A 39-year-old woman presented with severe lower abdominal pain and vaginal bleeding for one day along with passing products of conception. On examination, she was in pain and had mild pallor. Her cervix was dilated to 5 cm. She was diagnosed with incomplete abortion. She was given misoprostol to expel the remaining products, but required dilatation and curettage when this failed. An ultrasound later confirmed complete removal of tissue. Incomplete abortion occurs when vaginal bleeding and cervical dilation begin but some pregnancy tissue remains in the uterus, requiring surgical evacuation to remove it.

1. KABALE UNIVERSITY – SCHOOL OF MEDICINE (KABSOM)
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
CASE WRITE UP ON INCOMPLETE ABORTION
DONE BY
CHERUIYOT CALEB CHEROP
16/A/MBChB/0742/F
YEAR III
LECTURERS’ NAME: Prof. Lule John
Dr. Godwin Turyasingura

2. GYNECOLOGIC CASE 5: INCOMPLETE ABORTION
Name: Ndyomuhaki Carol
Age: 39 years
Occupation: Peasant
Tribe: Mukiga
Marital status: Married
Parity: Grávida 6 Para 4 + 1
LNMP: 3/7/2018
EDD: 10/4/2019
Weeks of Gestation: 8 weeks 5 days
Address: Bugongi
Next of kin: Komuhangi Beatrice (Sister)
Date of admission: 30th September, 2018
Date of clerking: 30th September, 2018
Presenting complaint
Lower abdominal pain for one day.
Vaginal bleeding for one day.
Products of conception seen on pad
History of presenting complaint
Patient was well until one day ago when she started experiencing severe excruciating lower abdominal pain in
the morning at around 7:00 am. The pain was of gradual onset with no exercabating and relieving factors. The
pain was associated with vaginal bleeding. In the evening, she saw some clots coming from her vagina and the
pain did not cease but kept increasing making her come to the hospital.
Review of other systems
Gastrointestinal system
She reported no vomiting, no loss of appetite, no constipation, no diarrhea, no nausea, no hematemesis.
Respiratory system
She reported no night sweats, no shortness of breath, no chest pain, no cough.
Cardiovascular system
She gave no history of palpitations, no fatigue, no chest pain, no dyspnea, no ankle swelling.
Central nervous system
She reported having headache and dizziness, no fitting, no tremors, no hallucinations.
Musculoskeletal system
She reported no muscle pain and joint pain, no general body weakness.
Menstrual history
Her menarche was at 14 years of age for 5 days followed by a period of amenorrhea and irregular periods.
Her menstrual cycle is a regular one of 28 days with 5 days of vaginal bleeding. It is not usually associated with
pain and she uses 3 pads in a day.

3. Past gynecologic history
She has never been treated for a sexually transmitted infection, she has never had an abortion before.
Past obstetric history
She reported that this is her sixth pregnancy. The first was carried to term and she delivered a live baby girl
vaginally from home with no complications. She delivered all her children from home without any complications
and they are all alive and well. She was not receiving Antenatal Care from any health centre by the time she came
to the hospital.
Contraceptive history
She reported that she does not use any family planning methods.
Past medical history
She reported no history of chronic illnesses, she tested negative for HIV and is currently not on any medication.
Past surgical history
She gave no history of surgical operations, no blood transfusion, no history of burns, no history of accidents.
Family history
She gave no history of chronic illnesses or hereditary disease in the family. She however reports a history of twins
in the husbands family.
Social history
The patient is a farmer. She does not smoke and does not drink alcohol. She is married and her husband has only
one wife. They take a diet of Irish potatoes, sweet potatoes, beans, cabbages, avocado which they grow in their
garden.
Summary of history
An 39-year-old female presented with severe excruciating lower abdominal pain and vaginal bleeding for one day
with history of products of conception expelled vaginally. She however had no pain on urination, no abnormal
vaginal discharge apart from the bleeding, no decreased or increased urinary frequency.
Examination.
General Examination
On examination, patient looked weak and was in pain. She looked well-nourished.
She showed no signs of jaundice, mild pallor of mucous membranes observed, lymph nodes were not inflamed,
no finger clubbing, normal capillary refill and no signs of pitting edema.
Height 156 cm, Blood pressure 95/65 mmHg, Pulse 76 bpm, Temperature 38.0o C
Abdominal Examination
On inspection, her lower abdomen was not distended, it was moving freely with respiration, linea nigra was
prominent, striae gravidarum not prominent and no scars observed.
On palpation, there was tenderness at the right iliac fossa, hypogastric region and left iliac fossa. No obvious
organomegally, no palpable masses. On percussion, no hyper resonant sounds.
Vaginal Examination

4. Vulva and vagina looked normal on inspection but blood stained, no signs of inflammation, no watts, no visible
lesions or ulcers.
Cervix was thin and soft and dilated to 5 cm.
Impression
Incomplete abortion.
Plan
1. Do Ultra Sound Scan.
2. Do CBC
3. Evacuate the uterus
CASE DISCUSSION
Summary of the case
Tusingwire Patience , a married 39-year-old female presented with severe excruciating lower abdominal pain and
vaginal bleeding for one day with history of products of conception expelled vaginally. She however had no pain
on urination, no abnormal vaginal discharge apart from the bleeding, no decreased or increased urinary frequency.
On examination, patient looked weak and was in pain. She looked well-nourished. She showed no signs of
jaundice, had mild pallor of mucous membranes, lymph nodes were not inflamed, no finger clubbing, normal
capillary refill and no signs of pitting edema. Height 156 cm, Blood pressure 95/65 mmHg, Pulse 76 bpm,
Temperature 38.0o C. Per abdomen, on inspection, her lower abdomen was not distended, it was moving freely
with respiration, linea nigra was prominent, striae gravidarum not prominent and no scars observed. On palpation,
there was tenderness at the right iliac fossa, hypogastric region and left iliac fossa. No obvious organomegally,
no palpable masses. On percussion, no hyper resonant sounds. Per vagina, vulva and vagina looked normal on
inspection but blood stained, cervix was thin and soft and dilated to 5 cm.
The patient was admitted and given IV fluids and misoprostol to increase contractions in order to expel remaining
products of conception. The products of conception failed to be expelled and therefore dilatation and curettage
was done. She then did an ultra sound scan to confirm complete removal of remaining tissue and she was later
discharged.
Problem list
Lower abdominal pain
Vaginal bleeding
Diagnosis
Incomplete abortion.
Differential diagnosis
Adnexal Tumors
Amenorrhea
Anemia and Thrombocytopenia in Pregnancy
Cervical Cancer
Cervicitis
Elective Abortion
Ovarian Cysts
Von Willebrand Disease
Actual management of the patient

5. The goal was to increase uterine contractions to expel contents. The patient was given 200 mcg of misoprostol
sublingually and monitored. However, the products were not expelled and Dilatation and Curettage was done and
products were successfully expelled.
Key information in the history that aided diagnosis
History of amenorrhea for past four months.
Lower abdominal pain
History of vaginal bleeding that started with the pain
Products of conception reported
Key information in the physical examination that aided diagnosis, including points missed
Abdominal examination
Linea nigra prominent
Vaginal examination
Cervix dilated
Relevant pathophysiology to this condition
Incomplete abortion is a pregnancy that is associated with vaginal bleeding, dilatation of the cervical canal, and
passage of products of conception. Usually, the cramps are intense, and the vaginal bleeding is heavy. Patients
may describe passage of tissue, or the examiner may observe evidence of tissue passage within the vagina.
Ultrasound may show that some of the products of conception are still present in the uterus. Early placental
development requires a delicate balance between the entry of oxygenated maternal blood and the capacity of the
villous trophoblast to metabolise oxygen and eliminate its metabolites (free radicals). There is a rapid increase in
placental markers of oxidative stress as the maternal circulation is established, which may serve a physiological
role in stimulating placental differentiation, but which equally may result in free radical damage if antioxidant
defences are depleted. In normal early pregnancy, the rapid increase in oxygen tension is paralleled by a rise in
the expression of placental antioxidant enzymes. Bleeding in early pregnancy could change the delicate
equilibrium of placental production of reactive oxygen species and its natural antioxidant defences, leading to
disruption of normal development of the early placenta and placental membranes. This disruption results in a
range of adverse pregnancy outcomes, from miscarriage in the first trimester, to pre-term pre-labour rupture of
the membranes, pre-term labour, fetal growth restriction and pre-eclampsia in the third.
Causes of incomplete abortion
The actual cause of incomplete abortion is frequently unclear; the most common reasons include the following:
● An abnormal fetus that could be caused by defective chromosomes.
● Maternal factors like; chronic illnesses, including diabetes, severe high blood pressure, kidney disease,
Inadequate hormone production, acute infections, including CMV (cytomegalovirus), diseases and
abnormalities of the genital tract like fibroids, congenital anomalies. Other factors may be consumption
of drugs like caffeine, alcohol and tobacco.
● Toxic factors for example heavy metal poisoning.
● Immunologic factors like rhesus incompatibility.
Important and risk/predisposing factors and public health issues relevant to this case
Predisposing risk factors include an advanced maternal age of over 35 years.
Women who smoke tobacco products or drink alcohol are also predisposed to this.
Exposure to radiation increase risk of having changes in genetic material which may lead to fetal anomalies which
is a chief cause of abortion.
Bacterial and viral infections for example CMV

6. Strenuous exercises or work done during pregnancy
Poor social economic status may be a predisposing factor since such mothers may have to do heavy work during
pregnancy to try and fend for their families. This also relates with alcohol consumption and infection with viruses
like HIV, CMV that all add up to increase the risk for early loss of pregnancy.
extremes of age, feeling stressed, and advanced paternal age.
Precipitating factors
Relevant investigations
A complete blood count. A Complete Blood Count will help document the amount of blood loss and whether
anemia is present. If the hemoglobin and hematocrit are very low and the patient is symptomatic then transfusions
should be done. The CBC also will provide evidence regarding an infection, which, in the case of infection, would
yield an elevated white blood cell count and a left shift on differential.
An Ultrasound scan can be done to confirm presence of remaining tissue in the uterus.
Evidence based appropriate management plan
In management of incomplete abortion, the goal is to remove remaining parts from the uterus. First oral
misoprostol 600 microgram sublingual stat should be given and repeated after four hours if necessary. Fingers
can be used to remove products of conception that may be protruding through the cervix. If all this fails, the
uterus can be evacuated manually through Manual Vacuum Aspiration or Dilatation and Curettage. Follow up
should be done, an ultra sound scan should be done to confirm that all products of conception have been
completely removed. If there are signs of infection, antibiotics should be given, IV Ceftriaxone 2g and IV
metronidazole 500 mg orally every 6 hours for 7 days.
Prevention
Good antenatal care ensures follow up and health education is given
Quick seeking for help when bleeding is seen.
Personal learning points
Incomplete abortion can lead to other complications so should be immediately reported and managed
accordingly.

7. References
1. DC Dutta
Textbook of gynecology, Jaypee Brothers Medical Publishers.
2. Uganda Clinical Guidelines 2016, 16.3.2 Vaginal Bleeding in Early Pregnancy/Abortion, Pg668
3. Medscape, Early Pregnancy Loss
4. Healthline, Incomplete Abortion