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Spontaneous Abortion

Abortion is defined as termination of pregnancy resulting in expulsion of an immature, nonviable fetus. A fetus of <20 weeks gestation or a fetus weighing <500 gm is considered an abortus. Spontaneous abortion occurs in 15% of pregnancies.

Threatened abortion is defined as vaginal bleeding occurring in the first 20 weeks of pregnancy, without the passage of tissue or rupture.

Symptoms of pregnancy (nausea, vomiting, fatigue, breast tenderness, urinary frequency) are usually present. Speculum exam reveals blood coming from the cervical os without amniotic fluid or tissue in the endocervical canal. The internal cervical os is closed, and the uterus is soft and enlarged appropriate for 

Differential Diagnosis

Spontaneous Abortion

Benign and Malignant Lesions. The cervix often bleeds from an ectropion of friable tissue. Hemostasis can be accomplished by applying pressure for several minutes with a large swab or by cautery with a silver nitrate stick. Atypical cervical lesions are evaluated with colposcopy and biopsy.

Disorders of Pregnancy

Hydatidiform mole may present with bleeding, passage of grape-like vesicles, and a uterus that is enlarged in excess of that expected from dates. An absence of a heart tones by Doppler after 12 weeks is characteristic. Hyperemesis, preeclampsia, or hyperthyroidism may be present. Ultrasonography confirms the diagnosis.

Ectopic pregnancy should be excluded when first trimester bleeding is associated with pelvic pain. Orthostatic light-headed ness, syncope or shoulder pain (from diaphragmatic irritation) may occur.

Treatment of Threatened Abortion. Bed rest with sedation and abstinence from intercourse. The patient should report increased bleeding (>normal menses), cramping, passage of tissue, or fever. Passed tissue should be. partial birth

Inevitable abortion is defined as Spontaneous Abortion, abortion, misscarriage, miss carriage a threatened abortion with a dilated cervical os. Menstrual-like cramps usually occur.

Differential Diagnosis

Incomplete abortion is diagnosed when tissue has passed. Tissue may be visible in the vagina or endocervical canal.

Threatened abortion is diagnosed when the internal os is closed and will not admit a fingertip.

Incompetent cervix is characterized by dilatation of the cervix without cramps.

Treatment of Inevitable Abortion

Surgical evacuation of the uterus is necessary.

D immunoglobulin (RhoGAM) is administered to Rh-negative, unsensitized patients to prevent isoimmunization. Before 13 weeks gestation, the dosage is 50 mcg IM; at 13 weeks gestation, the dosage is 300 mcg IM.

Incomplete abortion is characterized by cramping, bleeding, passage of tissue, and a dilated internal os with tissue present in the vagina or endocervical canal. Profuse bleeding, orthostatic dizziness, syncope, and postural pulse and blood pressure changes may occur.

Rh typing

Blood typing and cress-matching.

Karyotyping of products of conception is completed if loss is recurrent.

Treatment

1. Stabilization. If the patient has signs and symptoms of heavy bleeding, at least 2 large-bore IV catheters (>16 gauge) are placed. Lactate Ringer's or normal saline with 40 U oxytocin/L is given IV at 200 mL/hour or greater.

2. Products of conception are removed from the endocervical canal and uterus with a ring forceps. Immediate removal decreases bleeding. Curettage is performed after vital signs have stabilized.

3. Suction Dilation and Curettage

a. Analgesia consists of meperidine (Demerol), 35-50 mg IV over 3-5 minutes until the patient is drowsy.

b. The patient is placed in the dorsal lithotomy position in stirrups, prepared, draped, and sedated.

c. A weighted speculum is placed intravaginally, the vagina and cervix are cleansed, and a paracervical block is placed.

d. Bimanual examination confirms uterine position and size, and uterine sounding confirms the direction of the endocervical canal.

e. Mechanical dilatation is completed with dilators if necessary. Curettage is performed with an 8 mm suction curette, with a single-tooth tenaculum or a ring forceps on the anterior lip of the cervix.

4. Post-curettage. After curettage, a blood count is ordered. If the vital signs are stable for several hours.