ABORTION

DEFINITION

It is the termination of pregnancy before gestation of viability which in Ghana is 28 weeks OR it

is the expulsion or extraction of a foetus (embryo) weighing less than 500g equivalent to
approximately 20-22 weeks of gestation (WHO 1997)..

TYPES

Types of abortion include spontaneous (threatened, inevitable, incomplete, complete, septic,

missed) and induced (therapeutic and criminal)

The incidence of spontaneous abortion (miscarriage) has been estimated at about 20% of all
pregnancies

CAUSES

Causes include

Maternal: infections and infestations, medical disorders, environmental factors, uterine

abnormalities.

Foetal: Genetic abnormalities, intrauterine infections

Immunological: Failure of mother’s immune system to recognize the foetus

The standard management will depend on the type of abortion. Below is case of missed
abortions for which a standard management would include taking a detailed history, thorough
examination including a speculum examination.

The following investigations too should be done:

Full blood count, Blood grouping and cross matching (GXM), Ultrasound scan, Rhesus
determination, Blood film for malaria parasites, Urine routine examination (R/E) and culture
and sensitivity(C/S).

TREATMENT

1. Resuscitation as necessary-IV fluids, blood transfusion

2. Counseling
3. Bed rest/pelvic rest(especially for threatened abortion)
4. Antibiotics triple regimen(e.g. cephalosporin+gentamycin+metronidazole)
5. Administration of oxytocics(for missed abortion, intravaginal prostaglandins should be
administered followed by oxytocin to expel uterine contents)
6. Evacuation of retained products of conception
7. Rh(D) negative women should be given antiD (Rh) immunoglobulin 250munits(150mg)
within 72 hrs
8. Put on antibiotics cover after evacuation
9. Counseling and psychological support to abstain from coitus for at least 2 weeks

Discharge home on haematinics

Review in two weeks.

12/01/12

10:01am

NAME: Appiah Elizabeth

AGE: 27 yrs

RESIDENCE: Russian bungalow

PARITY: G3P1A+1d

LAST MENSTRUAL PERIOD (LMP): 24/10/11

EXPECTED DATE OF DELIVERY (EDD): 31/7/12

ESTIMATED GESTATIONAL AGE (EGA):

PRESENTING COMPLAINT (PC): Bleeding per vagina-1/7

Lower abdominal pain-1/7

History of presenting complaint: patient has been well until 4 days ago prior to presentation in the
morning whilst doing her household chores she felt wet in the vagina. On checking she had spotting
vaginal bleeding. According to her it was unprovoked (trauma or coitus). The bleeding stopped within
some few hours so she did not do anything. It was the next morning she noticed she had the bleeding
again. This time it was heavy (she is already used 2 pads which were soaked and had associated clots
before reporting here) with an associated lower abdominal pains and so she decided to report here to
be managed.

On direct questioning: complains of dizziness, palpitation, easy fatigability and fever, vomiting (5 times
on reporting, it was watery and had no blood stains), loss of appetite, and headache

Cardiovascular system: no dyspnoea, no orthopnoea

Respiratory system: no cough, no chest pain

Gastrointestinal system: complains of constipation but no diarrhoea

Genitourinary system: no dysuria, no frequency of micturition, no urgency

Central nervous system: nil

Musculoskeletal system: There is waist knee and pain

Past medical history: 2 previous admissions on account of malaria and a caesarian section on account of
postdatism, no haemotransfusion

Chronic diseases- no hypertension, no diabetes mellitus, no Asthma, no sickle cell disease

Drug history: on antenatal medication, multivitamin

Family history: no Hypertension, no diabetes mellitus, no Asthma, no sickle cell disease

Gynaecological history: Menarche-cannot tell

Menstrual-6/30

Use at least three pads daily which are Flooded, no intermenstrual bleeds, no postcoital bleeds, no
dyspareunia, complains of vaginal discharge and itching. Does not use modern method of
contraception. Has not been diagnosed of any breast or cervical lesions and does not know about
the existence of such services.

Past obstetric history: she is G3P1A+1D. 1st pregnancy was 6yrs ago

Booked at 3 months. Antenatal attendance was regular. Quickening at 5 months

Pregnancy was carried beyond term for 4 weeks. She was admitted to Tamale Teaching Hospital
and a caesarian section was done for her. Baby was admitted to Neonatal Intensive Care Unit on
account of torn cord for about 1 week.

2nd pregnancy was 1 year

She did not book. She aborted spontaneously at 8 weeks of gestation. When she reported here
at Tamale Teaching Hospital they said her uterus was empty so no evacuation was done for her.

For her Index pregnancy: she booked at 7 weeks. Antenatal investigations were done. She has been
well until 4 days ago prior to presentation she noticed she was bleeding per vagina and therefore
reported to Tamale Teaching Hospital

On examination: no Pallor, no Jaundice, Hydration is fair, profuse sweating, cold extremities, no pedal
oedema, afebrile
Chest: clinically clear

Cardiovascular system: Pulse 110bpm, regular, good volume

Blood pressure: 120/80mmHg

Heart sounds: S1+S2+ o

Abdomen: Soft and tender at the suprapubic region. Slight guarding, no organomegally

Speculum Examination/Vaginal Examination: posterior fornix was bulging, Cervix was central, 0.5 cm
dilated, firm and long, adnexal tenderness, cervical excitation and no tenderness

Impression: ? Ectopic pregnancy

Rule out Threatened abortion

Urinary tract infection

Malaria

Plan+ Medical officer

1. Grouping and cross matching

2. Intravenous fluids-Normal Saline-1L
3. Pelvic Ultrasound scan
4. Full blood count, Blood for malaria parasites , Sickling
5. Urine Routine examination, culture and sensitivity
6. Supp diclofenac 100mg x bd x3/7
7. Admit to Gynaecologic ward

12:00pm Review + Dr. Kolbilla

Scan done: viable intrauterine sac

Gestation date- 8 weeks + 4 days

Cervix closed

: ? Threatened abortion

Urinary tract infection

PLAN

1. Bed rest
2. Pelvic rest
3. IM Pethidine 100mg start
 4. Supp Diclofenac 100mg bd x3/7
5. IV Cefuroxime 750mg x bd x 48hrs
6. Intravenous-Normal Saline-1L x 24hrs
7. Admit to gynaecology ward

12/01/12

5:49pm

Patient complains of Per vagina bleed and headache. No complaint of Lower abdominal pain, chest
pain, dysuria

Examination: Not pale

Blood pressure 130/90mmHg

Temperature 36.7⁰C

Pulse 84bpm, regular

PLAN

1. Continue with analgesics and IV fluids

2. When stable do speculum exam
3. Patient to apply clean pads
4. Monitor Blood pressure, Pulse and temperature
5. Pelvic rest

13/01/12 Case Summary

27yrs old G3P1A (by c/S)+ 1A(1yr ago) at EGA of 8w+5d(scan at 8w+4D) presented yesterday with bleeding
per vaginum associated with lower abdominal pain, headache, chills

: Threatened abortion/Urinary tract infection

Examination: Afebrile, not pale, hydration fair

Blood pressure-120/80mmHg

Pulse-100bpm

Abdomen

Soft

Suprapubic tenderness

No masses palpable
Vaginal Examination:

Cervix central

Os closed

Ultrasound scan with senior colleague showed an intrauterine gestation sac

Medication

 IV Cefuroxime 750mg bd
 IV Normal saline-1L
 Pelvic rest

Plan + Dr. Soale

 Urine Routine examination+ Culture and sensitivity

 Malaria parasites, Full blood count
 Review with labs

14/01/12 Review

: Threatened abortion

Urinary tract infection/ Malaria in cyesis

Complain of Lower abdominal pain

Chills

On direct questioning: complains of fever, headache, and dysuria but no bleeding per vaginum, no
vomiting

Examination: warm, not pale, hydration fair

Abdomen: soft, suprapubic tenderness

2KO, LO, SO

Vulva pad-not blood stained

Lab

Leucocytes - +

Protein - Trace

Nitrate - Negative
 PLAN

 Tb Cefuroxime 500mg bd x 7/7

 Tb Coarthem 480/80mg bd 3/7
 Inj Buscopan 40mg st
 Pelvic rest
 Continue treatment

Ultrasonography shows RPOC

Imp

Missed abortion

15/1/12 Review

7.05am

: missed abortion

Vagina cleaned and 200mcg of Tb Cytotec inserted into the posterior fornix

PLAN

 Review at 1.35pm
 Continue treatment

Review

2.00pm

Vaginal examination: OS cervix; finger tip dilated,

200mcg of Cytotec inserted into the posterior fornix

Next review at 6pm

16/1/12 Evacuation of uterus Note

Operation: Evacuation of uterus

Indication: Retained Products of Conception secondary to missed abortion

Findings: Retained Products of Conception non-offensive

Surgeon: Dr. Koomson

Procedure
 Under aseptic condition, patient was placed in lithotomy position and cleaned, then a sterile cuscos
speculum was introduced to visualize the cervix and volselum forceps was used to hold the anterior lip.
The Retained Products of Conception (RPOC) was removed by Manual Vacuum Aspiration. Findings are
as above.

Post-operative condition: satisfactory

Post-operation management

1. Supp Diclofenac 100mg bd x 3/7

2. Tab Amoxiclav 625mg bd x 5/7
3. Tab Flagyl 400mg tid 5/7

16/01/12 Review + Dr. Hawa

Evacuation of uterus done this morning

Complains: nil

Scanty Bleeding per vaginum

On direct questioning: no dizziness, no palpitation, no fever ,no chills, no headache

Examination

Central Nervous System: nil

Abdomen: nil

Cardiovascular system: nil

Genitourinary system: nil

Chest: nil

Vulvar pad-blood stained

No active Bleeding per vaginum noticed

PLAN

 Discharge on oral medication today

 Review in 2/52 with Ultrasonography report

Management appraisal

Patient was managed well