DISCUSSION

ABORTION

DEFINITION
The World Health Organization define abortion as pregnancy termination before 20 weeks
gestation or with a fetus born weighing < 500 g.
In the Clinical Practice Guidelines published by the Philippine Obstetrical and
Gynecological Society (2015), the lower limit of viability is presently recognized to be 24 weeks
age of gestation but this may well change with progress in maternal-fetal and neonatal care.
Termination prior to 13 weeks age of gestation (AOG) is first trimester or early pregnancy loss
and after 13 weeks but before 20-24 weeks, it is termed second trimester or late pregnancy loss.
Categories
Spontaneous abortion. This category includes threatened, inevitable, incomplete,
complete, and missed abortion. Septic abortion is used to further classify any of these that are
complicated further by infection.
Recurrent abortion. This term is variably defined, but it is meant to identify women with
repetitive spontaneous abortions so that an underlying factor(s) can be treated to achieve a viable
newborn.
Induced abortion. This term is used to describe surgical or medical termination of a live
fetus that has not reached viability.
The history of our patient reveals that she belongs to the spontaneous abortion category.
There was no history of induction to terminate her pregnancy. The patient is presently on her
second gestation hence cannot be classified as recurrent abortion.
The following table summarizes the characteristics of the different types of spontaneous
abortion.
Table 1. Characteristics of Different Types of Spontaneous Abortion

History

Vaginal Passage of Abdominal

Physical Findings Ultrasound
Bleeding Products Cramps
Imaging
of and other
conception symptoms

Threatened Light Absent Lower Closed Cervical Os Visualized

Bleeding Abdominal; Uterus softer than Fetal heart
Painful normal Activity
Uterus corresponds
to dates

Inevitable Heavy Absent Lower Open Cervical Os; FH Activity

Bleeding Abdominal; Ruptured Membrane may not be
very painful Tender Uterus visualized
Uterus corresponds
to dates

Incomplete Heavy Present; Lower Open Cervical Os Retained

Bleeding with Abdominal; Uterus softer than Products;
retained painful normal No Fetal Heart
tissues Uterus corresponds Activity
or smaller than dates

Complete Light Present; Present; Closed Cervical Os Empty Uterus

Bleeding complete Light Uterus softer than
passage cramping normal
/may not be Uterus smaller than
painful dates

Missed May be Absent Asymptomatic Closed Cervical Os No Fetal Heart

present at early weeks Uterus smaller than Activity
dates

Septic Bleeding May or Lower Open or Closed May or may

may not Abdominal Cervix not have fetal
be Cramping and heart activity
Fever
 The patients signs and symptoms, along with the history and physical examination led us
to the conclusion that she went through a threatened abortion. There was no passage of the
products of conception, ultrasound revealed fetal heart activity and contractions and vaginal
spotting ceased on the 6th hour of medication.
RISK FACTORS
Spontaneous expulsion is typically preceded by embryonic or fetal demise in early
miscarriage so that determining the cause of death uncovers the cause of pregnancy loss. Most first
trimester miscarriages are due to chromosomal abnormality fetal factor. For the maternal factors,
advanced maternal age, previous spontaneous abortion, and maternal smoking are the best
documented (POGS, 2015). In the case of our patient, there were no risk factors that would
contribute to the threatened abortion. Other maternal factors include the following:
1. Infections (Chlamydia trachomatis)
2. Medical Treatment
- A pregnancy with an intrauterinedevice (IUD) in situ has an increased risk
of abortion andspecifically of septic abortion; with the newerIUDs,
Moschos and Twickler (2011) reported that only 6 of 26intact pregnancies
aborted before 20 weeks
- Radiation/Chemotherapy
- Uncontrolled DM
- Thyroid Disorders
- Extremes of nutritionsevere dietary deficiency and morbidobesityare
associated with increased miscarriage risks.
3. Uterine defects
4. Immunologic Factors anti-phospholipid antibody syndrome
5. Heredofamilial Disease - Inherited Thrombophilias
6. Environmental Exposure
- DDTdichlorodiphenyltrichloroethanemay cause excessive
miscarriage rates
- arsenic, lead, formaldehyde, benzene, and ethylene oxide can also cause
early miscarriages
7. Social and Behavioral Factors
- Cigarette Smoking can cause early pregnancy loss by a number of
mechanisms
- Excessive caffeine consumptionnot well definedhas been associated
with an increased abortion risk. There are reports that heavy intake of
approximately five cups of coffee perdayabout 500 mg of caffeine
slightly increases the abortion risk
- Heavy and Regular consumption of alcohol
DIAGNOSIS
The diagnosis is usually made by correlating clinical with ultrasound findings. Abortion is
classified based upon the location of the products of conception and the degree of cervical dilation,
which is determined mainly by pelvic examination, although pelvic ultrasound helps the define the
location of the products of conception.
These findings on transvaginal ultrasound are diagnostic of pregnancy loss (except for
threatened abortion):
1. Crown-rump length 7mm and no cardiac activity.
2. Mean gestation sac diameter 25mm without embryo.
3. Absence of embryo with cardiac activity 2 weeks after a prior scan that found
gestational sac without yolk sac.
4. Absence of embryo with cardiac activity 11 days after a prior scan that found
gestational sac with yolk sac
In this case, we were able to visualize fetal heart activity through ultrasonography.
Management of Spontaneous Abortion

Expectant, medical or surgical management are reasonable options unless there is serious
bleeding or infection.

Surgical evacuation is acceptable as standard and traditional practice. Expectant

management is also an acceptable alternative but it carries a higher risk of incomplete miscarriage
and bleeding, and subsequent need for surgical emptying of the uterus. Expectant management of
spontaneous incomplete abortion has failure rates as high as 50 percent.

The basis for expectant management was demonstrated in a study that more than 80% of
women with a 1st trimester spontaneous abortion have complete natural passage of tissues within
2-6 weeks with no higher complication rate than that from surgical intervention. Obviously,
surgical evacuation is the management of choice in women experiencing spontaneous abortion
with unstable vital signs, heavy vaginal bleeding or uncontrolled bleeding, or evidence of
infection. Curettage usually results in a quick resolution that is 95-100 percent successful.
Gynecological infection after surgical, expectant, and medical management of 1st trimester
miscarriage is low (2-3%) and no evidence exists of a difference by the method of management as
evidenced by the miscarriage treatment trial. However, significantly curettage occurred after
expectant management and medical management than after surgical management.
Antibiotics are indicated management where these are signs of infection in a case of
incomplete abortion, especially when unsafe abortion is suspected.
Threatened Abortion
Analgesia will help relieve discomfort from cramping. If uterine evacuation is not
indicated, bed rest is often recommended but according to POGS CPG 2015, there is no evidence
to support the prevention of miscarriage. Progesterone on the other hand reduces the rate of
spontaneous miscarriage. In cases in which there is a live fetus, further observation is needed.

The patient was still advised bed rest without toilet privileges. Dihydrogesterone was
started along with isoxsuprine. 6 hours into the patients admission, the vaginal bleeding stopped
and there were no longer complaints of crampy abdominal pain.