CASE REPORT

INCOMPLETE ABORTION

dr. Iga Nuryanti – 21075

Internship Islamic Hospital Jakarta, Cempaka Putih

Supervisor : dr. Reno Yovial

Doctor in charge : dr Ribkhi Amalia Putri Sp.OG

 IDENTITY

PATIENT HUSBAND
¡ Name : Mrs. R ¡ Nama : Mr. M
¡ Age : 43 years old ¡ Age : 44 years old
¡ Marital Status : Married (1x)
¡ Marital Status : Married (1x)
¡ Hospitalized : August, 16th 2021
¡ Education : SHS
¡ Assurance : BPJS
¡ Profession : Salesman
¡ Education : SHS
¡ Profession : Housewife ¡ Religion : Islam
¡ Religion : Islam ¡ Address : Pulo Gadung
¡ Address : Cempaka Putih
CHIEF COMPLAINT
Vaginal’s bleeding 3 hours ago

HISTORY OF ILLNESS

Fresh red blood

A total of 2 pads in a day
Blood clots, with a tissue. A size like a cashew
Abdominal cramps
Claimed to be 6 weeks pregnant, HPHT 05/07/2021, Test Pack (+)
History of fever, genital infection, trauma, previous drug consumption was
denied
ANTENATAL HISTORY
ANC since 5 weeks of pregnancy in the midwife
Other drugs consumption except from midwives denied (folic acid)

MENSTRUAL HISTORY
Menarche age 12 years
Regular cycle every 30 days
Lasts for 7 days
2-3x change of sanitary napkins/day
Dysmenorrhea is denied

PREGNANCY AND CHILDBIRTH HISTORY

1. 2014 / Female / 2600 gram / 48 cm / SC / Pertamina Jaya / Breastfeeding
2. 2015 / Incomplete Abortion / Curretage
3. 2017 / Female / 2800 gram / 46 cm / SC / RSIJCP / Breastfeeding
4. 2019 / Incomplete Abortion / Curretage
5. Now
MARITAL HISTORY
First marriage
Been married for 9 years
Age at marriage 34 years old

CONTRASEPTION HISTORY
-

SOSIO-ECONOMIC HISTORY
Patient : Housewife, smokes (-), drinks alcohol (-)
Husband: Salesman, smokes (+), drinks alcohol (-)
Past Medical History

• Incomplete Abortion (2015, 2019)

• HT(-)
• DM (-)
• Immunological disorders (-)
• Psyciatry disorders (-)
• Uterine disorders (-)
• Other disorders (-)

Family Medical History

• HT, DM and other chronical diseases denied

GENERAL EXAMINATION

¡ General condition : Moderate Anthropomethry

¡ Consciousness : Composmentis ¡ Weight before pregnancy : 50 kg
¡ Weight : 51kg
¡ Height :153cm
Vital Sign
BMI 21,3 à normoweight
¡ Blood Pressure : 160/92 mmHg
¡ Heart Rate : 109 x/minute, regular
¡ Temperature : 36,6 °C
¡ Respiration rate : 16 x/minute
¡ Oxygen saturation : 98% room air
PHYSICAL EXAMINATION

¡ Eyes : anemic conjungtiva -/-

¡ Skin : normal
OBSTETRIC STATUS
¡ Head : normal
External examination
¡ Neck : normal
¡ Inspection : Looks a bit convex
¡ Thorax :
¡ Palpation : Ballotement not palpable
Cardio: Heart sound SI-II regular, murmur(-), gallop(-)
Pulmo: vesicular, rh (-), wh(-)
Internal examination
¡ Abd: striae (+), linea nigra(-), Saecarian marks (+)
¡ Inspektion : Bleeding (+)
Ekst: warm(+/+), crt<2s, oedema (-/-)
¡ Inspeculo : -
 TEST RESULTS PARAMETER
Hemoglobin 12.6 L 13.2-17.3g/dl
MCV 78 L 80 – 100 fL
MCH 26 26 – 34 pg
MCHC 33 32 – 36g/dl
LAB 16/8/2021 Leukocytes 9.0 3600 – 11.000
• Limfosit 25 25 – 40 %
• Monosit 8 2–8%
• Eosinofil 2 2–4%
• Basofil 0 0–1%
• Rod Neutrophyls 3 3–5%
• Segment Neutrophyls 67 50 – 70%

Neutrofil Limfosit Rasio (NLR) 3.10 <3.13

Erithrocytes 3.9 3,8 – 5,2 juta
Hematochrite 36 35 – 47 %
Thrombocytes 415 150 – 440 ribu
 Blood Sugar (non fasting) 101 70 – 200 mg/dl

Electrolite
• Natrium 136 135 – 147 mEq/L
LAB 16/8/2021 • Kalium 3.8 3.5 – 5.0 mEq/L
• Chlorida 106 94 – 111 mEq/L

Rapid Test Antigen Negative Negative

Plano Test Positive Negative

THORAX RONTGEN
16/8/2021
WORKING DIAGNOSIS
Incomplete Abortion dd Complete Abortion, G5P2A2 Pregnancy 6weeks

INITIAL TREATMENT
IVFD RL
Ketorolac Injection
Amlodipine 10 mg
Consult to dr. Ribkhi Sp.OG
dr. Ribkhi Sp.OG : dr. kemalasari Sp.P :
HBsAg and Anti HIV Test Non-Isolation room confirmed
BT CT Test
PCR swab
Bedrest
Consult to Sp.P
 ABORTION
Definition
The loss of pregnancy less than 20 weeks gestation either natural or induced

Incidence :
¡ Is the commenest gynaecological & obstetric disorder
• About 15% of clinically recognized pregnancies end in abortion (this rise
to 30% if unrecognized pregnancies are included).
• Most abortions occur between 8 and 12 weeks of pregnancy.

Source : Dugas C, Slane VH. Miscarriage. 2021 Jun 29. StatPearls Publishing;
2021 Jan–. PMID: 30422585.
ETIOLOGY AND RISK FACTOR
¡ Fetal chromosomal abnormalities
¡ Advanced maternal age
¡ Early pregnancy loss history
¡ Alcohol consumption, smoking, and cocaine use.
¡ Several chronic diseases
¡ Infections (cervicitis, vaginitis, HIV infection, syphilis, malaria)
¡ Environmental contaminants (arsenic, organic solvents)
¡ Structural uterine abnormalities (congenital anomalies, leiomyoma,
intrauterine adhesions)

Source : Alves C, Rapp A. Spontaneous Abortion. [Updated 2021 Jul 20].

Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
CLASSIFICATION
According to occurrence:
a. Spontaneous abortion: occurs by itself (not preceded by
mechanical factors / medical.
b. Provocatus abortion: occurs as a result of certain (deliberate)
efforts. Provocatus abortion is divided into 2, namely:
1. Medical abortion: for medical indications (if the pregnancy is
continued, it will endanger the life of the mother.
2. Criminal abortion: illegal without medical indication
Source : Ilmu kebidanan sarwono prawirahardjo. Fourth Edition. 2014.
Publishing : PT. Bina pustaka sarwono prawira
CLASSIFICATION

Spontaneous Abortion
Imminens abortion Insipiens abortion
Initiation of abortions Threatening abortion
Signs and symptoms : Signs and symptoms :
1. Vaginal bleeding 1. Massive vaginal bleeding, sometimes blood
clots come out
2. Uterine ostium is still closed
2. Cervix has flattened
3. Conception is still good in the womb 3. Uterine ostium has opened
The products of conception are still in the
uterine cavity, in the process of expulsion
Source : Ilmu kebidanan sarwono prawirahardjo. Fourth Edition. 2014.
Publishing : PT. Bina pustaka sarwono prawira
CLASSIFICATION

Spontaneous Abortion
Incomplete abortion Complete abortion
Some of the products of conception has came out All products of conception have come out of the
of the uterine cavity and some are left in the uterine cavity
uterine cavity.
Signs and symptoms :
Signs and symptoms :
1. Cervix closes
1.Vaginal bleeding continues even though some of
2. Pregnancy test (-)
the tissue has come out
3. The results of the conception have come out
2. Uterine ostium opens
completely
3. The release of the product of conception
Source : Ilmu kebidanan sarwono prawirahardjo. Fourth Edition. 2014.
Publishing : PT. Bina pustaka sarwono prawira
CLASSIFICATION

Spontaneous Abortion
Missed abortion Habbitual abortion
The embryo has died in a pregnancy before 20
Spontaneous abortion that occurs 2 or more
weeks of gestation and the entire product of
times in a row.
conception is still retained in the womb.
Signs and symptoms :
1. The uterus is not getting bigger
2. Pregnancy symptoms (-)
3. The products of conception are still stuck in the
womb
4. Amenorrhea Source : Ilmu kebidanan sarwono prawirahardjo. Fourth Edition. 2014.
Publishing : PT. Bina pustaka sarwono prawira
CLASSIFICATION

Spontaneous Abortion
Septic abortion Anembryonic pregnancy / Blighted Ovum
Abortion with infectious complications. (lower A pregnancy that does not form an embryo early
sal.genital infection after spontaneous abortion or on even though the gestational sac has formed.
unsafe abortion, products of conception remain
and evacuation is delayed.

Source : Ilmu kebidanan sarwono prawirahardjo. Fourth Edition. 2014.

Publishing : PT. Bina pustaka sarwono prawira
DIAGNOSIS Source : Hendriks E, MacNaughton H, MacKenzie MC. First Trimester
Bleeding: Evaluation and Management. Am Fam Physician. 2019
History
• Vaginal bleeding
• Lower stomach pain
• History of Amenorrhea

Physical examination
Imminent Abortion:
• Internal examination: there is flux (a little), the uterine ostium is closed, the conception tissue is not palpable and
the uterus is large according to gestational age.
Abortion Insipiens
• Internal examination: there is flux, the uterine ostium is open, the tissue of conception is not palpable and the
membranes are intact (possibly protruding).
Incomplete Abortion
• Internal examination: open uterine ostium, palpable tissue of conception (partially out).
Missed Abortion
• Obstetric examination of the uterine fundus is smaller than the gestational age and the fetal heart sound is absent
Septic Abortion
• Vital signs and general status: elevated temperature, rapid pulse, bleeding, and lower abdominal tenderness.
• Internal examination: Fluxus, open cervical analysis and palpable tissue.
DIFFERENTIAL DIAGNOSIS
• Disrupted ectopic pregnancy (GER): abdominal pain, amenorrhea,
vaginal bleeding, USG: extrauterine pregnancy, culdocentesis (+)
• Hydatidiform mole : amenorrhoea, ultrasound snowstorm.
• Ectopic pregnancy : can also cause cramping, vaginal bleeding, and a plateau
or decline in the natural rise of beta-hCG in early pregnancy.
• Cervical pathologies : infectious cervicitis, cervical polyps, ectropion, and
dysplasia. These etiologies should be high on the differential in the setting of
post-coital bleeding.
• Cervical and vaginal trauma
Source : Alves C, Rapp A. Spontaneous Abortion. [Updated 2021 Jul 20].
Treasure Island (FL): StatPearls Publishing; 2021 Jan
 THERAPY
Imminens Abortion
¡ Keep it safe the pregnancy
¡ Avoid sexual intercourse
¡ Bed rest to increase blood flow to the uterus
and reduce mechanical stimulation
¡ If the bleeding stops, monitor the mother's
condition further during antenatal
examinations including monitoring of Hb
levels and serial ultrasound every 4 weeks
¡ If the bleeding does not stop, assess the
condition of the fetus by ultrasound and
assess for the presence of other possible
causes.
¡ Counseling to the patient and her families
regarding discomfort and risk of
miscarriage.
Insipiens Abortion
< 16 weeks, plan to evacuate uterine contents with MVA (Manual Vacuum
Aspiration). If evacuation cannot be carried out immediately:
¡ Ergometrine 0.2 mg IM (repeat after 15 minutes if necessary) or misoprostol
400 g orally (repeat once after 4 hours if necessary).
¡ Plan an immediate evacuation.
> 16 weeks
¡ Wait for the spontaneous expulsion of the products of conception, then
evacuate the contents of the uterus to clear any remnants of conception that
remain.
¡ If necessary, infusion of oxytocin 40 IU in 1 L of intravenous fluids (saline / RL)
at a rate of 40 TPM to assist spontaneous expulsion of products of conception.
¡ Closely monitor the condition of the mother after the procedure.
¡ Counseling to mothers and families regarding discomfort and risk of
miscarriage.
Source : Ilmu kebidanan sarwono prawirahardjo. Fourth Edition. 2014.
Publishing : PT. Bina pustaka sarwono prawira
 THERAPY
Incomplete Abortion Complete Abortion
¡ Light/moderate bleeding < 16 weeks, use finger/ring forceps to ¡ No evacuation required
remove the result of the concession that is sticking out of the
cervix ¡ Observation of mother's condition
¡ Heavy bleeding and < 16 weeks, AVM (sharp curettage if AVM is ¡ If there is moderate anemia give ferrous sulfate tablets
not available). If evacuation cannot be performed immediately, give 600 mg/day for 2 weeks, if severe anemia give
Ergometrine 0.2 mg IM (can be repeated 15 minutes later if
necessary). transfusion up to a target Hb of 9 g/dL
¡ >16 weeks, infusion of 40 IU of oxytocin in 1 liter of 0.9% NaCl ¡ Counseling on emotional support and post-abortion
or RL 40 tpm, to aid in expulsion of products of conception. contraception
¡ Evaluate postoperative vital signs every 30 minutes for 2 hours. If
the mother's condition is good, move to the inpatient room.
¡ Evaluate vital signs, vaginal bleeding, acute abdominal signs and
urine output every 6 hours for 24 hours. Check Hb levels after
24 hours. If the monitoring results are good and the Hb level is >
8 g/dL, the mother is allowed to go home.

Source : Ilmu kebidanan sarwono prawirahardjo. Fourth Edition. 2014.

Publishing : PT. Bina pustaka sarwono prawira
 THERAPY

Missed Abortion

¡ <12 weeks of gestation: AVM / spoon curettage

¡ 12-16 weeks of gestation: make sure the cervix is open, if necessary perform cervical ripening before dilatation
and curettage. Evacuate with abortion forceps and a curette spoon
¡ 16-22 weeks gestation: Perform cervical ripening and then evacuate with 20 units of oxytocin infusion in 500 ml
of 0.9% NaCl or RL at a rate of 40 TPM until expulsion of the products of conception occurs. If expulsion does
not occur within 24 hours, re-evaluate before planning further evacuation.

Source : Ilmu kebidanan sarwono prawirahardjo. Fourth Edition. 2014.

Publishing : PT. Bina pustaka sarwono prawira
COMPLICATIONS
• Shock
• Infection
• Uterine perforation

Source : Ilmu kebidanan sarwono prawirahardjo. Fourth Edition. 2014.

Publishing : PT. Bina pustaka sarwono prawira
SOURCES
1. Alves C, Rapp A. Spontaneous Abortion. [Updated 2021 Jul 20]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
2. Dugas C, Slane VH. Miscarriage. 2021 Jun 29. StatPearls Publishing; 2021 Jan–. PMID: 30422585.
3. Hendriks E, MacNaughton H, MacKenzie MC. First Trimester Bleeding: Evaluation and Management.
Am Fam Physician. 2019
1. Ilmu kebidanan sarwono prawirahardjo. Fourth Edition. 2014. Publishing : PT. Bina pustaka sarwono prawira
2. Sajadi-Ernazarova KR, Martinez CL. Abortion Complications. [Updated 2021 May 24]. Treasure Island (FL):
StatPearls Publishing; 2021 Jan-.