# Obstetrics and Gynecology/Abortion

The term abortion is used by the lay person to refer to an elective termination of pregnancy. Medical staff working in the field of obstetrics use this term to describe miscarriage before 24 weeks gestation and is also referred to as spontaneous abortion. There are different types of spontaneous abortion and the importance of diagnosis cannot be underestimated as each is managed in a different way. The physician dealing with a woman who has presented with spontaneous abortion must choose his/her words carefully when discussing the diagnosis with the patient. This is already a very stressful time for such patients and the term "abortion" used inappropriately may cause this stress and anxiety to be unduly exasperated. Therefore, the term "miscarriage" will be used in place of the word "abortion" for the rest of this article.
The risk Factors for spontaneous Abortion are:
* Increasing maternal age
* Increase in parity
* Interval of pregnancies outside the range of 12-36 months
* Previous
* Smoking, alcohol and radiation

## Threatened Miscarriage

Threatened miscarriage is defined as vaginal bleeding before 20 weeks gestation in the presence of a viable fetus. One in five pregnancies will present in this manner and these pregnancies are 2.6 times more likely to result in complete miscarriage.

### Clinical Features

History:
* Slight blood loss - fresh blood with clots or brown staining
* Little or no pain
* Fetal movements may be present
* No products of conception have been passed
Examination:
* Uterine size normal for dates
* Cervix closed
* Fetal heart sounds present
* Fetal movements may be present
Investigation:
* Positive pregnancy test
* Positive ultrasound scan

### Management

Unfortunately, there is no medical treatment indicated. Management involves bed rest if bleeding recurs and anti-D if indicated. Prognosis can be assessed with further ultrasound scans.

## Inevitable Miscarriage

In inevitable miscarriage, the cervix has begun to open and some products of conception have passed, therefore, the pregnancy cannot be saved and miscarriage is inevitable.

### Clinical Features

History:
* Heavy Bleeding getting worse
* Severe colicky abdominal pain
* Products of conception may have passed
Examination:
* Cervix is open
* Products of conception may be passing through the os

### Management

Medical
* IV infusion if bleeding is severe
* Remove products from os
* Syntometrine 1ml intramuscularly PRN
Surgical
* Evacuate uterus under general anaesthetic

## Complete Miscarriage

This is defined as the return to normal uterine size after the passage of all products of conception and normally occurs before 8 weeks gestation.

## Incomplete Miscarriage

This is most common between 8 and 14 weeks gestation. All the products of conception have not been passed and the patient requires evacuation of the retained products of conception.

### Clinical Features

History:
* Heavy Bleeding getting worse
* Severe colicky abdominal pain
* Products of conception may have passed
Examination:
* Cervix is open
* Products of conception may be passing through the os

### Management

Medical
* IV infusion if bleeding is severe
* Remove products from os
* Syntometrine 1ml intramuscularly PRN
Surgical Abortion
* Evacuate uterus under general anesthetic

## Missed Miscarriage

A missed (or silent) miscarriage is the spontaneous abortion of a pregnancy in the absence of vaginal bleeding. In essence, the fetus is dead in utero.

### Clinical Features

History:
* No fetal movements
* No symptoms of pregnancy
Examination
* Uterus smaller than dates suggest
* No fetal movements
* No fetal heart sounds
Investigations
* Ultrasound negative for fetal heart movement

### Management

Evacuate uterus

## Septic Miscarriage

This is a uterine infection of the retained non-viable products of conception following an incomplete miscarriage. An attempt at an illegal termination of pregnancy (back-street abortion) should be suspected.

### Clinical Features

History
* Pain
* Fever
Examination
* Pyretic
* Open cervix with discharge
Investigations
* Blood cultures

### Management

IV antibiotics, fluids and curretage.

## Patient help

If you or someone you know has been affected by any aspect of this topic, help and support is available online here:
* The Miscarriage Association UK
* The Mayo Clinic