A CAJM article on abortion.Between 800 and 1,200 cases of abortion are seen annually at Harare Hospital, Salisbury. Prior to 1st February, 1969, all cases of incomplete abortion were routinely admitted to the gynecological ward for observation and further treatment. In 1967, for example, 533 cases of abortion were seen during the six-month period 1st February to 31st of  July. Of these, 396 were classified as non-septic and 137 as septic. All 533 patients were hospitalized, the average duration of stay in hospital being four days

Allen, A.

Philpott, R.H.

Central African Journal of Medicine

English

IDS OpenDocs

SUPPLEMENT TO VOLUME 17, NUMBER 1, JANUARY, 1971
FACTORS AFFECTI NG THE OUTCOME OF 
TREATMENT OF PULMONARY TUBERCULOSIS  
IN SUB- OPTI MAL CONDI TI ONS :
An 18-month Follow-up of 224 Patients
By
D. H. SHENNAN and M. LOUISE WESTWATER.
T h e  C e n t r a l  A f r i c a n
Journa l  of Medicine
Volume 17 MAY, 1971 No. 5
Management of Incomplete 
Abortion as an 
Outpatient Procedure
BY
A. ALLEN 
Registrar;
AND
R. H. PHILPOTT
Professor
Division of Obstetrics and Gynaecology, Harare Central 
Hospital, Salisbury.
I ntroduction
Between 800 and 1,200 cases of abortion are 
seen annually at Harare Hospital, Salisbury. Prior 
to 1st February, 1969, all cases of incomplete 
abortion were routinely admitted to the gynae­
cological ward for observation and further treat­
ment. In 1967, for example, 533 cases of abortion 
were seen during the six-month period 1st Feb­
ruary to 31st luly. Of these, 396 were classified 
as non-septic and 137. as septic. All 533 patients 
were hospitalised, the average duration of . stay in 
hospital being four days.
A case of uncomplicated, incomplete abortion 
was taken to theatre the morning following ad­
mission for evacuation under general anaesthesia. 
Post-operativejy, she was observed for 24 hours, 
and then if she had remained—
(a) apyrexial; . .
(b) without clinical signs of pelvic infection;
(c) free from further haemorrhage; and
(d) passing urine adequately; 
she was allowed to go home.
The gynaecological wards in 1967 contained 58 
beds. This figure could be increased to 68 by the 
introduction into the main ward of temporary 
beds. This in fact was often the case. The aver­
age bed occupancy rate in 1967 was 110.4 per 
cent., but in 1969 it was brought down to 100.1 
per cent.
The chronic overcrowding that previously 
occurred affected:
(a) The Admission o f . Cold Cases.—Bookings are 
heavy from the gynaecological outpatient clinic and 
there were often unfortunate but unavoidable de-
' lays before patients—could be admitted for in­
vestigation or cold surgery. Often patients had to 
be turned away even though they had been booked 
some weeks previously for that specific day. Cases 
of abortion were responsible for the use of 48 per 
cent, of the total gynaecological beds available in 
the ward during 1967. .
(b) The General Standard of Nursing and Medical 
Care.—Due to a heavy intake of emergency cases, 
it is always. a problem, even without managing 
abortion cases, to keep the number of patients in 
the ward at reasonable proportions for the purpose 
of adequate nursing and medical supervision.
As these cases were being taken to the main 
theatre for evacuation under general anaesthesia, 
there was an added strain on the theatre staff 
and the anaesthetic department.
We therefore sought to relieve this pressure on 
the gynaecological services by implementing an 
outpatient regime for the management of incom­
plete abortion, and relief for the anaesthetic 
services by considering alternative methods of. 
analgesia which would be both safe and effective. 
This was commenced on 1st February, 1969.-
Selection of Patients Suitable for 
Outpatient Management
A patient presenting herself at the hospital with 
an abortion is referred by the casualty officer to 
the senior house officer on gynaecological call for 
examination, diagnosis and treatment either, as 
an in- or outpatient. She is seen in the observa­
tion bay in the casualty department where six 
beds are reserved for such gynaecological prob­
lems.
The patient’s general condition is assessed with 
particular reference to—
(a) evidence of shock, either endotoxic or 
haemorrhagic;
(b) blood pressure, pulse and temperature;
(c) haemoglobin level, which is checked at the 
patient’s bedside;
91
M ay, 1971,, MANAGEMENT OF INCOMPLETE ABORTION T h e  Central African ;
J ou rn al  op Medicine
(d) pelvic examination to confirm the diagno- 
' sis and to assess any associated infection;
(e) urinary output.
Criteria for Admission
(1) Cases with associated sepsis, i.e., with 
pyrexia plus abdominal or pelvic tenderness and / 
or signs of peritonitis.
(2) Cases complicated by severe anaemia, i.e., 
with a low haemoglobin concentration (10.0 g./ 
100 ml. (70 per cent.) or less).
(3) Cases suffering from septicaemia or hypo- 
volaemic shock, i.e., with signs of peripheral 
vascular collapse, tachycardia and a systolic blood 
pressure below 100.
(4) Patients who had aborted as a result of 
some other serious illness, e.g., typhoid, amoebia- 
sis, tuberculosis and malaria. “
Management of Patients in  Casualty
A patient with a threatened abortion is sent 
home with advice to rest in bed and phenobar- 
bitone gr. 1 three times a day is prescribed. How­
ever, if the haemorrhage has been heavy or there 
is uncertainty as to the diagnosis, the patient is 
kept under observation and is re-assessed by a 
registrar or consultant.
Complicated cases receive emergency treatment 
as follows:
(a) Blood is taken for grouping and emergency cross­
matching and the estimated amount of blood re­
quired is ordered.
(b ) An intravenous infusion of Ringer’s lactate is 
commenced.
(c) A central venous pressure manometer is set up, 
if the patient is severely shocked, as a guide to 
fluid replacement requirements.
(d ) Ergometrine 0.5 mg. is given intramuscularly.
(e) Chemotherapy is instituted and the initial dose 
administered.
The case is then admitted and managed along 
normal accepted lines.
Management of T hose Patients K ept 
in  Casualty
A case of uncomplicated incomplete abortion 
is routinely observed by half-hourly pulse, blood 
pressure and four-hourly temperature recordings. 
A half-hourly pad check is carried out and any 
blood loss noted. If a patient is pyrexial, chemo­
therapy is commenced; penicillin and streptomycin 
in combination are the antibiotics in routine use. 
An intravenous oxytocin infusion is used to ex­
pedite delivery of the foetus in certain cases of 
incomplete abortion where the period of gestation 
is greater than 14 weeks.
Evacuation lists are carried out twice daily at 
8 a.m. and 2 p.m. in the casualty theatre.
A nalgesia
In an endeavour to determine an optimal 
method of analgesia, one of the authors (A.A.) 
personally employed three methods in common 
use in our outpatient regime in the management 
of 100 cases of incomplete abortion. For the 
purpose of the study these cases were divided 
into three groups:
(1) Group A, consisting of 25 patients, who 
were given paracervical block anaesthesia, 
using 20 ml. of a 1 per cent, lignocaine 
solution.
(2) Group B, consisting of 25 patients, who 
were given pethidine 50 mg. by intramus­
cular injection as a premedication 30 
minutes prior to the paracervical block.
(3) Group C, consisting of 50 patients, who 
were given pethidine 100 mg. and valium 
10 mg. diluted in. 10 ml. of water, ad­
ministered by slow intravenous injection, 
followed immediately by evacuation and 
curettage.
. The effectiveness of the analgesia produced 
was recorded as follows:
+  +  +  =  good analgesia.
+  +  =  fair analgesia.
+  =  poor analgesia.
The assessment was made on the basis of the 
patient’s opinion expressed to the theatre sister 
in attendance during the procedure.
Method of Paracervical Block
With the patient in the lithotomy position an 
Auvard’s speculum was passed into the vagina. 
The cervix was visualised, grasped with a single­
toothed Volsellum forceps and drawn to one 
side exposing the lateral fornix on the opposite 
side. Twenty ml. of 1 per cent, lignocaine solution 
had been drawn up and the syringe attached to a 
No. 20 gauge 6 in. needle. The needle was in­
troduced through the vaginal skin in the exposed 
lateral fornix to a depth of 1-2. cm. This was 
at 4 and 8 o’clock on each side, the points where 
the paracervical ganglia are situated in close 
proximity to the medial attachment of the utero- 
sacral ligaments. The plunger of the syringe was 
drawn back to exclude entry into a blood vessel, 
then 10 ml. of the solution was slowly infiltrated 
into this region; another 10 ml. was injected in 
the other fornix.
Ten minutes after the completion of the para­
cervical block a routine examination and evacua­
tion followed by curettage was carried out. 
Ergometrine 0.5 mg. was given routinely by intra­
muscular injection.
T h e  Central African
J ournal of M edicine
May, 1971. MANAGEMENT OF INCOMPLETE ABORTION
The patients were assessed four to six hours 
post-operatively, and if their condition was con- 
; sidered satisfactory they were discharged. Patients 
who were pyrexia! on admission, but whose tem­
peratures were settling and were otherwise without 
complications, were allowed home on oral chemo­
therapy, tetracycline 250 mg. four times a day 
for five days.
Results
A. Outpatient Regime
In the first six-month period, 1st February to 
31st July, 1969, in which the regime outlined 
was instituted, 558 cases of abortion were seen 
and assessed in the casualty department (see Table 
I). There were 410 known cases of incomplete 
abortion and only 59 of these required admission.
Table I
Types of Abortion Seen in  the Casualty 
Department Between 1st February and 
31st J uly, 1969
Incomplete abortion ..............................  410
Complete abortion ..............................  62
Threatened abortion ......   41
Unknown (inadequate records) ...............  45
TOTAL ......................    558
Of the incomplete abortions managed in the 
outpatient department, 74.4 per cent, were dis­
charged within 12 hours of arrival in hospital and 
11.2 per cent, within 12 to 24 hours. The re­
maining 14.4 per cent, who were in hospital for 
over 24 hours had been warded due to the pre­
sence of complications requiring inpatient treat­
ment.
Table II shows the period of time patients in 
Groups A, B and C spent in the casualty depart­
ment.
Table II
Admission-Discharge
Interval
Group
A j - B Group C
Under 12 hours 26 ( 52%) 31 (62% )
12 to 24 h o u rs ............. 6 (12% ) 5 (10% )
Over 24 hours .... .. _ 18 (36% ) 14 (28% )
TOTAL ...................... 50 (100%) 50 (100%)
B. Comparison of Analgesic Methods 
Table III compares the analgesic effect pro­
duced by the three methods in the author’s 
study.
Table III
Analgesic
Effeot Group A Group B Group C
+ + + 9 (36%) 15 (60% ) 26 (52% )
+ + 11 (44% ) 7 (28% ) 19 (38% )
+ 5 (20% ) 3 (1 2 % ) 5 (10% )
TOTAL 25 (100%) 25 (100% ) 50 (100%
D iscussion
Results of an Outpatient Regime 
The essence of this regime is to ensure a safe, 
minimal, admission-treatment-discharge interval. 
That this was achieved to a highly satisfactory 
degree is shown by the fact that it was possible 
to discharge 74.4 per cent, of cases of incomplete
Table IV
Analysis of 13 Patients whose Response to A nalgesia was Poor
GROUP A GROUP B GROUP C
No. of 
Patients Age Parity.
Cervix
Dilated
(cm.) Age Parity
Cervix
Dilated
(cm .). Age Parity
Cervix 
Dilated 
. r (cm.)
1 19 0 3 18 0 2 16 0 4
2 20 1 0 18 0 4 . 18 0 •1
3 21 0 2 ' 19 O’ ■ 2 ■ 20 O ' 4
4 21 0 3 — — — 21 - 0 2.
5 30 5 2 — — — 26 4- .. 0
93
M ay, 1971. MANAGEMENT OF INCOMPLETE ABORTION T h e  Central  AfricanJ ou rn al  of Medicint
abortion within 12 hours of their arrival in the 
hospital outpatient department. In the whole of 
1969 there is record of only one patient being 
re-admitted as a result of inadequate outpatient 
management. This case is discussed below.
In 1967, when cases of incomplete abortion 
were routinely admitted, they accounted for 48 
per cent, of all gynaecological cases in the wards 
during the 12 months. In 1969 only 10 per cent, 
of cases of incomplete abortion required inpatient 
management following the commencement of our 
outpatient regime, and: as a result of this they 
now constitute merely 6 per cent, of the total 
number of ward patients. Since we treat between 
800 and 1,200 cases a year, we can now antici­
pate saving the hospital administration and ward 
the unnecessary cost and work involved in the 
inpatient management of approximately 1,000 
patients every year. We have estimated that the 
saving in hospital bed days during 1969 compared 
with 1967 was in the region of 3,400.
It can be appreciated that this regime has 
brought definite relief to the ward and nursing 
staff concerned. Medical services similarly have 
been assisted in providing more time for adequate 
attention to the more seriously ill patients. There 
has been a beneficial effect on the waiting lists 
of cold cases. For the patients it has provided a 
minimal period spent in the casualty department, 
uterine evacuation without having to undergo a 
general anaesthetic, and minimal side effects.
In the six-month review period 408 cases of 
incomplete abortion underwent uterine evacuation 
in the casualty theatre with the use of the methods 
of analgesia described. This has proved a tremen­
dous saving on anaesthetic services and has 
greatly relieved the pressure on the main theatre 
staff.
Methods of Analgesia in 
Outpatient Management
Evacuation of the uterus in cases of uncom­
plicated incomplete abortion is a relatively simple 
procedure and therefore each of the three simple 
methods of analgesia studied proved fairly satis­
factory. However, it will be noted that a para­
cervical block alone was not as efficient as a 
block done with pethidine premedication or when 
intravenous pethidine and valium was used as 
the method of • analgesia. We would therefore 
recommend one of the two latter forms of anal­
gesia for the outpatient management of incom­
plete abortion.
A paracervical block is particularly valuable 
when there is need to dilate the cervix. It is our 
experience that effectiveness improves with the 
increasing experience of the operator and it is a 
technique, which has many other indications in
obstetrics and gynaecology. The procedure is 
relatively free of side effects. In the six-month 
period under review 220 patients were given para­
cervical blocks and only one patient developed a 
complication that could be attributable to this 
technique.
The patient concerned was pyrexial on arrival, 
but had no localising signs of pelvic sepsis. 
Therapy was commenced with penicillin and 
streptomycin and evacuation was carried out six 
hours later. She was discharged four hours post- 
operatively on oral tetracycline. The patient was 
re-admitted to the gynaecological ward 48 hours 
later suffering from pelvic inflammatory disease 
and peritonitis. She responded well to intramus­
cular, and later oral, Chloromycetin and was fit 
to be discharged after five days’ treatment. There 
was no evidence of infection at the follow-up 
visit to the outpatient clinic. It is suspected that 
in this case the infiltration of local anaesthetic 
into the utero-sacral ligaments opened up a plane 
of cleavage and this facilitated the spread of 
infection which till then had been localised to 
the uterus. We feel, therefore, that proven or 
suspected sepsis is a contraindication to the use 
of paracervical block.
Van Praagh and Povey (1967) mention sus­
pected or known allergy to local anaesthesia as 
the only contraindication they encountered and 
they advise keeping vasopressors and oxygen 
available. Bonica (1967) states that severe con­
vulsions, vascular collapse and even death have 
been reported in the literature. He feels that these 
complications are usually due to errors on the 
part of the operator and can be avoided by the 
use of thin, sharp needles, checking that a vessel 
has not been accidentally punctured and by using 
a safe dose of the local anaesthetic.
The combination of pethidine and valium given 
intravenously also proved to be a very satisfactory 
and safe method of analgesia. During the six 
months under review this method was used for 
255 patients undergoing uterine evacuation, its 
advantage lying in the ease of administration and 
the almost immediate hypnotic and analgesic 
effect. The saving of time which is undoubtedly 
achieved with this method is an important factor 
in considering the management of a long list of 
evacuations which is a particular problem in a 
large hospital.
Pethidine in common with all narcotics, is of 
course a respiratory depressant. As such its use 
is contraindicated in the presence of diminished 
resoiratory reserve as may be found in patients 
suffering from tuberculosis, asthma or other pul­
monary diseases, and in patients with chest de­
formities or obesity.
MANAGEMENT OF INCOMPLETE ABORTION T h e  Central AfricanJ ournal of MedicineMay, 1971.
Fig. 1—Relation of analgesic response to age.
M ay, 1971. MANAGEMENT OF INCOMPLETE ABORTION T h e  Central  African
J o u rn al  of Medicine
Fig. 3—Relation of analgesic effect to cervical dilatation.
There were no unpleasant side or after-effects 
seen in patients who were given pethidine and 
valium. In particular, there was no significant 
hypotension or prolonged narcotic effect. This 
was important, as it meant that there was' no 
unnecessary delay in discharging patients after 
completion of the uterine evacuation.
An analysis of the 100 cases in which the three 
regimes of analgesia were compared^ reveals that 
13 cases had a relatively poor response to their 
analgesia. It must be pointed out that the criteria 
used were very strict, and in fact each of these 
patients underwent uterine evacuation without 
real distress. They were fairly evenly distributed 
in the three groups. A study of these 13 patients 
shows that 10 of them were nulliparous patients 
between the ages of 16 and 21.- We therefore 
now recommend that the few young nulliparous 
patients who show evidence of fear and appre­
hension should be given a general anaesthetic.
Conclusion
We have shown that, in a busy hospital prac­
tice, 90 per cent, of cases of incomplete abortion 
can be satisfactorily treated on an outpatient 
basis in the’ casualty department. Furthermore, . 
general anaesthesia is not necessary in this group,
except in the few young nulliparous patients who 
show evidence of apprehension. Two alternative 
methods of analgesia have been shown to be 
safe and effective for uterine evacuation in the 
casualty department. These'are either paracervi­
cal block with pethidine premedication or intra­
venous pethidine and valium.
REFERENCES
Bonica, J ohn  H. (1967). Principles and Practice of 
Obstetrics, Analgesia and Anaesthesia, ' p. 507. 
M eehan, F. P., Spriggs, A. S., Strong, S. J. & Wil­
liams, E. A. (1969). J. Obstet. Gynaec. Brit. Cwlth., 
76, 163.
Van P raagh, I. G. L. & P ovey, W: G. (1967). Obstet. 
and Gynec., 29, 167.
Acknowledgments
We wish to record our appreciation for the 
work done by the nursing staff in casualty and 
the house surgeons in the division of gynaecology. 
We also wish to thank the matron, Miss M. 
MacLennan, and the medical superintendent, Dr. 
D. Goold, for permission to make use of the 
casualty department in the way described in the 
article; and also Miss I. A. Edmonstone and Mr. 
D. M. Barley for invaluable assistance in collat­
ing patients’ records. We acknowledge the per­
mission, of the Secretary for Health, Dr. M. 
Webster, to publish this article.
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Management of Incomplete Abortion as an Outpatient Procedure

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Management of Incomplete Abortion as an Outpatient Procedure

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