Definition: It is the clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible.
It is characterized by:
- considerable bleeding
- lower abdominal pain
- the general condition of the patient is proportionate to the visible blood loss
- internal examination reveals dilated internal os of the cervix through which the products of conception is felt
- a dilated cervix – note the external os of a multigravida usually admits the tip of a finger
- products may have been passed – do not confuse with clots
Management: The principles in the management are:
(1) to act appropriately to look after the general condition.
(2) To accelerate the process of expulsion.
(3) To maintain strict asepsis as outlined in conduction of labour.
Morphine 15 mg is given intramuscularly. Excessive bleeding should be promptly controlled by administering methergin 0.2 mg if the cervix is dilated and the size of the uterus is less than 12 weeks. The shock is corrected by intravenous fluid therapy and blood transfusion.
- Before 12 weeks: (1) dilatation and evacuation followed by curettage of the uterine cavity by blunt curette under general anaesthesia is quite effective and a safe procedure.(2) alternatively suction evacuation followed by curettage may be employed.
- After 12 weeks: (1) the uterine contraction is accelerated by oxytocin drip (10 units in 500 ml of 5% dextrose) 40-60 drops per minute. If the fetus is expelled and the placenta is retained, it is removed by ovum forceps, if lying separated. If the placenta is not separated, digital separation followed by its evacuation is to be done under general anaesthesia. (2) if the bleeding is profuse with the cervix closed (suggestive of low implantation of placenta) – evacuation of the uterus may have to be done by abdominal hysterotomy.