Obgyn · Year 3 · from Obgyn

Case 2: Threatened Abortion Progressing to Incomplete Abortion

Patient Demographics

  • Age: 34 years
  • Sex: Female
  • Occupation: Financial analyst

Chief Complaint

"I'm having heavy bleeding and cramping. I'm 9 weeks pregnant."

History of Present Illness

The patient had vaginal spotting starting 4 days ago. Her OB saw her 3 days ago and ultrasound showed a viable intrauterine pregnancy at 9 weeks with fetal heart activity. She was diagnosed with threatened abortion and placed on pelvic rest. This morning, she developed heavy vaginal bleeding with clots, soaking 4 pads in 2 hours, and severe cramping. She passed some tissue that she brought with her in a container.

Past Medical History

  • Hypothyroidism on levothyroxine
  • Two prior uncomplicated term pregnancies

Physical Examination Findings

  • Vital Signs: BP 110/70 mmHg, HR 96 bpm, Temperature 98.2F
  • General: Pale, anxious, moderate distress from cramping
  • Abdomen: Soft, suprapubic tenderness, no rebound
  • Pelvic: Moderate active bleeding, cervix dilated to 2 cm with tissue visible at os, uterus 8-week size, tender
  • Tissue examination: Grayish tissue consistent with products of conception

Diagnostic Workup

  • Hemoglobin: 10.2 g/dL (was 12.5 at first prenatal visit)
  • Blood type: A negative
  • Quantitative beta-hCG: 45,000 mIU/mL
  • Transvaginal Ultrasound:
  • Irregular gestational sac with no fetal pole identified (previously seen)
  • Heterogeneous material in lower uterine segment and cervical canal
  • No fetal cardiac activity
  • Small amount of free fluid in pelvis

Diagnosis

Incomplete Abortion (previously viable pregnancy)

  • Open cervical os with tissue at os
  • Incomplete passage of products of conception
  • Significant anemia from blood loss

Management Options

Option 1: Expectant Management

  • Wait for spontaneous passage
  • Higher failure rate with incomplete abortion
  • Not ideal given significant bleeding

Option 2: Medical Management

  • Misoprostol 800 mcg vaginally
  • May expedite passage
  • Success rate 80-90% for incomplete abortion

Option 3: Surgical Management (D&C)

  • Suction dilation and curettage
  • Most definitive and rapid option
  • Appropriate given heavy bleeding and anemia

Chosen Management: Surgical (D&C)

Rationale:

  • Significant ongoing hemorrhage
  • Anemia (Hgb drop of 2.3 g/dL)
  • Tissue at cervical os causing incomplete passage
  • Patient preference for definitive management

Procedure:

  • Performed under IV sedation in operating room
  • Cervix already dilated
  • Suction curettage performed
  • Products of conception sent to pathology
  • Estimated blood loss 150 mL
  • Uterus firm post-procedure

RhoGAM Administration:

  • Patient is Rh negative
  • RhoGAM 300 mcg IM administered (standard dose for pregnancy losses after 12 weeks, but 50 mcg mini-dose acceptable <12 weeks at some institutions)

Post-Procedure Care

  • Tolerated procedure well
  • Bleeding reduced to light
  • Hemoglobin check in 1 week
  • Iron supplementation started
  • Counseled on grief resources
  • May attempt conception after 1 menstrual cycle
  • Pathology confirmed products of conception (no molar pregnancy)

Emotional Support

  • Validated grief and loss
  • Reassured that miscarriage is common (10-20% of recognized pregnancies)
  • Reassured this was not her fault
  • Support group resources provided
  • Follow-up call scheduled for 48 hours

Clinical Image

Image Description: Transvaginal ultrasound demonstrating heterogeneous echogenic material within the uterine cavity and cervical canal, representing retained products of conception in incomplete abortion.

Attribution: Image from Radiopaedia. Educational case. Licensed under CC BY-NC-SA 3.0.


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