Incomplete abortion is the delay of the fetus or its membranes in the uterine cavity during spontaneous or induced termination of pregnancy for up to 22 weeks. It is manifested by pulling or intense cramping pain in the lower abdomen, bloody vaginal discharge, in which fragments of the fetal egg may be present. To make a diagnosis, a chair examination, ultrasound of the uterus are used, if necessary, laboratory tests and hysteroscopy are prescribed. The patient’s management plan involves the removal of the remnants of abortive material by vacuum aspiration or curettage of the uterine cavity, followed by the appointment of uterotonics, antibiotics, infusion therapy.
According to research in the field of obstetrics and gynecology, from 1 to 5% of spontaneous miscarriages, instrumental or medicinal interruptions of gestation end with incomplete abortion. At this stage, it is not possible to save the fetus, since it has already died. The main task of the doctor when detecting such a pathology is the rapid correction of disorders to exclude possible complications and eliminate threats to the reproductive health of the patient. More often, incomplete spontaneous abortion is diagnosed in women over 35 years of age with genital and extragenital pathology. Incomplete induced abortion with late development of clinical symptoms may occur in a patient of any age with a pharmacological method of termination of pregnancy.
Both spontaneous and artificial termination of pregnancy in the early stages can be incomplete. Usually, the complete discharge of the remains of the fetal egg is prevented by the anatomical features of the uterus, insufficient opening of its neck, the presence of a connection of parts of the fetus or its membranes with the uterine wall. The immediate causes of an incomplete abortion are:
- Medical abortion. In most cases, incomplete termination of pregnancy is observed when taking medications in the early stages of gestation. Despite the low invasiveness of the technique, some patients have a violation of the contractility of the myometrium and insufficient opening of the cervical canal.
- Improper performance of surgical abortion. Part of the fetal egg remains attached to the uterine wall during the operation by an inexperienced obstetrician-gynecologist or the absence of ultrasound control before or after the intervention to terminate pregnancy. The risk of incomplete expulsion of abortive material increases with criminal operations.
- Dishormonal states. The degree of opening of the cervix, the strength and rhythm of contractions of the myometrium are regulated hormonally. With an imbalance of estrogens, prostaglandins, oxytocin, progesterone, and other mediators, the contractile activity of the muscle layer becomes insufficient for the complete expulsion of the fetal egg.
- Abnormalities of the structure of the uterus. In rare cases, anatomical features such as a two-horned or saddle-shaped uterus, submucous fibroids in the isthmus area are obstacles to the free expulsion of the rejected fetal egg. With hypoplasia of the organ, there is insufficient contractile activity of its muscles.
The risk group for the possibility of incomplete abortion is patients with impaired secretion of female sex hormones (polycystic ovaries, depletion or resection of ovarian tissue), extragenital somatic and endocrine pathology (diabetes mellitus, hypothyroidism, adrenal diseases), obesity. The probability of incomplete completion of abortion also increases in women with chronic specific and nonspecific endometritis, abortions and diagnostic curettage.
The mechanism of development of incomplete abortion and the formation of its clinical picture is common, despite the difference in etiological factors. Partial separation of the fetal egg due to technical errors or insufficient contractile activity of the myometrium under the embryo implantation site, the delay of its parts in the uterus due to the presence of mechanical obstacles (myomatous node, closed cervical canal, etc.) makes it impossible to adequately reduce the organ wall. As a result, bleeding from gaping vessels continues, characteristic pain occurs and a nutrient substrate is formed for possible infection.
The clinical picture of the disorder is a continuation of the symptoms of spontaneous miscarriage in progress or gradually develops within a few hours after a surgical abortion. With a drug interruption of gestation, pathological signs may appear several days or even weeks after taking medications. Incomplete abortion is manifested by intense cramping pains in the lower abdomen, often radiating into the lower back and sacrum, as well as abundant uterine bleeding with the possible presence of fragments of abortive material in the secretions. Less often, painful sensations have a pulling character. The infection is indicated by the appearance of a sharp putrid odor of vaginal discharge, an increase in body temperature to 37.5-38.0 ° C and above. When the pathology is aggravated, patients complain of weakness, dizziness, fainting.
In case of untimely diagnosis, incomplete abortion is complicated by profuse uterine bleeding, hematometry, infection of abortive material. At first, the inflammation is local in nature and is manifested by the clinical picture of acute endometritis. Subsequently, the generalization of the process with the involvement of uterine appendages (acute salpingitis or adnexitis), pelvic peritoneum (pelvioperitonitis), sepsis is possible. The long-term consequences of an incomplete abortion are chronic inflammatory diseases of the pelvic organs, cervical insufficiency, habitual miscarriage, infertility. If chorion fragments remain in the uterine wall, a placental polyp may form from them in the future, accompanied by copious and prolonged menstrual bleeding.
If an incomplete abortion is suspected, studies are prescribed to determine the presence of abortive material in the uterus, confirm the termination of pregnancy, and establish possible causes. For timely detection of complications, temperature, heart rate and blood pressure are monitored. The most informative in diagnostic terms are:
- Gynecological examination. During the examination, blood clots are found in the mirrors in the vagina, sometimes abortive material. The neck is smoothed, blood is released from its channel. With bimanual palpation, the uterus is enlarged, soft, painful. The inner pharynx is slightly open or fully opened.
- Ultrasound of the uterus. The size of the organ is less than the expected duration of pregnancy. A deformed fetal egg or amorphous inclusions of different sizes, shapes and echogenicity are determined in the cavity. The fetus shows no signs of vital activity. It is possible to identify anatomical anomalies.
Usually, a typical clinical picture with characteristic ultrasound signs is sufficient when making a diagnosis. In doubtful cases, laboratory methods are prescribed to confirm the termination of gestation (colpocytology with an assessment of the karyopycnotic index, determination of the levels of chorionic gonadotropin, estradiol, progesterone). To exclude infectious and hemorrhagic complications, a general blood test and hemostasis indicators are monitored. Differential diagnosis is carried out with an accomplished abortion, ectopic pregnancy, failed miscarriage. If necessary, an anesthesiologist-resuscitator, infectious disease specialist, hematologist are involved in the examination of the patient.
The main tasks are to remove the deceased fetus and its parts from the uterine cavity, stop bleeding and prevent possible infectious complications. An attempt to expel abortive material with the help of uterotonics, as a rule, is rarely effective and only increases cramping pains. The standard management scheme for a patient with incomplete spontaneous or induced abortion includes such stages as:
- Cleansing of the uterine cavity. To remove the remaining fetal egg, an abortion is used, after which, taking into account the gestational period, vacuum aspiration (up to 12 weeks of pregnancy) or classical curettage of the uterine walls (from 12 weeks onwards) is performed. Effective management of the patient without complete cleaning of the uterine cavity is impossible. Hysteroscopy can be used for optical quality control of the intervention.
- Stopping uterine bleeding. When incomplete termination of pregnancy is combined with coagulopathic and hemodynamic disorders, depending on the results of laboratory tests, oxytocin is drip-injected with Ringer’s solution or saline. In exceptional cases, with significant blood loss, hemostatics, transfusion of blood or its components are recommended.
- Antibacterial therapy. The use of broad-spectrum antibiotics is directly indicated for clinical and laboratory signs of an infectious process. For preventive purposes, drugs with antimicrobial action are administered at a late diagnosis of incomplete discharge of the fetal egg. The course of antibiotic therapy lasts from 7 to 10 days with simultaneous administration of eubiotics and antifungal agents.
In the postoperative period, according to indications, nonsteroidal anti-inflammatory drugs, iron preparations are used. If an incomplete miscarriage or induced abortion is diagnosed in a woman with a negative Rh blood factor, anti-Rh0(D)-immunoglobulin is prescribed. Within 2 weeks after curettage, the patient is recommended to give up sexual contact, douching, intra-vaginal administration of tampons, candles. In the normal condition of the patient, a control examination is performed after 14 days. An increase in temperature and deterioration of the general condition are grounds for a more thorough diagnostic search, the appointment of massive antibiotic therapy and possible repeated curettage of the uterine cavity. Women with neurotic and subdepressive disorders associated with the unexpected loss of a child are shown mild sedatives, mild antidepressants, psychotherapy.
Prognosis and prevention
Timely detection of signs of incomplete abortion, adequate treatment can quickly eliminate the symptoms of the disorder and preserve the chances of a normal repeat pregnancy in 80-85% of patients. For preventive purposes, women with dishormonal conditions or anatomical features of the uterus are recommended to plan pregnancy, early registration in a women’s consultation and regular observation by an obstetrician-gynecologist. If there is a threat of miscarriage, compliance with the therapeutic and protective regime and appropriate drug therapy is indicated. If the rejection of the fetal egg has occurred, it is necessary to monitor its complete evacuation from the uterine cavity during ultrasound or hysteroscopy. The control of the withdrawal of abortive material is especially important after the medical interruption of gestation.