CASE PRESENTATION

Incomplete Abortion

Rinda Martanti 1006803335

Dr. Dr Junita Indarti, SpOG (K)

Obstetric and Gynecology Department December, 2010

I. LITERATURE REVIEW

I.1. Introduction

Abortion or miscarriage can be defined as the termination of conception before the fetus can live outside the uterus. The borderline of pregnancy period is before 20 weeks or if the fetus is weighed under 500 grams. Abortion that happens without any intervention is called spontaneous miscarriage, while the one with efforts to terminate the conception is termed induced abortion. There is one more type, habitual miscarriage, is called when the miscarriage is occured three times in a row. Miscarriage can cause psychological trauma to the family, especially mother. Thus, comprehensive management should be conducted for its recovery process.

I.2. Epidemiology based

Abortion is common in Indonesia. The cases per year estimated two million occured in 2000; covered in six regions, includes unknown and small numbers of miscarriage. The estimation annual rate is 37 miscarriage in 1,000 women of reproductive age (15-49 years). This number is quite high compared to other countries in Asia. While the cases

of induced abortion is reached to 4.5 million per year, with 760,000 (17%) cases were unwanted or mistimed. In an hour, 114 abortion is estimated to happen, with 15-20% cases are spontaneous abortion (miscarriage). The level of miscarriage is somewhat difficult to be defined as high prevalence of chemical pregnancy loss that is unknown or misdiagnosed during 2-4 weeks after conception. Most of the termination is due to the fail of gamet, sperm and oocyte disfunction for instance. A study conducted in 1988 to 221 women who has been studied for 707 menstruation cycles in total, it was found that in 198 pregnancy pccured 43 (22%) had abortion before the next cycle. The rate of habitual abortion is around 3-5%. This number showing a couple has 15% higher risk to develop another abortion after their first loss. While the risk has reaced to 25% after two abortion occured. Few studies stated that risk of abortion after three times in a row is about 30-45%.

I.3. Etiology The cause of this early pregnancy loss is varied and still debated. However, there must be multifactors, with most cases are due to:
1. Genetic factors, such as Mendelian, Robertsonian, Resiprokal

2. Uteri congenital defect, such as Mulleri duct anomali, Bicornal uteri, servical uteri incompetence, myoma uteri 3. Autoimmune, such as Alloimmune, humoral immunity mediation, cellular immunity mediation 4. Luteal phase defect, such as external endocrine factor, antibody anti thyroid hormone, high LG synthesis 5. Infection 6. Hematology factors 7. Environmental factors

1. Genetic factors

Most of the causes are associated with embryo kariotype defect. More than 50% abortion cases occured in the first trimester are due to cytogenic defect, such as aneuploid that is caused by sporadical factors (nondisjunction meiosis) or polipoid of abnormal fertility. However around 50% of abortus due to cytogeneti defect in the first trimester are due to autosomal trisomi. While triploid was found in 16% of abortion, where fertilation process is happened between normal ovum and two sperm (disperm). Trisomy occured due to nondisjunction meiosis along gametogenesis process in patient with normal karyotype. The incidence of trisomi increases with age. Trisomi 16 is occured in most cases, around 30% of all. While turner syndrome causes 20-25% cytogenetic defect. One of three fetus with Down Syndrine (trisomy 21) can survive until birth. The risk of having aneuploid was found 1:80 in women above 35 years, as the evidence of chromosomal.trisomy defect happened after 35. Tetraploid occured in 8% of abortion cases. Other factors can be defect of chromosomal structure and abnormal gene. Structural deformity happens in 3% of cytogenetic defect. While in the gene defect, there must be gene mutation that may disturb the implantation process, even causes to death.

2. Anatomical factors

The evidence of anatomical defect of uteri was reported between 1:200 to 1/600. The risk of anomaly is increased by 27% in women with history of previous abortion. Most of the factors causing the defect are due to septum uteri (40-80%), bicorn/unicorn uteri (10-30%). Myoma uteri contributes to higher risk of 10-30% women who are in their reproductive age. Asherman syndrome also may cause disturbance where the implantation takes place, as well as on the endometrium surface where the blood sources located.

3. Autoimmune based

Repeated abortion is associated with autoimmune diseases, such as Systematic Lupus Erythematous (SLE) and Antiphospholipid Antibodies (aPA). The risk of spontaneous abortion (miscarriage) is increased by 10% in women with SLE compared to healthy women. Antiphospholipid

syndrome (APS) also can be found in several pregnancy condition, such as pre-eclampsia, IUFD, and prematurity. Other conditions associated with APS are artery-vein thrombosis, autoimmune thrombocytopenia, hemolytic anemia, chorea, pulmonal hypertension.

4. Infection Infection sources can be from 1) bacteria, such as Listeria monocytogenes, Chlamydia trachomatis, Ureaplasma urealyticum, Microplasm hominis, Bacterial vaginosis; 2) Virus, such as Cytomegalovirus, Rubela, Herpes simpleks virus (HSV), Human immunodeficiency virus (HIV), Parvovirus; 3) Parasite, such as Toxoplasmosis gondii, Plasmodium falciparum; and 4) Spirochaeta, such as Treponema pallidum. Some theories describe how infection may play a role in the risk of abortion, as: The occurence of toxic metabolism, endotoxin, cytokines that directly harms fetus Infection of fetus that causes fetal death or defect Infection of placenta that causes placenta insufficiency and fetal death Chronic infection of endometrium from the spread of genital microrganism Amnionitis The infection may cause genetical and anatomical changes of embryo exotoxin, or

5. Environmental factors

Around 1-10% fetal malformation are induced by drugs or chemical exposures and radiation. For instances, ciggarettes contain hundreds toxic regimens (nicotine and others) that is known to have vasoactive effect thus disturbing uteroplacenta circulation. Carbon monosida, as well, may decreases oxygen level in mother and fetal and also induce neurotoxin.

With the occurence of disturb in the fetoplacenta circulation, fetal growth disorder occurs and giving high risk to be aborted.

6. Hormonal factors

Hormonal factors described can be associated with: a. Diabetes mellitus, especially insulin-dependent diabetes with controlled glucose has 2-3 times higher risk to develop abortion b. Low level of progesterone c. Defect of luteal phase d. Hormonal effects to decidua immunity

7. Hematological factors

Hypercoagulation is happened in pregnant women due to 1) the increase of pro-coagulan level, 2) the decrease of anti-coagulan level, and 3) the decrease of fibrinolytic activity level. There is a study revealed that women with history of repeated abortion had exaggerated increase of tromboxan production during 4-6 weeks of gestation, and decrease of prostacyclin production on 8-11 weeks of gestation. The changes of tromboxan-prostacyclin ratio induce vasospasm and thrombosis aggregration that may cause microthrombi and placenta necrosis.

I.4. Types of Spontaneous Abortion

1. Iminens Abortion / Abortus Iminens

This is the early and stage and is the thread to abortion. The symptoms are vaginal bleeding, closed ostium uteri, and the conception is still in the uteri. The early detection conducted when there is complain of vaginal bleeding under 20 weeks of gestation. However, the ostium uteri

is still closed, the size of uteri folows gestation age, urine test showing positive result. To define prognosis, urine pregnancy test is conducted using undiluted urine and urine with 1/10 dilution. If the result is positive in both test, the prognosis is good, while if negative result showed in the 1/10 diluted urine, then the prognosis is dubia ad malam. The use of ultrasonography (USG), transabdominal or transvaginal is also useful to discover fetal growth, to know the condition of placenta, to describe fetal heart rate and fetal movement. The main management is total bedrest until the bleeding stops. Spasmolytic agent can be given to stop the contraction of uterus. Other agent, such as progesterine or its derivates, play a role in preventing abortion. Patient can be sent home after the absence of active bleeding. However, patient is prohibited to have sexual intercourse for two weeks.

2. Insipiens Abortion / Abortus Insipiens

The criteria of insipiens abortion include flatten cervix and and opened ostium uteri. However, the conception is still inside cavum uteri, in the termination process. In this condition, patient may suffer from abdominal pain due to strong contraction. The raise of active bleeding is associated with cervical dilation and gestation age. At this stage, the size of uterus is similar to gestation age and urine test still showing positive result. Ultrasonography may describes size of uteri similar to gestation age, clear fetal heart rate and movement even though the defect may initiate, the thinning of cervix or its opening may be also pictured. The initial management is associated with hemodynamic and vital signs control. If massive bleeding occurs, termination of conception is immediately to conduct. In the gestation of above 12 weeks, the termination using intervention (kuretase) must be very careful. If it is needed, the intervention to terminate may include digital. Kuretase is then continued with given uterotonica. This prevents perforation of uteri wall. The monitor includes maintaining general condition, giving of uterotonica and prophylaxis antibiotic.

3. Complete Abortion / Abortus Kompletus

At this stage, the conception has been terminated from cavum uteri in under 20 weeks of gestation or fetal weight under 500 grams. Conception has been terminated, ostium has been closed, uteri is getting small so that the bleeding can be less. The size of uteri does not similar to gestation age. Ultrasonography is not necessary to be done if clinical signs are adequate. Positive urine test is still occured up to 7-10 days after abortion. There is no intensive treatment for this condition. Uterotonica is unecessary to be given.

4. Incomplete Abortion / Abortus Inkompletus

The criteria includes termination of conception, but some of the compartments are still left inside the cavum uteri. When the vaginal touche conducted, cervical canal is still opened and tissue is palpable in cavum uteri or protruded in external cavum uteri. The volume of bleeding depends on the amount of unterminated tissue, which may cause some part of placenta is still exposed and induce to continuing bleeding. If the condition persists, patient can become anemic condition or hemorrhagic shock before the remaining tissue can be taken out. The initial management include observation of vital signs and hemodynamic condition. Curetage is conducted after patient is stabilised. The use of USG is unecessary unless the diagnosis based clinical signs are still doubtful. The size of uteri is smaller than gestation age. If massive bleeding occurs, termination of conception is done manually so that the remaining tissue would not prevent uteri contraction. Good contraction is required to stop further bleeding. Then kuretase is conducted . Parenteral or oral uterotonica and antibiotic is given after kuretase ends.

5. Missed Abortion

The criteria of missed abortion is the embryo or fetus has died in the uteri before gestation reached 20 weeks and the full conception is still in the uteri. There is usually no complains except the size of pregnancy does not progress. Even some cases showing that patient feels their uteri is getting small, as well as the mammae. Urine test would reveal negative

one week after the gestation progress ended. USG would describe small uteri, small gestation pouch, and died fetus. The management includes conduction of curetage and give information concerning the complication of this intervention. If the gestation under 12 weeks, curetage can be performed without any other interventions. Whilst gestation above 12 weeks needs induction to terminate the conception or ripening cervical canal. Several managements include giving intravenous oxitocin starting in a low dose of 10 units in 500 cc dextrose 5% 20 drops per minute. Repeating dose can be given with the maximum dose of 50 unit of oxitocin. If this does not work, patient needs total bed rest along a day and the induction is repeated with maximal of three times. Prostaglandin or its derivates also can be given by the administration of sublingual misoprostol 400 mg. This dose can be repeated two times with six hours interval. This drug is purposed to open the cervical ostium so that the evacuation and curetage can be conducted to empty the cavum uteri. Recovery of the mother and family also should be concerned, especially phsychological trauma that happens to the mother.

6. Habitual Abortion / Abortion Habitualis

Habitual abortion can be defined as spontaneous abortion (miscarriage) that happens three times or more in a row. The causes are mostly associated with anatomical factors, immunological factors, such as the failed of antigen lymphocyte trophoblast cross reactive (TLX) reaction, cervical incompetent (a condition where the cervical uteri cannot withstand the load to keep closing after the first trimester of pregnancy. The cervical ostium would open (incompetent) without a sense of abdominal pain or contraction of uterus and the fetus finally terminated. Cervical incompetent is usually associated with trauma in the previous pregnancy. The management includes intervention to give fixation into the cervix so that cervix may withstand the load of pregnancy.

II. CASE ILLUSTRATION

Name Age Address Tribe Religion

: Ny. Dela : 22 years old : Cip Galur Kulon, Jatinegara RT 009/RW 013 Jakarta Timur : Betawi : Islam : 342-84-52

Medical record no

Keluhan Utama Kontrol setelah kuretase (di RSCM) 1 minggu SMRS

Riwayat Penyakit Sekarang Pasien mengaku telat menstruasi 2 bulan. Hari pertama haid terakhir 20 Agustus 2010. Usia Gestasi saat itu 13 minggu. Saat itu (1 minggu SMRS), ketika pasien sedang mencuci, pasien mengalami perdarhan berupa gumpalan darah (+) merah tua, lendir (-), daging (-), dan sangat nyeri. Pasien langsung dibawa ke Rumah Sakit, di USG, dan dikatakan untuk segera dikuret. Pasien dipulangkan dan diberikan 3 macam obat. Selama 1 minggu setelah kuretase, keluhan nyeri (+) perut kiri bawah, keputihan (+) jumlah sedang, gata; (+), berbau (+). Riwayat buang air kecil dan buang air besar baik. Riwayat demam (-)

Riwayat menstruasi 4x/hari, nyeri (-) Riwayat perkawinan

: menarche 9 tahun, 7 hari, ganti pembalut : belum menikah

Riwayat obstetric : PoAo Riwayat KB : belum pernah KB

Riwayat Penyakit Terdahulu Hipertensi (-), diabetes mellitus (-), asma (-) usia 12-15 tahun, alergi obat (-)

Riwayat Penyakit dalam Keluarga Hipertensi (+) pada Ibu, diabetes mellitus (-), asma (-), penyakit jantung (-)

Pemeriksaan Fisik Keadaan umum Tekanan darah Nadi Pernapasan Suhu Keadaan gizi Tinggi badan Berat badan BMI : Compos Mentis : 110/80 mmHg : 80x/menit : 20x/menit : 36.5 C : baik : 149 cm : 55 kg : 24.77

General status Mata THT Jantung Paru Abdomen : anemic konjunctiva -/-, icteric sclera -/: dalam batas normal : S1-2 normal, murmur (-), gallop (-) : vesikuler/vesikuler, rhonki (-), wheezing (-) : buncit sesuai kehamilan

Ekstremitas: akral hangat, edema -/-

Obstetric Status I : v/u tenang

Io : portio licin, fluor (+) putih kental jumlah banyak, fluxus (-), ostium tertutup VT : bentuk dan ukutan servix uteri normal, massa adneksa -/-, nyeri -/-, parametrium lemas, cavum douglas tidak menonjol, nyeri goyang portio (-)

Hasil laboratorium

Hb Ht

: 12.8 : 39 : 10.000

Leukosit

Trombosit : 272.000 MCV MCH MCHC GDS 139 : 39 : 27 : 33

Urinalisis Sedimen :+ : 1-2 : 18-20 :::-

Sel epitel Leukosit Eritrosit Silinder Kristal Bakteri

Berat Jenis PH Protein Glukosa Keton Darah/Hb Urobilinogen Nitrit

: 1.020 : 5.0 :::+ : +++ :: 0.2

Esterase Leukosit : -

Hasil Patologi Anatomi Histologik dapat sesuai dengan gambaran endometrium masa hamil

Daftar Masalah 1. PoA1 Post Kuretase dengan indikasi abortus inkomplit 1 minggu yang lalu 2. Riwayat unwanted dan unplanned pregnancy 3. Fluor albus

Pengkajian Masalah Wanita, 22 tahun Post kuretase abortus inkomplit

bakteriosus vaginosus (pemeriksaan parasitologi) Edukasi tentang infeksi menular seksual (IMS) Konseling KB

Hasil Parasitologi Yeast cell (++), pseudohifa (-), Trichomonas vaginalis (-) Diagnosis : candidiasis

Perencanaan 1. Edukasi pemberian KB (pil KB atau kondom) 2. Konseling IMS

3. Hygiene vulva dan alat genital

5. Kontrol Poli satu minggu

III.DISCUSSION AND CONCLUSION

Satu minggu yang lalu, pasien wanita, 22 tahun, datang ke RSCM dengan keluhan perdarahan berupa gumpalan darah merah tua dan sangat nyeri. Pada kehamilan muda dibawah 20 minggu (13 minggu) sangat rentan untuk mengalami keguguran spontan (miscarriage). Anamnesis mengarah pada abortus inkomplit dikarenakan gumpalan darah yang telah keluar dan sangat nyeri. Akan tetapi tidak ada daging yang keluar ( dapat diartikan bahwa sebagian jaringan konsepsi masih tertinggal didalam kavum uteri). Pemeriksaan fisik dilakukan untuk mengukur besarnya uterus apakah sesuai dengan usia kehamilan saat ini. Biasanya akan terdapat ukuran uterus yang lebih kecil dari usia gestasi. Untuk memastikan hasil dari pemeriksaan fisik, pemeriksaan penunjang dilakukan. Ultrasonografi (USG) adalah alat yang sesuai untuk memastikan apakah janin masih terdapat tanda-tanda kehidupan atau tidak. Pada anamnesis, pasien mengatakan bahwa setelah USG dilakukan, pasien diharuskan untuk segera dilakukan kuretase. Dapat disimpulkan bahwa hasil USG tidak ada gerak janin maupun denyut jantung janin. Sebelum kuretase dilakukan, pastikan keadaan pasien dalam kondisi stabil. Pemeriksaan penunjang kedua, yaitu pemeriksaan laboratorium (darah perifer lengkap dan urinalisis) dilakukan untuk mengetahui keadaan umum pasien, seperti apakah pasien anemia dikarenakan perdarahan yang dialaminya, adanya tanda-tanda infeksi, dan lainnya. Urin tes akan tetap menunjukkan hasil positif sampai satu minggu setelah jaringan konsepsi dikeluarkan.

Pada saat kuretase, harus hati-hati dan sampai bersih (semua jaringan konsepsi harus terambil). Hal ini dikarenakan sisa jaringan yang mengganjal didalam akan mencegah uteri untuk berkontraksi sehingga dapat terjadi perdarahan yang berlebihan. Setelah dipastikan uteri bersih, monitor tanda vital dan keadaan umum pasien kembali. Pada pasien dengan keguguran, trauma psikis sangat besar kemungkinannya. Adanya riwayat unwanted dan unplanned pregnancy juga memperkuat kemungkinan trauma psikis paska aborsi. Untuk itu diperlukan pendekatan moral dan konseling. Pasien ini belum menikah, maka harus diberikan konseling tentang alat KB untuk mencegah terjadinya kehamilan lagi dan informasi tentang infeksi menular seksual (IMS) yang saat ini sedang berkembang.

Keluhan saat ini berupa fluor albus dan nyeri satu minggu setelah kuretase. Fluor albus dipikirkan tidak dikarenakan oleh proses kuretase karena cairan keputihan berupa cairan putih kental, dalam jumlah banyak, berbau, dan gatal. Ciri ini sangat mungkin dikarenakan infeksi. Hasil parasitologi juga menunjukkan adanya pertumbuhan jamur yang banyak. Infeksi dikarenakan alat kuretase yang tidak steril biasanya berupa bakteri gram negatif. Untuk itu pasien diberikan obat anti jamur dan kontrol poli kembali setelah satu minggu.

Manajemen pada ibu yang mengalami keguguran spontan (miscarriage) haruslah komprehensif dimulai dari manajemen awal (keadaan umum dan tanda vital) saat pasien datang, manajemen aktif setelah diagnosis inkomplit abortus (kuretase), manajemen pada trauma psikis paska tindakan (kuretase), dan konseling-konseling, seperti konseling KB dan informasi mengenai IMS, sebagai pemberian edukasi terhadap pasien untuk mencegah adanya unwanted dan unplanned pregnancy di kemudian hari.

IV.

References

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2. Guttmatcher Institute. Abortion in Indonesia. 2008. 3. Utomo B et al., Incidence and Social-Psychological Aspects of

Abortion in Indonesia: A Community-Based Survey in 10 Major Cities and 6 Districts, Year 2000, Jakarta, Indonesia: Center for Health Research, University of Indonesia, 2001. 4. Sedgh G et al., Induced abortion: estimated rates and trends worldwide, Lancet, 2007, 370(9595):13381345 5. United Nations Department of Economic and Social Affairs, Population Division, World Population Prospects: the 2006 Revision, New York: United Nations, 2007 6. Badan Pusat Statistik (BPS) and ORC Macro, Indonesia Demographic and Health Survey 20022003, Calverton, MD, USA: BPS and ORC Macro, 2003