View Full Version : Tx for "missed abortion"?
2+ Mo. fetal postmortem & fetus is still in the uterus. Signs of pregnancy are past, uterus may have gotten smaller. Possible brownish discharge from vagina.
And if evacuation to an MD is not possible?
How common is this, anyway? Never heard of it before, or at least didn't remember it since I read "Spiritual Midwifery" the first time, and the descript is really short then just says "consult a doctor"...
Say what? Do I read this correctly, fetal remains are in place 2 months after fetal death has occured? Pregnancy was 2 months along? How did they know the fetus was dead? Did they see fetal parts pass? Details!
Retained fetal or placental fragments predispose to bleeding and infection...I suppose it is possible that retained products of conception could not produce problems, but every case I have seen has been trouble shortly after the miscarrige. Interesting...
from spiritual midwifery, 3rd ed., p413:
Missed Abortion:
When the baby is kept inside for two or more months after it has died, this is called a missed abortion. Sometimes the lady has blead or spotted and cramped and then stoped, but sometimes she hasn't had any signes of misscarrage. THe uterus stops growing and may actually get smaller; changes in the breasts and other signes of pregnancy stop. THere may be a brownish discharge, but there will be no period. Usually a missed abortion will end up with the baby coming out spontainiously. If a lady in your care seems to have one, consult with a doctor.
that's all it says.
Wow, that is an old definition. Pretty much now we consider it "missed" if the fetal remains have not passed in a week or so - of course this is in the context of current medical care availability. Very few patients are willing to carry a dead fetus for any length of time, I certainly do not blame them. We usually (always) induce labor and deliver or procede with chemical or surgical removal if there is no spontaneous resolution in a few days.
For austere conditions, lets assume that there is no method for detecting fetal heart tone, or urine preg tests. We would monitor the progress of pregnancy by measuring uterine size on the belly, pubic symphesis to top of uterus, it should grow 1 cm per week of gestation. Rule of thumb first detectable at top of PS at 12 weeks, belly button at 20 weeks. Along with that it would be helpful to monitor moms weight gain (3/4 pound/week average)and symptoms like morning sickness, edema, breast tendernes, fetal motion (starts being detectable between 12 & 16 weeks on average), etc.
Death of the fetus would be detected in time by loss of uterine growth and absence of above. Pure loss with 100% retention would be better than incomplete loss. The yolk sack + placenta + fetus could simply be absorbed with time. This is what happens in the so called "disapering twin" cases where one fetus dies and is simply absorbed. And of course this is what happens in very early losses, before the woman is even aware of being pregnant - about 20% of pregnancies end this way and are never even detected.
For a 100% retention case with no significant bleeding and no infection I would do nothing - in time most or all of the remaining tissue would either be absorbed or fibrose and wall off. I think that this would be preferable to using herbal abortifactants and uterotonics in an effort to get the tissue to pass, due to the very high risk of incomplete evacuation, bleeding and infection.
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Do No Harm. Do Know Harm.
interesting reply - thanks!
yes, the Farm book was printed in 1990, I found another ref: Manual of Gynaecology by Varma, dated 1986 that also uses that term but says much the same thing in more technical language.
I'm querious as to: "fibrose and wall off" - what kind of consequence does that have for future pregnancies?
as to cases where infection is pressent, what is the recomended Tx? (obviously antibiotics, but what kind of bug and antibio's?) - I've also heard of a "brown leakage" in reference to infections secondary to C-sections done in Austere conditions (w/ a razorblade, by candle light, in a hut w/ a dirt floor, at night.) Presume both are uterine infections or infections caused by missed fetal matter.
I would imagine that spontanious or missed abortions might be common in highly stressfull conditions such as disasters and wartime. Any idea how common it is to run into things like this? (failed pregnancies, for whatever reason, and I'm not refering to the 20% that never knew they were pregnant - though I thought that number was much higher...)
Speaking of C-Sections - the new SF Med Ops HBK had the interesting statement that "if a women has ever had a C-Section, *ALL* future deliveries must be by C-Section." But I've never seen that expressed any where else - how true is it?
what is your opinion on botanical OB/GYN meds, anyway?
Two things :
Firstly in the context of the SOF advice re. C-sections. If a relatively untrained medic had done the procedure, the safest option by far is all future births by c/s. Frequently women have what is known as a trial of scar - they are allowed to start to labour under close supervision, and if everything goes well they have a normal delivery - any problems then a c/s. But this sort of situation doesnt really apply in remote or primitive situations, hence the very sound advice.
Secondly re Resqdoc's comments on missed abortion. I agree that one to two months is a bit long. However your comments on intervening within a few days of a missed I think reflects only North American practice and womens expectations. The practice in Australia/NZ and the UK is much more conservative - despite free access to all the options. With a missed from 6-12 weeks frequently we will wait until the missed becomes a spontaneous by itself. All the worries about coagulopathy etc, have been proved to be unfounded, and now most women with a missed are given the wait and see option - some obviously "just want it out" and they get an induction immediately, but most do wait and see, with no real adverse effects - most evolve to a spontaneous miscarriage in a couple of weeks. Equally our management of spontaneous miscarriages has become more conservative, with many women not having the usual evacuation. Its not as tidy as doing an evacuation on everyone, but for many women they prefer it - even if it means pv bleeding on and off for several weeks. Again sepsis isnt the problem North American texts seem to think - even with this approach we dont see many (= none I can remember) septic miscarriages. Interesting contrast.
cheers
Craig
Excellent input Craig!!!!! I agree completely about the different perspectives and social expectations. Most patients here seem to want the dead fetus out ASAP, and are intolerant of even relatively minor bleeding. They would rather undergo a D&C or induction almost immediately.
Interesting that you are not seeing much in the way of sepsis though, this is a HUGE problem in my area. I wonder if it has to do with differing patient demographics? In my “middle class” patients who are mostly farm families with a high school education, basic services available, and a lower than average tobacco/drug/alcohol use profile we rarely see miscarriage, although they do occur. This group also has a very low infection rate, far less than 5% I would say. Contrast that with our other patient population, native american indians living on the reservation nearby. Many of these people have extremely bad living conditions with no electricity or running water (I am NOT joking), basic sanitation availability and knowledge is lacking, and the tobacco/drug/alcohol use is very, very high. The miscarriage rate is very high, and the missed/incomplete infection rate is equally high. We now routinely put these women on oral antibiotics when they present, but find that in many cases they do not complete the antibiotic plan and their hand washing and hygiene are impaired for a variety of reasons, leading I think to the high infection rates. These women run about 50% infection after a missed/incomplete. Occasional full-blown endometritis, hospitalization, IV antibiotics, and rarely even hysterectomy. One patient refused hospitalization although was very ill, ended up with dissecting fascitis (“flesh eating strep” if you prefer) & died despite multiple surgeries & etc. We take this pretty seriously. Note that the native american population living in town rather than on the reservation does not have this level of problems, despite having similar incidence of hypertension, diabetes, etc., thus it seems to be the social and environmental conditions of the reservation that is the problem.
This I think has implications for operating under austere conditions, to wit: basic sanitation, hygiene, and healthy living options to the extent possible are once again shown to be of critical importance.
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Keith
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