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noted, in case the decidua is so completely detached from the uterine walls as to permit descent of the whole remaining portion of the ovum into the cervix, this may still be sufficiently large to restrain the effused blood and to permit the occurrence of spontaneous delivery—a state of affairs which is to be surmised from the non-appearance of haemorrhage and the persistence of pains, after the escape of the foetus.
On assuming the charge of a case of inevitable abortion, the physician's first duty is to collect and examine all the clots which have been passed, so far as they can be obtained; and as the ovum or totus is usually enveloped in blood when voided, it. is necessary to tear apart, under water and with the utmost carefulness, all clots of any considerable size before assuming its absence. If after this examination no portion of the ovum is found, or if on vaginal examination the smooth elastic surface of the intact membranes is felt within the cervix, the use of any form of manipulation which could possibly rupture the decidua should be avoided, and the treatment confined to the use of ergot and the tampon.
Ergot during the first three months of pregnancy has an effect closely similar to that which it exerts on the non-pregnant uterus, and in moderate, continued doses distinctly promotes expulsion; but after the end of the third month it is less reliable, of account of its tendency to produce a tonic constriction of the then more developed cervix.
The Tampon, if properly applied, is perhaps the best and most efficient means at our command for the treatment of abortion, so long as the ovum completely fills the cervix. For this purpose, the application of a small tampon through the cylindrical or bivalve speculum, with the patient upon her back, is totally inefficient; to secure the best results, the patient must be placed in the left latero-prone position, and the perinaeum retracted by a Sims' speculum; the vagina should then be carefully swabbed out, under the guidance of the eye, with a one to twenty carbolic acid or a one to sixty creolin solution, care being taken to omit no portion of the vaginal walls or cervix; and a number of small plugs of cotton, strips of gauze, or pieces of lamp wicking, should be wrung out of the same solution, and packed around the cervix one after another, with a pair of uterine dressing forceps, until the fornix of the vagina is thoroughly distended; the speculum should then be slightly withdrawn, and the lower portion of the vagina packed in the same manner; a degree of distention being obtained which just avoids the production of severe pain or discomfort.
The tampon should not be left in situ more than twelve hours, at the end of which time it should be removed by the physician (preferably with the patient in Sims' position), piece by piece, under the guidance of the eye. In many cases the ovum and clots will be found already in the vagina, behind the tampon; but if this has not occurred and the patient's condition is not such as to afford any indication for hurry, another tampon should be introduced, to be removed in its turn at the expiration of an equal number of hours; this process should be repeated until the desired end has been attained, or until the patient begins to show signs of exhaustion which call for more radical measures; and the action of the tampon may, with advantage, be reinforced by the administration of ergot, if the pains are weak.
After rupture of the ovum it is proper to administer ergot, or introduce a tampon, and wait a few hours in the hope that spontaneous expulsion may still occur, provided that the hemorrhage is not excessive; but if at the end of this time no progress has been made, or if haemorrhage is still going on, the physician should not wait for the appearance of exhaustion, but should at once apply himself to the immediate removal of the remains of the ovum. This may be done with the finger or by a dull curette, and it may be said that here, as elsewhere in obstetrics, the sentient finger is ordinarily a better tool than any rigid instrument, but in this case the choice of methods must depend mainly upon the degree of dilatation present; if the cervix is so far patulous that the finger can be passed into the uterine cavity without undue force, this is by far the better method; but if the canal of the cervix is too small to admit the finger the curette must be employed instead.
Removal by the Finger.—If the patient is not extremely sensitive, and rough or abrupt movements be avoided, it is usually possible, with the woman in the lithotomy position, to so far depress the uterus by palpation through the abdominal walls as to enable the finger of the other hand to be passed through the os and up to the fundus without the use of ether. When this has been done, the attempt to extract the ovum should be delayed until the tip of the finger has been made to pass up along one lateral wall of the uterus to the fundus, and entirely above the ovum; it should then be made to pass gently across the fundus to the opening of the other Fallopian tube, and swept downward along the corresponding lateral wall, driving the clots and retained membranes into the vagina in the process; but if, during this manipulation, the decidua escape from under the finger and slip back to the fundus, it must again be carried above them before their removal is attempted.
Removal by the Curette.—The use of the finger is less difficult to the inexperienced than that of the curette, but in cases where the cervix is not sufficiently dilated to permit the easy introduction of the finger, the smaller size of the curette makes it the better instrument. It may be used through the bivalve speculum, and with the patient upon her back, but an operator who is familiar with the use of Sims' speculum will prefer the semi-prone position on account of the greater freedom of motion which it permits to the curette. The patient being in position, a medium-sized Thomas' dull wire curette should be passed gently through the cervix, and made to traverse all portions of the uterine wall, the complete removal of the decidua being recognized by the sensation of grating which the firm uterine tissue gives to the hand, during the use of the curette.
Whichever method has been adopted should be followed by flushing out the uterine cavity through a Bozeman or other double-current, intra-uterine catheter, with a 1:4,000 solution of corrosive subimate at a temperature of from 100° to 110' F.; and this should be succeeded by a small intra-uterine douche of boiled water which has been reduced to the same temperature. These, like all intra-uterine injections, should be given under the guidance of the eye, and a careful watch should be kept to see that the return current is constantly maintained, as any neglect of this precaution may result in forcing a portion of the injection into the Fallopian tube, and in thus setting up a salpingitis or pelvic peritonitis.
Fibrinous Mole.—Any small portion of the decidua which may be left within the uterus ordinarily disintegrates and causes no trouble, if full antiseptic precautions have been observed; it occasionally happens, however, that such retained portions may obtain sufficient nourishment to remain alive, and may then develop into a polypus-like mass which is known by the name of a fibrinous mole (Fig. 4). The formation of such a growth is marked by fresh or increased haemorrhage, and the only proper treatment conns. .— 'BM- sists m ^ removai Dv tlle finger or curette in the Nots Mole. '°
manner already described.
Neglected Abortion.—When either abortion or miscarriage has been allowed to proceed without treatment to a point at which the patient is greatly exhausted by haemorrhage, or till sepsis has distinctly set in, it was formerly the custom to counsel delay until efforts to improve the patient's general condition had been successful, in the fear that local treatment might induce collapse or an increase of inflammation—an accident which in the patient's exhausted condition might hasten a fatal termination. The more modern view is, that the immediate, gentle, and thoroughly aseptic use of the curette, if followed by the administration of a careful intra-uterine douche, is almost invariably the best treatment, and this is the only course which can now be recommended. It is certainly injudicious to resort to general sustaining measures in the treatment of collapse from haemorrhage while the bleeding is still going on, and it is rarely possible to prevent still further loss of blood in such cases until after the complete evacuation of the uterus; while an arrest of septic absorption can hardly be hoped for as long as the original source of infection remains in place—theoretical considerations which are sustained, by the fact that practical experience proves that the operation is attended by but slight exhaustion and that sepsis in particular is usually found to decrease rapidly after the removal of the. ovum, provided that the most rigid antisepsis is employed throughout the operation. If in such cases a temporary improvement is followed by recurrence of the trouble, a prompt repetition of the operation is always advisable.
Lochia of Abortion.—A slight lochial discharge usually persists for about three times as many days as the gestation has lasted months.
The management of miscarriage differs but little from that of abortion except in the following particulars. After the formation* of the placenta the discharge of an intact ovum is comparatively rare. The birth of the foetus differs from delivery at term only in the fact that the dilatation of the cervix is apt to be slow and tedious; but this may in itself be sufficient to result in undue prolongation or even in an arrest of labor, and may necessitate a manual dilatation. In breech presentations, which are extremely common in miscarriage, the after-coming head is usually arrested by a constriction of the os around the neck of the foetus, which must then be delivered by traction upon the lower extremities, but in this process great care should be taken to avoid laceration of the cervix. In the great majority of cases, the placenta is retained and requires manual removal; and in miscarriage, unless during the fourth month, the use of the finger is preferable to that of the curette, for the reasons already given, and because in a great majority of cases the os is freely patent.
Premature labor differs in no way from labor at term, and should only be expedited in the presence of some one of the usual obstetric indications.
Malpositions And Abnormalities Of The Uterus.
Prolapse.—Prolapse of the uterus is rarely initiated during gestation, but since uncomplicated prolapse offers no obstacle to conception, the minor degrees of this condition are not infrequently observed in co-existence with pregnancy. When the pelvic space becomes insufficient for the increased size of the uterus, its ascent into the abdomen, which occurs about the end of the third month, usually puts an end to prolapse, but this malposition produces so distinct a tendency to abortion that the pregnancy is not infrequently terminated before this natural relief occurs. It is consequently important to relieve prolapse by the adjustment of a suitable pessary, whenever the lesion is observed in any considerable degree during the early months of pregnancy, since the presence of a pessary is less likely to result in abortion than is the persistence of a displacement which has already produced sufficient discomfort to lead the patient to seek advice, but the exertion of the utmost care to prevent irritation of the vagina by the pessary is here of even more importance than under ordinary circumstances; to which end it is important that the patient should be examined at intervals of from two to three weeks. At each visit the physician should make a careful determination of the relations between the pessary and the vaginal walls and uterus, in order to alter its shape or size from time to time, as the increased size of the fundus may require. The use of too large a pessary cannot be too carefully avoided, as any ulceration of the vaginal walls or even undue pressure upon the uterine body may readily be followed by abortion. Preference should be given to soft and elastic, rather than to rigid instruments; the Meig's elastic ring, and that variety of the Hodge pessary which is sold under the trade-name of "patent process," being the preferable forms.
Incarceration.—In prolapse of the second degree, where treatment has been neglected and abortion does not occur, incarceration of the gravid uterus within the pelvic cavity may exceptionally be produced. This accident not only exposes the patient to certain miscarriage, but also involves some danger of sloughing and gangrene of the pelvic contents from the pressure due to the increased size of the uterus. If this rare condition is found to exist, it is, therefore, always a sufficient indication for immediate abortion, provided that all attempts at elevation of the uterus fail. Such attempts, to be efficient, should be conducted with the patient in the knee-chest position, and by the introduction of the half or whole hand into the vagina, if necessary under anaesthesia.