Case Based Discussion

“Abortion”
17 October 2019

DEPARTEMEN OBSTETRI DAN GINEKOLOGI

RSI JEMURSARI SURABAYA
UNIVERSITAS NAHDLATUL ULAMA SURABAYA
 Pembimbing :
dr. Amir Fahad, Sp.OG

Dokter Muda :
Dinda Mutiara Sukma Prastika
Anang Maulana Yusuf
Aisyah Imas Setiawati
Himami Firdausiyah
Fithrotun Nisak

2
Introduction

•Abortion is the expulsion of the conceptus before 28 completed weeks of

gestation, or a fetus weighing less than 500g

• WHO and FIGO state less than 20-22 weeks.

• It could be induced or spontaneous.

Risk factors of abortion •Intrauterine device use

•Maternal infections : BV, mycoplasmosis,

herpes simplex, torch, malaria, syphilis, HIV,

•Advanced maternal age
•Alcohol use chlamydia, listeriosis

•Anesthetic gas use (nitrous oxide) •Medication : misoprostol, retinoid,

•Caffeine use (heavy)
•Chronic maternal disease : DM, celiac
disease, autoimmune disease
•Cigarette smoking
•Cocain use
•Conception within 3-6 months after delivery
methotrexate, NSAID
•Multiple previous elective abortion
•Previous spontaneous abortion
•Toxin : arsenic, lead, ethylen glycol, carbon
disulfide, heavy metals
•Abnormalities of uterine
Causes of abortion
• Chromosomal causes (genetic) are most frequent, about 70% within the first 6 weeks, 50% before 10 weeks, 5%
after 12 weeks.
• Errors during fertilization, Could be: -errors during gametogenesis, non disjunction in paternal or maternal
meiosis, resulting in monosomy (15%), trisomy (54%) or a double trisomy (3%).
• Error of segmentation during 1st zygotic cell division, resulting in tetraploidy (4% of cases) or in mosaicism (1% of
cases).
•Maternal age and the aging of the gametes favor these abnormalities.
•Errors could be due to radiation
• Other ovum abnormalities can be responsible for abortions such as: multiple pregnancies, abnormal placental
insertion, hydramnios, single umbilical artery etc.
• Infections, representing about 15% of the cases. can be toxoplasma, rickettsia, mycoplasma, viral infections
(rubella, herpes, CMV, HbAv), nonspecific infections (colibacilli), local infections (cervicitis, endometritis) and
malaria especially in our milieu.
Causes of abortion

•Thrombophilias
•Acquired Thrombophilia (APS).
•Inherited Thrombophilia (factor V Leiden, prothrombin gene mutations, protein C and S
deficiencies).
•Methylenetetrahydrofolate reductase (MTHFR) gene mutation.

•Endocrine causes
•Polycystic ovary syndrome (PCOS), and insulin resistance(IR).
•Luteal Phase defect (LPD).
•Diabetes Mellitus (DM).
•Thyroid Disorders; Subclinical hypothyroidism and thyroperoxidase antibodies (TPO-Ab).
•Sperm DNA fragmentation

•Lifestyle factors; Alcohol, coffee, smoking, advanced maternal age, and BMI ≥30
kg/m2
 CLINICAL SIGN OF ABORTION

•Vaginal bleeding : the bleeding is heavy with clots, but not severe - it is more like a
heavy period.
•Cramping pain : rhythmic pain such as during menstruation in the suprasymphysis,
waist and spinal region
•Febris : the process of intra-genital infection, usually accompanied by smelly and
painful lochia at the time of deep examination
Abortion diagnosis according to clinical features:

i. Imminens Abortion (Threatened abortion)

a. History - slight bleeding from the birth canal and absent or mild abdominal pain.
b. VT examination is present (few fluxus), uterine ostium is closed, and large of uterus according to
gestational age.
c. Investigations - USG results.
ii. Insipiens Abortion (Inevitable abortion)
a. History - bleeding from the birth canal accompanied by pain / uterine contractions.
b. VT examination, uterine ostium is open, the fetus still in the uterus, and intact
membranes (may be prominent).
iii. Incomplete abortion or complete abortion
a. History - bleeding from the birth canal (usually a lot), pain / contraction of the
uterus, and if there is a lot of bleeding shock can occur.
b. VT examination - uterine ostium is open, palpable residual fetus tissue of pregnancy.
iv. Missed Abortion
a. History - bleeding may or may not.
b. Obstetric examination - uterine fundus is smaller than gestational age and fetal
heart sound is absent.
c. Investigations - USG, laboratory (hemoglobin, platelets, fibrinogen, bleeding time,
freezing time and prothrombin time).
v. Habitualis Abortion (Recurrent abortion)
a. Hysterosalfingography - to determine the presence or absence of submucous
uterine myomas and congenital anomalies.
b. BMR (basal metabolic rate) and blood iodine levels are measured to find out
whether or not there is a thyroideal gland disorder.
vi. Septic Abortion
a. Abortion: amenorrhea, bleeding, outgoing tissue that has been helped outside the
hospital.
b. Examination: open cervical canal, palpable tissue, bleeding.
c. Signs of genital infection: fever, rapid pulse, bleeding, tenderness and leukocytosis.
d. Sign of infection: severe pain, high fever, chills, small and rapid pulse, blood
pressure drops to shock.
Provocate Abortion

Provocate abortion is a deliberate abortion by using drugs or tools.

Provocate abortion is divided into two:
1) Abortus provocatus medicinalis
Is an abortion performed by a doctor on the basis of medical indications, if an abortion is not
taken it will endanger the life of the mother. Provokatus medicinalis / artificialis / therapeuticus
abortion is an abortion performed with medical indications.
2) Abortion provocatus criminalis
Abortion is caused by actions that are not legal or not based on medical indications, for
example abortion performed in order to eliminate the fetus as a result of sexual relations outside
of marriage. In general, the notion of criminal provocatus abortion is an early birth before the
baby can in time live alone outside the womb.
Imminent Abortion

The incidence of bleeding from intrauterine in pregnancy less than 20 weeks without
the presence of cervical dilatation with the results of conception is still in the uterus.
Insipiens Abortion

The incidence of bleeding from intrauterine in pregnancy less than 20 weeks with the
existence of cervical dilatation is continuous and progressive, miscarriage will not be
prevented anymore.
incomplete abortion

Definition:
the entire products of conception are not expelled, instead a part of it is left inside the
uterine cavity.

Clinical feature:
-Partial expulsion of products
-Bleeding and colicky pain continue.
-VT: opened cervix
-USG: retained products of conception.
management
1. Improving the general condition due to bleeding
Evaluate the signs of shock, plug the IV line (if necessary double IV line) immediately infuse
physiological NaCl or lactated ringer followed by blood transfusion (if needed)
2. Methylergometrine 0.5 mg IV or IM
3. Evacuation of retained products of conception
-early abortion: Vacuum aspiration: uterus is vacuum with a syringe through a dilated cervix
to remove conceptus
- late abortion: fetus, conceptus, and placenta are removed by ovum forceps or blunt curette
Complete Abortion

Spontaneous passage of all products of

conception and a closed internal cervical os
Diagnosis of Complete Abortion
• Products of conception expelled completely
• Significant cramping and bleeding have resolved
• Can be difficult to confirm clinically
• On internal examination, there was slight bleeding and the uterine os had closed
• On ultrasound: no gestational sac is detected; endometrial thickness < 15 mm

Management
• does not require special treatment
• Psychological support
• anemia : needs to be given sulfas ferrosus and
• healthy life style, recommended that the food contains lot of proteins, vitamins and minerals
• Genetic counselling offers the couple a prognosis for the risk of future pregnancies with an unbalanced
chromosome complement
prevention and prognosis

- Antenatal routine examination

- Eat, nutritious food (vegetables, milk, fish, meat, eggs)
- Maintain personal hygiene, especially the female area with the aim of preventing
infection
- Avoid smoking, because nicotine has a vasoactive effect that inhibits uretroplacental
circulation
If anemia is given sulfas ferosus table 600mg / day for 2 weeks, if anemia is severe
then give a blood transfusion
- Prognosis (ad Malam, refer immediately to an advanced health facility
complication
- Bleeding
- Shock
- Infection and sepsis
- Perforation
Abortion on Law and Moral Perspective in
Indonesia
• Pro and cons about abortion is still being debated today. Actually, abortion is prohibited in
Indonesian Medical Ethics Code and Criminal Code, however The Law on Health 2009
• The Medical Ethics Code of Indonesia (KODEKI) and Indonesian Criminal Code (KUHP)
prohibit an abortion. The Law on Health No.23/1992 which has been replaced with Law on
Health 2009 No. 36/2009 basically prohibit an abortion, and an abortion can be done with
some certainties.
• This ethics research is observed based on general ethics, and it is also related to the ethics of
Doctoral profession, because The Law onHealth 2009 only determines the doctors who are
allowed to do the abortion.
•Abortion according to Act 75 Law on Health is prohibited, but an abortion can be the
exception if: 1) Medically Indicated; 2) fetus suffered from severe genetic diseases
and congenital malformations; and 3) as an impact of the rape.
•An abortion for the pregnancy that threats the life of the expectant mother and the
fetus can be agreed fron the ethics and moral perspective; while the abortion for
fetus suffered from severe genetic diseases and congenital malformations cannot be
agreed from the ethics and moral aspects;
CASE
Patient’s Identity

Name : Mrs. L
Gender : Woman
Age : 37th years old
Adress : Surabaya
Occupation :
Marital Status : Married
Religion : Muslim
Date of examination : 15th October 2019
Time of examination : 19.30 WIB
Place of examination : PONEK Jemursari Surabaya Hospital
Anamnesis
Main complaint
Bleeding from the birth canal
Current complaint
Patients came to the ER Jemursari Hospital Surabaya with complaints of
bleeding from the birth canal since 3 days before she came, initially only blood
spots. Today there is a lot of blood and tissue. The patient claimed a blood clot
came out today like tissue. Blood that comes out a lot in 2 hours can replace 2
softex. Another problem is that the patient feels lower abdominal pain such as
menstrual pain. The patient complained of nausea and vomiting, since one month
ago.
The patient did not complain of dizziness or blurred eyes. According to the
patient, her last menstruated in August. September is not menstruating. The
patient claimed to be still actively intimate with her husband without using
contraseption. She never feel like this before.
Anamnesis

Hisroty of Medical
hypertention -, diabetes melitus -, ashtma -

History of Medical family

hypertention +, diabetes melitus +, asma -

History of medical treatments

-

History of allergies
-
Obstetric Status

- LMP : 15th August 2019

- EDC : 20 May 2020
- History of Pregnancy:
1. Ist : Spontaneus Delvery/Male/3000g/12 y.o
2. 2nd :Spontaneus Delvery/Female/3000g/9 y.o
3. 3rd : Spontaneus Delvery/Male/3200g/5 y.o
4. 4th : This Pregnancy
- Fundal Height : not palpable,
- Leopold : -
 Obstetric Status
Vaginal Examination : 19.45
VE : dilatation of cervix 1cm, bleeding +, tissue expelled +
Physical Examination

Status generalis
General : Enough
Awareness : CM (GCS 456)
Blood pressure : 112/72
Pulse frequency : 89 x / minute (regular)
RR : 20x / minute
Temperature : 36.1 C
SpO2 :-
Current BB : 58 kg
Current height : 154cm
BMI : 26
 Physical Examination
Head and Neck
A- / i- / c- / d-
Nasal lobe breathing (-)
KGB and thyroid enlargement (-)
↑ JVP (-)
Pharyngeal hyperemia (-)
Dry mouth mucosa (-)
Coward eyes (-)
Swallow pain (-)
Thoraks
Pulmo
I: Symmetrical shape, retraction (-),
symmetrical chest movement.
Pa: Symmetrical lung development, right
hemithorax fremitus is decreased.
Pe: Sonor in left lung hemithorax, dim in
right hemothorax
A: Vesicular decreased left hemithorax.
Rhonki (- / -) wheezing (- / -)
Heart Abdomen:

• I: Normochest, ictus cordis is not seen •I: Flat, no traces of surgery, no mass.
• Pa: Ictus cordis is not palpable • A: BU (+) increases
• Pe: Right border of the heart, in the • Pa: Supple, tenderness (-) There is
parasternal line of ICS 4 and left lateral
no enlargement of the liver or spleen
in the lateral 2 cm mid clavicular line of
• Pe: Hipertimpani
ICS 5 sinistra - - -

• A: Nomal heart sound - - -

- - -
Extremities:
Warm, dry, red on all four extremities,
Minimal pitting (- / -) edema of the limbs
CRT <2s
Diagnosis :
G4P3A0H3 9/10 weeks + Incomplete Abortion + Age >35
years old
• Planning of Diagnosis
USG, DL, Plano test
• Planning of Therapy
Infus RL life line
Curratage
• Planning of Monitoring
Vital Sign
Amount of bleeding
• Planning of Education
Bed Rest
If more bleeding happen, please contact the officer
USG
 Parameter Value Reference Inteval

Leukosit 10.47 3.60 - 11.0

Basofil 0.822 0-1
Neutrofil 66.11 39.3 - 73.7
Limfosit 25.630 25 - 40
Complate Blood Count Eosinofil 1.668 2-4
15/10/19 Monosit 5.775 2-8
Eritrosit 4.52 3.8 - 5.20
Hemaglobin 11.67 11.7 - 15.5

Hematokrit 36.8 35 - 47
MCV 81.5 80 - 100
MCH 25.8 26.0 - 34.0
MCHC 31.7 32 - 36
RDW-CV 12.5 11.5 - 14.5

Trombosit 280 150 - 450

MPV 81.5 7.2 - 11.1
Plano Test
15/10/19 Parameter Value

Plano Test Positif

 THANK YOU
JAZAKUMULLAH