GYNAECOLOGICAL CASE NUMBER ONE

INCOMPLETE MISCARRIAGE: MANUAL VACUUM ASPIRATION

Name: Mrs M. M.

Hospital Number: 216837

Age: 29 years

Tribe: Igbo

Religion: Christainity

Occupation: Teaching

Address: Wuse zone 6, Abuja

Parity: G1P0+0 `

LMP: 03/11/20

EGA: 10 weeks

Date of Admitted:: 12/01/21

Date of Discharge: 12/01/21

PRESENTING COMPLAINTS

 Vaginal bleeding of 1 day duration

 Abdominal pain of 1-hour duration.

HISTORY OF PRESENTING COMPLAINTS

Mrs M. M. presented at the gynaecological emergency unit of Maitama District Hospital with a

day history of vaginal bleeding and lower abdominal pain of one hour duration. The vaginal

bleeding was spontaneous in onset, initially scanty but subsequently became profuse with the

passage of clots mixed with fleshy material, she had used about 3 sanitary pads which were fully

soaked to contain the bleeding. There was associated intermittent lower abdominal pain which

was noticed about an hour ago. There was no dizziness or fainting attacks. There was no

preceding history of fever, headache, abnormal vaginal discharge, urinary symptoms or

abdominal trauma. The pregnancy was desired and spontaneously conceived. It was suspected

after a missed period and was confirmed by an ultrasound scan done at 8 weeks gestation.

GYNAECOLOGICAL HISTORY

She attained menarche at 13 years and menstruated for 4 days in regular cycles of 30 days with

moderate flow. There was no dysmenorrhoea. She was aware of contraception but had not used

any. She was aware of Pap smear but had never done any.

OBSTETRIC HISTORY

She was G1P0+0

PAST MEDICAL HISTORY

She was not a known hypertensive, diabetic, sickle cell disease or asthmatic patient. Her blood

group was A Rhesus ‘D’ positive. She had no blood transfusion or surgery in the past.
DRUG HISTORY

She has no known drug allergy

FAMILY AND SOCIAL HISTORY

Mrs M. M was married to a 34 year old Banker in a monogamous family setting. She neither

smoked cigarettes nor drank alcohol. There was no family history of hypertension or diabetes

mellitus.

SYSTEMIC REVIEW

There was no significant finding.

PHYSICAL EXAMINATION

She was a young woman, anxious, afebrile , not pale ,anicteric, and not dehydration. She had no

pedal oedema.

CARDIOVASCULAR SYSTEM

Her pulse rate was 84 beats per minute, regular and of full volume. The blood pressure was

110/70 mmHg. The first and second heart sounds were heard only.

RESPIRATORY SYSTEM

Her respiratory rate was 20 cycles per minute and the lung fields were clinically clear.

ABDOMEN

The abdomen was full and moved with respiration. There was mild suprapubic tenderness. There

were no palpable masses. The liver and spleen were not palpably enlarged and kidneys were not

ballotable. The uterus was not palpable.

PELVIC EXAMINATION

The vulva was smeared with blood and there was active bleeding. The cervical os was open with

some products of conception plugging the os which were gently removed using sponge-holding

forceps. The uterus was consistent with 10 weeks’ gestational size and anteverted. The adnexa

and pouch of Douglas were free. The examining finger was stained with blood.

DIAGNOSIS

Incomplete miscarriage at 10 weeks gestation.

MANAGEMENT

The findings were explained to her. She was counselled on the need for evacuation of the uterus

to prevent further bleeding. An intravenous line was secured and infusion of normal saline was

commenced. Samples were taken for PCV, Blood group, retroviral screening, HBsAg and

urinalysis. The options of management with the use misoprostol or manual vacuum aspiration

were explained to her. She opted for manual vacuum aspiration and written informed consent

was obtained.

INVESTIGATIONS AND RESULTS

The tests whose results appear below were conducted:

Packed Cell Volume: 32%

Blood group: A Rhesus ‘D’ positive

HIV I and II: Negative

HBsAg: Negative

Urinalysis Negative
OPERATION

Manual vacuum aspiration

ANAESTHESIA

Paracervical block and diclofenac 75mg intramuscularly.

FINDINGS

1. The vulva and vagina were normal.

2. The cervical os was 2cm dilated.

3. The uterus was about 10 weeks’ gestational size.

4. About 120ml of products of conception were evacuated.

PROCEDURE

The Ipas MVA kit was tested for its functionality. Mrs M. M. was asked to empty her bladder.

She was placed in the lithotomy position with the buttocks projecting slightly over the end of the

table. The surgeon scrubbed and gowned and the patient was cleaned and draped. A bimanual

examination was done with findings as noted above. A Cusco’s speculum was gently introduced

into the vagina to expose the cervix and the cervix was cleaned. The anterior lip of the cervix

was held with a vulsellum. A size 8mm cannula was inserted through the cervix into the uterine

cavity until resistance was felt at the fundus, this was gently drawn backwards. The already

assembled and charged vacuum aspirator was connected to the cannula. The pinched valves were

released creating a negative pressure and gentle rotatory, back and forth movements were made

with the cannula within the uterine cavity in a clockwise fashion. The retained products of

conception were drawn into the vacuum aspirator which was then detached leaving the cannula

in situ when the cannula got clogged. The products were emptied into a kidney dish and the

vacuum aspirator was recharged and reconnected to the cannula. This process was repeated until
a gritty sensation was felt and pinkish foamy blood was seen in the cannula. Subsequently, the

pinched valves were pressed back to close the vacuum aspirator and this was removed with the

cannula. The vulsellum and Cusco’s speculum were removed after confirming that the bleeding

had stopped. Blood on the vulva was cleaned and a pad was placed over it. The products of

conception was inspected and the specimen were sent for histopathological examination.

POST OPERATIVE PERIOD

She was observed for about 2 hours. Her vital signs remain stable. The respiratory rate was 20

cycles per minute; her pulse rate was 84 beats per minute, regular and of good volume. The

blood pressure was 110/60mmHg. The perineal pad was dry and no vagina bleeding. She was

given capsule doxycycline 100mg twice daily and tablets metronidazole 400mg three times daily

both for 7 days. She also placed on tablet diclofenac 50mg three times daily for 3 days. Tablet

ferrous sulphate 200mg daily and folic acid 5mg daily for two weeks was given to her. She was

discharged home and to be seen in gynecological clinic with histopathology report in 2 weeks

GYNAECOLOGICAL CLINIC (28/01/21)

She had no complaint. Her general condition was satisfactory. The histopathology report was

explained to her and she was reassured. Mrs M. M. was counselled on the need to start folic acid

prior to conception and thereafter discharged from the gynaecology clinic.

HISTOPATHOLOGY REPORT

Macroscopy- Fragments of greyish brown tissue that aggregated 6cm.

Microscopy- Section showed chorionic villi which were lined by two layers of trophoblastic

cells. Also seen were sheets of decidual cells and extensive areas of haemorrhage.

Diagnosis: Products of conception.

COMMENTARY

Mrs M. M. a 29-year-old Primigravida who presented with an incomplete miscarriage. She had a

manual vacuum evacuation. She had an uneventful postoperative recovery and was discharged

home in good condition. Miscarriage is defined as the termination of pregnancy before the age of

viability. In most parts of the world, gestational age of less than 20 to 22 weeks or a fetal weight

of less than 500g is regarded as unviable. In Nigeria and some other under-developed countries,

miscarriage is the termination of pregnancy before 28 weeks. It could be spontaneous or induced.

Over half of all pregnancies are lost as spontaneous abortions as in the case of Mrs M. M.;

however, the vast majority of these are not recognizable. 1 The incidence of spontaneous abortion

is 10 - 15% of all pregnancies. 2 A miscarriage is said to be incomplete when some but not all of

the products of conception have passed out of the uterine cavity.3 Most spontaneous abortions in

the first trimester tend to be incomplete while those in the second trimester tend to be complete.

This is because, in the first trimester, the placenta has an ill-defined plane of cleavage. 1 In the

case of Mrs M. M., the abortion occurred in the first trimester and it was incomplete.

The commonest cause of abortion in the first trimester is chromosomal abnormality such as

trisomy (16, 22, 21 and 15), followed by monosomy, triploidy and tetraploidy. Other causes

include uterine abnormality, immunological, endocrine deficiencies, uterine abnormalities,

intrauterine infections, maternal febrile illnesses and trauma. 4 In the case of Mrs M. M, no

aetiological factor was identified.

Incomplete abortion is characterized by a history of amenorrhoea followed by vaginal bleeding

and low abdominal pain or abdominal cramps. The patient may have passed large blood clots or

products of conception from the vagina. The cervix is usually dilated.5 These were found in the

case of Mrs M. M.
Delay in the management of incomplete abortion is associated with the high risk of excessive

blood loss, hence Mrs M. M. was quickly assessed for shock and anaemia. The blood sample was

sent for packed cell volume which was 32%. Evacuation of retained products was done by

manual vacuum aspiration using the Karman syringe, which is a one of the treatment options of

incomplete abortion in our centre. This method has been studied extensively and its

effectiveness, simplicity, minimal loss of blood and low risk of complication associated with its

use makes it the preferred method in the first trimester as recommended by World Health

Organisation.6,7 Expectant management or use of misoprostol are alternative modes of treatment. 8

Adequate anaesthesia was required, hence paracervical block and diclofenac was used.

Antibiotic was given to prevent sepsis and the possible long-term sequelae like chronic pelvic

pain and secondary infertility.1 Other possible complications such as excessive blood loss and

uterine perforation were not found in this case.

It is routine to send the products of evacuation for histology to exclude other causes of vaginal

bleeding and this was done in the case of Mrs. M. M. 1 The histology report for this patient

confirmed products of conception. She had no complaint and her physical examination did not

reveal any abnormality at the follow-up visit.

Mrs M. M. was desirous of conception and was counselled on early presentation to the hospital

for antenatal care as soon as she missed her menstrual period.

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of Abortion in Nigeria. International Perspectives on Sexual and Reproductive Health.

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of cases of miscarriage in a tertiary hospital in Abakaliki, South East, Nigeria. Trop J

Obstet Gynaecol. 2019;36:367-72

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Complicated unsafe abortion in a Nigeria teaching hospital: pattern of morbidity and

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Textbook of Obstetrics and Gynaecology for Postgraduates, 9th Edition, UK: John Wiley

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