2018 21www.drjayeshpatidar.blogspot.com
  22. 22. Roe vs. Wade 1/22/73 “We recognize the right of the individual, married or single, to be free from unwanted governmental intrusion into matters so fundamentally affecting a person as the decision whether to bear or beget a child. That right necessarily includes the right of a woman to decide whether or not to terminate her pregnancy.” 5/18/2018 22www.drjayeshpatidar.blogspot.com
  23. 23. Benefits of Legal Abortion  Death from illegal abortion used to be a major component of maternal mortality  Hospital wards were filled with patients suffering from septic “spontaneous abortion”  In 1940, 1407 died from complications of induced abortion  1987 (last year of available data) – 12 deaths from spontaneous abortion – 6 deaths from legally induced abortion – 2 deaths from illegally induced abortion 5/18/2018 23www.drjayeshpatidar.blogspot.com
  24. 24. Benefits of legal abortion Global perspective: – WHO estimates 20,000,000 illegal abortion world wide annually – 50,000-100,000 deaths annually – 250-500/100,000 mortality rate (0.4/100,000 in United States) 5/18/2018 24www.drjayeshpatidar.blogspot.com
  25. 25. Gestational age and procedure – 50% of abortion performed 8 weeks or earlier – 12% of abortion performed past 12 weeks – 1.4% of abortion performed past 20 weeks 5/18/2018 25www.drjayeshpatidar.blogspot.com
  26. 26. First Trimester Abortion Early Uterine Evacuation (EUE), Minisuction, Menstrual Regulation Suction Abortion, Vacuum Curettage Medical Abortion 5/18/2018 26www.drjayeshpatidar.blogspot.com
  27. 27. Minisuction Introduced in 1972 by Karman and Potts 5/18/2018 27www.drjayeshpatidar.blogspot.com
  28. 28. Minisuction  Requires early recognition of pregnancy. Performs abortions up to 7-8 weeks from LMP  Cervical dilation not required, 6 mm diameter cannula used  Simplest, safest, least expensive  examine aspirated tissue is essential 5/18/2018 28www.drjayeshpatidar.blogspot.com
  29. 29. 5/18/2018 29www.drjayeshpatidar.blogspot.com
  30. 30. Dilatation and curettage (D&C)  Removal of pregnancy contents by some mechanical means  Vacuum most commonly used  12-13 weeks is the upper limit of gestational age  Usually performed in free standing clinics5/18/2018 30www.drjayeshpatidar.blogspot.com
  31. 31. D&C (vacuum curettage)  The cervix must be dilated to permit larger diameter suction curettes  Premedication with NSAID  Local (paracervical block), spinal, conscious sedation, or general anesthesia5/18/2018 31www.drjayeshpatidar.blogspot.com
  32. 32. 5/18/2018 32www.drjayeshpatidar.blogspot.com
  33. 33. 5/18/2018 33www.drjayeshpatidar.blogspot.com
  34. 34. 5/18/2018 34www.drjayeshpatidar.blogspot.com
  35. 35. 5/18/2018 35www.drjayeshpatidar.blogspot.com
  36. 36. Medical Abortion Mifepristone (RU486) – analogue of progestin norethindrone – strong affinity for the progesterone receptor, acting as an antagonist – a single oral dose given to women 5 weeks or less produces abortion in 85% of cases 5/18/2018 36www.drjayeshpatidar.blogspot.com
  37. 37. Medical Abortion - politics RU486 - Mifepristone – developed in 1980’s – approved for use by French government 1988 • one day later manufacturer withdrew it from the market succumbing to international boycott • French government ordered redistribution – Prohibited in US during Reagan and Bush – Ban lifted by Clinton, clinical trials, preliminary FDA approval 9/96 – Final approval stalled secondary to inability to manufacture and distribute until 9/20005/18/2018 37www.drjayeshpatidar.blogspot.com
  38. 38. Mifepristone protocol Women less than 49 days LMP with confirmed b-hCG 600mg mifepristone on day 1 On day three, return for prostaglandin, Misoprostil 400 mcg orally Patient remain in clinic four hours, during which time expulsion of pregnancy usually occurs 5/18/2018 38www.drjayeshpatidar.blogspot.com
  39. 39. Alternative Regimens 200 mg Mifepristone 800 mcg Mistoprostil vaginally 5/18/2018 39www.drjayeshpatidar.blogspot.com
  40. 40. Medical Abortion in the US Women less than 49 days LMP with confirmed pregnancy Methotrexate 50 mg/m2 on day 1 Misoprostol 800mg intravaginally on day 5,6, or 7, repeat x 1 in 48 hours if pregnancy persists Abortion off site in 1-5 days. Surgical intervention if pregnancy persists to day 29 5/18/2018 40www.drjayeshpatidar.blogspot.com
  41. 41. Surgical vs. Medical: pro vs. con Patient perspective:  Private  More sense of autonomy  “More natural”  Earlier intervention unwanted pregnancy  Longer process with unclear endpoint  More pain  More bleeding  Anxiety regarding abortion off site 5/18/2018 41www.drjayeshpatidar.blogspot.com
  42. 42. Surgical vs. Medical: pro vs. con Provider perspective:  Less skill needed to provide  Methotrexate also treats ectopic pregnancy  Increased anxiety re: off site management  More unscheduled care: calls, ER visits  Need to guard against unnecessary intervention  Limited to 49 days LMP 5/18/2018 42www.drjayeshpatidar.blogspot.com
  43. 43. Second Trimester Termination Dilatation and evacuation (D&E) Intrauterine injection of abortifacients Prostaglandin vaginal suppositories High dose oxytocin Hysterotomy 5/18/2018 43www.drjayeshpatidar.blogspot.com
  44. 44. D & E Mechanical and suction removal of formed pregnancy after cervical dilation Technically more difficult than earlier suction procedures Associated with fewer complications than instillation and suppository methods General anesthesia is not required 5/18/2018 44www.drjayeshpatidar.blogspot.com
  45. 45. 5/18/2018 45www.drjayeshpatidar.blogspot.com
  46. 46. Picture of laminaria 5/18/2018 46www.drjayeshpatidar.blogspot.com
  47. 47. Intrauterine injection of abortifacients Prostaglandin, hypertonic saline, hypertonic urea are introduced by amniocentesis Fetus and placenta are aborted vaginally Osmotic dilators are used to decrease time to delivery and decrease complications 5/18/2018 47www.drjayeshpatidar.blogspot.com
  48. 48. Prostaglandin suppositories  20 mg suppositories of PGE2 typically given q 3 hours – mean time to induction 13.4 hours, with 90% aborting by 24 hours – GI side effects: 39% vomiting, 25% diarrhea – Fever: temperature elevation of 1 degree c  Prostaglandin F2alpha 250 mg IM q 2 hours – mean time to abortion 15-17 hours, with 80% aborting by 24 hours – GI side effects: 83% vomiting, 71% diarrhea  Misoprostil (PGE1) 5/18/2018 48www.drjayeshpatidar.blogspot.com
  49. 49. High Dose Oxytocin As effective as PGE2 when used in appropriate doses Risk of water intoxication 5/18/2018 49www.drjayeshpatidar.blogspot.com
  50. 50. Hysterotomy Surgical method to remove pregnancy abdominally (mini-cesarean section) Other methods are preferred 5/18/2018 50www.drjayeshpatidar.blogspot.com
  51. 51. Complications - rates Varies as a function of the gestational age they are performed – Major complications: • 0.25% < 7 weeks • 1% < 12 weeks • 2% over 12 weeks 5/18/2018 51www.drjayeshpatidar.blogspot.com
  52. 52. Complications - immediate Complications of local anesthetic Cervical shock Cervical lacerations Uterine perforation Hemorrhage Post abortal syndrome 5/18/2018 52www.drjayeshpatidar.blogspot.com
  53. 53. Complications - delayed Bleeding – retained products Infection Continued pregnancy – ectopic – intrauterine 5/18/2018 53www.drjayeshpatidar.blogspot.com
  54. 54. Thank You 5/18/2018 54www.drjayeshpatidar.blogspot.com

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