2. Abortion is the spontaneous or induced
termination of pregnancy before fetal viability
miscarriage and abortion appropriately are
terms used interchangeably
abortion by laypersons implies a deliberate intact
pregnancy termination
miscarriage for spontaneous fetal loss.
3. define abortion
The Centers for Disease Control and
Prevention {CDC) and the World Health
Organization (WHO) define
abortion as any pregnancy termination-
spontaneous or induced-before 20 weeks'
gestation or with a fetus born weighing <500 g.
The term "fetus" will be used for all , although
the term "embryo" is the correct
developmental term at ≤10 weeks of
gestation.
4. pregnancy of unknown location (PUL) aids timely
identification and management of ectopic pregnancy.
In the context of early pregnancies, five categories have
been proposed:
definite ectopic pregnancy
probable ectopic
PUL
probable intrauterine pregnancy (IUP)
definite IUP .
Of IUPs, those that spontaneously abort during the first
trimester, that is, within the first 12 6 or 7 weeks of
gestation, are also defined as early pregnancy loss by the
ACOG
5. If studies are confined to first-trimester
abortions, up to 70 percent are anembryonic,
that is, with no identifiable embryonic
elements.
The remaining pregnancies are an embryonic
miscarriages, which may be further grouped
as either those with chromosomal anomalies-
aneuploid abortions,or those with a normal
chromosomal complement euploid abortions.
6. SPONTANEOUS ABORTION
Incidence
More than 80 percent of spontaneous abortions
occur during the first 12 weeks of gestation
Their rate increases significantly with advancing
maternal age.
For example, the clinical miscarriage rate nearly
doubles with maternal or paternal age older than
40
7. 31 percent of pregnancies were lost after
implantation
two thirds of these very early losses were clinically
silent
Eight to 20 percent of clinically recognized
pregnancies under 20 weeks of gestation will
undergo Sab
The overall risk of SAb after 15 weeks is low
(about 0.6 percent) for chromosomally and
structurally normal fetuses, but varies according
to maternal age and ethnicity
8. Loss of unrecognized or subclinical pregnancies is even
higher, occurring in 13 to 26 percent of all pregnancies.
Early pregnancy losses are unlikely to be recognized
unless daily pregnancy tests are performed.
If preimplantation losses are considered, 50 percent of
fertilized oocytes do not result in a live birth
A study that compared women's bleeding following a
pregnancy loss before 6 weeks of gestation with their
typical menstruation found that mean bleeding length
following a pregnancy loss was 0.4 days longer than the
woman's average menses and the amount of bleeding
was light
9.
10. Fetal Factors
Approximately half of embryonic first-trimester miscarriages are
aneuploid.
This incidence declines markedly with advancing gestation at the
time of pregnancy loss.
In general, aneuploidy fetuses aborts earlier than those with a
normal chromosomal complement.
75 percent of aneuploid fetuses abortes before 8 weeks, whereas
the rate of euploid abortions peaks at approximately 13 weeks.
Almost 95 percent of chromosomal abnormalities in aneuploid
fetuses are caused by maternal gametogenesis errors.
lmportantly, the American College of Obstetricians and
Gynecologists (2018a) does not recommend routine use of
chromosomal microarray analysis of first-trimester fetal tissues.
11. Aneuploid Abortion
autosomal trisomy is the most frequently
identified chromosomal anomaly in early
miscarriages.
Although most trisomies result from isolated
nondisjunction, balanced structural
chromosomal rearrangements are present in
one partner in approximately 2 percent of
couples with recurrent pregnancy loss
12. Monosomy X (45)is the single most common
specific chromosomal abnormality, also
known as Turner syndrome.
Most affected fetuses spontaneously abort,
but some are live born females.
Conversely, autosomal monosomy is rare and
incompatible with life.
13. Ploidy
describes the number of complete chromosome sets.
Triploidy is often associated with hydropic or molar
placental degeneration.
Of hydatidiform moles, partial moles are
characteristically triploid.
The associated triploid fetuses frequently abort early,
and those born later are all nonviable and grossly
malformed.
Advanced maternal and paternal ages do not
increase the incidence of triploidy.
Tetraploid fetuses most often abort early in gestation
and are rarely liveborn.
14. Chromosomal structural abnormalities
infrequently cause abortion.
Neonates with a balanced translocation who
are live born usually appear normal, but as
adults they may experience recurrent
pregnancy loss
15. Euploid Abortion
The causes of euploid abortions are poorly
understood
maternal medical disorders
uterine defects
environmental and lifestyle conditions.
The subsequent etiologies are most logically
discussed with sporadic spontaneous abortion
17. Medical Disorders
Pregnancy loss is clearly associated with
diabetes mellitus and thyroid disorders.
Inflammatory Bowl disease and systemic
lupus erythematous-especially anti
phospholipid syndrome-may independently
also raise the risk.
Beyond these,few acute or chronic diseases
convey early pregnancy risk.
18. Infection
Only a few organisms are proven to cause
abortion.
In general,systemic infections likely infect the
feto placental unit by a blood-borne route.
Others may infect locally via maternal
genitourinary infection or colonization.
19. importantly, some infections truly cause
miscarriage, whereas others may serve as only an
associated marker.
Chlamydia trachomatis is suspected to cause
abortion.
The mechanism is unclear, but this infection may
adversely affect outcome
By infecting the fetus
by stimulating a fetal inflammatory response
by promoting an excessive maternal immunologic
reaction
20. An association between bacterial vaginosis
and first-trimester miscarriage is controversial.
Ebola virus and Mycoplasma genitalium
infection were significantly associated with
spontaneous abortion .
Data concerning the abortifacient effects of
some other infections are conflicting.
21. Namely, roles for Mycoplasma hominis and
Ureaplasma urealyticum are unclear.
Human immunodeficiency virus infection is
not associated with excessive abortion risks.
Of other viruses, human papilloma virus
(HPV) infects trophoblasts, but it does not
appear to play a role in miscarriage
22. Infections caused by parvovirus,
cytomegalovirus, herpes simplex virus, or
Listeria monocytogenes likely have no
abortifacient effects .
Last, several infections cause abortion in
livestock, but data remain inconclusive in
humans.
These include Brucella abortus,
Campylobacter fotus, and Toxoplasma gondii
23. Imaging and Surgery
With low-dose radiation from diagnostic imaging,
embryo fetal risks appear to be minimal.
Current evidence suggests that malformation, growth
restriction, or miscarriage rates are not increased from
a radiation dose less than 0.05 Gy (5 rad).
gross congenital malformation rates would not be
higher with exposure to less than 0.2 Gy (20 rad).
Because diagnostic x-rays seldom exceed 0.1 Gy {10
rad), these procedures are unlikely to cause disordered
embryogenesis
24. With computed tomography, radiation doses can be higher.
Thus, modified protocols or substitution with magnetic
resonance (MR) imaging is preferred.
Importantly, with MR imaging, use of gadolinium is not
recommended unless benefits outweigh risks.
For surgery during pregnancy, the risk of miscarriage is not
well studied.
No currently used anesthetic agents have teratogenic
effects when used at any gestational age.
Uncomplicated surgical procedures-including abdominal or
pelvic surgery do not appear to increase the miscarriage
risk .
25. elective surgery be postponed until delivery and nonurgent surgery
be performed in the second trimester.
This practice lowers the theoretical risk for miscarriage for preterm
contractions.
Laparoscopy also is suitable
Ovarian tumors or Cysts can be safely resected without causing
pregnancy loss.
An important exception involves early removal of the corpus
luteum or the ovary in which it resides.
If performed prior to 1 0 weeks' gestation, supplemental
progesterone is given.
Between 8 and 1 0 weeks, a single 1 50-mg injection of
intramuscular 17 -hydroxyprogesterone caproate is given at the
time of surgery.
26. If the corpus luteum is excised between 6 to 8 weeks, two
additional 150-mg injections are given 1 and 2 weeks after the first.
Other suitable progesterone replacement regimens include:
(1) micronized vaginal progesterone (Prometrium) 200 mg twice or
three times daily
(2) 8-percent progesterone vaginal gel (Crinone) 90 mg once or twice
daily
(3) progesterone vaginal insert (Endometrin) 1 00 mg twice or three
times daily
( 4) micronized oral progesterone (Prometrium) 200 mg orally twice or
three times daily
(5) progesterone in oil (compounded in a specialty pharmacy) 50 to 1
00 mg daily intramuscular injection.
27. Any of these regimens is continued until 1 0
weeks' gestation.
Trauma seldom causes first-trimester
miscarriage, and although Parkland Hospital is
a busy trauma center, this is an infrequent
association.
Major trauma-especially abdominal can
cause fetal loss but is more likely as pregnancy
advances.
28. Radiotherapy and Chemotherapy
In utero exposure to radiation may be
abortifacient, teratogenic,or carcinogenic
depending on the level of exposure and stage
of fetal development.
Threshold doses that cause abortion are not
precisely known but definitely lie within the
therapeutic doses used for maternal disease
treatment.
29. Methotrexate is a known teratogen
Female cancer survivors who were treated in the
past with abdominopelvic radiotherapy may be at
higher risk for miscarriage.
a two- to eight fold greater risk for miscarriage,
perinatal mortality, preterm delivery, and low-
birth weight and growth-restricted neonates in
women with prior radiotherapy.
higher miscarriage risk in those given
radiotherapy and chemotherapy in the past for a
childhood cancer
30. Medications and Vaccines
Certain medications are known abortifacients
and include progesterone antagonists,
prostaglandin E1 (misoprostol), and
methotrexate.
The prescribing information document for
each drug is best consulted prior to use.
Many routine immunizations can be given
safely during pregnancy.
31. Most studies have demonstrated safety of
both the HPV and influenza vaccines if given in
early pregnancy.
However,most live-virus vaccines are
proscribed during pregnancy.
That said, robust evidence to link live-virus
vaccines with miscarriage is lacking.
32. Nutritional Factors and Weight
Dietary deficiency of any one nutrient or
moderate deficiency of all nutrients does not
appear to be an important cause of abortion.
Even in extreme cases-for example,
hyperemesis gravidarum-abortion is rare.
Dietary quality may be important,and
miscarriage risk is reportedly reduced in
women who consume fruit, vegetables,
whole grains, and fish.
33. Data also suggest that extremes in weight can
be deleterious.
Obesity is associated with subfertility, raises
the risk of miscarriage, and results in a host of
other adverse pregnancy outcomes.
the pregnancy and live birth rates were
reduced progressively for each incremental
rise in body mass index (BMI) units
34. Although the risks for many adverse late-
pregnancy outcomes decline after bariatric
surgery, its salutary effect on the miscarriage
rate is unclear.
Low BMI in some but not all studies has been
associated with greater miscarriage risk.
primary modifiable prepregnant risk factors
for miscarriage are being underweight, obese,
or aged 30 years or older at conception
35. Behavior
Of lifestyle choices, alcohol use has been best studied in
pregnancy.
Earlier observations were that both miscarriage and fetal
anomaly rates rose with alcohol abuse rates during the
first 8 weeks of gestation.
Such outcomes likely are dose related, although safe levels
have not been identified.
significantly greater risk only with regular or heavy alcohol
use.
In some studies, low-level alcohol consumption apparently
did not significantly raise the abortion risk.
hazard ratio for first-trimester fetal death of 1.66 with as few as
two drinks per week
36. Cigarettes may cause early pregnancy loss by
several mechanisms that also cause adverse late-
pregnancy outcomes.
Some but not all studies link smoking with
abortion risk and find a dose-response effect.
"Heavy" caffeine consumption has been
associated with greater abortion risk, and this
association is enhanced in smokers.
Studies of "moderate, intake-less than 200 mg
daily-do not demonstrate a higher risk.
37. the ACOG (2018d) concludes that moderate
consumption likely is not a major abortion risk
and that any associated risk with higher intake
is unsettled.
The adverse effects of illicit drugs on early
pregnancy loss also are unclear.
Although cocaine was linked to an increased
miscarriage rate in one study, reanalysis
refuted this conclusion
38. Occupation and Environment
Some environmental toxins such as benzene are
implicated in fetal malformations, but data regarding
miscarriage risk are less clear.
Earlier reports implicated arsenic, lead,formaldehyde,
benzene, and ethylene oxide .
More recently, evidence suggests that bisphenol A,
polychlorinated biphenyls, and DDT
(dichlorodiphenyltrichloroethane) may raise
miscarriage rates.
Nevertheless, DDT containing insecticides are
endorsed by the WHO (2011) for mosquito control to
prevent malaria.
39. Few studies have assessed occupational
exposure and abortion risks.
An elevated risk has been described for dental
assistants exposed to 3 or more hours of nitrous
oxide per day in offices without gas-scavenging
equipment.
a small incremental risk for spontaneous
abortion in women who worked with cytotoxic
antineoplastic chemotherapeutic agents
40. RISK FACTORS
Age
Advancing maternal age is the most important
risk factor for spontaneous miscarriage in healthy
women.
The overall rate of SAb was 11 percent and the
approximate frequencies of clinically recognized
miscarriage according to maternal age were
age 20 to 30 years (9 to 17 percent)
age 35 (20 percent)
age 40 (40 percent), and age 45 (80 percent)
41. Previous spontaneous abortion
Past obstetrical history is an important predictor
of subsequent pregnancy outcome.
The risk of miscarriage in future pregnancy is
approximately 20 percent after one miscarriage
28 percent after two consecutive miscarriages
43 percent after three or more consecutive
miscarriages.
By comparison, miscarriage occurred in only 5
percent of women in their first pregnancy or in
whom the previous pregnancy was successful.
42. Smoking Heavy smoking (greater than 10 cigarettes per day) is associated
with an increased risk of pregnancy loss.
This association is more pronounced when controlling for other
causes of pregnancy loss, such as limiting the analysis to
chromosomally normal abortuse.
The mechanism is not known, but may be related to
vasoconstrictive and antimetabolic effects.
Paternal smoking may also increase the risk of pregnancy loss.
Smoking cessation should be recommended for its overall health
benefit
Alcohol moderate to high alcohol consumption increases the risk of SAb.
increased risk of miscarriage in women who drank more than 3
drinks per week in the first 12 weeks of pregnancy .
Women planning pregnancy should avoid alcohol consumption
since alcohol is a known teratogen and a safe level of alcohol
intake has not been established at any stage of pregnancy.
43. Gravidity Some studies have shown an increased risk of miscarriage with increasing
gravidity ,while others have not.
Possible reasons for this association include
(1) reproductive compensation behavior (pregnancy failure is likely to be
associated with repeated attempts at conception resulting in higher
gravidity)
(2) short interpregnancy intervals in multigravid women
Cocaine Use of cocaine is associated with preterm birth, and may also be a risk
factor for spontaneous abortion.
the presence of cocaine in hair samples was independently associated with
an increase in the occurrence of spontaneous abortion after adjustment for
demographic and drug-use variables
Nonsteroidal
anti-
inflammatory
drugs
But not acetaminophen , may be associated with an increased risk of
miscarriage if used around the time of conception
prostaglandin inhibitors interfere with the role prostaglandins play in
implantation, thus potentially leading to abnormal implantation and
pregnancy failure , NSAID SHOULD BE AVOID IN EARLY PREGNANCY
Caffeine mechanism for the increased rate of SAb with high caffeine intake might be
related to maternal metabolism and clearance of this substance
Fever Fevers of 100°F (37.8°C) or more may increase the risk of miscarriage
44. Prolonged
ovulation to
implantation
interval
Early losses have also been related to a prolonged interval (ie,
>10 days) between ovulation and implantation.
Such delays might result from fertilization of an older ovum,
delayed tubal transport, or abnormal uterine receptivity.
Prolonged time to
pregnancy
— Observational studies have reported that prolonged time to
achieving pregnancy correlates with an increased risk of
miscarriage
Low-folate level low plasma folate levels (≤2.19 ng/mL [4.9 nmol/L]) were
associated with an increased risk of SAb at 6 to 12 weeks of
gestation, but only when the fetal karyotype was abnormal.
Low folate levels with normal fetal karyotype and high folate
levels had no such adverse effect
increase the risk of meiotic nondisjunction.
There is no evidence that vitamin supplementation prevents
miscarriage
Maternal weight Prepregnancy body mass index less than 18.5 or above
25 kg/m2 has been associated with an increased risk of
infertility and SAB
celiac disease Untreated celiac disease may be associated with a higher
risk of SAb
45. ETIOLOGY
In one-third of imaging studies at or before 8
weeks of gestation, no embryo or yolk sac is seen
in the gestational sac.
In the two-thirds of cases in which an embryo is
found, approximately 50 percent are abnormal,
dysmorphic, stunted, or too macerated for
examination .
Abnormal embryos may result from
chromosomal abnormalities or exposure to
teratogens.
46. Chromosomal abnormalities
Chromosomal abnormalities account for
approximately 50 percent of all miscarriages.
Most of these abnormalities are aneuploidies
structural abnormalities and mosaicism are
responsible for relatively few abortions.
The earlier the gestational age at abortion, the
higher the incidence of cytogenetic defects: the
incidence of abnormal fetal karyotype is
90 percent in anembryonic products of conception
50 percent for abortuses at 8 to 11 weeks of gestation
30 percent of abortuses at 16 to 19 weeks .
47. The most frequent types of abnormalities
detected were:
Autosomal trisomies — 52 percent
Monosomy X — 19 percent
Polyploidies — 22 percent
Other — 7 percent
48. Trisomy 16 is the most common autosomal trisomy
and is always lethal.
Most chromosomal abnormalities in the embryo arise
de novo.
Rarely, these defects are inherited as a consequence of
parental karyotypic abnormalities, such as balanced
translocations.
Genetic abnormalities not detected by conventional
cytogenetic analysis (G-banded karyotype) account for
an undefined proportion of spontaneous abortions.
These abnormalities include small deletions and
duplications and point mutations.
49. Congenital anomalies
Congenital anomalies are caused by genetic or
chromosomal abnormalities, extrinsic factors (eg,
amniotic bands), and exposure to teratogens.
Potential teratogens include
maternal disorders (eg, diabetes mellitus with poor
glycemic control)
drugs (eg, isotretinoin )
physical stresses (eg, fever)
environmental chemicals (eg, mercury).
50. Trauma
Invasive intrauterine procedures
/trauma, such as chorionic villus sampling and
amniocentesis, increase the risk of abortion.
In contrast, the early gestational age uterus
is generally protected from blunt trauma to
the maternal abdomen
51. Host factors
Pregnancy loss may also be related to the host
environment.
As an example, congenital or acquired uterine
abnormalities (eg, uterine septum, submucosal
leiomyoma, intrauterine adhesions) can interfere with
optimal implantation and growth
Acute maternal infection with any of a large number of
organisms
Listeria monocytogenes, Toxoplasma gondii, parvovirus
B19, rubella, herpes simplex
cytomegalovirus, lymphocytic choriomeningitis virus can
lead to abortion from fetal or placental infection.
52. Maternal endocrinopathies (eg, thyroid
dysfunction, Cushing's syndrome, polycystic
ovary syndrome) can also contribute to a
suboptimal host environment.
Since corpus luteum progesterone production
is an integral component of successful
pregnancy, it is plausible that early pregnancy
loss could be due to corpus luteum
dysfunction; however, this is controversial.
53. The use of progesterone to distinguish between
a nonviable (missed abortion or ectopic
pregnancy) and a viable pregnancy when the
location of the pregnancy is unknown is
addressed separately.
A hypercoagulable state due to inherited or
acquired thrombophilia and abnormalities of the
immune system (eg, systemic lupus
erythematosus, antiphospholipid syndrome) that
lead to immunological rejection or placental
damage are active areas of investigation
54. Unexplained
The etiology of abortion of chromosomally
and structurally normal embryos/fetuses in
apparently healthy women is unclear.
genetic abnormalities not detected by
standard karyotype analysis (small deletions
and duplications and point mutations) account
for an undefined proportion of spontaneous
abortions.
55. Clinical Classification
As a group, abortion can be divided clinically
several ways.
Commonly used categories include
threatened
inevitable
incomplete
complete, and missed abortion.
When the products of conception and uterus
become infected, the term septic abortion is used
56. Threatened Abortion
The diagnosis of threatened abortion is presumed when
bloody vaginal discharge or blood exits through a closed
internal cervical os during the first 20 weeks of gestation.
In early pregnancy,bleeding is common and includes that
with blastocyst implantation at the time of expected
menses.
Approximately one fourth of pregnant women
experiences first-trimester spotting or bleeding.
Of these, 43 percent will subsequently miscarry.
Bleeding is by far the most predictive risk factor for
pregnancy loss, but this risk is substantially less if fetal
cardiac activity is seen sonographically
57. However, the combination of bleeding and
uterine cramping predicts a poor prognosis for
pregnancy continuation.
Even if miscarriage does not follow early
bleeding, the risks for later adverse pregnancy
outcomes are elevated.
In a study of almost 1.8 million pregnancies,
the risk for many of these pregnancy
complications rose threefold.
58.
59. modest association (odds ratio ≤2) between first trimester
bleeding and various adverse outcomes (eg, miscarriage,
preterm birth, premature rupture of membranes, growth
restriction, antepartum bleeding) later in pregnancy .
The prognosis is worse when the bleeding is heavy or
extends into the second trimester .
As an example, in one large prospective series, the
frequency of preterm delivery with no, light, or heavy first
trimester bleeding was 6, 9.1 and 13.8 percent,
respectively, and the frequency of spontaneous loss before
24 weeks of gestation was 0.4, 1.0, and 2.0 percent,
respectively .
60. Diagnosis.
In a woman with an early pregnancy, vaginal
bleeding will prompt evaluation.
The primary goal is to diagnose abnormal
pregnancies that include spontaneous
abortion,ectopic pregnancy, or molar pregnancy.
With initial physical evaluation, abdominal
tenderness and its location are sought.
During speculum examination, blood flow from
the cervix is assessed, and a swab or ring forceps
gently probes for internal cervical os integrity..
61. The external os is less informative and is often
slightly dilated in parous women.
Of laboratory tests,hematocrit, blood type, and a
quantitative serum b-hCG level are determined.
Last, TVS can help ascertain if the fetus is alive
and if it is within the uterus.
Repeat evaluations are often necessary as neither
-hCG nor TVS has 1 00-percent accuracy for the
diagnosis of pregnancy location or fetal viability
62. Several predictive models based on serum b-
hCG levels done 48 hours apart have been
described
Of these, serum b-hCG levels with a robust
uterine pregnancy should increase at least 33
to 49 percent every 48 hours depending on
the baseline level.
63. serum b hCG level disappearance in women with a
PUL and bleeding who ultimately went on to have an
early miscarriage.
A serum progesterone level can be added to provide
information,although its sensitivity is poor.
Levels <5 ng/mL suggest a dying pregnancy.
Values >20 ng/mL support the diagnosis of a healthy
pregnancy.
However, progesterone levels often lie between these
thresholds, are then considered indeterminate, and
thus are less informative
64. TVS can document the location and viability of a
gestation.
If this cannot be done, then a PUL is diagnosed.
Notably,a consensus conference in 2012 concluded
that prior sonographic criteria for fetal viability
yielded unacceptably high rates of viable IUPs being
falsely diagnosed as nonviable or as PULs.
Such errors can lead to unnecessary surgical or
medical treatment, interruption of a viable IUP,or
incorrect assumption that a woman is at recurrent risk
for an ectopic pregnancy.
65.
66. Reassuring ultrasound findings
Ultrasound findings of a normal yolk sac and fetal cardiac activity early in
pregnancy are reassuring.
The presence of a yolk sac between 22 and 32 days from in vitro
fertilization (IVF) was associated with the development of fetal heart
motion in 94 percent of pregnancies, and the absence of the yolk sac by
32 days after fertilization was always associated with a poor outcome.
Valvular motion confirms a live pregnancy, but does not eliminate the
possibility of future pregnancy loss.
When embryonic heart motion was detected at 5 to 6 weeks of gestation
in women less than 36 years of age, the risk of subsequent SAb was 4.5
percent; however, the risk of miscarriage despite previous detection of
embryonic heart activity increased to 10 percent in women aged 36 to 39
years and 29 percent in women greater than or equal to 40 years of age .
In women with recurrent pregnancy loss, the risk of spontaneous
pregnancy loss after observation of embryonic heart activity remains high,
about 22 percent
67. One early TVS sign of an IUP is the gestational sac.
This anechoic fluid collection represents the
exocoelomic cavity.
It may be encircled by two echogenic external layers,
the double decidual sign, which represent the decidua
parietalis and decidua capsularis.
the gestational sac can usually be seen by 4.5 weeks
with maternal (b-hCG levels between 1500 and 2000
miU/mL.
threshold value of 3500 miU/mL may be required to
detect a gestational sac in 99 percent of cases(ACOG).
68. Importantly, a gestational sac may appear
similar to other intrauterine fluid
accumulations such as the pseudogestational
sac present with ectopic pregnancy.
A pseudosac may be excluded once a definite
yolk sac or embryo is seen inside the sac.
The diagnosis of an IUP should be made
cautiously if the yolk sac is not yet seen .
69. The yolk sac is a circular, 3- to 5-mm-diameter
anechoic structure.
It is typically seen within the gestational sac
at approximately 5.5 weeks' gestation and
with a mean sac diameter (MSD) > or equal to
10 mm.
At approximately 6 weeks' gestation, a 1 to 2-
mm embryo adjacent to the yolk sac can be
found.
70. Absence of an embryo in a sac with a MSD of
16 to 24 mm is suspicious for pregnancy
failure .
Cardiac motion can be detected at 6 to 6.5
weeks' gestation, at an embryonic length of 1
to 5 mm.
absent cardiac activity at certain stages can
be used to diagnose pregnancy failure.
71. The exact etiology of bleeding often cannot be
determined and is frequently attributed to marginal
separation of the placenta.
The term "threatened" abortion is used to describe
these cases because pregnancy loss does not always
follow vaginal bleeding in early pregnancy, even after
repeated episodes or large amounts of bleeding.
In fact, 90 to 96 percent of pregnancies with both fetal
cardiac activity and vaginal bleeding at 7 to 11 weeks
of gestation will result in an ongoing pregnancy, with
the higher success rate occurring at the later
gestational ages
72. Findings potentially predictive of
pregnancy loss
If any of these ominous findings are noted,
then a repeat ultrasound examination in
about one week is indicated because of the
high likelihood of embryonic/fetal demise.
When more than one ominous finding is
present, the risk of subsequent abortion
increases several-fold
73. Abnormal yolk sac
An abnormal yolk sac may be
large for gestational age
irregular, free floating in the gestational sac rather than at
the periphery, or calcified.
a yolk sac diameter more than two standard
deviations of the mean for the menstrual age had a
sensitivity, specificity, positive predictive value, and
negative predictive value for pregnancy loss of 65, 97,
71, and 95 percent, respectively .
a mean sac diameter of 13 mm without a visible yolk
sac was diagnostic of a nonviable gestation in 100
percent of case
74. Slow fetal heart rate
Embryonic heart rate below 100 beats per minute (bpm)
at 5 to 7 weeks of gestation is slow .
Higher rates of pregnancy loss are associated with lower
embryonic heart rates; survival is zero at heart rates below
70 bpm at 6 to 8 weeks of gestation .
An increased risk of first trimester embryonic demise
persists in embryos with a slow heart rate at 6.0 to 7.0
weeks but normal heart rate at follow-up ultrasound at 8
weeks; one in four of these fetuses were lost .
If slow cardiac activity is observed, it is prudent to perform
a follow-up sonogram (in five to seven days) to document
loss of the cardiac activity before proceeding to dilatation
and curettage.
75. Small sac
Small mean sac size (MSS) is diagnosed when
the difference between the MSS and crown-rump
length (CRL) is less than 5 mm (MSS - CRL < 5).
Other findings suggestive of poor pregnancy
outcome are a
sac with an irregular contour
mean sac diameter growth rate less than 1 mm/day
minimal decidual thickness hypoechogenicity of the
choriodecidual area/absent double decidual sac
low sac position in the uterus
76. Subchorionic hematoma
A subchorionic hematoma is a risk factor for SAb.
A large subchorionic hematoma (ie, comprising
at least 25 percent of the volume of the
gestational sac) is concerning.
There was also an increased risk of placental
abruption (4 versus 1 percent and preterm
premature rupture of membranes.
Increased risks of preterm labor and stillbirth
appeared to be dependent upon the presence of
vaginal bleeding.
77. Pregnancy outcome associated with subchorionic
hematoma appears to depend upon location, with
worse outcomes for retroplacental than marginal
hematomas.
The location, rather than the size, of a subchorionic
hematoma is the most salient characteristic in terms of
pregnancy outcome, in our experience.
Women with retroplacental hematomas are more likely
to have an adverse outcome than those that are
marginal (only the margin of the placenta is separated).
78. The only management option for subchorionic
hematoma is expectant management.
Some clinicians repeat an ultrasound in two
weeks to confirm fetal viability and assess for
change in size of the hematoma.
This is often reassuring to the patient, but does
not alter management.
A subchorionic hematoma is not an indication for
an evaluation for an inherited thrombophilia
79. Management.
With threatened abortion, bed rest is often
recommended but does not improve outcomes.
Neither has treatment with a host of medications and
hormones that include progesterone and chorionic
gonadotropin.
Acetaminophen based analgesia will help relieve
cramping discomfort.
If anemia or hypovolemia is significant from active
bleeding, pregnancy evacuation is generally indicated.
In cases in which there is a live fetus, less often, some
instead may choose transfusion and further
observation.
80. Inevitable Abortion
Amnionic fluid leaking through a dilated cervix
portends almost certain abortion.
Sonography will usually show markedly
diminished fluid volume.
Following such membrane rupture, either
uterine contractions begin promptly or infection
develops.
Rarely is a gush of vaginal fluid during the first
half of pregnancy without serious consequence.
81.
82.
83. In the rare case, fluid may have collected
previously between the amnion and chorion
and may not be associated with pain,fever, or
bleeding.
TVS will typically show normal fluid volume.
If a live fetus and normal fluid volume is
documented, diminished activity with
observation is reasonable.
84. After 48 hours,if no additional amniotic fluid
has escaped and no bleeding,cramping, or
fever is noted, a woman may resume
ambulation.
Initial abstinence from intercourse and
exercise also is recommended.
Instead, with bleeding, cramping, or fever,
abortion is considered inevitable, and the
uterus is evacuated.
85. Incomplete Abortion
With first-trimester losses, death of the
embryo or fetus nearly always precedes
spontaneous expulsion.
Death of the conceptus is usually
accompanied by hemorrhage into the decidua
basalis.
This is followed by adjacent tissue necrosis
that stimulates uterine contractions and
expulsion.
86. An intact gestational sac is generally filled with
fluid and may or may not contain an embryo or
fetus.
With miscarriage, bleeding usually begins first,
and abdominal cramping follows hours to days
later.
Low ,midline rhythmic cramps persistent low
backache with pelvic pressure or dull and midline
suprapubic discomfort are common symptoms
87. Partial or complete placental separation and dilation
of the cervical os is termed incomplete abortion.
The fetus and the placenta may remain entirely within
the uterus or partially extrude through the dilated os.
Before 10 weeks, they are frequently expelled
together, but later in pregnancy, they deliver
separately.
Management options of incomplete abortion include
curettage
medical abortion
expectant management in clinically stable women
88. With surgical therapy, additional cervical dilation
may be necessary before suction curettage is
performed.
In others, retained placental tissue simply lies
loosely within the cervical canal and allows easy
extraction with ring forceps.
The removed products of conception are sent to
pathology for standard histologic analysis.
By this, products of conception are confirmed,
and gestational trophoblastic disease is excluded.
89. When an abortion occurs before 12 weeks of gestation, it is
common for the entire contents of the uterus to be expelled,
thereby resulting in a complete abortion.
Over one third of all cases are complete, rather than incomplete,
abortions.
If a complete abortion has occurred, the uterus is small and well
contracted with a closed cervix, scant vaginal bleeding, and only
mild cramping.
After 12 weeks, the membranes often rupture and the fetus is
passed, but significant amounts of placental tissue may be retained,
leading to an incomplete abortion, also called an abortion with
retained products of conception.
On examination the cervical os is open, gestational tissue may be
observed in the vagina/cervix, and the uterine size is smaller than
expected for gestational age, but not well contracted
90. ultrasonographic diagnosis of an incomplete miscarriage or
retained products of conception is problematic.
Measurement of endometrial thickness and the appearance of the
midline echo have been used to make these diagnoses, but there is
no agreement on the appropriate cut-off for endometrial thickness
(15 mm is commonly used) and no threshold has been proven to be
reliable .
When heterogeneous material is present in the endometrial cavity,
Doppler ultrasound can be helpful in distinguishing between
retained products of conception and blood clot.
If blood flow to retained placental tissue is visualized, then it is
possible to make the diagnosis of retained products of conception.
However, if blood flow is absent, then either devascularized
retained products of conception or blood clot could be present.
91. Complete Abortion
In some cases, expulsion of the entire
pregnancy is completed before a patient
presents for care.
In such cases, a history of heavy bleeding,
cramping, and tissue passage at home is
common.
On pelvic examination, the cervical os is
closed.
92. Patients are encouraged to bring in passed
tissue, which may be a complete gestation, blood
clots, or a decidual cast.
The last is a layer of endometrium in the shape
of the uterine cavity that when sloughed can
appear as a collapsed sac .
If a gestational sac is not identified grossly in the
expelled specimen, sonography is performed to
differentiate a complete abortion from
threatened abortion or ectopic pregnancy
93. With TVS, characteristic intrauterine findings of a complete
abortion include a thickened endometrium without a
gestational sac.
However, this does not guarantee a recent IUP.
152 women with heavy bleeding, an empty uterus with
endometrial thickness < 15 mm, and a diagnosis of
completed miscarriage.
Of these, 6 percent were subsequently found to have an
ectopic pregnancy.
Thus, a diagnosis of complete abortion should not be made
unless an intrauterine pregnancy was previously diagnosed
sonographically or passage of a gestational sac has been
confirmed.
94. In unclear settings, serial serum 13-hCG
measurements aid clarification.
With complete abortion, these levels drop
quickly
mean serum decline of 70 percent after 2
days and a minimum decline of 36 percent.
After 4 days, these values were 91 percent
and 64 percent respectively.
95. Missed Abortion-Early Pregnancy Loss
The term missed abortion requires clarification.
Historically, the term was used to describe dead
products of conception that were retained for
weeks or months in a uterus with a closed
cervical os.
Despite this, concurrent early pregnancy findings
of amenorrhea, nausea and vomiting, breast
changes, and uterine growth appeared normal.
aborted fetuses and observed that the mean
interval from death to abortion was
approximately 6 weeks.
96. This historical description of missed abortion is in
contrast to that defined currently based on results of
serial serum 13-hCG assays and TVS.
With these tools, fetal or embryonic death is
confirmed relatively rapidly even in early pregnancies.
Although many classify this as a missed abortion, the
term is used interchangeably with early pregnancy loss.
Management options include dilation and curettage,
medical abortion, or expectant management
97. Septic Abortion
Horrific infections and maternal deaths
associated with septic abortions have become
rare with legalized abortion.
With current abortion practices, rates are < 1
percent.
That said, elective abortion, either surgical or
medical, is occasionally complicated by severe
and even fatal infections.
98. Bacteria gain uterine entry and colonize dead
conception products.
Organism may invade myometrial tissues and
extend to cause parametritis, peritonitis,
septicemia And rarely, endocarditis .
99. Infections are usually polymicrobial.
But significant necrotizing infections and toxic
shock syndrome can be caused by group A
streptococcus-S pyogenes.
In addition,rare but severe infections with
otherwise low-virulence organisms have
complicated medical abortions.
These include deaths from toxic shock
syndrome due to Closteridium perifrings.
100. Similar infections caused by Closteridium Sordele
and novyi have clinical manifestations that begin
within a few days after an abortion.
Women may be afebrile when first seen with
prominent endothelial injury, capillary leakage.
hemoconcentration, hypotension,and a profound
leukocytosis.
Maternal deaths from these clostridial species
approximate 0.58 per 100,000 medical abortions
101. Infection is usually due to Staphylococcus
aureus, Gram negative bacilli, or some Gram
positive cocci.
Mixed infections, anaerobic organisms, and
fungi, can also be encountered.
The infection may spread, leading to
salpingitis, generalized peritonitis, and
septicemia.
Most spontaneous abortions are not septic.
102. Septic abortion is, however, a common complication
of illegally performed induced abortion.
Infrequently, septic abortion is related to foreign
bodies (eg, intrauterine contraceptive device,
laminaria), invasive procedures (eg, amniocentesis,
chorionic villus sampling), maternal bacteremia, or
incomplete spontaneous or legally induced abortion.
Septic deaths related to Clostridium sordellii have been
reported after medical termination of early pregnancy
103. Treatment of infected abortion or postabortal
sepsis includes prompt administration of broad-
spectrum antibiotics.
For women with septic incomplete abortion or
for those with retained fragments, intravenous
antimicrobial therapy is promptly followed by
uterine evacuation.
Most women respond to this treatment within 1
to 2 days and are discharged when afebrile.
104. Continued outpatient oral antibiotic treatment is
likely unnecessary .
Rarely, sepsis causes acute respiratory distress
syndrome,acute kidney injury, or disseminated
intravascular coagulopathy.
In these cases, intensive supportive care is essential.
To prevent postabortal sepsis, prophylactic antibiotics
are given at the time of surgical evacuation of
incomplete or induced abortion.
Guidelines recommend doxycycline as a sole 200-mg
oral preoperative dose (ACOG).
105. Management
Unless there is serious bleeding or
infection, management of spontaneous
abortion can be individualized.
Any of three management options is
reasonable
Expectant
Medical
surgical.
Each has its own risks and benefit.
106. For example, the first two are associated with
unpredictable bleeding, and some women will require
unscheduled curettage.
Neverthless,expectant management for suspected
first.-trimester miscarriage results in spontaneous
resolution of pregnancy in more than 80 percent of
women.
Whereas surgical treatment is definitive and
predictable, it is invasive and not necessary for all
women.
If anemia or hypovolemia is significant pregnancy
evacuation is generally indicated.
107. First success is dependent on the type of early
pregnancy loss, that is, incomplete versus missed
abortion.
Second, expectant management of spontaneous
incomplete abortion has failure rates as high as 50
percent.
Curettage results in a quick resolution that is 95- to
100-percent successful.
Last, medical therapy failure rates with prostaglandin E
1 (PGE1) may be related to dose, route , and form-
tablet, gel, dissolved- and rates vary from 5 to 40
percent
108. The addition of mifepristone and laminaria
appear to improve efficacy of PGE1.
Importantly, subsequent pregnancy rates do not
differ among these management methods.
As a single agent for medical management, a
common standard is misoprostol, given 800 lug
vaginally as a single dose(ACOG).
The dose may be repeated in 1 to 2 days.
If mifepristone is selected for pretreatment to
misoprostol, an oral dose of200 mg is given prior
to the misoprostol800-ug vaginal dose.
109. During spontaneous miscarriage, 2 percent of D-
negative women will become isoimmunized if not
provided passive isoimmunization.
With an induced abortion, this rate may reach 5
percent.
ACOG recommends anti-Rh (D)immunoglobulin
given as 300 ug intramuscularly (IM) for all
gestational ages.
Alternatively, some give 50 ug IM for pregnancies
< or equal to 12 weeks and 300 ug for>or equal to
13 weeks.
110. With a threatened abortion, immunoglobulin
prophylaxis is controversial, and
recommendations are limited by scarce evidence-
based data
Up to 12 weeks ' gestation, prophylaxis is
optional for women with threatened abortion
and a live fetus.
At Parkland Hospital, we administer a 50-ug dose
to all D-negative women with first trimester
bleeding.
111.
112. The use of progestins to reduce the risk of miscarriage
among women with threatened abortion is
controversial.
Progestins were administered either orally or vaginally,
and subgroup analysis found a significant decrease in
the rate of abortion only for oral progestins; the
analysis of vaginal progestins lacked sufficient
statistical power to detect a difference.
There was no significant increase in congenital
anomalies or pregnancy-induced hypertension in the
progestin group.
113. Abstinence from sexual intercourse is also
typically advised, although there are no data
to support this.
Bed rest is commonly recommended, but
randomized trials have not found that bed rest
at home or in the hospital is beneficial in
preventing fetal loss
114. SEPTIC ABORTION
Suspected septic abortion with retained products of conception
should be managed by:
Stabilizing the patient
Obtaining blood and endometrial cultures
Promptly administering parenteral broad spectrum antibiotics
(eg, clindamycin 900 mg every eight hours
and gentamicin 5 mg/kg daily with or without ampicillin 2 g every four
hours
ampicillin and gentamicin and metronidazole 500 mg every eight
hours
levofloxacin 500 mg daily and metronidazole; or single agents such
as ticarcillin-clavulanate 3.1 g every four hours, piperacillin-
tazobactam 4.5 g every six hours, or imipenem 500 mg every six hours)
115. Intravenous antibiotics are administered until the
patient has improved and been afebrile for 48
hours, then are typically followed by oral
antibiotics to complete a 10- to 14-day course.
The need to complete a full course with oral
antibiotics after clinical improvement has been
questioned, based upon data from a randomized
trial that found no difference in women who
received only a short course of intravenous
therapy .
116. Evacuation of the uterus should begin promptly after initiating antibiotics and
stabilizing the patient in cases of suspected septic abortion or retained products of
conception as delay in evacuation may be fatal .
Suction curettage is less traumatic than sharp curettage.
Indications for surgery and possible hysterectomy include
failure to respond to
uterine evacuation antibiotics
pelvic abscess
clostridial necrotizing myonecrosis (gas gangrene).
A discolored, woody appearance of the uterus and adnexa, suspected clostridial
sepsis, crepitation of the pelvic tissue, and radiographic evidence of air within
the uterine wall are indications for total hysterectomy and adnexectomy.
Surgery, if indicated, may be performed by laparoscopy.
On the other hand, mild endometritis (low grade fever, mild uterine tenderness,
empty uterus on ultrasound examination) after a complete spontaneous abortion
can be managed with oral broad spectrum antibiotics.
117. A complete abortion theoretically should not require
therapy, but complete abortions generally cannot be
reliably distinguished from incomplete abortions either
clinically or ultrasonographically.
As a result, some providers perform suction curettage in all
of these patients
surgical, medical, and expectant management of women
with first trimester missed or incomplete abortion generally
concluded that all of the therapies were effective
but complete evacuation within 48 hours was more likely
with surgical than medical management and more likely
with medical than expectant management
118. Surgical management
The conventional treatment of first or early second trimester failed
pregnancy is dilatation and curettage (D&C) or dilatation and
evacuation (D&E) to prevent potential hemorrhagic and infectious
complications from the retained products of conception.
This procedure carries anesthesia risks and complications such as
uterine perforation, intrauterine adhesions, cervical trauma, and
infection, which might lead to subsequent infertility or ectopic
pregnancy.
The risks, however, are small and uterine evacuation can be
performed safely and effectively as an office procedure
Surgical management is appropriate for women who do not want
to wait for spontaneous or medically induced evacuation of the
uterus and those with heavy bleeding or intrauterine sepsis in
whom delaying therapy could be harmful.
119. Suction curettage is preferable to sharp curettage, which is
associated with greater morbidity.
We recommend doxycycline (100 mg orally for two doses 12 hours
apart on the day of the surgical procedure) to reduce the risk of
postabortal sepsis.
This recommendation is based on a meta-analysis that found
women given periabortal antibiotics had a 42 percent lower risk of
infection .
These trials involved women undergoing induced abortion, but it is
likely similar benefits would be observed for women undergoing
surgical evacuation of a failed pregnancy.
However, the only randomized trial that evaluated antibiotic
prophylaxis before curettage for incomplete abortion did not
observe a significant decrease in febrile morbidity
120. Medical treatment
The availability of effective medical therapies for inducing abortion has
created new options for women who want to avoid surgery and in areas
where surgical intervention is not practical.
Misoprostol (a prostaglandin E1 analog) is the most commonly used such
agent.
The advantages of misoprostol over other drugs (including prostaglandin
E2) are its low cost , low incidence of side effects when given
intravaginally, stability at room temperature, and ready availability.
In medically managed patients, complete expulsion occurred in 71
percent by day three and 84 percent by day eight.
Pregnancy duration did not affect the rate of successful expulsion, but
successful expulsion was lower with missed abortion compared with
incomplete or inevitable abortion (81 versus 93 percent).
Both medical and surgical therapies were safe, effective, and acceptable
to patients.
121. The efficacy of medical treatment with prostaglandins
depends upon both the dose and route of
administration, but there is no consensus on the
optimal choice for either.
A single oral dose of 400 mcg misoprostol resulted in a
low rate (13 percent) of expulsion , whereas the same
dose given multiple times resulted in an expulsion rate
of 50 to 70 percent .
The expulsion rate was even higher with a dose of 600
to 800 mcg given vaginally (70 to 90 percent).
122. This may be due to the local effect of misoprostol on
the uterine cervix, the high drug concentration
achieved in uterine tissue, and the increased
bioavailability with vaginal administration.
Buccal administration appears to be as effective as
vaginal administration, but is associated with more
side effects, probably related to differences in
pharmacokinetics for the two routes of administration.
women treated with misoprostol experienced
significantly longer duration of bleeding and greater fall
in hemoglobin than those who underwent curettage.
123. dose and route and frequency
For missed abortion – 800 mcg per vaginam OR 600 mcg
sublingually (each of these is a single dose)
For incomplete abortion – 600 mcg orally (single dose)
Our preference is to use misoprostol 400 mcg per vaginam every
four hours for four doses to take advantage of the increased
effectiveness of the vaginal route while minimizing the risk of side
effects, which are dose and route dependent.
The expulsion rate is 70 to 90 percent within 24 hours; thus, some
women will still require surgical evacuation.
However, the immediate, short-term, and medium-term medical
complications associated with misoprostol use are significantly
lower than with surgery
A combination of a progesterone antagonist ( mifepristone )
and misoprostol (400 mcg orally) has also been used .
124. Due to low serum progesterone levels in
women with abnormal pregnancy , the value of
adding a progesterone antagonist is
questionable and expensive.
misoprostol alone or a combination of
misoprostol and mifepristone had similar success
rates in treatment of early pregnancy failure
Patients who are treated medically are instructed
to go to the emergency department if they
develop excessive bleeding.
125. Tissues that are passed vaginally should be
placed in a container and brought to the
hospital for analysis.
The long-term conception rate and
pregnancy outcome are similar for women
who undergo medical or surgical evacuation
for early pregnancy failure.
Methotrexate is not used in management of
spontaneous abortion.
126. second trimester abortion over 16 weeks is
completed with misoprostol in the hospital
setting and surgical evacuation is reserved for
retained products of conception.
However, clinicians proficient in mid-
trimester surgical pregnancy termination may
offer patients surgical evacuation.
127. Expectant management
Expectant management (EM) is an alternative
for women with early pregnancy failure at less
than 13 weeks of gestation who have stable vital
signs and no evidence of infection.
EM was associated with a higher risk of
incomplete miscarriage, need for unplanned
surgical emptying of the uterus, and bleeding, but
was not an unreasonable approach if the woman
preferred nonintervention.
medical management to EM have reported
similar rates of successful evacuation.
128. Discrepancies in success rates relate to the duration of EM, the
medical treatment regimen, the negative value placed on various
maternal morbidities, and whether the subjects had asymptomatic
early pregnancy failure or incomplete miscarriage.
The majority of expulsions occur in the first two weeks after
diagnosis; however, some women may require prolonged follow-up
Incomplete miscarriage is more likely to proceed to expulsion
within two weeks than a missed abortion.
An interval of three to four weeks between diagnosis of nonviable
pregnancy and expulsion is not unusual.
Most women are willing to wait when appropriately counseled
[ 55 ] and prepared for what to expect
129. If spontaneous expulsion does not occur, medical
or surgical treatment can be administered.
Following spontaneous or medically induced
expulsion, some providers perform an ultrasound
examination routinely to evaluate the uterine
cavity, others perform this examination
selectively in patients whose clinical examination
is suggestive of retained products of conception.
There are no universally defined criteria for an
empty uterus.
130. One option is to proceed with surgical evacuation if
retained tissue with a diameter of more than 15 mm
is found
Others use a homogeneous intrauterine dimension
less than 11 cm2 in combined transverse and sagittal
planes to define an empty uterus.
If the ultrasound reveals retained tissue and the
patient is asymptomatic or having only minimal
bleeding, we offer the patient surgical evacuation of
the uterus or expectant management for another two
weeks.
131. Successful spontaneous abortion occurred in
81 percent of all expectantly managed patients
91 percent of those with incomplete miscarriages
76 percent of those with missed abortions, and 66 percent of
those with anembryonic pregnancies.
Complications, such as infection and excessive pain or
bleeding, occurred in 1 percent of expectantly and 2
percent of surgically managed patients.
Thus, EM for one month appears to be a safe and effective
alternative to immediate surgical evacuation. In addition,
sonographic classification of the miscarriage at
presentation appears predictive of successful outcome
without surgical intervention.
132. POSTABORTION CARE AND
COUNSELING
Women are advised to maintain pelvic rest (ie,
nothing per vagina) until two weeks after evacuation or
passage of the products of conception, at which time
coitus and use of tampons may be resumed.
It is customary to advise that pregnancy be deferred
for two to three months, although several studies have
shown no greater risk of adverse outcome with a
shorter interpregnancy interval.
Any type of contraception, including placement of
intrauterine contraception , may be started
immediately after the abortion has been completed.
133. Light vaginal bleeding can persist for a couple of weeks
after the abortion.
Patients should call their provider if heavy bleeding, fever,
or abdominal pain develops.
Menses typically resume within six weeks; if normal
menses do not resume, then the presence of a new
pregnancy or, rarely, gestational trophoblastic disease
should be considered.
Although rare, intrauterine adhesions (also known as
Asherman's syndrome) could occur after surgical
evacuation of the uterus.
In the severe form, menses do not resume or are scanty.
134. Women who are Rh(D)-negative and unsensitized
should receive Rh(D)-immune globulin following
surgical evacuation or upon diagnosis if medical
management or EM is planned.
A dose of 50 mcg is effective through the 12th week
of gestation due to the small volume of red cells in the
fetoplacental circulation (mean red cell volume at 8
and 12 weeks is 0.33 mL and 1.5 mL, respectively),
although there is no harm in giving the standard 300
microgram dose, which is more readily available.
135. Resolution of positive hCG
Serum hCG values typically return to normal within
two to four weeks after a completed abortion.
Follow-up hCG testing is unnecessary if normal
menstrual cycles resume.
Grief counseling
Grief counseling is appropriate.
It is important to acknowledge the patient's (and
partner's) grief and provide empathy and support.
Risk factors for abnormal grief following a miscarriage
include
136. A history of or current depression, anxiety, or
other psychiatric disorder
Neurotic personality traits
Lack of social support
137. If the etiology of the loss is known or suspected,
the couple should be informed and counseled
about recurrence risks.
If reversible risk factors for spontaneous abortion
are present, these can be addressed, as
appropriate, in a nonjudgmental way.
When an etiology cannot be determined, it is
important to reassure the woman that there is no
evidence that something she might have done (eg,
sexual intercourse, heavy lifting, bumping her
abdomen, stress) caused the miscarriage.
138. FUTURE REPRODUCTIVE ISSUES
The overall risk of miscarriage in future
pregnancy is approximately 20 percent after
one miscarriage, 28 percent after two
miscarriages, and 43 percent after three or
more miscarriages .
There also appears to be an increased risk of
preterm delivery in subsequent pregnancies .
The risk increases with increasing number of
miscarriages
139. Second trimester pregnancy loss is significantly
associated with recurrent second-trimester loss and
future spontaneous preterm birth.
After a second trimester pregnancy loss, one study
reported 39 percent of women had a preterm delivery
in their next pregnancy, 5 percent had a stillbirth, and 6
percent had a neonatal death.
In another study of 30 women with second trimester
loss, the frequency of recurrent second trimester loss
was 27 percent and the frequency of subsequent
preterm birth was 33 percent
