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Therapy of Missed Abortion
Therapy of Missed Abortion JOHN J. BATTAGLINO, JR. ROBERT B. WILSON
the time J. Matthews Duncan coined the term "missed abortion" there has been little agreement as to the definition of this entity. Litzenberg and others 7, 8,17 have held that retention in the uterus of a dead fetus for a minimum of two months at any stage of gestation should be called a "missed abortion." For a number of reasons this criterion is seldom used today.1, 6, 11, 12, 16 Common practice names as an abortion the termination of pregnancy prior to the twenty-eighth week of gestation and pregnancies that terminate thereafter are designated as "premature" or "term delivery." The presence of a fetus is not essential, since many ordinary abortions occur in the absence of a fetus; there is, therefore, no reason to require the presence of a fetus in this condition. A missed abortion varies primarily from an ordinary abortion in the length of time the conception is retained in the uterus after it has ceased to grow. As it is often possible to ascertain conceptual death of four weeks' duration, the requirement of two months' fetal death is not necessary. For these reasons this study deals with patients in whom conception occurred with or without a fetus, in whom the conception ceased to develop prior to the twenty-eighth week of gestation, and in whom this failure of development had been present for at least four weeks. The management of missed abortion, as well as its definition, also has been controversial. Table 1 shows the recommendations for treatment by a number of writers. A perusal of this table shows that for the most part there has been a tendency in recent years toward conservative or nonsurgical therapy. The various authors1, 8,12 who most strongly recommend conservative treatment base their opinions on the good results obtained by allowing these patients to abort spontaneously and also because they feel that surgical intervention is difficult and dangerous as the cervix is frequently closed and rigid, the uterine wall is thin and easily perforated and the uterine musculature is not responsive to oxytocic drugs. Also they write that there is increased danger of hemorrhage and infection. We have reviewed the type of treatment employed in 161 missed SINCE
1119
John J. Battaglino, Jr., Robert B. Wilson
1120
Table 1 RECOMMENDED TREATMENT TREATMENT AUTHORITY
CASES
YEAR
Litzenberg ...... Peckham ..... Dippel. .... Jeffcoate ... Lubin and Waltman" .. De Lee and Greenhill. Lubin and Waltman l2 . Novak and Novak ... Appelberg ..... Fisher ....... O'Driscoll and Lavelle .. Titus and Willson ...... Martin and Menzies ... Eastman ......... Borglin .....
13 41
1921 1936 1939 1940 1943 1947 1949 1952 1952 1953 1955 1955 1955 1956 1957
26 18 39 104 30 1 12 123
Conservative
Surgical Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
abortions occurring in 147 patients who were seen at the Clinic during the 23 years from January, 1935, to January, 1958. These patients have been under the management of the consultants in the Section of Obstetrics and Gynecology at the Clinic. The diagnoses were based primarily on the finding of a uterine size not compatible with the duration of the amenorrhea. A pregnancy test giving negative results was often an associated finding. It is our opinion that negative results to pregnancy tests are of considerable value in making an accurate diagnosis and that, should surgical intervention be the treatment selected, such treatment should rarely be employed unless a pregnancy test has been done and the results reported to be negative. Table 2 shows that in this series of 161 cases, 94 (58.4 Table 2 PREGNANCY TESTS IN MISSED ABORTION RESULT OF TEST
Positive Negative TOTAL
TERMINATION OF PREGNANCY
TOTAL
Spontaneous
Surgical
Number
Percent*
9 32 41
8 45 53
17 77 94
10.6 47.8 58.4
* Per cent of total of 161 cases in this series.
1121
Therapy of Missed Abortion Table 3
DURATION OF PREGNANCY, TIME RETAINED AND TREATMENT EMPLOYED TREATMENT TOTAL DURATION OF PREGNANCY* (weeks)
Conservative
Number
5- 9 10-14 15-19 20-24 25-28 TOTAL
19 22 28 14 5 88 (54.66 per cent)
Mean Number of Weekst
6.6 10.1 8.1 6.1 5.4 7.8
Surgical
Number
15 36 12 8 2 73 (45.34
Mean Number ofWeekst
Number
Meah Number of Weekst
7.7 9.5 8.8 9.2 16.0 9.2
34 58 40 22 7 161
7.1 9.7 8.3 7.2 8.4 8.4
per cent)
* Duration of pregnancy refers to length of time from last menstrual period to estimated time of death of conception. t Mean number of weeks, the length of time from death of conception to termination of pregnancy.
per cent) patients had had a pregnancy test and that the results were negative in 77 or 81.9 per cent of those so tested. During the last half of this study the incidence of pregnancy tests has been 65 per cent, indicating an increasing reliance on this diagnostic aid. During the 23-year period treatment for this condition has varied at the Clinic. Table 3 shows that 88 patients (54.66 per cent) were treated conservatively and that 73 (45.34 per cent) were subjected to some type of operative treatment. By conservative treatment is meant that which depends on the expulsion of the uterine contents spontaneously without operative interference or in those instances in which the expulsion followed some sort of medical induction by oxytocics or hormones or both. These latter procedures were attempted 28 times in these 88 conservatively treated patients with apparent success in 20 of the 28 and failure in eight. In spite of these results the study of Martin and Menzies is worth noting here as these authors, using controls, wrote that hormones, and perhaps oxytocics, are probably of no value in the treatment of missed abortion and missed labor. Nine (10.2 per cent) of our conservatively managed patients required dilatation and curettage for complete evacuation of the uterus. Morbidity occurred in two patients (2.3 per cent). Five (5.7 per cent) of the 88 patients treated conservatively required transfusion of blood. Three were given 500 cc. each, one 2500 cc. and one 3500 cc. The patient who received 3500 cc. of blood had chronic nephritis with uremia and
John J. Battaglino,
1122
Jr~,
Robert B. Wilson
Table" TYPE OF TREATMENT BY PERIODS PATIENTS January 1935June, 1946
July, 1946January, 1958
Total
TREATMENT
Conservative Surgical TOTAL
Number
Per cent
Number
Per cent
Number
Per cent
28 16 44
63.6 36.4 100.0
60 57 117
51.3 48.7 100.0
88
73 161
54.7 45.3 100.0
anemia; blood was administered intermittently both before and after the abortion. Only one patient who received a transfusion bled because of a probable afibrinogenemia. A positive diagnosis in this regard is not available because this patient was seen prior to our awareness of this entity. We now determine the concentration of fibrinogen after the diagnosis is made and subsequently as indicated. The average hospital stay for this group of patients was 5.5 days. Of the 73 patients treated surgically 64 underwent a dilatation and curettage; six had a vaginal hysterotomy and three had an abdominal hysterotomy. The indications for the abdominal hysterotomies were medical in nature and were associated with pregnancies considered too far advanced for safe vaginal delivery. Eleven of the 73 patients required transfusion: two patients received 1000 cc. of blood, one 1500 cc., one 2000 cc. and seven 500 cc. Four patients received transfusions before operation because of anemia and seven because of loss of blood associated with the surgical procedure. This incidence of transfusion indicates that blood should be readily available in patients who are treated surgically. Morbidity occurred in two patients (2.7 per cent) and the average hospital stay was 4.7 days. There were no deaths in either group. It is of interest to note that in the last half of this study (Table 4) surgical treatment was used more commonly (48.7 per cent) than during the first half of the study (36.4 per cent). COMMENT
From this analysis it might seem that we presently favor surgical treatment in almost half of our patients. However, referring to Table 3, it is of importance to note that there was a mean duration of death of the products of conception of 9.2 weeks in the patients treated surgically and of 7.8 weeks in those treated conservatively. This means that surgically treated patients were observed approximately ten days longer than were those in whom the uterus had emptied spontaneously.
Therapy of Missed Abortion
1123
This portrays our idea of therapy, namely, that it is usually wise to observe patients for approximately two months and then to intervene surgically sometime thereafter in these patients who do not abort. This plan permits a high degree of accuracy in the diagnosis of the condition and yet it does not usually permit the development of hypofibrinogenemia or serious emotional disturbance. While this factor of emotional equanimity may not seem important to some it does seem important to us, for many of our patients are greatly disturbed because their desire to have a child has been temporarily thwarted and also because there is seemingly something inherently distasteful in their retention of that which is dead. We have not found the complications subsequent to surgical therapy to be significantly greater than those which follow conservative therapy, and therefore it seems reasonable to us to intervene surgically in those patients who retain the dead products of conception for longer than two months. REFERENCES 1. Appelberg, Gustaf: "Missed Abortion." Nord. med. 47: 670-672,1952. 2. Borglin, N. E.: Missed Abortion: Analysis of a 10-Year Series. Acta obst. et gynec. scandinav. 36: 512-523, 1957. 3. De Lee, J. B. and Greenhill, J. P.: Principles and Practice of Obstetrics. Ed. 9, Philadelphia, W. B. Saunders Co., 1947, p. 386. 4. Dippel, A. L.: Diagnosis and Treatment of Missed Abortion. M. Clin. North America 23: 389-404 (March) 1939. 5. Douglas, R. G. and Stromme, W. B.: Operative Obstetrics. N ew York, AppletonCentury-Crofts, Inc., 1957, pp. 174-175. 6. Duncan, J. M.: Clinical Lecture on Missed Abortion. M. Times & Gaz. 2: 729731 (Dec. 28) 1878. 7. Eastman, N. J.: Williams' Obstetrics. Ed. 11, New York, Appleton-CenturyCrofts, Inc., 1956, pp. 525; 528. 8. Fisher, J. J.: Missed Abortion: AmI-lysis of 30 Cases and Discussion of Etiology. Obst. & Gynec. 1: 529-534 (May) 1953. 9. Je/Icoate, T. N. A.: Missed Abortion and Missed Labour. Lancet 1: 1045-1048 (June) 1940. 10. Litzenberg, J. C.: Missed Abortion. Am. J. Obst. & Gynec. 1: 475-484 (Feb.) 1921. 11. Lubin, Samuel and Waltman, Richard: Missed Abortion: An Analysis of Results Following Conservative Treatment. Am. J. Obst. & Gynec. 45: 89-95 (Jan.) 1943. 12. Lubin, Samuel and Waltman, Richard: Missed Abortion: An Evaluation of Conservative Management. Am. J. Surg. 77: 202-207 (Feb.) 1949. 13. Martin, R. H. and Menzies, D. N.: Oestrogen Therapy in Missed Abortion and Labour. J. Obst. & Gynaec. Brit. Emp. 62: 256-258 (April) 1955. 14. Novak, Emil and Novak, E. R.: Textbook of Gynecology. Ed. 4, Baltimore, Williams & Wilkins Co., 1952, pp. 727-729. 15. O'Driscoll, D. T. and Lavelle, S. M.: Blood-Coagulation Defect Associated with Missed Abortion. Lancet 2: 1169-1172 (Dec. 3) 1955. 16. Peckham, C. H.: Abortion: A Statistical Analysis of 2,287 Cases. Surg., Gynec. & Obst. 63: 109-115 (July) 1936. 17. Titus, Paul and Willson, J. R.: The Management of Obstetric Difficulties. Ed. 5, St. Louis, C. V. Mosby Co., 1955, p. 225.
the time J. Matthews Duncan coined the term "missed abortion" there has been little agreement as to the definition of this entity. Litzenberg and others 7, 8,17 have held that retention in the uterus of a dead fetus for a minimum of two months at any stage of gestation should be called a "missed abortion." For a number of reasons this criterion is seldom used today.1, 6, 11, 12, 16 Common practice names as an abortion the termination of pregnancy prior to the twenty-eighth week of gestation and pregnancies that terminate thereafter are designated as "premature" or "term delivery." The presence of a fetus is not essential, since many ordinary abortions occur in the absence of a fetus; there is, therefore, no reason to require the presence of a fetus in this condition. A missed abortion varies primarily from an ordinary abortion in the length of time the conception is retained in the uterus after it has ceased to grow. As it is often possible to ascertain conceptual death of four weeks' duration, the requirement of two months' fetal death is not necessary. For these reasons this study deals with patients in whom conception occurred with or without a fetus, in whom the conception ceased to develop prior to the twenty-eighth week of gestation, and in whom this failure of development had been present for at least four weeks. The management of missed abortion, as well as its definition, also has been controversial. Table 1 shows the recommendations for treatment by a number of writers. A perusal of this table shows that for the most part there has been a tendency in recent years toward conservative or nonsurgical therapy. The various authors1, 8,12 who most strongly recommend conservative treatment base their opinions on the good results obtained by allowing these patients to abort spontaneously and also because they feel that surgical intervention is difficult and dangerous as the cervix is frequently closed and rigid, the uterine wall is thin and easily perforated and the uterine musculature is not responsive to oxytocic drugs. Also they write that there is increased danger of hemorrhage and infection. We have reviewed the type of treatment employed in 161 missed SINCE
1119
John J. Battaglino, Jr., Robert B. Wilson
1120
Table 1 RECOMMENDED TREATMENT TREATMENT AUTHORITY
CASES
YEAR
Litzenberg ...... Peckham ..... Dippel. .... Jeffcoate ... Lubin and Waltman" .. De Lee and Greenhill. Lubin and Waltman l2 . Novak and Novak ... Appelberg ..... Fisher ....... O'Driscoll and Lavelle .. Titus and Willson ...... Martin and Menzies ... Eastman ......... Borglin .....
13 41
1921 1936 1939 1940 1943 1947 1949 1952 1952 1953 1955 1955 1955 1956 1957
26 18 39 104 30 1 12 123
Conservative
Surgical Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
abortions occurring in 147 patients who were seen at the Clinic during the 23 years from January, 1935, to January, 1958. These patients have been under the management of the consultants in the Section of Obstetrics and Gynecology at the Clinic. The diagnoses were based primarily on the finding of a uterine size not compatible with the duration of the amenorrhea. A pregnancy test giving negative results was often an associated finding. It is our opinion that negative results to pregnancy tests are of considerable value in making an accurate diagnosis and that, should surgical intervention be the treatment selected, such treatment should rarely be employed unless a pregnancy test has been done and the results reported to be negative. Table 2 shows that in this series of 161 cases, 94 (58.4 Table 2 PREGNANCY TESTS IN MISSED ABORTION RESULT OF TEST
Positive Negative TOTAL
TERMINATION OF PREGNANCY
TOTAL
Spontaneous
Surgical
Number
Percent*
9 32 41
8 45 53
17 77 94
10.6 47.8 58.4
* Per cent of total of 161 cases in this series.
1121
Therapy of Missed Abortion Table 3
DURATION OF PREGNANCY, TIME RETAINED AND TREATMENT EMPLOYED TREATMENT TOTAL DURATION OF PREGNANCY* (weeks)
Conservative
Number
5- 9 10-14 15-19 20-24 25-28 TOTAL
19 22 28 14 5 88 (54.66 per cent)
Mean Number of Weekst
6.6 10.1 8.1 6.1 5.4 7.8
Surgical
Number
15 36 12 8 2 73 (45.34
Mean Number ofWeekst
Number
Meah Number of Weekst
7.7 9.5 8.8 9.2 16.0 9.2
34 58 40 22 7 161
7.1 9.7 8.3 7.2 8.4 8.4
per cent)
* Duration of pregnancy refers to length of time from last menstrual period to estimated time of death of conception. t Mean number of weeks, the length of time from death of conception to termination of pregnancy.
per cent) patients had had a pregnancy test and that the results were negative in 77 or 81.9 per cent of those so tested. During the last half of this study the incidence of pregnancy tests has been 65 per cent, indicating an increasing reliance on this diagnostic aid. During the 23-year period treatment for this condition has varied at the Clinic. Table 3 shows that 88 patients (54.66 per cent) were treated conservatively and that 73 (45.34 per cent) were subjected to some type of operative treatment. By conservative treatment is meant that which depends on the expulsion of the uterine contents spontaneously without operative interference or in those instances in which the expulsion followed some sort of medical induction by oxytocics or hormones or both. These latter procedures were attempted 28 times in these 88 conservatively treated patients with apparent success in 20 of the 28 and failure in eight. In spite of these results the study of Martin and Menzies is worth noting here as these authors, using controls, wrote that hormones, and perhaps oxytocics, are probably of no value in the treatment of missed abortion and missed labor. Nine (10.2 per cent) of our conservatively managed patients required dilatation and curettage for complete evacuation of the uterus. Morbidity occurred in two patients (2.3 per cent). Five (5.7 per cent) of the 88 patients treated conservatively required transfusion of blood. Three were given 500 cc. each, one 2500 cc. and one 3500 cc. The patient who received 3500 cc. of blood had chronic nephritis with uremia and
John J. Battaglino,
1122
Jr~,
Robert B. Wilson
Table" TYPE OF TREATMENT BY PERIODS PATIENTS January 1935June, 1946
July, 1946January, 1958
Total
TREATMENT
Conservative Surgical TOTAL
Number
Per cent
Number
Per cent
Number
Per cent
28 16 44
63.6 36.4 100.0
60 57 117
51.3 48.7 100.0
88
73 161
54.7 45.3 100.0
anemia; blood was administered intermittently both before and after the abortion. Only one patient who received a transfusion bled because of a probable afibrinogenemia. A positive diagnosis in this regard is not available because this patient was seen prior to our awareness of this entity. We now determine the concentration of fibrinogen after the diagnosis is made and subsequently as indicated. The average hospital stay for this group of patients was 5.5 days. Of the 73 patients treated surgically 64 underwent a dilatation and curettage; six had a vaginal hysterotomy and three had an abdominal hysterotomy. The indications for the abdominal hysterotomies were medical in nature and were associated with pregnancies considered too far advanced for safe vaginal delivery. Eleven of the 73 patients required transfusion: two patients received 1000 cc. of blood, one 1500 cc., one 2000 cc. and seven 500 cc. Four patients received transfusions before operation because of anemia and seven because of loss of blood associated with the surgical procedure. This incidence of transfusion indicates that blood should be readily available in patients who are treated surgically. Morbidity occurred in two patients (2.7 per cent) and the average hospital stay was 4.7 days. There were no deaths in either group. It is of interest to note that in the last half of this study (Table 4) surgical treatment was used more commonly (48.7 per cent) than during the first half of the study (36.4 per cent). COMMENT
From this analysis it might seem that we presently favor surgical treatment in almost half of our patients. However, referring to Table 3, it is of importance to note that there was a mean duration of death of the products of conception of 9.2 weeks in the patients treated surgically and of 7.8 weeks in those treated conservatively. This means that surgically treated patients were observed approximately ten days longer than were those in whom the uterus had emptied spontaneously.
Therapy of Missed Abortion
1123
This portrays our idea of therapy, namely, that it is usually wise to observe patients for approximately two months and then to intervene surgically sometime thereafter in these patients who do not abort. This plan permits a high degree of accuracy in the diagnosis of the condition and yet it does not usually permit the development of hypofibrinogenemia or serious emotional disturbance. While this factor of emotional equanimity may not seem important to some it does seem important to us, for many of our patients are greatly disturbed because their desire to have a child has been temporarily thwarted and also because there is seemingly something inherently distasteful in their retention of that which is dead. We have not found the complications subsequent to surgical therapy to be significantly greater than those which follow conservative therapy, and therefore it seems reasonable to us to intervene surgically in those patients who retain the dead products of conception for longer than two months. REFERENCES 1. Appelberg, Gustaf: "Missed Abortion." Nord. med. 47: 670-672,1952. 2. Borglin, N. E.: Missed Abortion: Analysis of a 10-Year Series. Acta obst. et gynec. scandinav. 36: 512-523, 1957. 3. De Lee, J. B. and Greenhill, J. P.: Principles and Practice of Obstetrics. Ed. 9, Philadelphia, W. B. Saunders Co., 1947, p. 386. 4. Dippel, A. L.: Diagnosis and Treatment of Missed Abortion. M. Clin. North America 23: 389-404 (March) 1939. 5. Douglas, R. G. and Stromme, W. B.: Operative Obstetrics. N ew York, AppletonCentury-Crofts, Inc., 1957, pp. 174-175. 6. Duncan, J. M.: Clinical Lecture on Missed Abortion. M. Times & Gaz. 2: 729731 (Dec. 28) 1878. 7. Eastman, N. J.: Williams' Obstetrics. Ed. 11, New York, Appleton-CenturyCrofts, Inc., 1956, pp. 525; 528. 8. Fisher, J. J.: Missed Abortion: AmI-lysis of 30 Cases and Discussion of Etiology. Obst. & Gynec. 1: 529-534 (May) 1953. 9. Je/Icoate, T. N. A.: Missed Abortion and Missed Labour. Lancet 1: 1045-1048 (June) 1940. 10. Litzenberg, J. C.: Missed Abortion. Am. J. Obst. & Gynec. 1: 475-484 (Feb.) 1921. 11. Lubin, Samuel and Waltman, Richard: Missed Abortion: An Analysis of Results Following Conservative Treatment. Am. J. Obst. & Gynec. 45: 89-95 (Jan.) 1943. 12. Lubin, Samuel and Waltman, Richard: Missed Abortion: An Evaluation of Conservative Management. Am. J. Surg. 77: 202-207 (Feb.) 1949. 13. Martin, R. H. and Menzies, D. N.: Oestrogen Therapy in Missed Abortion and Labour. J. Obst. & Gynaec. Brit. Emp. 62: 256-258 (April) 1955. 14. Novak, Emil and Novak, E. R.: Textbook of Gynecology. Ed. 4, Baltimore, Williams & Wilkins Co., 1952, pp. 727-729. 15. O'Driscoll, D. T. and Lavelle, S. M.: Blood-Coagulation Defect Associated with Missed Abortion. Lancet 2: 1169-1172 (Dec. 3) 1955. 16. Peckham, C. H.: Abortion: A Statistical Analysis of 2,287 Cases. Surg., Gynec. & Obst. 63: 109-115 (July) 1936. 17. Titus, Paul and Willson, J. R.: The Management of Obstetric Difficulties. Ed. 5, St. Louis, C. V. Mosby Co., 1955, p. 225.