ABORTION

Vaginal Bleeding in Early Pregnancy

This is almost always abnormal, and patients may need to be admitted or referred. The most common causes of bleeding in the first six months (<26 weeks gestation) are abortion and ectopic pregnancy

Abortion (miscarriage) occurs when the foetus is lost before 28 weeks of pregnancy.

Cause

  • Not known in the majority of patients
  • May be intentional (induced abortion)
  • May be spontaneous (often as a result of fever)
  • If mother has more than 2 miscarriages, refer for assessment

Differential diagnosis

  • Pregnancy outside the uterus (ectopic pregnancy)
  • Other causes of bleeding from the vagina, e.g. cancer
  • Other causes of lower abdominal pain, e.g. PID

Investigations

  • Urine: Pregnancy test
  • Ultrasound
  • Blood: Complete count

Clinical features, terminology and management

  • Depend on the stage of the abortion

See table below.

FEATURES MANAGEMENT

Threatened abortion

Little vaginal bleeding
No or moderate lower
abdominal pain
Uterus is of expected
size by date
Cervix is closed
Pregnancy may still
continue

  • Medical treatment is
    usually not necessary
    (hormones and
    tocolytics will not
    prevent a miscarriage)
  • Observe for 4-6 hours
  • Paracetamol 1 g every
    6-8 hours prn for 5 days

If bleeding stops:

  • Avoid strenuous activity
    and abstain from sex for
    at least 14 days
  • Follow up in 2 days in
    ANC clinic

If bleeding persists

Inevitable abortion

Process irreversible
Products of
conception not yet
expelled but painful
contractions (pain
similar to labour
pains) and bleeding
Cervix proceeds to
open

  • Bed rest
  • If there are signs of
    infection, give antibiotics
  • Observe for continued
    bleeding.

If patient in shock

  • Resuscitate with IV
    fluids (Normal Saline)

If anaemic

  • Refer for
    replacement of blood lost
  • Establish IV access
    before referral
  • Give stat dose of
    antibiotics before
    referral
  • Treat anaemia

Incomplete abortion

Uterine contents not
completely passed out
Bleeding sometimes
with clots from
the vagina (may be
severe) or
Severe lower
abdominal cramps
Cervix open
Products of
conception (POC)
may be felt in the
cervical canal

If evacuation of uterus is
not immediately possible

  • Give oral misoprostol
    600 microgram
    sublingual stat (repeat
    once after 4 hours if
    necessary)
  • Refer after misoprostol
  • Use fingers to remove
    POC protruding through
    the cervix
  • Evacuate the uterus
    by Manual Vacuum
    Aspiration (if pregnancy
    <16 weeks) or Dilation
    and Curettage
  • Ensure follow up


If signs of infection (fever,
foul smelling blood)

  • Give a stat dose of IV
    Ceftriaxone 2 g and IV
    metronidazole 500 mg
  • Amoxicillin 500 mg
    orally every 6 hours for
    7 days
  • Plus metronidazole 400
    mg orally every 8 hours
    for 7 days

Complete abortion

All uterine contents
have been passed out
Bleeding is decreasing
Cervix closed
Uterus empty and
reduced in size
  • Examine to make sure
    that all products have
    been passed
  • Follow up for continuous
    bleeding (it should stop
    in a few days)

Septic abortion

Incomplete abortion
with infection (may
follow induced
abortion)
Fever
Offensive vaginal
discharge
Lower abdominal
pain
Tenderness on
palpating the
abdomen
  • Give 7-day course
    of antibiotics as in
    incomplete abortion
    (above)
  • Evacuate the uterus

Post-abortal Sepsis

Patient has signs
and symptoms of
sepsis following an
abortion, but there
are no products of
conception in the
uterus
  • Give IV antibiotics
    ceftriaxone 2 g +
    metronidazole 500
    mg IV 8 hourly for 48
    hours, until fever has
    disappeared, then switch
    to oral treatment as for
    septic abortion

Missed abortion

Foetus died
Contents of the uterus
not expelled
May be dark blood
drops (spotting) from
the vagina
Uterus smaller than
expected by dates/not
growing
  • Refer to hospital for
    evacuation

Molar abortion

Abnormal placenta,
no foetus, vaginal
bleeding, and passing
of red material like
ripe coffee berries/
white (translucent)
grape like material;
uterus much bigger
than expected;
mother feels no foetal
movements even after
five months
  • Resuscitate and refer the
    patient
  • Do not attempt to
    evacuate the uterus
    unless you have facilities
    for blood transfusion and
    oxytocin
  • Refer to hospital for
    further management