Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Basic Obstetrics and Obstetric Surgery in a Mission Setting
drome. We will focus on spontaneous abortion and ectopic pregnancy, which commonly
require surgical intervention.
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Spontaneous Abortion
In most studies the incidence of bleeding in the first 20 weeks of pregnancy is
high. It can be documented in up to 40% of all recognized pregnancies. About half
of these pregnancies will end in spontaneous abortion.
A small amount of bleeding, consistent with a “light” period, may occur at the
time of the first missed menses. This is believed to be bleeding at the site of implantation
and is without significance (except that it may confound the patient’s estimate
of her last menstrual period). If the patient reports cramping, and/or if the
bleeding continues, the prognosis for maintaining the pregnancy is poor.
If a doppler stethoscope is available, listen for fetal heart tones (audible a 12-14
weeks). Heart tones become detectable with a fetoscope around 18-20 weeks. If
transabdominal or transvaginal ultrasound is available, try to locate the sac (cardiac
activity is detectable around 7 weeks.) Perform a speculum exam to identify the
source of the blood, followed by a bimanual exam to elicit tenderness suggestive of
an infectious process or an ectopic pregnancy.
Irrespective of fetal cardiac activity, if you observe bleeding through a closed
cervix, the clinical diagnosis is threatened abortion. The patient may rest at home if
she appears to be stable and reliable. If she needs to travel far or appears to have bled
or be bleeding a great deal, admit her for continued observation.
If the cervix has begun to dilate, the diagnosis is inevitable abortion. There may
be products of conception (POC) in the cervix. Removing these with a ring forceps
or other instrument may significantly relieve your patient’s cramping pain. POC in
the cervix may also cause a vasovagal attack, in which case the patient may appear to
be in shock. Removing the POCs in such a case is curative.
A complete abortion expels all products of conception—fetus, sac and placenta.
The cervical os will be closed. No surgical intervention is required. In an incomplete
abortion, the os is open, and the placenta is most often the retained part. An incomplete
abortion, in which you elicit symptoms or signs of infection, is a septic abortion.
A missed abortion by definition has occurred eight weeks or more prior to its
recognition. The patient has not bled or experienced other symptoms. If this occurs
in the latter half of pregnancy, she is at significant risk for disseminated coagulopathy.
Fortunately, over 90% will spontaneously enter labor within four weeks of fetal
demise although this delay lengthens with the gestational age. Management of spontaneous
abortion differs with gestational age as described below. After 20 weeks, loss
of a pregnancy is considered to be intrauterine fetal demise (IUFD).
First Trimester
Threatened Abortion
Withold surgical intervention. Supportive measures only. Patient need not be
admitted if reliable and living nearby.
Inevitable or Incomplete Abortion
Supportive measures. Type and cross-match blood. Watch the patient for no
more than 24 hours. Proceed to evacuate the uterus sooner if bleeding is severe or if
you can prove by history or exam that POCs are retained.
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