The term abortion is defined as the death or expulsion of the fetus (or products of conception) before the age of viability. About 15% to 20% of all known pregnancies end in spontaneous abortion.³ The major complications are hemorrhage and infection. Pregnancy loss in the first trimester is largely the result of embryonic chromosomal defects. Loss after the first trimester more frequently is associated with infections, maternal endocrine disorders, or anatomic abnormalities of the mother’s reproductive tract. Spontaneous abortions are classified as threatened, inevitable, incomplete, complete, missed, and septic. See Table 46-2 for a comparison of these types of abortion.

TABLE 46-2 TYPES OF ABORTION

TYPE	DESCRIPTION	THERAPEUTIC INTERVENTIONS
Threatened abortion	Early symptoms of abortion include episodic, painless uterine bleeding and mild cramping The cervical os is closed and the uterus is enlarged and soft Quantitative beta hCG (serum) test provides better indicator of fetal development than qualitative beta hCG (urine) test	Bed rest Pelvic rest—no tampons, douches, or sexual intercourse Mild sedatives Ultrasound confirmation of pregnancy
Inevitable abortion	A threatened abortion may progress to inevitable abortion Signs and symptoms include increased pain, cramping, and bleeding The cervical os is dilated 3 cm or more	Bed rest Analgesics Uterine evacuation (dilation and curettage or dilation and evacuation) performed at discretion of provider and patient
Incomplete abortion	Bleeding is heavy, cramping is severe, and the cervical os is open Patient has a positive pregnancy test and an enlarged uterus Tissue has been passed but some products of conception are retained	Obtain intravenous access and infuse lactated Ringer solution Oxytocin (Pitocin, Syntocinon) in lactated Ringer solution to induce uterine contractions Facilitate surgery for uterine evacuation Administer Rho(D) immune globulin as needed
Complete abortion	A small amount of bleeding occurs, cramping is mild, all tissue has been passed (often in an intact amniotic sac), and the cervical os is closed	Observation Ultrasound may be indicated to determine if all products of conception have been passed If mother is Rh negative, administer RhoGAM according to institutional guidelines to prevent Rh incompatibility in future pregnancies
Missed abortion	A pregnancy loss in which the products of conception remain in the uterus for an extended period after fetal demise Characteristic symptoms of bleeding and cramping are absent	Uterine evacuation may be performed Patient may be sent home for expectant management or scheduled evacuation
Septic abortion	May occur in patients who have a complete abortion without surgical uterine evacuation More frequently the result of an elective abortion or delayed treatment for an incomplete abortion Common causative bacteria include: • Alpha- and beta-hemolytic streptococci • Gram-negative aerobes such as Escherichia coli, Clostridium perfringens Signs and symptoms include: • Foul vaginal discharge • Constant pelvic pain • Uterine tenderness • Fever, chills	Initiate an oxytocin infusion to expel uterine contents Administer appropriate antibiotics Prepare the patient for dilation and curettage Observe for signs of toxic shock: • Hypotension • Renal failure • Tachycardia

hCG, Human chorionic gonadotropin.

General Post-Abortion Care

• If procedural sedation was administered for uterine evacuation, ensure that the patient is fully recovered before discharge; follow institutional policy and procedures regarding discharge.

• Explain potential medication effects.

• Assess amount and characteristics of vaginal bleeding.

• Many women (and men) find the loss of their child devastating, even when it occurs early in pregnancy.

• Comfort the patient and significant others as appropriate. (See Chapter 17, End-of-Life Issues for Emergency Nurses, for more specific information.)

• Determine what information is needed regarding the cause of abortion. Refer the patient to experts (e.g., obstetrician, geneticist) for evaluation, as indicated.

• Provide the names of local support groups such as Compassionate Friends and Share. The hospital’s obstetric unit may have a list of resources.

• Refer patients for psychological counseling as needed, especially if the patient has a history of depression or significant concurrent stressors.

Septic Abortion

Patients with septic abortion resulting from Clostridium infection are of particular concern. This anaerobic organism may produce gas gangrene, tissue necrosis, and uterine tissue sloughing. To avoid significant morbidity and mortality, treatment of septic abortion must be immediate and aggressive. If the patient does not improve after dilation and curettage, hysterectomy is indicated.

Discharge Instructions

• Vaginal bleeding may last 1 to 2 weeks. The bleeding should get progressively lighter until it subsides.

• Slight cramping for several days is normal.

• Avoid douching, tampons, or intercourse for at least 2 weeks (or until after a follow-up visit with a gynecologist).

• Bed rest is not necessary but exertion should be minimal for 2 to 3 days.

• Monitor body temperature in the morning and evening for 5 days.

• Seek medical care for the following:

• Temperature above 37.7°C (100°F)

• Chills

• Severe nausea and vomiting

• Severe cramps

• Excessive bleeding, which can be defined for the patient as:

• Consistently soaking a pad in less than 1 hour

• Bleeding more than a normal heavy period

• Clots larger than a quarter

Gestational Hypertension

Gestational hypertension is the current global term for hypertension complicating pregnancy and has replaced the term pregnancy-induced hypertension (PIH).⁴ Any patient presenting with signs and symptoms consistent with a hypertensive disorder of pregnancy should receive an obstetric consult as soon as possible. Both the woman and her fetus can change status quickly and need intensive obstetric management.