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BLEEDING IN EARLY PREGNANCY


Bleeding in pregnancy:
Vaginal bleeding during pregnancy is abnormal. It is cause of concern to mothers
& may result foetal loss
Midwife must assess the amount of blood loss, colour of the loss, any associated
pain. Assessment of the fetal condition depends on gestation. Ultrasound
scanning confirms the viability of the pregnancy.
Implantation bleeding:
As the trophoblast erodes the endometrial epithelium & the blastocyst implants a
small vaginal blood loss may be apparent to the mother
Cervical eversion also called cervical erosion. High levels of estrogens encourage
the proliferation of columnar epithelial cells, found in the cervical canal.
Hyperactivity of the endocervical cells increases the quantity of vaginal
discharge. As the cells are vascular it may also cause intermittent blood stained
loss or spontaneous bleeding. The eversion usually disappears during the
puerperium.
The causes of bleeding in early pregnancy are broadly divided into two groups:
Those related to the pregnant state: this group relates to abortion (95%).
Ectopic pregnancy, hydatidiform mole & implantation bleeding.
Those associated with the pregnant state: the lesions are unrelated to
pregnancy-either pre-existing or aggravated during pregnancy.
Cervical lesions such as vascular erosions, polyp, ruptured varicose veins &
malignancy are important causes.
Cervical polyps:
Small vascular pedunculated growths attached to the cervix may bleed during
pregnancy
Carcinoma of the cervix

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It is the most frequently diagnosed cancer in pregnancy. It is treatable condition if


diagnosed & treated early.
Cervical intra epithelial neoplasia (CIN) is the precursor to invasive cancer of the
cervix. A papanicolaou smear test will detect atypical cells on the surface of the
cervix or within the endocervix.
The causes of bleeding in pregnancy are usually considered in relation to the
stage of gestation. Frequent causes of bleeding during the first half of pregnancy
include abortion, ectopic pregnancy, & hydatidiform mole. The most common
causes of hemorrhage in the latter half of pregnancy are placenta praevia &
abruption placenta.
ABORTION
Introduction
One of the most ethical dilemmas the society is facing for decades is the
issue on abortion. There are many strong arguments about the issue for those
who are in favor and against it. Abortion is defined as pregnancy termination. It
could be done intentionally (by choice) or accidentally as in miscarriage.
Abortions caused by rape, incest and possible health concerns to mother or baby
constitute just 7%. Social and personal issues are the cause for rest of the
abortions.
Many pregnancies are lost in the early weeks than at any other stage of
gesitation. While early pregnancy losses are often considered to be less important
than the loss of the baby in later pregnancy,the loss of a wanted pregnancy is
always distressing to the mother irrespective of the timing. This is particularly
true of recurrent abortions. Abortion is one of the complications of early
pregnancy and can either be spontaneous or induced
Abortion is the termination of pregnancy before the fetus becomes viable.
Viability is usually reached at 28weeks when the fetus weighs slightly more than
1000gms. Viable means capable o f living a separate existence.
Definition

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1. Abortion is confined to the period before the 20th week of pregnancy or the
delivery of a fetus weighing less than 500gm (about one lb) which is 454gm
Cunningham 1993
2. Abortion is the expulsion or extraction from its mother of an embryo or
fetus weighing 500 gm or less when it is not capable of independent
survival
WHO
Incidence
The incidence of abortion is difficult to work out but probably 10-20% of all
clinical pregnancies end in miscarriage & another optimistic figure of 10% are
induced illegally. 75% abortions occur before the 16th week & of these, about 75%
occur before the 8th week of pregnancy.
Classification or varieties

Abortio

Spontaneou
s
Recurre
Isolated
nt
(Sporadic)

Induced
Legal

Illegal
(criminal)
Septic
common
Septic (Less
common)

Threaten Inevitab Complet Incomple Misse


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Etiology:
It is often complex & in many obscure
In many cases abortions occur primarily as result of ovum which is not
viable & in others as a result of abnormal uterine activity.
The following are the potential causes
Genetic factors

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Majority 50% of early miscarriages are due to chromosomal abnormality in


the conceptus.
Autosomal trisomy is the commonest cytogenetic abnormality
Endocrine & metabolic factors
Luteal phase defect (LPD) results in early miscarriage implantation &
placentation are not supported adequately.
Deficient progesterone secretion from corpus luteum or poor endometrial
response to progesterone is the cause
Thyroid abnormalities: overt hypothyroidism or hyperthyroidism are
associated with increased fetal loss
Diabetes mellitus when poorly controlled causes increased miscarriage
Hormonal imbalance, maternal diabetes, hypo & hyper thyroidism,
inadequate luteal phase & inadequate production of progesterone by the
placenta may lead to abortion
Anatomical abnormalities
Cervico-uterine factors: these are mostly related to the second trimester
abortions
Cervical incompetencies
Congenital malformation of the uterus
Uterine fibroid
Intra uterine adhesions
Infections
Transplacental fetal infections occur with most micro organisms & fetal
lossws could be cause
Viral: rubella, cytomegalo, variola, vaccinia or HIV
Parasitic : toxoplasma, malaria
Bacterial; ureaplasma, Chlamydia, brucella, spirochaete
Immunological disorders
Autoimmune disease-these patients form antibodies against their own
tissue & the placenta. These antibodies ultimately cause rejection of early

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pregnancy
Alloimmune disease: paternal antigens which are foreign to the mother
invoke a protective blocking antibody response. These blocking antibodies
prevent maternal immune cells from recognizing the fetus as a foreign
entity. Therefore, the fetal allograft containing foreign paternal antigens are
not rejected by the mother. Paternal human leukocyte antigen (HLA) sharing
with the mother leads to diminished fetal-maternal immunological
interaction & ultimately fetal rejection
Blood group incompatibility:
Incompatibility ABO group matings may be responsible for early pregnancy
wastage & often recurrent but Rh incompatibility is a rare cause of death of
the fetus before 28th week.
When the mothers blood group is Rh negative & that of the father id Rh
positive the fetal blood group may be Rh positive & mat therefore
haemolysis on account of the immune iso-antibodies formed in the maternal
blood. The haemolysis may causes fetal death & late abortion. ABO
incompatibility may also be an etiological factor
Others
Maternal
medical
illness:
cyanotic
heart
disease,
haemoglobinopathies are associated with early abortion
Premature rupture of membranes inevitably leads to abortion
Parenteral factors: sperm chromosomal anomaly (translocation) can
cause abortion
Inherited thrombophilia causes both early & late miscarriages due to
intravascular coagulation. Protein C resistance is the most common
cause.
Environmental factors
Cigarette smoking, alcohol consumption, X-Irradiation & antineoplastic
drugs are known to cause abortion
Various maternal, paternal & fetal causes are responsible for abortion
Foetal factors:

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Intrinsic defects of varying degrees in the fertilized ovum


Unsatisfactory uterine environment produces embryonic defects & faculty
implantation
Cystic degeneration of the chorionic villi is a common cause producing
primary death of the fertilized ovum & abortion
Hemorrhage into the deciduas is the cause of spontaneous abortion
Infection of the placenta
Placenta praevia, multiple pregnancy, hydramnios in the early months may
cause abortion
Umbilical, cord anomalies produce fetal death & abortion occasionally
Maternal factors:
Maternal systematic diseases like maternal acute infections, fevers, HTN, chronic
pyelonephritis
Trauma in the early weeks
Effects of drugs
Stress leads to instability or excitability of the autonomic nervous system is
the causation of abortion
Psychogenic trauma may precipitate an abortion
Uterine causes:
Congenital anomalies of the uterus. Fibroid tumours of the uterus.
Cervical incompetence either congenital or acquired as a result of obstetric
or surgical trauma
Retroversion of the uterus
Ovarian tumours complicating early pregnancy may produce abortion
especially in the torsion of the tumour
Common cause of abortion
First trimester: Genetic factors
Endocrine factors
Immunological disorders
Infection
Second trimester:Anatomic abnormalities- cervical incompetence, mullerian

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fusion defects, uterine synechiae, uterine fibroid


Maternal medical illness
Mechanism of abortion
In the early weeks, death of the ovum occurs first, followed by its expulsion. In
the later weeks, maternal environmental factors are involved leading to expulsion
of the fetus which may have signs of life but is too small to survive.
Before 8 weeks: the ovum, surrounded by the villi with the decidual
coverings, is expelled out intact. Sometimes, the external os fails to dilate
so that the entire mass is accommodated in the dilated cervical canal & is
called cervical abortion
8-14 weeks: expulsion of the fetus commonly occurs leaving behind the
placenta & the membranes. A part of it may be partially separated with
brisk haemorrhage or remains totally attached to the uterine wall.
Beyond 14th week; the process of expulsion is similar to that of a mini
labour. The fetus is expelled first followed by expulsion of the placenta
after a varying interval
Signs & symptoms
Pain due to uterine contractions
Haemorrhage as the result of separation of the ovum
Dilatation of the cervix due to uterine contractions
Expulsion of a part of or the entire ovum
Depending upon the signs & symptoms the following types of abortions
may be recognized

1. Spontaneous abortion;
The process starts of its own accord through natural causes. It is defined as the
involuntary loss of the products of conception prior to 24 weeks gestation

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Incidence
15% of all confirmed pregnancies are said to result in a miscarriage, some 80% of
which happen in the first trimester
Etiology: the cause in most instances remain unknown
Foetal causes: 50% are due to chromosomal abnormalities of the conceptus.
Genetic & structural abnormalities cause pregnancy loss
Maternal causes: structural abnormalities of the genital tract such as
retroversion of uterus, bicornuate uterus & fibroids.
Infections such as rubella, gonorrhea & Chlamydia
Maternal diseases such as diabetes, renal diseases & thyroid dysfunction
Environmental factors: excessive consumption of alcohol & cigarette
smoking
Multigravidae are more at risk than primigravidae
Types of spontaneous abortion
Threatened
Inevitable
Complete
Incomplete
Missed
Septic\

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TYPE OF
ABORTION

BLEEDING

PAIN

CERVICAL
DILATION

TISSUE
PASSAGE

Threatened

Slight

Mild
cramping

No

No

Inevitable

Moderate

Moderate
cramping

Yes

No

Incomplete

Heavy

Severe
cramping

Yes

Yes

Complete

Decreased;
slight

Mild
cramping

No

Yes

Missed

None; slight

None

No

No

Threatened abortion:
In this condition after a period of amenorrhoea, the mother complaints of slight
coliky pain in the lower abdomen associated perhaps with backache, frequency of
micturation & slight bleeding per vaginum. The cervix found softened, uterus
enlarged & more or less globular size depending on the period of pregnancy. The
os is generally closed. There is no actual sign suggestive of death or expulsion of
a portion of the ovum. 70-80% of all mothers, diagnosed as having a threatened
miscarriage in the first trimester continue with their pregnancies to term. If the
bleeding settles & the pregnancy continues, subsequently management should
take account of the possibility of intra-uterine growth retardation due to poor
placental function. There is also an increased risk of a preterm labour.
If the loss persists, the pain may become rhythmical & the uterus contracts
to expel its contents as the miscarriage becomes inevitable.
Definition:
Threatened abortion is a clinical entity where the process of abortion has started
but has not progressed to a state from which recovery is impossible

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Clinical features:
The patient, having symptoms suggestive of pregnancy, complains of:
1. Bleeding per vaginum: -slightly bright red in colour.
2. Pain-usually painless bleeding, but there may be mild backache or dull pain in
lower abdomen. Pain appears usually following haemorrhage
Pelvic examination should be done gently(avoided if USG available)
Speculum examination reveals-bleeding.(if escapes through external os)
Digital examination-revarls closed external os
The uterine sixe xorresponds to the period of amenorrhoea
The uterine & cervix feel soft
Investigations:
Routine investigations:
1. Blood-hemoglobin, hematocrit, ABO & Rh grouping
2. Urine for immunological test of pregnancy
3. USG: reveals a well formed gestation ring with central echoes from the
embryo indicating healthy fetus.
4. Observation of fetal cardiac motion
5. A blighted ovum evidenced by loss of definition of the gestation sac, smaller
mean gestational sac diameter, absent fetal echoes & absent fetal cardiac
movements
Treatment:
Rest-for few days
Drugs- sedation & relief of pain phenobarbitone 30mg or diazepam 5mg given
twice daily.
Inevitable abortion:
Vaginal bleeding is heavy, with clots or products of conception. Blood loss

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may be heavy & the mother is in a shocked state. The uterus may be smaller than
expected the membranes ruptures, cervix dilates & products may be seen in the
vagina. Blood loss may be excessive & if bleeding to be controlled by syntocinon
20 units intravenously or ergometrine 0.5mg intravenously or intramuscularly can
be given.
The pain experienced by the mother may be intense so adequate analgesia
can be given.
Definition
Inevitable abortion is the clinical type of abortion where the changes have
progressed to a state from where continuation of pregnancy is possible.
Clinical features
Increased vaginal bleeding
Aggravation of pain in the lower abdomen which may be colicky in nature
Internal examination reveals dilated internal os of the cervix through which
the products of conception are felt
Management:
General measures:
Excessive bleeding should be promptly controlled by administering Methergin
0.2mg if the cervix is dilated & the size of the uterus is less than 12 weeks. The
shock is corrected by intravenous fluid therapy & blood transfusion
Active treatment:
Before 12 weeks:
- Dilatation & evacuation followed by curettage of the uterine
cavity blunt curette under general anaesthesia
- Alternatively, suction evacuation followed by curettage is done
After 12 weeks:
- Uterine contraction is accelerated by oxytocin drip (10 units in

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500 ml of normal saline) 40-60 drops per minute.


If bleeding is profuse with the cervix closed-evacuation of the
uterus may have to be done by abdominal hysterectomy.

Complete abortion:
The conceptus, placenta & membranes are expelled completely from the
uterus. Once this has occurred, pain subsides & bleeding decreases. The uterus
on palpation, is firmly contracted & is empty. Cervical canal may be closed. No
further medical intervention is required, although support to the mother is
required.
Definition
When the products of conception are expelled, it is called complete abortion
Clinical features:
Subsidence of abdominal pain
Vaginal bleeding becomes trace or absent
Internal examination reveals
- Uterus smaller than the period of amenorrhoea & a little firmer
- Cervical os is closer
- Bleeding is trace
- Examination of the expelled fleshy mass is found intact
Management:
The effect of blood loss, if any, should be assessed & treated
Transvaginal sonography is useful to prevent unnecessary surgical procedure
Incomplete Abortion:
When only a part of the products of conception has been expelled, it is
termed incomplete abortion. Remnants of placenta remain within the uterine

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cavity contributing to the degree of bleeding which may be heavy & profuse.
Intravenous or intramuscular ergometrine 0.5 mg may be given to control the
loss. Evacuation under general anesthesia to remove any retained tissue should
be done, once the mother is in a stable condition.
Definition
When the entire products of conception are not expelled, instead a part of it is left
inside the uterine cavity, it is called incomplete abortion
Clinical features:
History of expulsion of a fleshy mass per vaginum followed by
Continuation of pain lower abdomen, colicky in nature
Persistence of vaginal bleeding varying magnitude
Internal examination reveals- Uterus smaller than the period of amenorrhoea,
- patulous cervical os often admitting tip of the finger,
- varying amount of bleeding,
- on examination the expelled mass is found incomplete
Termination
The products left behind may lead to
a. profuse bleeding
b. sepsis
c. placental polyps
d. rarely choriocarcinoma
Management:
Early abortion: dilatation & evacuation under general anesthesia
Late abortion- the uterus is evacuated under general anesthesia & the products
are removed by ovum forceps or by blunt curette

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Missed abortion:
When the fetus has died but is retained, the products of conception are
often spontaneously expelled within 4-5weeks of fetal death. In this condition, the
symptoms of abortion occur but subside later, without any part of the ovum being
expelled. A brown loss originating from the degeneration of placental tissue may
present. There is a reduction & then cessation of the symptoms of pregnancy.
Uterine growth stops. Treatment of missed abortion is evacuation of the uterus by
dilatation & curettage under general anesthesia.
During D & C procedure the cervical canal is gently dilated to allow a small
curette to be introduced into the uterine cavity. The curette is used to remove any
retained products.
Septic abortion
This condition is most commonly a complication of induced or incomplete
abortion & is due to ascending infection. In addition to the signs of miscarriage,
the mother complaints of feeling unwell & may have headache, nausea, pyrexia.
There is a localized infection in the uterine tubes & the uterine cavity or as
generalized septicemia with peritonitis.
Blood culture & vaginal swabs should be taken to identify the cause of the
infection. Intravenous 7 antibiotics should be given to control infection.
RECURRENT ABORTION
This term refers to any case in which there is have been three or more
consecutive spontaneous miscarriages.
Unless each successive abortion occurred about the same time and in a
similar fashion it should not be assumed that there is a common underlying
cause.
Approximately 1-4% are habitual aborters
There is increased risk of abortion after a previous abortion.
Repeated midtrimester abortions may result from cervical in competence.

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Abortion
Types

Characteristics

Management

occurring before the 20th week 1. Bedrest


2. No coitus up to 2 weeks after
of gestation
bleeding stopped
characterized by cramping and
vaginal bleeding with no
cervical dilation.
it may subside or an
incomplete abortion may
follow.

Threatened
Abortion

Imminent
or
Inevitable
Abortion

membranes rupture and the


cervix dilates
characterized by lower
abdominal cramping and
bleeding.

1. Hospitalization
2. D and C
3. Oxytocin after D and C
4. Sympathetic
5. Understanding and
emotional support

Incomplete
Abortion

is characterized by expulsion
of only part of the products of
conception (usually the fetus).
severe uterine cramping
bleeding occur with cervical
dilation.

1. D and C
2. Oxytocin after D and C
3. Sympathetic
4. Understanding and
emotional support

characterized by complete
expulsion of all products of
conception
light bleeding
mild uterine cramping
passage of tissue

1. There is no treatment other


than rest is usually needed.
2. All of the tissues that came
out should be saved for
examination by a doctor to
make sure that the abortion

Complete
Abortion

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Missed
Abortion

Recurrent
orHabitual
Abortion

Septic
Abortion

closed cervix

intrauterine pregnancy is
present but is no longer
developing normally
the cervix is closed, and the
client may report dark brown
vaginal discharge.
pregnancy test findings are
negative.
characterized by spontaneous
abortion of three or more
consecutive pregnancies

is complete.
3. The laboratory examination
of the saved tissue may
determine the cause of
abortion.
1. Usually treated by induction
of labor by dilation (or
dilatation) and curettage (D
& C).

1. Trace the cause of recurrent


abortion

abortion complicated by
1. Antibiotics as prescribed by
your Obstetrician
infection
foul smelling vaginal discharge
uterine cramping
fever

Management
General management:
Hospitalization
Vaginal /cervical swab for culture
Vaginal examination
Overall assessment
Investigation protocol

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Grade-I
Antibiotics
Prophylactic anti gas gangrene of 8000 units & 3000 units of antitetanus
serum intramuscularly
Analgesics & sedatives
Blood transfusion
Evacuation of the uterus
Grade-II
Antibiotics
Surgery- evacuation of the uterus
Posterior colpotomy
Grade-III
Antibiotics
Clinical monitoring
Supportive therapy
Issue on Abortion
The issue on abortion is impossible to solve. What an individual can do is to
understand the different aspects of the argument so that when that person is
faced with the ethical dilemma he or she would be able to make rational,
educated and thoughtful decisions in dealing with the situation. Debates are
usually focused on politics and the law. However, behind the debates are more
fundamental ethical questions which are not always given specific attention they
deserve.
Arguments AGAINST abortion
A growing embryo is considered a human being with heart beats initiating as
early as the 21st day age of gestation.
Unplanned pregnancies may be proved to be wanted later.

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Terminating a pregnancy is being unmerciful to the unborn child.


If the mother has financial difficulty raising the child after giving birth
choosing adoption is an alternative that would honor the babys right to live.
Abortion presents life-threatening complications and death. These
complications include infection, sepsis and recurrent miscarriages.
The woman may suffer from serious psychological impairment (depression
and guilt) after abortion.

Arguments IN FAVOR of abortion


The life of the baby depends on the mothers health and it would be best for
the mother to choose for herself either she wants the baby or not.
The mother is the one who will be going through the actual labor, continuing
pregnancy and giving birth to the baby. In addition to that she will be the one
to parent the child together with her daily life obligations and responsibilities.
Thus, she can decide on what she wants.
Restricting abortions would cause an elevation of the illegal and unsafe
abortion percentage. Once made legal abortion complications will most likely
be prevented as people can receive the care they need during an abortion.
Medical diagnosis & prognosis:
Determining the cause of vaginal bleeding in early pregnancy is essential
for accurate diagnosis.
The vagina & cervix is carefully inspected for cause of possible bleeding.
Ultrasound used todifferentiate between a live fetus & pregnancy loss.
Medical management:
The pregnant mother should contact obstetrician immediately whenever
bleeding occur. Mother may be kept at home bedrest & sexual abstinence may be
prescribed. Occasionally sedatives are ordered to promote relaxation.
If bleeding becomes copious & is accompanied by pains or uterine
contractions, immediate hospitalization, IV therapy for fluid replacement or blood

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transfusions if necessary.
INDUCTION OF ABORTION
Deliberate termination of pregnancy before the viability of the fetus is alled
induction of abortion
The induced abortion may be legal or illegal
In India , the abortion was legalized by medical Termination of Pregnancy Act of
1971, & has been enforced in the year April 1972. The provisions of the act have
been revised in 1975.
MEDICAL TERMINATION OF PREGNANCY
MTP is Medical Termination of Pregnancy. It also called induced abortion. It is the
medical way of getting rid of unwanted pregnancy. Any qualified gynecologist
(MD/DGO) can perform MTP. Any MBBS Doctor, who has obtained training in MTP,
is allowed to perform this procedure. However, MTP should always be performed
at a place recognized by government authorities.
Following are the Indications for Medical Termination of Pregnancy
Medical Termination of Pregnancy is legally permitted up to 20 weeks of gestation.
Pregnancy termination performed in first trimester is safer than in second
trimester since it has fewer complications. It is illegal to perform MTP after
determining sex of the child as Government of India has banned sex
determination.
Complications of Medically Terminated Pregnancy
Medical Termination of Pregnancy(MTP) is a procedure that is carried out under
anesthesia & increases the risk for the procedure. Patient can have lot of bleeding
during & after the procedure. There are high chances of patient having recurrent
abortions. Rarely, patient may not conceive again if infection sets in.
Medical Termination of Pregnancy, 1971 (Act No. 34 of 1971) (10th August
1971)
An Act to provide for the termination of certain pregnancies by registered Medical
Practitioners and for matters connected therewith or incidental thereto.

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Be it enacted by Parliament in the Twenty-second Year of the Republic of India as


follows :Short title, extent and commencement
(1)This Act may be called the Medical Termination of Pregnancy Act, 1971.
(2)It extends to the whole of India except the State of Jammu and Kashmir.
(3)It shall come into force on such date as the Central Government may, by
notification in the Official Gazette, appoint.
Definitions- In this Act, unless the context otherwise requires, (a)guardian means a person having the care of the person of a minor or a
lunatic;
(b)lunatic has the meaning assigned to it in section 3 of the Indian Lunatic Act,
1912 ( 4 of 1912);
(c)minor means a person who, under the provisions of the Indian Majority Act,
1875 ( 9 of 1875), is to be deemed not to have attained his majority;
(d)registered medical practitioner means a medical practitioner who possesses
any recognized medical qualification as defined in clause (h) of section 2 of the
Indian Medical Council Act, 1956, (102 of 1956), whose name has been entered in
a State Medical Register and who has such experience or training in gynaecology
and obstetrics as may be prescribed by rules made under this Act.
When pregnancies may be terminated by registered medical
practitioners(1)Notwithstanding anything contained in the Indian Penal Code (45 of 1860), a
registered medical practitioner shall not be guilty of any offence under that Code
or under any other law for the time being in force, if any pregnancy is terminated
by him in accordance with the provisions of this Act.
(2)Subject to the provisions of sub-section (4), a pregnancy may be terminated by
a registered medical practitioner, (a) here the length of the pregnancy does not exceed twelve weeks if such
medical practitioner is, or

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(b) Where the length of the pregnancy exceeds twelve weeks but does not exceed
twenty weeks, if not less than two registered medical practitioner are, of opinion,
formed in good faith, that (i) the continuance of the pregnancy would involve a risk to the life of the
pregnant woman or of grave injury to her physical or mental health; or
(ii)there is a substantial risk that if the child were born, it would suffer from such
physical or mental abnormalities to be seriously handicapped.
Explanation 1- Where any pregnancy is alleged by the pregnant woman to have
been caused by rape, the anguish caused by such pregnancy shall be presumed
to constitute a grave injury to the mental health of the pregnant woman.
Explanation 2- Where any pregnancy occurs as a result of failure of any device
or method used by any married woman or her husband for the purpose of limiting
the number of children, the anguish caused by such unwanted pregnancy may be
resumed to constitute a grave injury to the mental health of the pregnant woman.
(3)In determining whether the continuance of a pregnancy would involve such risk
of injury to the health as is mentioned in sub-section (2), account may be taken of
the pregnant womens actual or reasonable foreseeable environment.
(4)(a)No pregnancy of a woman, who has not attained the age of eighteen years,
or, who, having attained the age of eighteen years, is a lunatic, shall be
terminated except with the consent in writing of her guardian.
(b)Save as otherwise provided in clause (a), no pregnancy shall be terminated
except with the consent of the pregnant woman.
4. Place where pregnancy may be terminated- No termination of pregnancy
shall be made in accordance with this Act at any place other than (a) a hospital established or maintained by Government, or

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(b) a place for the time being approved for the purpose of this Act by
Government.
Sections 3 and 4 when not to apply(1) The provisions of section 4, and so much of the provisions of sub-section (2) of
section 3 as relate to the length of the pregnancy and the opinion of not less than
two registered medical practitioners, shall not apply to the termination of a
pregnancy by a registered medical practitioner in a case where he is of opinion,
formed in good faith, that he termination of such pregnancy is immediately
necessary to save the life of the pregnant woman.
(2) Notwithstanding anything contained in the Indian Penal Code (45 of 1860), the
termination of a pregnancy by a person who is not a registered medical
practitioner shall be an offence punishable under that Code, and that Code shall,
to this extent, stand modified.
Explanation- For the purposes of this section, so much of the provisions of
clause (d) of section (2) as relate to the possession, by a registered medical
practitioner, of experience or training in gynaecology and obstetrics shall not
apply.
Power to make rules(1) The Central Government may, by notification in the Official Gazette, make
rules to carry out the provisions of this Act.
(2) In particular, and without prejudice to the generality of the foregoing power,
such rules may provide for all or any of the following matters, namely (a) the experience or training, or both, which is registered medical practitioner
shall have if he intends to terminate any pregnancy under this Act; and
(b) Such other matters as are required to be or may be, provided by rules made
under this Act.
(3) Every rule made by the Central Government under this Act shall be laid, as
soon as may be after it is made, before each House of Parliament while it is in
session for a total period of thirty days which may be comprised in one session or
in two successive sessions, and if, before the expiry of the session in which it is so
laid or the session immediately following, both Houses agree in making any
modification in the rule or both Houses agree that the rule should not be made,

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the rule shall thereafter have effect only in such modified form or be of no effect,
as the case may be; so, however, that any such modification or annulment shall
be without prejudice to the validity of anything previously done under that rul
Nursing management
Nursing assessment:
The nurse must obtain a detailed accurate history including length of
gestation, onset, durtation & intensity of the bleeding episode. Describe the
quantity of bleeding in amounts.
Observe presence, nature & location of pains.
Assess blood loss i.e. weighing perineal pads before & after use & then
substracting to find the difference.
Observe pads for any tissues to ascertain whether the abortion is complete.
Observe for signs of shock, syncope.
Nursing Diagnosis:
Anxiety related to uncertainty of pregnancy outcome
Fluid volume deficit related to excessive blood loss from spontaneous
abortion
Anticipatory grieving related to actual or threatened loss of pregnancy
Pain related to uterine contractions
Risk for infection related to retained products of conception
Situational low self esteem related to inability to carry pregnancy to term
successfully.
Nursing interventions are based on the type of abortion, prognosis & identified
nursing diagnosis
Complete bed rest & restriction of activities
Well balanced diet
Inspection of perineal pads
Explanations to mother regarding prognosis

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Monitor mothers status i.e. vital signs, amount of bleeding, comfort level,
facilitate diagnostic tests.
Psychosocial support
She may express guilt & blame. So verbalization o
1. Nursing Diagnosis : Risk for fluid volume deficit r/t maternal bleeding
Nursing Interventions
Report any tachycardia, hypotension, diaphoresis, or pallor, indicating
hemorrhage and shock.
Draw blood for type and screen for possible blood administration.
Establish and maintain an IV with large-bore catheter for possible
transfusion and large quantities of fluid replacement.
2. Nursing Diagnosis : Anticipatory grieving r/t loss of pregnancy, cause of
abortion, future childbearing
Nursing Interventions
Assess the reaction of patient and support person, and provide information
regarding current status, as needed.
Encourage the patient to discuss feelings about the loss of the baby include
effects on relationship with the father.
Do not minimize the loss by focusing on future childbearing; rather
acknowledge the loss and allow grieving.
Providing time alone for the couple to discuss their feelings.
3. Nursing Diagnosis : Risk for infection r/t dilated cervix and open uterine
vessels
Nursing Interventions
Evaluate temperature q 4H if normal, and every 2H if elevated.
Check vaginal drainage for increased amount and odor, which may indicate
infection.
Instruct on and encourage perineal care after each urination and defecation
to prevent contamination.
4. Nursing Diagnosis : Acute pain r/t uterine cramping and possible procedures

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Nursing Interventions
Instruct patient on the cause of pain to decrease anxiety.
Instruct and encourage the use of relaxation techniques to augment
analgesics.
Administer pain medication as needed and as prescribed.
5. Nursing Diagnosis : Knowledge deficit r/t signs and symptoms of possible
complications
Nursing Interventions
Teach the woman to observe for signs of infection (fever, pelvic pain,
change in character and amount of vaginal discharge), and advise to report
them to provider immediately.
Deal with clients anxiety.
Present information out of sequence, if necessary, dealing first with material
that is most anxiety producing when the anxiety is interfering with the
clients learning process.
Teach client of the complications for a mother has reason to be especially
worried about her infants health.

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