Obstetrics and Gynecology/Abortion

The term abortion is used by the lay person to refer to an elective termination of pregnancy. Medical staff working in the field of obstetrics use this term to describe miscarriage before 24 weeks gestation and is also referred to as spontaneous abortion. There are different types of spontaneous abortion and the importance of diagnosis cannot be underestimated as each is managed in a different way. The physician dealing with a woman who has presented with spontaneous abortion must choose his/her words carefully when discussing the diagnosis with the patient. This is already a very stressful time for such patients and the term "abortion" used inappropriately may cause this stress and anxiety to be unduly exasperated. Therefore, the term "miscarriage" will be used in place of the word "abortion" for the rest of this article.

The risk Factors for spontaneous Abortion are:
 * Increasing maternal age
 * Increase in parity
 * Interval of pregnancies outside the range of 12-36 months
 * Previous
 * Smoking, alcohol and radiation

Threatened Miscarriage
Threatened miscarriage is defined as vaginal bleeding before 20 weeks gestation in the presence of a viable fetus. One in five pregnancies will present in this manner and these pregnancies are 2.6 times more likely to result in complete miscarriage.

Clinical Features
History:
 * Slight blood loss - fresh blood with clots or brown staining
 * Little or no pain
 * Fetal movements may be present
 * No products of conception have been passed

Examination:
 * Uterine size normal for dates
 * Cervix closed
 * Fetal heart sounds present
 * Fetal movements may be present

Investigation:
 * Positive pregnancy test
 * Positive ultrasound scan

Management
Unfortunately, there is no medical treatment indicated. Management involves bed rest if bleeding recurs and anti-D if indicated. Prognosis can be assessed with further ultrasound scans.

Inevitable Miscarriage
In inevitable miscarriage, the cervix has begun to open and some products of conception have passed, therefore, the pregnancy cannot be saved and miscarriage is inevitable.

Clinical Features
History:
 * Heavy Bleeding getting worse
 * Severe colicky abdominal pain
 * Products of conception may have passed

Examination:
 * Cervix is open
 * Products of conception may be passing through the os

Management
Medical
 * IV infusion if bleeding is severe
 * Remove products from os
 * Syntometrine 1ml intramuscularly PRN

Surgical
 * Evacuate uterus under general anaesthetic

Complete Miscarriage
This is defined as the return to normal uterine size after the passage of all products of conception and normally occurs before 8 weeks gestation.

Incomplete Miscarriage
This is most common between 8 and 14 weeks gestation. All the products of conception have not been passed and the patient requires evacuation of the retained products of conception.

Clinical Features
History:
 * Heavy Bleeding getting worse
 * Severe colicky abdominal pain
 * Products of conception may have passed

Examination:
 * Cervix is open
 * Products of conception may be passing through the os

Management
Medical
 * IV infusion if bleeding is severe
 * Remove products from os
 * Syntometrine 1ml intramuscularly PRN

Surgical Abortion
 * Evacuate uterus under general anesthetic

Missed Miscarriage
A missed (or silent) miscarriage is the spontaneous abortion of a pregnancy in the absence of vaginal bleeding. In essence, the fetus is dead in utero.

Clinical Features
History:
 * No fetal movements
 * No symptoms of pregnancy

Examination
 * Uterus smaller than dates suggest
 * No fetal movements
 * No fetal heart sounds

Investigations
 * Ultrasound negative for fetal heart movement

Management
Evacuate uterus

Septic Miscarriage
This is a uterine infection of the retained non-viable products of conception following an incomplete miscarriage. An attempt at an illegal termination of pregnancy (back-street abortion) should be suspected.

Clinical Features
History
 * Pain
 * Fever

Examination
 * Pyretic
 * Open cervix with discharge

Investigations
 * Blood cultures

Management
IV antibiotics, fluids and curretage.

Patient help
If you or someone you know has been affected by any aspect of this topic, help and support is available online here:


 * | The Miscarriage Association UK
 * | The Mayo Clinic