MISSED ABORTION. — The embryo sometimes dies as a result of the con ditions ,c_riving rise to abortion, and re mains in the uterine cavity,—the so called "missed abortion." The active symptoms of miscarriage may be pres ent; or the patient may only ascertain by the cessation of all foetal motion that it is no longer living. The foetus may entirely disappear, or become trans formed into a shrunken remnant. They are most frequently expelled within six months, but sometimes remain in the uterus as long as eleven months. The usual symptoms of premature delivery are gone through. In its altered con dition, the product is variously termed "fleshy mole," "blighted ovum," or "apoplectic ovum." The occurrence of this complication is comparatively rare. It may repeatedly occur in the same woman.
Case of missed abortion in which the embryo perished during the second month of pregnancy. and was retained until the tenth month. I. Robro (Norsk Mag. f. 4 IL, X 12, S. 1110. '95).
The first factor is the death of the foetus; this is followed by shrinking of the chorionic sac and blood-extravasa tion among the villi. As a result, nu merous small, rounded protrusions are to be seen when the interior of the sac is examined,—the so-called "subchorionic hsematomata," "tuberous subchorionic hnmatomata," or the "tuberculous ova" of Granville. They are considered by some observers as malignant.
When the fretal circulation ceases. the vessels of the placenta are rapidly ob literated. The foetal epithelium covering the chorion and its villi degenerate. and the maternal blood between the villi forms clots, which are altered into dense laminated fibrin. The decidual cells then multiply and invade the fibrin, which they gradually replace, filling the inter vinous space with layers and bands of decidual tissue. At the same time they disintegrate the foetal epithelium, which comes to be represented by scattered heaps and rows of nuclei. and finally dis appears. The amnion remains almost unaltered, but adheres closely to the chorion. and the united membranes are thrown into folds and convolutions, cov ering the rounded lobes of altered pla cental tissue. The fatal portion of the placenta does not grow after the death of the though the maternal por tion containing the decidual cells re mains active. It is therefore improbable
that malignant new growths can arise from festal placental elements. W. E. Fothergill (Brit. Med. Jour., Mar. 20, '97).
The fleshy mole is undoubtedly a form of the process known as "abortion," but the obstetrician should remember that the pathological changes which produce it may occur at very different stages of pregnancy. The precise time at which the arrest of normal pregnancy occurs cannot always be determined by exami nation of a fleshy mole. Neumann (Monats. f. Geburt. u. Gyn.. Feb., '97).
In tuberose fleshy mole abortion is pro duced in the following manner: There is an undue blocking of the serotinal si nuses in the large-celled layer, leading to a slow engorgement of the intervil Ions (imitation. This will bulge out the chorio-basal septa, and. as these tack down the chorion at definite points. the amnion and chorion will bulge up between. 1 his produces the tuberose swellings. The embryo dies as the re sult of this interference with the eir eulation, and its death is "secondary." The placenta becomes a thrombosed mass and is retained a certain time before expulsion. The military link in the chain of events is the excessive clotting in the serotinal sinuses from a cause as yet unknown. 1). Berry Hart (Jour. of Obstet. and Brit. Em pire. May. 1902).
The first symptom is usually a bloody discharge, which is frequently taken for the return of menstruation. The uterus is found to be enlarged according, of course, to the size of the foetus, and the internal os generally permits of the introduction of a finger-tip. The pres ence of the ovum, or Reins, may there fore be ascertained in a proportion of cases, but when this is impossible the diagnosis is established with difficulty. The discharges generally become very foetid, however, and suggest, by the char acter of the odor emitted, the nature of the body present.
Treatment. — Removal of the dead foatus is the only course to be pursued. The means are precisely those for the removal of the placenta just described, the strictest antisepsis being observed.