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.