COURSE IN THE WARD

HOSPITAL DAY 1
SOA Plan
S: Patient was admitted. Complete bed rest without bathroom
(+) brownish vaginal privileges was ordered. IVF was started.
discharge Vital signs were monitored every 4 hours.
(+) Hypogastric pain Patient was monitored for: hypogastric pain, vaginal bleeding,
passage of meaty tissue.
O: The following labs were requested: CBC, Urinalysis and TVS
Temp: 37.4C
PR: 80 bpm Medication started:
RR: 20 cpm o Dydrogesterone (Duphaston) 10mg tab, 1 tab BID
BP: 104/70 mmHg o Isoxuprine drip: D5LR 500 ml + 5 ampules isoxuprine at
20 ugtt/min to be titrated with 5 ugtt/min increments for 30
(+) hypogastric minutes until without hypogastric pain and vaginal
tenderness (left) spotting
(+) minimal brownish
vaginal discharge

IE:
Cervix closed, corpus
sl. Enlarged, no
adnexal masses,
(+)wriggling tenderness
(left)
(+)adnexal tenderness
(left)

CBC results:
Hemoglobin 92.0 L
Hematocrit 0.28 L
RBC count 4.32 L
WBC count 8.90
Neutrophil 0.59
Lymphocyte 0.28 L
Monocytes 0.08
Eosinophil 0.04
Platelet count 322
RH +
Urinalysis results:
Light, Clear
(-) Glucose
(-) Albumin
WBC: 1; RBC: 37H;
Epithelial cells:3;
Bacteria 18
 TVS results:
FHR: 113 bpm
EDC: 03/21/2017
Cervix: 3.1x2.19 cm
long and closed
Adnexae: right ovary =
3.1 x 3.1 x 2.6 cm with
corpus luteum
surgically absent left
ovary
Early intrauterine
pregnancy 6weeks
1day by fetal pole
measurement with slow
cardiac activity. May
repeat scan after 1-2
weeks for reevaluation

A: t/c threatened
abortion r/o ectopic
pregnancy

SOA Plan
th
S: 6 hospital hour
Awake, not in distress,
comfortable Perineal hygiene
(-) vaginal spotting Started with:
(-) hypogastric pain o FeSO4 (Sorbifer) durule, 1 durule PO BID
o Lactulose 30 cc PO
O: o Isoxsupine 10 mg tab, 1tab TID PO once isoxsupine
Temp: 36.6 C drip is at 100 cc
PR: 84 bpm
RR: 18 cpm
BP: 110/80 mmHg

Soft, non-tender
abdomen

A: G2P1(1001); PU 6
1/7 weeks AOG;
threatened abortion

HOSPITAL DAY 2
SOA Plan
S: May go home orders given after APs rounds:
Awake, comfortable, o Home medications:
not in distress Dydrogesterone (Duphaston) 10mg tab, 1 tab PO
(-) Hypogastric pain BID for 7 days
(-) vaginal spotting FeSO4 (Sorbifer) durules, 1 tab BID daily
Voiding freely Isoxilan 10 mg tab, 1 tab TID for 7 days
Adequate urine output o To repeat TVS after one week
at 2.1 cc/kg/hr o To follow-up after one week with attending physician

O:
Temp: 37.1C
PR: 82 bpm
RR: 21 cpm
BP: 110/70 mmHg

Clear breath sounds,

soft, nontender
abdomen

A: G2P1 (1001)
Pregnancy uterine, 6
2/7 weeks AOG,
threatened abortion

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.
In this case, our patients pregnancy was terminated with no history of any induction at 6
weeks and 2 days age of gestation. Thus, the case is considered as spontaneous abortion
particularly threatened abortion based on the history and physical findings upon admission.
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 Imaging
Bleeding Products of Cramps
conception and other
symptoms
Threatened Light Bleeding Absent Lower Abdominal; Closed Cervical Os Visualized
Painful Uterus softer than normal Fetal heart Activity
Uterus corresponds to dates
Inevitable Heavy Absent Lower Abdominal; Open Cervical Os; FH Activity may not
Bleeding very painful Ruptured Membrane be visualized
Tender Uterus
Uterus corresponds to dates
Incomplete Heavy Present; with Lower Abdominal; Open Cervical Os Retained Products;
Bleeding retained painful Uterus softer than normal No Fetal Heart
tissues Uterus corresponds or Activity
smaller than dates
Complete Light Bleeding Present; Present; Closed Cervical Os Empty Uterus
complete Light cramping Uterus softer than normal
passage /may not be Uterus smaller than dates
painful
Missed May be present Absent Asymptomatic at Closed Cervical Os No Fetal Heart
early weeks Uterus smaller than dates Activity
Septic Bleeding May or may Lower Abdominal Open or Closed Cervix May or may not
not be Cramping and have fetal heart
Fever activity

Light Bleeding takes longer than 5 minutes for a clean pad or cloth to be soaked; Heavy bleeding takes less than 5 minutes for a
clean pad or cloth to be soaked. An open cervical os is enough to admit a fingertip during digital examination.

Sources: 1.Williams Obstetrics 24th Edition

2.Philippine Obstetrical and Gynecological Society (POGS)- Clinical Practice Guidelines 2015

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 this case, advance maternal age is the only risk factor,
although fetal factor is highly likely but warrants karyotyping. The rate of clinical miscarriages
is almost doubled when either parent is older than 40 years.
The following are the various maternal risk factors associated with an increased risk of
pregnancy loss not present in this patient.
I. Maternal Factors
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 earlypregnancy loss by a number of
mechanisms
- Excessive caffeine consumptionnot well definedhas beenassociated
with an increased abortion risk. There are reportsthat heavy intake of
approximately five cups of coffee perdayabout 500 mg of caffeine
slightly increases the abortionrisk
- 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 defree of cervical
dilation, which is dertermined mainly by pelvic examination, althought 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, clinical findings and imaging were used to arrive at the most likely
diagnosis, as shown below.

Table 2. Case Summary relative to the Diagnosis of Spontaneous Abortion

Clinical Findings
Imaging
History
via Transvaginal Most likely
Vaginal Passage of Abdominal
Physical Findings Ultrasound Diagnosis
Timeline Bleeding Products of Cramps
conception and other
symptoms

Closed Cervical Os; 1st TVS done revealing

Prior to Light Nontender hypogastric 6 weeks and 2 days
Admission Bleeding Absent none area; age of gestation with Threatened
Uterus corresponds to good cardiac activity Abortion
dates

TVS done revealing

no intrauterine GS
nor embryo noted;
no Fetal Heart
Activity;
Open Cervical Os
retained secundines
Course of Heavy Incomplete
Hospitalization Bleeding Present Present Abortion

Management of Spontaneous Abortion

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.

Multiple randomized controlled trials and cohort studies reviewed but Butler, et al. have
demonstrated 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. This is the basis for so called expectant management. 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.
 The miscarriage treatment trial saw that the incidence of 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. 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. In contrast, the effectiveness
of routine use of antibiotics prior to evacuating the uterus in cases of incomplete abortion has not
been supported by adequate studies. May, et al. cited the paucity of trials comparing a policy of
prophylaxis versus no prophylaxis. The one study that qualified for their review showed no
differences in postabortal infection rates with routine prophylaxis control.

Threatened Abortion
Summary of the POGS - Clinical Practice Guidelines 2015
1. There is no evidence to support bed rest and vitamin supplementation in the prevention of
miscarriage (Level 1, Grade A).
2. Progesterone use reduces the rate of spontaneous miscarriage (Level 1, Grade A).