Clinical Varieties of Abortion

OBSTETRICS
Lecture: 20.
fifth Year Medical College.
Lecturer: Professor Layla Abdul Amir.

Clinical Varieties of Abortion
Threatened abortion:
There will be bleeding into the choriodecidual space but not sufficient to kill the embryo, so the patient present with mild vaginal bleeding. Mild or negligible pain.
On examination:
1. Size of uterus = expected size at that time.
2. Bleeding is mild to moderate.
3. Cervix is not dilated.
4. No cervical excitation.
5. No pelvic mass.
Treatment:
1. Intercourse is forbidden, all pads & anything passed should examined.
2. Admit to hospital.
3. Pregnancy test.
4. Ultrasound to confirm viability.
5. General investigation include blood group, P.C.V, G.U.E, F.B.S.
6. Diazepam 2.5 mg and folic acid 5 mg/day.
Inevitable abortion:
The patient present with:
1. Sever bleeding (bright red) with clot.
2. Sever pain like labour pain (uterine contraction become rhythmic and strong).
3. We may receive the patient with hypovolemic shock.
Differential diagnosis of inevitable abortion:
a. Ectopic pregnancy.
b. Hydatidiform mole.
In all 3 present with pain, vaginal bleeding and amenorrhea.
4. Cervical dilatation.
5. Tender contracted uterus.

Treatment:
Admit the patient to hospital and prepare blood. If the abortion is not quickly completed or if haemorrhage become sever, so the contents of uterus removed by curettage. If bleeding is heavy, give ergotamine 0.5 mg. also analgesics as 100 mg pethidine.
Complete abortion:
Mean products of conception have been expelled (intelligent patient bring it with them). Usually:
1. Bleeding is slight and pain is absent.
2. Uterus is smaller than the period of amenorrhea suggest.
3. Cervix is closed.
Treatment:
Assurance and the patient be warned that if pain or bleeding recurs or if she develop fever, this suggest retained product of conception.
Incomplete abortion:
Means part has passed (fetus) and part has been retained (placenta). So patient present with:
1. History of passing clot or fleshing material.
2. Moderate bleeding.
3. Uterus is bulky and tender.
4. Cervix is open.
Treatment:
1. Prevent infection.
2. Control bleeding.
3. Obtaining empty and involuted uterus.
So uterus evacuated under general anaesthesia in theater. In some cases bleeding continue for several weeks (3-4 wk) and uterus remain enlarged and so surgical evacuation and with histological examination in indicated.
Risks of incomplete abortion:
1. Bleeding.
2. Sepsis.
Septic abortion:
This can complicated any type of abortion as: incomplete, complete, inevitable, threatened or missed… etc. but most commonly complicated illegally-induced abortion.
Micro organisms: Staphylococcus aureus, Coliform bacteria, Bacteriods organisms and Clostridium welchii.
The most dangerous are Gram negative. Lethal cases of infection with ?-haemolytic Strept. Group A.
Sometime the micro organism invade the blood stream ? bacteraemia and septicemia.
Infection depend on:
1. Immunity of the patient.
2. Virulence of micro organism.
3. Injury like cervical tear or uterine perforation.
Clinical features:
1. Tachycardia.
2. Rapid pulse rate.
3. High temp.
4. Rigor.
5. Abnormal vaginal discharge (if purulent = pyogenic M.O. infection) and if mixed with blood = incomplete evacuation of uterus and if foul and frothy = infection with Cl. welchii.
6. Leucocytosis (mainly PMN).
Examination:
1. Abdominal rigidity.
2. Uterus is bulky, tender and subinvolute.
3. Cervix is open.
4. Purulent vaginal discharge mixed with blood.
5. Signs and symptoms of peritonitis as diarrhea.
Treatment:
I. Admit to hospital and investigations are done ? B.P, W.B.C differential, Bl. Group & Rh, G.U.E, blood urea and electrolytes and prepare blood for patient.
II. Good hydration ? anorexic & tired patient so give I.V.F.
III. Use of antibiotics ? cephradine 250-500 mg every six hours + metronidazole 500 mg. ? given intravenously if patient has vomiting.
If infection with Cl. welchii Rx. is:
1. Surgical removal of retained placenta.
2. Blood transfusion.
3. Massive dose of crystalline penicillin + anti-gas gangrene serum.
IV. Observation ? Close observation because patient may pass into endotoxic shock, so we do chart Rx. vital signs, temp., pulse rate, B.P, respiration, WBC count and bleeding.
V. Blood transfusion ? If there is anemia and it is sever.
VI. Surgical intervention ? After 12 hr. from the use of antibiotics I.M. or I.V.
VII. Laparotomy indicated ?
1. Lacerated vaginal vault.
2. Perforation of uterus.
3. Gas under diaphragm in X ray.
4. Sign of free fluid in peritoneal cavity by using syringe.
Missed abortion:
Means embryo dies or fails to develop and the gestational sac is retained in uterus for weeks or months.
Clinical features:
1. Signs & symptoms of pregnancy regressing (as N & V, enlargement of breast and abdomen).
2. Absent fetal movements.
3. Brownish vaginal discharge.
Examination:
Size of uterus is smaller than the expected date of gestation and absent fetal heart sound.
Investigation:
1. Pregnancy test remain equivocal for weeks.
2. Ultrasound ? non-viable fetus.
3. Send for ? bl. group & Rh, Hb, G.U.E, F.B.S, S. fibrinogen, blood urea & S. creatinine.
Treatment:
All missed abortion expelled spontaneously, but not wait more than 3 weeks because of risk of hypofibrinogemia.
So treatment depends on size of uterus ?
If < 12 wk ? dilatation and curettage = surgical method.
If > 12 wk ? I.V. pitocin = medical method.
If all fail ? hysteratomy.

Complication of missed abortion:
1. Uterine perforation.
2. Anaerobic media in the uterus.
3. Hypofibrinogemia.
Recurrent abortion:
The occurrence of three successive abortion. usually the cause is recurrent or persistent as: hepatitis, endocrine disease, cervical incompetence.
Treatment:
1. Try to know the cause.
2. Psychological support and encouragement.
3. Rx local disease if fibroid = myomectomy, if cervical incompetence = Shirodkar suture.
4. Use of hormone as twice-weekly intramuscular injections of 17-?-hydroxy progesterone hexanoate (proluton Depot) 250 mg.