An overview of an inevitable abortion explaining the procedures of this condition and also looking at incomplete abortion and complete abortion and treatment of these conditions.

The abortion becomes inevitable if, in addition to the signs described in threatened abortion, the uterine contractions become increasingly painful and strong. And lead to dilatation of the cervix. The patient complains of severe colicky uterine pain, and vaginal examination shows a dilated os with some part of the conception sac bulging through. This sequence may follow signs of threatened abortion, or, more commonly, may occur without warning, the whole process being speeded up. Quite soon after the onset of the symptoms, the abortion occurs, either completely, when all the products of conception are expelled, or incompletely when either the pregnancy sac, or placental tissue remains in the uterine cavity or distends the cervical canal. This last can produce considerable shock, even in the absence of marked haemorrhage.

The majority of patients present with an incomplete abortion. The amount of bleeding may have been considerable, associated with cramp like uterine contractions and the patient claims that she has passed ‘something’. This may mean that all the products of conception have been passed and the uterus is empty or it may mean that only part has been passed. If the obstetrician has not had the opportunity to examine everything that has been expelled, he should consider the abortion to be incomplete.

Unless the patient has aborted completely when seen or the abortion is imminent, she should be transferred to hospital. Should she have bled considerably and be in shock, the emergency obstetric service should be called and blood given. Whilst waiting for the arrival of the ‘flying squad’, morphine 15 mg. or pethidine 100 mg. should be given if the patient is in pain. A sterile vaginal examination must be made, as placental tissue distending the cervix can cause considerable shock. Any tissue in the cervix should be removed with finger or sponge forceps, and if there is any degree of haemorrhage, ergometrine 05 mg. should be given intramuscularly. Once this has been done, the patient’s condition usually improves and evacuation of the uterus can be completed by curettage in a calm and deliberate way when convenient.

In hospital, treatment is conservative only if the abortion is proceeding quickly and with minimal blood loss. On admission, the general condition is assessed and compatible blood obtained. A vaginal examination is carried out and if products of conception are distending the cervix, these are removed with a sponge forceps or the finger. Pethidine 100 mg. or morphine 15 mg. is given to relieve the pain, and ergometrine 025 mg. intravenously to control bleeding.

If the entire products of conception are not rapidly expelled, active intervention is required and the sooner the uterus is emptied the better. Evacuation of the pregnant uterus should be done with care as in unskilled hands damage can easily occur. Under general anaesthesia the patient is examined, and if the cervix is sufficiently dilated to admit a finger, this is used to detach any remnants of placental tissue.

It is by far the safest instrument! Alternatively, a sponge forceps can be used. The sponge forceps is introduced until the tip reaches the endometrium at the fundus, and then the two jaws are opened and closed again whilst rotating the forceps. In this way products of conception are grasped without danger to the myometrium. Finally the uterine cavity is curetted. A large sharp curette, used gently, is safer than a blunt curette used roughly. Towards the end of the operation ergometrine 025 mg. is given intravenously and intramuscularly.

After a complete abortion the bloody discharge diminishes and ceases in about when placental remnants have been left in the uterus, bleeding continues beyond this time and varies in severity from day to day, and may be accompanied by periodic uterine cramps. Examination shows a bulky uterus, with a patulous os. Careful curettage should be performed in these cases, and all tissue examined histologically in case the rare choriocarcinoma is present.

An overview of causes of bleeding in the first trimester and looking at varieties of abortion and threatened abortions plus describing the treatment options and prognosis.

Although abortion accounts for 95 % of cases of bleeding in the first trimester, the rarer causes such as ectopic gestation (1 %), hydatidiform mole (0.2 to 1 %), cervical ‘erosion’ or polyp (1 %) and cervical carcinoma (00.5 %) must be considered in each case.

For descriptive purposes the abortion is classified according to the findings when the patient is first seen, but obviously one kind may change into the next with the passage of time. The following clinical types are recognized:

Threatened abortion, inevitable abortion, incomplete abortion, complete abortion, missed abortion.

Any of the above types, but usually the inevitable or incomplete types, may be complicated by infection, when the term septic abortion is used.

Habitual abortion indicates that the woman has had three or more known successive abortions, and therapeutic abortion indicates that the pregnancy was terminated legally for a specific medical indication. Induced or criminal abortion indicates that the abortion was induced illegally for social reasons.

An abortion is presumed to threaten when a woman who is known to be pregnant develops vaginal bleeding during the first 28 weeks of pregnancy, whether this bleeding is associated with uterine contractions or not A few patients bleed slightly at the time of the first missed period when the trophoblast is implanting deeply, and this is called implantation haemorrhage. It may be difficult to distinguish this type of bleeding from threatened abortion, but in the former the amount is slight, the color bright red, and the bleeding settles quickly.

Threatened abortion is diagnosed by (1) determining that the patient is pregnant; (2) determining that the bleeding is coming from inside the cervix; (3) deciding that the uterine contractions, if present, are only slight and that the cervix is not dilated. It is sometimes advised that a speculum or bimanual examination should not be carried out on a patient threatening to abort, as this may precipitate the abortion or introduce infection. This is bad advice, and provided the examination is done gently no harm will result, and the occasional mistake in diagnosis will be avoided. To avoid infection the speculum should be passed and the bimanual examination performed with attention to aseptic technique.

This is the most important part of treatment, as it increases uterine blood flow and reduces mechanical stimuli. The patient should remain in bed for from 5 to 7 days, or so long as the bleeding is bright red.

The only drugs of any value are mild sedatives such as phenobarbitone, which should be given both to reduce emotional stimuli, and to convince the patient that some treatment is being given. There is no evidence that progesterone, in whatever dosage and by whatever route, is of any value in the treatment of threatened abortion.

If the uterine contractions become strong, analgesics such as pethidine 100 to 150 mg. or morphine 15 mg. may be required.

Since the diagnosis of threatened abortion in many cases is uncertain, it is difficult to say what the outcome will be. Of all patients diagnosed as threatening to abort in the first trimester, 70 to 8070 continue their pregnancy. The character of the bleeding is of some prognostic help. If the bleeding is bright red and rapidly tapers off to brown only 1070 will abort. If the initial loss is brown and this persists 5570 will abort, whilst if the initial brown loss becomes red 6670 of patients will abort. The association of severe uterine contractions increases the likelihood of abortion.

An overview of ovo fetal causes explaining about the causes of defects in conception also the maternal causes and paternal causes plus describing mechanism of abortion.

Careful studies of abortuses show that in about 60 % of cases the ovum is defective and has failed to develop, or the fetus is malformed. In many cases the defect occurs at the time of conception, and chromosome studies of first trimester abortions show that at least 20 % have chromosomal abnormalities. As the defect affects all parts of the ovum, the trophoblast does not implant adequately, and is unable to synthesize progesterone in adequate amounts.

General maternal disease, especially acute fevers, favors abortion perhaps by the transplacental passage of viruses or bacteria, or perhaps due to the general metabolic affects of pyrexia and diminished oxygen release through the placenta.

Local disorders of the genital tract, such as retroversion, myomata and developmental defects were, at one time, considered to be important causes of abortion. It is now known that only when the retroverted uterus is fixed in the pelvis, or when the myomata distort the uterine cavity do these conditions increase the risk. Developmental defects are relatively uncommon, and of them a bicornute uterus may cause abortion, especially after the 12 th week of pregnancy. Another cause of late abortion is cervical incompetence which may be due to a congenital weakness, but is usually due to previous rough dilatation of the cervix. Psychosomatic causes. It is known that environmental stress operating through the cerebrum affects the secretion of substances by the medial eminence of the hypothalamus.

This area is richly supplied with nerves which are in intimate connection with the pituitary portal vessels. These carry the substances which regulate the release of pituitary hormones, which in turn affect uterine function. Stress can therefore affect uterine activity, and may lead to abortion. This is most clearly seen in the patient who habitually aborts, and the only common factor in the success of the many treatments offered is the interest shown in the patient by the obstetrician.

Since the paternal spermatozoa give to the ovum half of its chromosomes, defects may result in abortions. This is difficult to determine, but it is known that some women abort habitually with one partner and on marrying a different man have normal pregnancies. The immediate cause of the abortion is the separation of the ovum by minute haemorrhages in the deoidua. The altered uterine environment stimulates the onset of uterine contractions, and the process of abortion begins.

Before the 8 th week the ovum, covered with villi and some attached decidua, tends to be expelled. If the internal os dilates but the external os of the cervix fails to dilate, the sac may be retained in the cervix.

Between the 8th and the 14th week, the mechanism may be as described, or, more commonly, the membranes rupture expelling the defective fetus but the placenta is only partially separated and protrudes through the cervical os into the vagina or remains attached to the uterine wall. This type of abortion is attended by considerable haemorrhage. After the 14 th week, the fetus is usually expelled, followed by the placenta after an interval. Less commonly, the placenta is retained. Bleeding is not marked and the process of abortion resembles a ‘miniature labor’.

An overview of candida albicans describing the factors of the process and treatment also abortions and induced abortions plus aetiology of spontaneous abortion.

This fungus is a common cause of the vaginal discharge in pregnancy particularly in the diabetic patients, its growth being favored by a high glycogen content of the vaginal cells. It produces a thick cheesy discharge, which tends to form patches adherent to the vaginal wall. If the patch is lifted off, the superficial vaginal epithelium is also lifted exposing the basal layers and multiple haemorrhagic spots. The patient complains of an itchy vaginal discharge and often of vaginal tenderness. Diagnosis is made by examining a smear of the discharge stained with 10 % sodium hydroxide or 1 % methylene blue, when the long branched filaments of hyphae can be seen. Confirmation is obtained in doubtful cases by culturing the discharge in Nickerson’s medium.

Treatment is to paint the vagina with 1 % aqueous solution of gentian violet on alternate days for 2 weeks. This is cheap and effective but stains the patient’s vulval skin, and underclothes, blue. Alternatively the patient should use nystatin pessaries. One is placed as high in the vagina as possible night and morning for 7 days and one each night for a further 14 days.

Abortion means the expulsion of a fetus before viability, which in law is considered to occur at the 28th week of pregnancy. If the expelled fetus weighs less than 500 g. it is an abortus; if between 500 and 999 g. it is an ‘immature infant’. Occasionally the euphemism miscarriage is used, particularly by non medical people as synonymous with abortion, the latter term implying a ‘criminal’ abortion.

About 10 % of all pregnancies terminate as a spontaneous abortion, and a further 10 to 15 % are terminated by an induced abortion. The peak time of spontaneous abortion is between the 6th and 10th week of pregnancy, when 65 % of abortions occur. This has been connected with a reduced progesterone secretion, as at this time the activity of the corpus luteum is waning, and placental production of the hormone has not reached ‘adequate’ levels. The evidence today is that the association is casual and not causal.

The causes of abortion can conveniently be divided into three groups ovo fetal, maternal and paternal causes. In the early weeks of pregnancy, when most abortions occur, ovo fetal factors predominate, but in the later weeks maternal factors are most common and the fetus is often born fresh and apparently normal, although too immature to survive.

An overview of malformations of the uterus explaining about the abnormalities and effects of these also describing vaginal discharges in pregnancy and trichomonas vaginalis.

The uterus and vagina are formed by the fusion of the two Mullerian ducts and the subsequent ablation of the joining septum. Abnormalities may occur if only one Mullerian duct is present, or if the fusion of the two ducts is abnormal, or if the joining septum fails to be absorbed. About 3 %of women have some abnormality of the genital tract and many become pregnant. The commonest abnormalities are the arcuate uterus, the subseptate uterus and the bicornute uterus.

Abortion and premature labor are four times as frequent when the uterus is malformed but the majority of patients go to term. If the uterus is arcuate or subseptate, transverse lie or breech presentation is often found, and the recurrence of one of these malpositions in several pregnancies suggests that a uterine malformation is present.

Vaginal delivery occurs in 80% of cases and Caesarean section is required in 20%. The incidence of retention of the placenta is increased. Labor in these patients should be supervised with great care.

If a longitudinal vaginal septum is found on vaginal examination, it should be left and only removed if it causes delay in the second stage of labor, as the descending fetal head usually displaces it to one side or other.

The vagina is self sterilizing and this property is due to its acidity in which organisms are unable to grow. The acidity is due to the presence of Döderlein’s bacillus acting upon the glycogen in the exfoliated vaginal cells. The glycogen in turn is dependent upon the activity of oestrogen on the cells, causing their growth and maturation. During pregnancy, because of increased oestrogen production, the vaginal acidity potential is increased, but this is largely offset by the increased alkaline mucoid discharge which comes from the ectopic columnar epithelium of the cervix. Thus, although the vagina is too acid for significant bacterial growth the patient notices a vaginal discharge.

This discharge is a mixture of mucoid secretion and a glairy whitish discharge which forms when the mucus coagulates in its passage down the vagina. This is merely an exaggeration of the normal ‘vaginal’ secretion and requires no treatment beyond reassurance. Some patients are particularly sensitive to the presence of a vaginal discharge and for them the vaginal instillation of an acid jelly or any one of a variety of acid vaginal pessaries may be prescribed. Vaginal douching should be prohibited.

Two organisms which are widely distributed and are largely resistant to acidity, grow preferentially in the moist, high carbohydrate atmosphere of the pregnant vagina. These are trichomonas vaginalis and monilia albicans.

This small flagellated protozoon lives in the folds of the vaginal mucosa and causes a greenish yellow, offensive discharge, which consists of trichomonads, leukocytes and contaminating saprophytes the last causing the odor. The vagina is reddened and tender, and may show punctate reddened spots. The patient complains of an intense pruritus and itching just inside the vaginal introitus.

The diagnosis is made by examining a drop of the discharge mixed with a drop of saline, under the low power of the microscope, when the active flagellates will be seen moving about; or by culture in the laboratory. Treatment is by the oral administration of metronidazole mg. 200 three times a day for 10 days. For the theoretical reason that the drug may cause fetal malformations, it should not be used in the first 1 weeks of pregnancy. Vaginal trichomoniasis detected at this time should be treated by using natamycin vaginal pessaries for 20 days.