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Case Report Incomplete Abortion
Case Report Incomplete Abortion
INCOMPLETE ABORTION
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
Religion : Islam
Profession : Housewife
Address : Pulo Gadung
Religion : Islam
Address : Cempaka Putih
CHIEF COMPLAINT
Vaginal’s bleeding 3 hours ago
HISTORY OF ILLNESS
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
CONTRASEPTION HISTORY
-
SOSIO-ECONOMIC HISTORY
Patient : Housewife, smokes (-), drinks alcohol (-)
Husband: Salesman, smokes (+), drinks alcohol (-)
Past Medical History
Anthropomethry
General condition : Moderate
Weight before pregnancy : 50 kg
Consciousness : Composmentis
Weight : 51kg
Height :153cm
Vital Sign BMI 21,3 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
Head
External examination
: normal
Inspection : Looks a bit convex
Neck : normal
Palpation : Ballotement not palpable
Thorax :
Cardio: Heart sound SI-II regular, murmur(-), gallop(-)
Internal examination
Pulmo: vesicular, rh (-), wh(-)
Inspektion : Bleeding (+)
Abd: striae (+), linea nigra(-), Saecarian marks (+)
Ekst: warm(+/+), crt<2s, oedema (-/-) Inspeculo : -
TEST RESULTS PARAMETER
Electrolite
136 135 – 147 mEq/L
Natrium
LAB 16/8/2021 Kalium
3.8 3.5 – 5.0 mEq/L
106 94 – 111 mEq/L
Chlorida
INITIAL TREATMENT
IVFD RL dr. Ribkhi Sp.OG : dr. kemalasari Sp.P :
Ketorolac Injection HBsAg and Anti HIV Test Non-Isolation room confirmed
Amlodipine 10 mg BT CT Test
Consult to dr. Ribkhi Sp.OG 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)
Spontaneous Abortion
Imminens abortion Insipiens abortion
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
2. Pregnancy test (-)
of 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 times
weeks of gestation and the entire product of
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.
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 Insipiens Abortion
Keep it safe the pregnancy < 16 weeks, plan to evacuate uterine contents with MVA (Manual Vacuum
Aspiration). If evacuation cannot be carried out immediately:
Avoid sexual intercourse
Ergometrine 0.2 mg IM (repeat after 15 minutes if necessary) or misoprostol 400
Bed rest to increase blood flow to the uterus g orally (repeat once after 4 hours if necessary).
and reduce mechanical stimulation Plan an immediate evacuation.
If the bleeding stops, monitor the mother's > 16 weeks
condition further during antenatal Wait for the spontaneous expulsion of the products of conception, then evacuate
examinations including monitoring of Hb the contents of the uterus to clear any remnants of conception that remain.
levels and serial ultrasound every 4 weeks 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.
If the bleeding does not stop, assess the
Closely monitor the condition of the mother after the procedure.
condition of the fetus by ultrasound and assess
Counseling to mothers and families regarding discomfort and risk of miscarriage.
for the presence of other possible causes.
Counseling to the patient and her 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 Observation of mother's condition
cervix
If there is moderate anemia give ferrous sulfate tablets
Heavy bleeding and < 16 weeks, AVM (sharp curettage if AVM is
600 mg/day for 2 weeks, if severe anemia give
not available). If evacuation cannot be performed immediately, transfusion up to a target Hb of 9 g/dL
give Ergometrine 0.2 mg IM (can be repeated 15 minutes later if
necessary). Counseling on emotional support and post-abortion
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.