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Missed Abortion
MISSED
ABORTION Case Presentation
M
RS. A. M. is 37 years old, white, para ii, gravida iii, of a good socioeconomic background. Her last menstrual period was on July 18, 195;. Her previous pregnancies and deliveries had been normal in every rt’-. spect. The last pregnancy was 12 years previously. Prenatal visits during the present pregnancy began shortly after the first missed period and she seemed to be progressing normally. Shortly after quickening, which had been noted Dec. 12. 1957, disappearance of aY fetal movement followed by breast secretion announced the intrauterine demise of the fetus. She followed the advice of her obst.etrician to let naturti t,ake its course. Muddy and slightly malodorous vaginal discharge was hcl only symptom. There were no signs of labor until March 10, 1958, when she complained of one severe lower abdominal pain which eased after 1.0 minutes. Her physician advised admission to the hospital. The hemoglobin was 13.5 Gm. per cent; the leukocyte count was 11,500 with 83 per cent polymorphonuclear cells; the fibrinogen level was normal; the temperature was 99” F.. pulse 80, and respirations 20; a catheterized urine specimen contained a few white blood cells in each high-power field. A pregnancy test was negative. Examination disclosed a symmetrically enlarged uterus with the fundus 6 cm. below the umbilicus. The adnexa were normal. The cervix There was no loss of the was unusually long and firm with no dilatation. cervicofundal angle. The enlarged, *slightly boggy uterus failed to cont,raof when massaged between the exammmg fingers. Such efforts elicited a mod.” erate amount of pain. Problem:
What
is your recommended
management
of this case?
Consultation NICHOLSON J. EASTMAN, M.D., BALTIMORE, MD. PROFESSOR OF OBSTETRICS, JOHNS HOPKINS UNIVERSIX OBSTETRICIAN-IN-CHIEF, JOHNS HOPKINS HOSPITAL
The statement that ‘ ‘examination revealed a symmetrically enlarged uterus with the fundus 6 cm. below the umbilicus” permits the assumptiott that we have to deal here with a pregnancy located in the true uterine cavity. Since on Dec. 12, 1957, or at the twentieth week of pregnancy approximat,elv, the fundus should have been at the level of the umbilicus, it is evident that Iihad undergone pronounced diminution in size by March 10, 1958, when it was 6 cm. below the umbilicus. This, and other facts mentioned in the history, indicate that we are dealing with a missed abortion in which the dear1 fetus has been carried for 3 months without expulsion. The best course to pursue in this case is to await spontaneous expulsion of the products of conception. Although cases are on record in which dead 1361
CLINJC~ZL
1362
PROBLEMS
.\m. J. Obst. g, G,-ner. December. 1958
fetuses in utero have been carried for years, these are museum pieces of If we except the greatest rarity, especially in pregnancies of this duration. these rare curiosities, 5 months is about the limit for a fetus of this size to be retained in utero. This means that in the present case we have only 2 months to go; and since the patient has been resigned to a waiting program over the past 3 months, she would probably he willing to wait a little longer. During the waiting period, however, estrogens might well be tried. Est,rogens are moderately efficacious in promoting expulsion of the fetus in cases of missed abortion and, even if not effectual, they serve to beguile the time. Kurzrokl has reported excellent results with ethinyl estradiol marketed under the trade name of Estinyl,” in doses of 0.3 Gm. for 6 days. Others have had fairly good results with diethylstilbestrol. Since Pitocin has no oxytocic effects in the first half of pregnancy, even with a living fetus and normal hormonal-vascular relationships, it seems unlikely that it would be helpful in missed abortion. and it is not recommended. If the products of conception have not been expelled by the end of 5 months, despite estrogen therapy as mentioned, you are dealing with a very unusual and “stubborn” case of missed abortion. In that event, I would recommend abdominal hysterotomy for removal of the products of conception. This may sound radical but dilatation of these closed, rigid cervices as are usually present in missed abortion. has led to so many lacerations, perforations, and hemorrhages that I do not feel that. va.ginal interference in missed abortion has any place in modern obstetrics. Although the fibrinogen level has remained normal thus far, plasma fibrinogen estimations should be made every week and if the level falls to less than 150 mg. per 100 cc., immediate abdominal hysterotomy should be performed. The findings in this case correspond fairly well with missed abortion. The sudden pain may have been due to a brief, spasmodic, but ineffectual effort of the uterus to expel its contents, while the uterine tenderness may have been attributable to resultant placental separation. Failure of the uterus to contract on stimulation is common in missed abortion. In cases of this kind it is extremely important to rule out advanced and pregnancy in a rudimentary tubal pregnancy, abdominal pregnancy, horn of the uterus. Unless the examiner in this case has been mistaken in his reference to the “uterus,” the statements in the case history eliminate the first two conditions. Careful bimanual examination, if necessary under anesthesia, should permit palpation of the normal nonpregnant uterine body Even if you miss this diagnosis, in cases of gestation in a rudimentary horn. however, no harm is done by the management recommended since at laparotomy the condition will at once become apparent and can be handled at that time as circumstances dict,ate. Reference 1. Kurzrok,
*Schering
L:
Bm.
J. Obst.
Corporation,
& Gynec.
Bloomfletd,
56:
N.
796,
J.
1948.
Q
CLINICAL
136:;
PROBLEM8
M. EDWARD r~A\.IS. M.D., CHICAGO, ILL. JOSEPH B. MELEE PROFESSOR OF OBSTETRICS OF ‘rI
LYING-IN
HOSPITAL
The intrauterine death of a fetus at about 18 weeks’ gestation is a11 uncommon occurrence. The safest treatment for missed abortions at this late date is to await the spontaneous onset. of labor. This is not always eas;! to do, for the patient and her family may urge the physician to terrninate the pregnancy artificially to relieve the ansieties and emotional pressures of carrying a dead baby. There is no evidence that the patient can absorb toxic products from the degenerating conceptus. The hazard of intrauterine infection is small if there are no intravaginal or intrauterine manipulations. Fisher1 a.nalyzed 30 cases of missed abortion with the retention of uterine followed the S~OII contents for 2 to 6 months. The most favorable cnurse t.aneous onset of labor. The patient most often will develop increasing uterine irritability mar:ifested by uterine cramps. Labor will finally set, in a.nd usually spontaneous evacuation will follow in a short t,ime. Prophylactic antibiotic therapy may be started with the onset of labor and continued for several days after the evacuation of the uterus. Should uterine activity be initiated by the intravenous drip of an osyt,rItic drug? This may be effective when the patient exhibits irregular uterine contractions and some cervical effacement has taken place; however. labor is extremely difficult to initiate at this period of gest,ation. Repeated a.tempts at the induction of labor may disturb normal intrauterine relationships favoring the ascent of organisms from the lower genital tract and the devclopnnnt of an intrauterine infection. Operative intervention by cervical dilatation and the artificial evacuation of the uterus at this period of pregnancy are hazardous and may resuit in serious trauma. Evacuation o-f the uterus by hpsterotomy is a ma,jol procedure and is rarely indicated.
Reference 1. Fisher,
G. G.:
Obst.
& Gpnec.
1: 329, 1953.
Editor’s
Comment
On the day of admission the local consultant advised repeated att.empt,s to prepare the cervix by intravenous use of Pitocin. It was also suggested that fibrinogen levels be determined daily. The patient’s doctor ordered 21/, ounces of castor oil prior to the use of the intravenous Pitocin. The patient went into violent labor and was delivered of the macerated abortus in about 2 hours without having received any intravenous medication. HPl’ subsequent course has been uneventful.
ABORTION Case Presentation
M
RS. A. M. is 37 years old, white, para ii, gravida iii, of a good socioeconomic background. Her last menstrual period was on July 18, 195;. Her previous pregnancies and deliveries had been normal in every rt’-. spect. The last pregnancy was 12 years previously. Prenatal visits during the present pregnancy began shortly after the first missed period and she seemed to be progressing normally. Shortly after quickening, which had been noted Dec. 12. 1957, disappearance of aY fetal movement followed by breast secretion announced the intrauterine demise of the fetus. She followed the advice of her obst.etrician to let naturti t,ake its course. Muddy and slightly malodorous vaginal discharge was hcl only symptom. There were no signs of labor until March 10, 1958, when she complained of one severe lower abdominal pain which eased after 1.0 minutes. Her physician advised admission to the hospital. The hemoglobin was 13.5 Gm. per cent; the leukocyte count was 11,500 with 83 per cent polymorphonuclear cells; the fibrinogen level was normal; the temperature was 99” F.. pulse 80, and respirations 20; a catheterized urine specimen contained a few white blood cells in each high-power field. A pregnancy test was negative. Examination disclosed a symmetrically enlarged uterus with the fundus 6 cm. below the umbilicus. The adnexa were normal. The cervix There was no loss of the was unusually long and firm with no dilatation. cervicofundal angle. The enlarged, *slightly boggy uterus failed to cont,raof when massaged between the exammmg fingers. Such efforts elicited a mod.” erate amount of pain. Problem:
What
is your recommended
management
of this case?
Consultation NICHOLSON J. EASTMAN, M.D., BALTIMORE, MD. PROFESSOR OF OBSTETRICS, JOHNS HOPKINS UNIVERSIX OBSTETRICIAN-IN-CHIEF, JOHNS HOPKINS HOSPITAL
The statement that ‘ ‘examination revealed a symmetrically enlarged uterus with the fundus 6 cm. below the umbilicus” permits the assumptiott that we have to deal here with a pregnancy located in the true uterine cavity. Since on Dec. 12, 1957, or at the twentieth week of pregnancy approximat,elv, the fundus should have been at the level of the umbilicus, it is evident that Iihad undergone pronounced diminution in size by March 10, 1958, when it was 6 cm. below the umbilicus. This, and other facts mentioned in the history, indicate that we are dealing with a missed abortion in which the dear1 fetus has been carried for 3 months without expulsion. The best course to pursue in this case is to await spontaneous expulsion of the products of conception. Although cases are on record in which dead 1361
CLINJC~ZL
1362
PROBLEMS
.\m. J. Obst. g, G,-ner. December. 1958
fetuses in utero have been carried for years, these are museum pieces of If we except the greatest rarity, especially in pregnancies of this duration. these rare curiosities, 5 months is about the limit for a fetus of this size to be retained in utero. This means that in the present case we have only 2 months to go; and since the patient has been resigned to a waiting program over the past 3 months, she would probably he willing to wait a little longer. During the waiting period, however, estrogens might well be tried. Est,rogens are moderately efficacious in promoting expulsion of the fetus in cases of missed abortion and, even if not effectual, they serve to beguile the time. Kurzrokl has reported excellent results with ethinyl estradiol marketed under the trade name of Estinyl,” in doses of 0.3 Gm. for 6 days. Others have had fairly good results with diethylstilbestrol. Since Pitocin has no oxytocic effects in the first half of pregnancy, even with a living fetus and normal hormonal-vascular relationships, it seems unlikely that it would be helpful in missed abortion. and it is not recommended. If the products of conception have not been expelled by the end of 5 months, despite estrogen therapy as mentioned, you are dealing with a very unusual and “stubborn” case of missed abortion. In that event, I would recommend abdominal hysterotomy for removal of the products of conception. This may sound radical but dilatation of these closed, rigid cervices as are usually present in missed abortion. has led to so many lacerations, perforations, and hemorrhages that I do not feel that. va.ginal interference in missed abortion has any place in modern obstetrics. Although the fibrinogen level has remained normal thus far, plasma fibrinogen estimations should be made every week and if the level falls to less than 150 mg. per 100 cc., immediate abdominal hysterotomy should be performed. The findings in this case correspond fairly well with missed abortion. The sudden pain may have been due to a brief, spasmodic, but ineffectual effort of the uterus to expel its contents, while the uterine tenderness may have been attributable to resultant placental separation. Failure of the uterus to contract on stimulation is common in missed abortion. In cases of this kind it is extremely important to rule out advanced and pregnancy in a rudimentary tubal pregnancy, abdominal pregnancy, horn of the uterus. Unless the examiner in this case has been mistaken in his reference to the “uterus,” the statements in the case history eliminate the first two conditions. Careful bimanual examination, if necessary under anesthesia, should permit palpation of the normal nonpregnant uterine body Even if you miss this diagnosis, in cases of gestation in a rudimentary horn. however, no harm is done by the management recommended since at laparotomy the condition will at once become apparent and can be handled at that time as circumstances dict,ate. Reference 1. Kurzrok,
*Schering
L:
Bm.
J. Obst.
Corporation,
& Gynec.
Bloomfletd,
56:
N.
796,
J.
1948.
Q
CLINICAL
136:;
PROBLEM8
M. EDWARD r~A\.IS. M.D., CHICAGO, ILL. JOSEPH B. MELEE PROFESSOR OF OBSTETRICS OF ‘rI
LYING-IN
HOSPITAL
The intrauterine death of a fetus at about 18 weeks’ gestation is a11 uncommon occurrence. The safest treatment for missed abortions at this late date is to await the spontaneous onset. of labor. This is not always eas;! to do, for the patient and her family may urge the physician to terrninate the pregnancy artificially to relieve the ansieties and emotional pressures of carrying a dead baby. There is no evidence that the patient can absorb toxic products from the degenerating conceptus. The hazard of intrauterine infection is small if there are no intravaginal or intrauterine manipulations. Fisher1 a.nalyzed 30 cases of missed abortion with the retention of uterine followed the S~OII contents for 2 to 6 months. The most favorable cnurse t.aneous onset of labor. The patient most often will develop increasing uterine irritability mar:ifested by uterine cramps. Labor will finally set, in a.nd usually spontaneous evacuation will follow in a short t,ime. Prophylactic antibiotic therapy may be started with the onset of labor and continued for several days after the evacuation of the uterus. Should uterine activity be initiated by the intravenous drip of an osyt,rItic drug? This may be effective when the patient exhibits irregular uterine contractions and some cervical effacement has taken place; however. labor is extremely difficult to initiate at this period of gest,ation. Repeated a.tempts at the induction of labor may disturb normal intrauterine relationships favoring the ascent of organisms from the lower genital tract and the devclopnnnt of an intrauterine infection. Operative intervention by cervical dilatation and the artificial evacuation of the uterus at this period of pregnancy are hazardous and may resuit in serious trauma. Evacuation o-f the uterus by hpsterotomy is a ma,jol procedure and is rarely indicated.
Reference 1. Fisher,
G. G.:
Obst.
& Gpnec.
1: 329, 1953.
Editor’s
Comment
On the day of admission the local consultant advised repeated att.empt,s to prepare the cervix by intravenous use of Pitocin. It was also suggested that fibrinogen levels be determined daily. The patient’s doctor ordered 21/, ounces of castor oil prior to the use of the intravenous Pitocin. The patient went into violent labor and was delivered of the macerated abortus in about 2 hours without having received any intravenous medication. HPl’ subsequent course has been uneventful.