abortion · regarded as a 'missed abortion ', a condition whichwill be discussed later....

POSTGRAD. MED. J. (1962), 38, 245

ABORTIONJ. A. STALLWORTHY, M.A., M.B., CH.B., F.R.C.S., F.R.C.O.G., HoN.F.A.C.S.

Department of Obstetrics and Gyncecology, United Oxford Hospitals

DefinitionABORTION means the death or expulsion of thefoetus before viability. The twenty-eighth week ofpregnancy is generally accepted as the stage atwhich viability can be assumed. The Births andDeaths Registration Act, 1926, states:

' Stillbirth shall apply to any child which hasissued forth from its mother after the twenty-eighth week of pregnancy and which did not atany time after being completely expelled from itsmother breathe or show any other sign of life '.

If the foetus were expelled at the twentiethweek of pregnancy this would be an abortion. If,however, it died in utero and was not expelleduntil, say, the thirtieth week of pregnancy, itmight be considered a stillborn child according tothe literal interpretation of the legal definitiongiven above. In practice, however, it would beregarded as a 'missed abortion ', a conditionwhich will be discussed later.

Abortion is the most serious common complica-tion of pregnancy. It is estimated that in GreatBritain it occurs in o-i5% of all pregnancieswhile in countries in which abortion is legalizedthe incidence is very much higher. In Englandand Wales a I5%/ incidence of abortion wouldmean that approximately four times as manypotential infants were lost through abortion as thetotal losses from stillbirth and neonatal deathcombined. This unfortunately is only part of thestory. The Reports on Maternal Deaths inEngland and Wales for 1952-54, and 1955-57,recorded 153 and 141 maternal deaths from abor-tion but these figures are lower than the actualones. Comment was made that among deaths notregistered in the enquiry but recorded by theRegistrar-General there were a high proportiondue to abortion. McCormick (I944) estimatedthat 3,500 women died annually in America fromthis complication of pregnancy and a recentestimate in Turkey suggested that Io,ooo womena year died from this cause in that country.Serious morbidity due to chronic inflammatorypelvic disease, and acquired sterility, are commonsequels, particularly in those who survive criminalinterference.

EtiologyIn most cases no cause can be found while in

others more than one factor would appear to shareresponsibility. A long list of causes, or allegedcauses, could be given but would be of little helpin clinical practice. Certain guiding principles,however, can be of use. Every case should beinvestigated carefully once the emergency is overin an endeavour to find why the abortion occurredand in this way provide information whichmight be useful in preventing a recurrence. In75-80% the abortion occurs during the first I2weeks of pregnancy and there is evidence to suggestthat the danger is greatest during the days whenmenstruation would have occurred had thepatient not been pregnant. The uterus appearsto be more irritable at this time and more liableto respond excessively to stimuli which would onother occasions cause no trouble. This point isimportant because at their first ante-natal examina-tion, when this is during the first trimester,women should be warned of the fact that inter-course, spirits, horse-riding, excessive fatigue, andlong car journeys requiring several hours ofuninterrupted sitting are liable to be followed bybleeding and in some cases abortion. If there is aretroverted gravid uterus the danger appears to beincreased. Careful questioning of patientsadmitted to hospital with abortion reveals a highpercentage in whom one or other of these factorsseems to have been a contributory cause. Thepercentage of women in whom pregnancy con-tinues undisturbed by these possible indiscretionsis unknown so that the evidence is not conclusivebut it is sufficiently suggestive to warrant advisingwomen of the possible dangers.When abortion occurs in the first I2 to 14

weeks of pregnancy the gestation sac is usuallycompletely extruded as a result of death ordisease of the ovum or excessive uterine irritabilityas described above, whereas in the middletrimester abortion resembles labour in miniatureand the foetus may be expelled while placental orchorionic tissue is retained. When this occurshamorrhage and infection are likely sequels.

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These two complications are the most commoncauses of maternal death following abortion.

For ease of description the etiological problemcan be simplified by discussing abortion undertwo headings:-

Primary intra-uterine death of ovum or foetus.Primary abnormal uterine activity.

Death of OvumThe extent to which malformations of the

foetus and membranes are responsible for abortionhas not been precisely defined. Estimates varyfrom 15 to 50% of all spontaneous abortions.Hertig, Sheldon, and others have demonstrateddevelopmental defects in aborted ova in a highproportion of cases, particularly when the abortionoccurred in the early weeks of pregnancy. It isnot uncommon in practice to find that thegestation sac is complete after abortion but withno evidence of a developing foetus inside. Some-times the trophoblast is itself responsible andcareful naked-eye examination of the abortedmaterial will reveal cystic changes which can beconfirmed histologically as due to hydatidiformmole formation. Seminal defects have beenincriminated by some workers as a cause of foetalabnormality and there is experimental work withanimals to support this view; while it would beunreasonable to assume that one ovum was asgood as another and it would seem certain thatlethal genes can be transmitted by either sex. Themale has on occasions been unfairly incriminatedduring attempts to determine the cause of hiswife's abortion on the inadequate evidence thathe has an abnormal seminal analysis; a highproportion of abnormal spermatozoa in a husband'sspecimen can not be regarded as the explanation.Placenta praevia is a not uncommon cause ofabortion during the middle trimester. It must beapparent that a placenta which is low-lying atterm was in this position when it first developed.

Criminal interference is probably responsiblefor more abortions than any other single cause.It may take the form of administering drugs,injecting irritating material such as soap solutionsinto the uterine cavity, or attempts at destroyingthe foetus by inserting instruments. The responseof both the ovum and the patient to these proce-dures varies tremendously. A pregnancy has beenknown to continue undisturbed even aftercurettage and a patient may become gravely illfrom acute lead-poisoning following the ingestionof this substance as an abortive agent withoutabortion occurring. Sometimes when attempts atabortion have been unsuccessful the womanchanges her mind and decides to continue withthe pregnancy. It is not uncommon under thesecircumstances for her to worry excessively lest

the attempts at interference have damaged thefoetus. On this point she can be reassured. Thereis no evidence to suggest that the foetus that hassurvived these attacks will be affected by them inits subsequent development. An occasionalexception to this is where attempted abortion inthe later weeks of the first trimester has resultedin damage to the developing placenta and subse-quent relative placental insufficiency in the laterweeks of pregnancy with intra-uterine foetaldistress or even unexpected intra-uterine foetaldeath.

Syphilis transmitted from the mother to thedeveloping embryo was once more common thanit is today as a cause of abortion, particularly inthe middle trimester. Nonetheless it still occurseven in Great Britain and every pregnant womanearly in her pregnancy should have her W.R.tested. Chronic nephritis can produce sufficientplacental endarteritis to cause intra-uterine deathand abortion. Severe diabetes can also causedeath of the foetus and abortion in the middleweeks of pregnancy although it is more liable toproduce this complication after the twenty-eighthweek. The same applies to toxaemia of pregnancyand immunization due to Rhesus incompatibility.The foetus appears particularly sensitive tomaternal hyper-pyrexia and abortion can followacute infections such as pneumonia, pyelitis andperitonitis. In all such cases it is wise to keep thetemperature within reasonable limits by givingaspirin until such time as the infection is con-trolled by specific chemotherapy.There is a small but definite group of patients

in whom there is a recurrent tendency for abortionbetween the sixteenth and twenty-eighth week ofpregnancy preceded by intra-uterine foetal deathdue to asphyxia. In these cases there is a smallfibrous inadequate placenta. This may be due toinadequate pituitary gonadotrophins or be asso-ciated with disturbed function of other endocrineglands such as the thyroid.Primary Abnormal Uterine Activity

Extreme degrees of uterine hypoplasia areassociated with infertility. Less serious degreesof arrested uterine development can be charac-terized clinically by repeated abortion occurringat successively later stages of each pregnancy.During pregnancy there are large amounts ofoestrogenic hormone and progesterone in circula-tion; these hormones bring about preparation ofthe endometrium and its change into the deciduaduring the early weeks of pregnancy and subse-quently are responsible for the growth of theuterus and its response to the enlarging ovum. Ithas for long been believed, though withoutscientific proof, that progesterone, due to a

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STALLWORTHY: Abortion

sedative action on the activity of the uterinemuscle, is responsible for decreasing uterineirritability and that in this way it lessens thechance of the growing uterus expelling the ovumwhich distends it. It is certainly a clinical factthat in degrees of hypoplasia as described abovesuccessive pregnancies can bring about an altera-tion in the environment of the ovum to such anextent that each pregnancy allows the foetus todevelop until a later stage than the preceding oneuntil finally a viable child is delivered.

Congenital malformations of the uterus increasethe liability to abortion. When this occurs it isusually after the twelfth week but it should beremembered that even major developmentalerrors can be associated with full-term pregnancy.This would support the view that there is morethan one factor responsible for abortion in thesecases.

Displacements of the uterus, particularly retro-version, are commonly incriminated as a cause ofabortion, but the relationship has almost certainlybeen over-emphasised. As already describedcertain indiscretions are more likely to stimulateexpulsion of the ovum in a gravid uterus if it isretroverted but there is little evidence thatretroversion itself causes abortion when due careis taken to avoid these stimuli. Nonetheless, whenabortion is repeated and no factor other than aretroverted uterus is discovered it is reasonable toreplace the uterus into the anteverted positionbefore a further pregnancy is commenced.Attempts to replace a retroverted gravid uteruswith the object of preventing abortion are morelikely to produce it. On the rare occasions whenimpaction occurs at about the twelfth to fourteenthweek with retention of urine catheterisation willnot only give immediate relief but be followedusually within 24 hours by spontaneous correctionof the retroversion. Manipulation is unnecessaryand more traumatic than spontaneous correction.

Uterine fibroids are commonly found duringpregnancy but seldom can be responsible forabortion. When a fibroid is sub-mucous thechance of abortion occurring is increased andsometimes in the process the tumour itself isextruded into the uterine cavity as a polyp. Whenabortion is associated with fibroids it is importantto decide whether these were responsible asmyomectomy would improve the prognosis for afuture pregnancy. Once involution has occurreda hysterogram will reveal by filling defect andcavity distortion when a tumour is sub-mucous.Once a patient with fibroids becomes pregnanttreatment should be conservative and myomec-tomy has no place during pregnancy itself.

Expulsive efforts by the uterus can be stimulatedby over-distension such as is seen with hydatidi-

form mole, and in certain cases of multiplepregnancy, particularly if these are associated withhydramnios. The more acute the hydramnios themore likely the uterus is to respond by expellingits contents. When this occurs it is usually in themiddle trimester.

In recent years an important cause of abortionduring the middle trimester has been described byShirodkar and others. It is due to what is com-monly described as cervical insufficiency orincompetence although in many cases it can bedemonstrated that there is a lesion in the regionof the isthmus. This can be congenital in originand manifest itself during the first pregnancy ormore commonly is the result of trauma. This mayfollow excessive dilatation of the cervix fordysmenorrhoea, extensive cervical lacerationsduring childbirth, and even damage affecting theregion of the internal os associated with precipitatedelivery. When abortion occurs in these cases itis usually after the fourteenth week and may bedelayed until the twenty-fourth or later. Thecharacteristic clinical manifestations are a waterydischarge, sometimes of sudden onset, and abulging bag of membranes in the cervix orthrough this into the vagina. Although responsiblefor only a small percentage of the total number ofabortions the recognition of this clinical entity hasbeen a major contribution to obstetrics becauseits recognition prior to the rupture of the bag ofmembranes allows their replacement and sutureof the cervix with a high percentage of success. Itis logical to combine the surgical treatment withthe administration of progesterone in the hope ofreducing uterine activity. If a simple suturematerial such as nylon is used it can be dividedeasily at or near term and the cervix usuallyimmediately dilates and allows the membranes tobulge through. In those cases in which thedilatation is associated with strong uterinecontractions there is greater justification forusing progesterone at the time of the suture.

Psychogenic causes appear to be of importancein many cases in the etiology of abortion. Inrepeated abortion excitability of the autonomicnervous system is likely to become a major factorwhether it is the primary one or not. With eachsuccessive disappointment the anxieties of thewoman who is anxious to have a baby increase andcan affect the irritability of the uterus.

Types of AbortionThe process of abortion is labour in miniature.

The cervix must be effaced before the external osdilates and dilatation precedes expulsion of theovum. The following clinical types are recognized:

Threatened abortion.Inevitable abortion.

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248 POSTGRADUATE MEDICAL JOURNAL April I962

?: Ir'I..u I

FIG. I. I .:I Al'

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(Figures reproducedfrom 'British ObstetricPractice' by kind per-mission of William

Heinemann Ltd.)

Incomplete abortion.Missed abortion.In addition to the above basic clinical types

reference will be made to the following:-Septic abortion.Repeated or habitual abortion.Therapeutic abortion.Criminal abortion.The changes which occur as abortion progresses

from the stage of being threatened to that of beingcomplete are illustrated in Figures 1-4. Study ofthese will show that cervical signs are of impor-tance in indicating the stage the abortion hasreached. This is particularly true in distinguishingbetween threatened and inevitable abortion. Eachvariety will now be considered in more detail.

Threatened AbortionBleeding during pregnancy is usually due to

separation of the membranes or placenta. It maybe profuse and red, or scanty and brown. It iscustomary to presume that abortion is threatenedwhenever painless vaginal bleeding or blood-stained discharge occurs. Approximately 20% ofpregnant women have this symptom. It isimportant to remember however that vaginal' spotting' or bleeding is not always an indicationof threatened abortion. If it is associated withmidline lower abdominal discomfort or recurringpains the diagnosis is more likely to be correct.When the bleeding is painless, as it usually is, itmay arise from cervical polypi, erosions, and mostserious of all occasionally from carcinoma of thecervix associated with pregnancy. It is wise totreat the bleeding initially as due to threatenedabortion so that appropriate measures can betaken without delay. When the emergency is overand before the patient is allowed to return to

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normal activities the genital tract should beexamined gently with a speculum and adequatelight as well as with the finger.

If bleeding is associated with pain or discomfortin the hypogastrium or back and sometimes in bothiliac fossae, the patient is almost certainly threaten-ing to abort. The site of the pain and its relativemildness helps to distinguish it from the unilateralpain of ectopic pregnancy. On rare occasions painin the sites mentioned without bleeding is thefirst indication of a threatened abortion. This ismost likely to occur with a sub-mucous fibroid, orwith a patient who is emotionally tense and hasan irritable uterus.As a general rule vaginal examination should be

postponed if bleeding is slight. Once the emer-gency has subsided the examination should bemade. If examination is considered necessarygentle digital palpation of the cervix will give allthe information required at this stage. Referenceto Figure I will show that examination wouldreveal a closed uneffaced cervix.

Inevitable AbortionThis implies that nothing can prevent expulsion

of the ovum. The clinical change from threat toinevitability is indicated by more or less arbitrarysigns and symptoms. If the cervix is effaced andopened so that the lower pole of the ovumoccupies the cervical canal, or if liquor amnii hasescaped, the diagnosis is practically certain. It hasbeen mentioned, however, that in the special groupwith cervical incompetence the membranes maybe bulging through the cervix and yet be amenableto replacement with suture of the cervix. Bleedingis usually more severe than in threatened abortionbut the amount of loss is not an infallible guide toinevitability. Many pregnancies will continue toterm even after severe haemorrhage and the passageof clots. This is most likely to happen whenbleeding occurs during the middle trimester as aresult of a low lying placenta. The association ofrecurring pains in the lower abdomen or sacrumwith the passage of clots and considerablehaemorrhage is an indication that abortion isinevitable.

This stage usually terminates quickly. Expul-sion of the ovum causes little distress andsubsequent bleeding is minimal if no fcetalproducts are retained. The material passedshould be examined carefully. Failure to find anembryo does not necessarily mean that it has beenretained in utero. This is in fact unlikely for iftissue is retained it is usually chorionic orplacental, and absence of the embryo can be dueto its faulty development or absorption. Theretention of foetal products is more common afterinduced than after spontaneous abortion.

A useful clinical principle is that an emptyuterus will not bleed. When abortion occurringduring the first twelve weeks is completed bleedingshould stop within two to three days and blood-stained discharge by the end of a week. If itpersists longer or recurs the abortion should beregarded as incomplete. Complete abortion isfollowed by rapid involution of the uterus withreformation and closure of the cervix as illustratedin Figure 4.Incomplete AbortionAn empty uterus is the only safe one. Retention

of fcetal products is associated with the risks ofhemorrhage and infection which are the twogreat causes of maternal death from abortion. Interms of both mortality and morbidity incompleteabortion is the most dangerous variety. It isresponsible for more gynaecological emergenciesthan any other single condition and accounts forapproximately io% of the gynaecological admis-sions to a hospital in which there is no selectionof patients.

Incomplete abortion is characterized by persist-ing or recurrent hemorrhage which may beassociated with lower abdominal discomfort andon occasions with severe pains due to uterinecontractions. If the haemorrhage is severe digitalexamination will often disclose placental tissue inthe cervical canal. An open cervix suggests thatthe abortion is of recent occurrence but it isimportant to remember that a closed cervix doesnot necessarily exclude the presence of retainedproducts within the uterus. The uterus will beenlarged but the normal variations particularly inthe parous organ may make this sign of doubtfulvalue. Even when no uterine enlargement isdetected, if bleeding persists exploration of thecavity may reveal a surprising quantity ofplacental debris.

Missed AbortionIf a feetus dies in utero but the uterus fails to

expel it there may be no pain and no bleeding.The condition is known as a missed abortion.Sometimes hemorrhages occur in the spacebetween the decidua and the chorionic coveringof the ovum and result in its death. Recurrenthemorrhages may occur resulting in layers oforganized blood clot in the centre of which willbe the original amniotic sac and foetus. Thesemay both be absorbed. This constitutes aninteresting variety of missed abortion known as aCarneous Mole.Missed abortion may occur insidiously as in the

case of a woman who observes that the sensationsof pregnancy have ceased and her abdomen isdecreasing in size rather than enlarging. On the



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other hand it sometimes follows the signs of athreatened abortion with vaginal bleeding. Herbreasts become smaller and sometimes a womanwill complain of a sensation of coldness in herlower abdomen. On rare occasions she may feelill with no definite symptoms and even developskin rashes caused apparently by absorption offcetal products.The pregnancy urine test is of little value in

these cases. It can be negative even although thepregnancy is continuing normally and it can bepositive with a missed abortion as long as placentaltissue is retained.

Management of AbortionTreatment of abortion demands more than the

efficient handling of the emergency. When awoman loses a much-wanted baby she mayrequire reassurance before she is physically andmentally fit to embark on another pregnancy. Ifa woman's life is endangered by criminal abortionshe should not need to be exposed to this riskagain if her problems are handled wisely andsympathetically. There are four guiding principlesin the management of abortion. They are:-

(a) Treatment is both immediate and remote.Once the emergency is over steps should betaken to find out why it occurred, and plansshould be made to prevent its recurrence.

(b) The aim of treatment in threatened abortionis to prevent it from becoming inevitable.

(c) In all other types of abortion treatmentaims at emptying the uterus, controllinghaemorrhage, and preventing sepsis.

(d) No patient should be discharged frommedical care until her health is fullyrestored. Anaemia is common. A post-abortal examination is as essential as apost-natal one. Menstruation should returnnormally within one to two months butrecurrent or persisting bleeding or blood-stained discharge demands investigation.Chorion-epithelioma can follow abortion.The management of abortion based on theseguiding principles will now be discussed inmore detail.

Threatened AbortionTreatment is aimed at arresting the process.

Physical and mental rest are essential during theemergency. Calm reassurance can be of thegreatest help to the patient. It should be reinforcedby pethidine mg. o00-I50 or morphine mg. 15.Complete rest in bed until bleeding ceases isadvisable. Phenobarbitone 0.2 g. can be useful asan initial dose and sodium amytal 0.4 g. orseconal 0.2 g. at night will promote restful sleep.There has been much controversy over the use of

progesterone in these cases. Its use in threatenedabortion has long since been abandoned in theArea Department of Obstetrics and Gynaecologyat Oxford. It is, however, still used on occasionsonce the acute episode is over and before thepatient is allowed to return to full activity. Onthese occasions a pellet of Ioo mg. is implantedinto the muscle of the buttock under localanaesthesia. (Estrogenic hormones have beenadvised in the treatment of threatened abortionby some workers but their use is not recommended.When recurring uterine discomfort or pain is themain symptom of threatened abortion dramaticrelief can be given by the sublingual absorptionof glyceryl trinitrate 1/Ioo gr. This should be usedonly when the patient is in bed as it can causesyncope in an ambulant patient and it should notbe used if there is bleeding. In a threatenedabortion which responds to treatment the initialhaemorrhage is usually followed for a few days bya decreasing brown discharge, the extent andduration of which is not related to the amount ofexternal bleeding which took place. The patientshould be advised of this development andassured that it is not a cause for anxiety. She iswise to remain in bed for two to three days afterbright bleeding ceases and to restrict even herhousehold activities for a period of a week. If theabortion was threatened during the first I2 weeksshe should be warned to restrict activity as muchas possible when the next suppressed period is due.

Inevitable AbortionTreatment is aimed at emptying the uterus

with minimal delay and blood loss. The uterususually empties itself quickly and spontaneouslyand the stage of inevitability is brief. It canpersist for hours or even days and on occasionsrequires help urgently because of severe bleeding.If haemorrhage has been severe a further loss canprove fatal and a patient who has already bledheavily should not be transferred to hospital withthe uterus unemptied. If bleeding is severeergometrine 0.5 mg. should be given intravenouslyand careful aseptic digital exploration of thecervix will often reveal placental tissue lying inthe canal. If the bladder is emptied before theexamination this makes palpation of the uteruseasier and promotes uterine contractions. Inthese cases the uterine cavity can usually beevacuated by gentle digital exploration. If thecondition of the patient in domiciliary practicegave cause for alarm the wisest plan would be togive ergometrine 0.5 mg. intravenously andsummon the nearest Flying Squad. If there wasdelay in obtaining this and haemorrhage persisted,digital exploration would be indicated. Morphineo1 mg. relieves anxiety and improves uterine tone,

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whereas a larger dose can have the opposite effecton the uterus.

If the uterus is excessively enlarged andparticularly if there are associated ovariantumours, either unilateral or bilateral, the diagnosisis almost certainly a hydatidiform mole withtheca-lutein ovarian cysts. The latter will regressspontaneously after the mole has been evacuated.Posterior pituitary extract should not be given.Its action is not as constant as that of ergometrine,its effect is not so prolonged, and it can producesevere shock which may even be fatal. This appliesto the whole extract of the posterior pituitarygland. The oxytocic principle is safer and can beused instead of ergometrine. It can be adminis-tered when necessary by intravenous infusionusing the drip technique with 2.5 to 5 units perbottle of glucose saline.Immediate steps should be taken to prepare for

blood transfusion which will not only replace theblood which has been lost, but increase the safetymargin should further haemorrhage occur. It mustbe emphasised that on no account should acollapsed patient be transported to hospital.Resuscitation is more important than immediateremoval and failure to appreciate this fact hascaused many deaths. The Flying Squad has nobetter justification than its efficient handling ofjust this type of case. Until suitable blood isavailable it is wise to commence a slow saline orglucose saline infusion. This also avoids delayonce suitable blood is available.

Prolonged or severe painless bleeding duringthe middle trimester suggests the diagnosis ofplacenta praevia for which hospital supervision isessential. Transfer of the patient should beentrusted to the Flying Squad service.

Incomplete AbortionMore deaths occur from incomplete abortion,

including septic incomplete abortion, than fromall other varieties combined. As in inevitableabortion, treatment aims at emptying the uterus.Hospital practice gives a wrong impression of thefrequency of incomplete abortion and it should beremembered that most women who abort spon-taneously at home during the first I2 weeks expelthe complete ovum. When this occurs vaginalbleeding ceases in two or three days. The warningsign that abortion was incomplete is persisting orrecurrent bleeding and this should not be treatedlightly. The expectant attitude in these cases ofwaiting for tissue to be expelled and the admini-stration of ergometrine and other oxytocic drugsoften proves ineffective and is associated with thedanger of further hemorrhage and of infection.If bleeding persists after the administration ofergometrine 0.5 mg. intravenously, or o.25 mg.

intravenously and o.25 mg. intramuscularly, theuterus should be evacuated surgically. Thedecision when and where to operate is one onwhich the life of the patient may depend and isbased on the following general principles.Although it is best to operate in a well-equippedtheatre, lives will be saved in rural areas whenbleeding is severe by using the services of anemergency obstetric team and evacuating theuterus in the patient's own home. In severe casesblood transfusion before and during operation canbe life saving. The administration of ergometrineintravenously 0.25-0.5 mg. at the commencementof operation reduces blood loss, makes the uterusfirmer and its wall thicker, and in this wayreduces the chance of perforation. The detailedtechnique of evacuation is beyond the scope ofthis article but certain practical points should beemphasized. The bladder should be emptied andthe exact position of the uterus should be con-firmed before any instruments are passed toavoid perforating the anterior wall of a retroverteduterus. Narrow instruments such as uterinesounds, sharp dilators, and narrow curettesshould be avoided. When the cervix is sufficientlydilated to permit of the index finger being insertedinto the uterine cavity, the other hand can pressthe uterus down by abdominal manipulation on tothe exploring finger and in this way the cavitycan be emptied. In most cases, however, thistechnique is not possible. Sponge forceps are auseful means of removing larger pieces of placentaltissue, and a blunt flushing curette irrigated withsaline or a weak antiseptic solution at a temperatureof 43-45°C. is a useful means of emptying thecavity and promoting contraction of the uterus..Twenty-four to 48 hours in hospital is usually allthat is required when there is no infection.Discharge should cease within a week.

Septic AbortionInfection can occur at any stage of abortion.

Although it occurs most commonly after criminalinterference there is no justification for assumingthat because the genital tract is infected inter-ference has necessarily occurred. Organisms canbe introduced into the uterus by careless technique,.ascend from the patient's vagina during the courseof a spontaneous abortion, or be blood-borne asfor example during an acute general infection.Septic abortion in most cases is associated withthe incomplete variety of abortion. Uterineinfection behaves like infection elsewhere and canremain localised, or spread to the tubes andpelvic peritoneum, into the parametrium especiallyif there have been lacerations of the cervix, andoccasionally may cause general peritonitis orsepticaemia. The advent of chemotherapy and



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antibiotic drugs has completely changed theprognosis in these cases both in regard to mortalityand morbidity. The condition is, however, stilldangerous and certain basic facts must beremembered. They are:-

Sepsis and anaemia are often combined.Wounds heal more cleanly and rapidly when

dead tissue is removed.Infection or hemorrhage from the infected

placental site can cause the patient's death.Anaemia may be profound and can be caused

either from blood loss or from toxemia caused bythe infecting organism, particularly the hxemolyticstreptococcus and C. welchii. The latter infectioncan arise in a patient who has become anaemicafter spontaneous abortion, lowered resistanceleading to a fulminating and fatal infection. Atleast 25% of all septic abortions admitted tohospital need transfusing. When death occurs inthese cases it is due either to infection or haemorr-hage, or a combination of both, so that treatmentshould aim at overcoming the infection andremoving the threat of further bleeding. Whichshould be done first depends on the extent of thebleeding and unless hemorrhage is severe it iswise to control the infection first. Both aerobicand anaerobic cultures are made from high vaginalswabs and from the blood if there is pyrexia.Streptococci and E. coli are usually responsiblebut anaerobic organisms are not uncommon.Until the organism and its sensitivity are known,antibiotics capable of dealing with both theformer types of infection should be used. Peni-cillin, I,000,000 units, and streptomycin, g g.,should both be given as an initial dose and berepeated within 12 hours. If the haemoglobin isbelow 60% blood transfusion should be given. Ifanaemia is profound packed cells should be usedin the first instance. Special nursing is necessaryin the gravely ill patient, with frequent recordingsof temperature, pulse rate, and blood loss. Whenmental distress is acute sympathetic nursing,sedative drugs, and adequate sleep are essential.Once infection has been controlled the abortion

should be treated according to the instructionsalready given. In most cases sepsis is associatedwith septic incomplete abortion and when this isso the uterus should be evacuated. With this planof treatment there have been no deaths fromseptic abortion in the Oxford Department sinceI954-

Occasionally a patient with septic abortion isbleeding badly when first seen. When this happensan initial dose of I,OOO,ooo units of penicillin andi g. of streptomycin is given, ergometrine 0.5 mg.is given intravenously, a blood transfusion iscommenced, and the uterus is evacuated asgently as possible.

Many maternal deaths would be prevented andconsiderable morbidity avoided if more womenwith incomplete abortions were treated promptlyaccording to the methods advocated in this paper.Fetal products retained in utero after the mostinnocent spontaneous abortion can becomeseriously infected by organisms ascending fromthe vaginal vault.

Gas Gangrene InfectionsSpecial mention should be made of this

fortunately rare but extremely serious complicationof abortion. Its early clinical recognition wasadmirably described by Hill in 1936. Usually, butby no means always, there is a history of inter-ference particularly of fluid injected into thecervix with a Higginson syringe. Within I2 hoursthe patient can appear moribund. Lowerabdominal pain beginning in the hypogastriumand spreading over the whole abdomen indicatesthe onset of uterine infection with peritonitis.Either severe vaginal bleeding or a blood-staineddischarge may be present in the early stages. Thepatient looks and feels gravely ill. The pulse atthe wrist may be imperceptible. The systolicpressure is low and the diastolic unrecordable.The skin is cold and clammy and the peripheralcirculation may be so impaired that the limbs arecold and blue. There is suppression of urine evento the stage of complete anuria and any that isexcreted is heavily stained with blood pigment.This can be an early sign and should make onesuspicious of a fulminating gas gangrene infection.Toxaemia is profound and haemolytic anaemiadevelops rapidly. Icterus may be detected in afew hours in the conjunctivae. Even when thepatient is dying the mind remains clear and theeyes alert but there can be considerable mentaldistress. At this stage crepitus is seldom detectedand x-ray examination of the pelvis will seldomshow gas in the tissues. If the patient dies gasproduction in the tissues can be terrifyinglyrapid. A vaginal swab reveals the presence ofC. welchii either alone or with other organisms andblood cultures will be positive. Diabetic patientsare prone to this infection. The principles oftreatment are as follows:To combat the toxaemia.To destroy the infecting organism.To maintain life while the first two objects are

being achieved.Morphine io mg., or heroin 5 mg. are effective

in relieving anxiety. An intravenous infusion iscommenced but it is important that the volumeof fluid should be restricted, particularly if thereis anuria. The infusion provides a ready means ofgiving the necessary concentrated treatment.One million units of penicillin are given intra-

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venously with Ioo,ooo units of anti-gas gangreneserum. This is followed every four hours with500,000 units of penicillin and 50,000 units ofanti-gas gangrene serum until both toxaemia andinfection are controlled. Urine will not be secreteduntil the blood pressure rises and this will nothappen in the initial stages of treatment. Hydro-cortisone ioo mg. should be added to the infusionfluid and subsequent administration varied accord-ing to the response of the blood pressure. Ifparalytic ileus is associated with peritonitis thestomach should be kept empty by constant orperiodic suction and the administration of oxygenthrough a suitable mask can help in relievingrespiratory distress.

Signs of improvement are the general appearanceof the patient, rising blood pressure and fallingpulse rate and an increased urinary output.Retained placental tissue is an ideal culturemedium for anaerobic organisms and the uterusshould be evacuated as soon as the condition ofthe patient justifies it. Evacuation of the uterus isalso imperative if severe bleeding should occur orif in spite of the treatment outlined above thepatient's condition deteriorates. Hysterectomy isnot indicated. It must be re-emphasized that ifanuria persisted the chance of survival would bedecreased by giving excessive fluid intra-venously.

Treatment of Missed Abortion and CarneousMoleWhile it is distressing for a woman to know that

her baby is dead within her womb she should beassured that this is not dangerous and that inmost cases it will be safer for her to be patient andwait for nature to expel the uterine contentsrather than to embark on ill-chosen surgicalinterference. If intra-uterine death occurs in thelater weeks of the middle trimester and the foetusis retained for a fortnight or more there is thepossibility of blood-clotting defects developingwith spontaneous haemorrhages, but this conditionis rare in association with abortion. While it isusual for the uterus to empty itself within a fewdays of foetal death there are many instances inwhich the fcetal products have been retained formany months. If, for any reason, it seemsadvisable to empty the uterus this is best donevaginally after gentle dilatation of the cervix. Ifthe cervix is too firm to allow dilatation withouttearing, or if the uterus is enlarged beyond the

size of a 14 weeks gestation a vaginal hysterotomyis preferable.Repeated or Habitual Abortion

If every woman were investigated along thelines suggested above at the time of her firstabortion there would be fewer examples ofrepeated or so-called habitual abortion. Respon-sible factors such as indiscretions, sub-mucousfibroids, or an incompetent cervix would bediagnosed and treated. The problem with repeatedabortion is to try and determine the cause and totake the appropriate action. Once abortion isthreatened it is treated along the lines indicatedabove.

Therapeutic AbortionThis is a difficult and controversial subject in

which ethical and theological problems as wellas medical ones are involved. Because of themany difficulties it is advisable that any doctorassociated with a case of therapeutic abortionshould take certain precautions. They are:-He should never operate without the written

support of a second colleague and in someinstances, particularly when the mental health ofthe patient is in question, he is wiser to have theagreed opinion of two independent specialists.

Patients on whom therapeutic abortion isperformed should be treated in hospital ratherthan in private nursing homes. There are occasionswhen if single rooms are not available it may addto the distress of the patient to admit her to ageneral ward, just as there are other occasions onwhich it may be to her advantage to do this.

If for good reason it is deemed in the patient'sinterests to admit her to a private room the chanceof repercussions would be reduced for the surgeonif his fee were nominal rather than excessive.

In conclusion it is remarkable how often thelatent maternal instinct of a patient will triumphover the initial shock and fear associated with anunwanted pregnancy. The chance of this happen-ing will depend a great deal on the tact andsympathy with which she is handled by hermedical practitioner. Reassurance and a clearstatement of his attitude to the problems involvedwill do much to help the patient clarify her ownviews. The suggestion that 24 hours should betaken to reconsider the matter, and the provisionof a sedative to guarantee a good night's sleep,will on occasions be all that is necessary to bringabout a change of heart.



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abortion · regarded as a 'missed abortion ', a condition whichwill be discussed later....

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