Patient will present as → a 35-year-old G3P2 with cervical dilatation >3 cm, ruptured membranes, bleeding >7 days, and the presence of cramping (inevitable abortion)
Fetal death and early delivery are classified as follows:
- Abortion: Death of the fetus or passage of products of conception (fetus and placenta) before 20 weeks gestation
- Fetal demise (stillbirth): Fetal death after 20 weeks
- Preterm delivery: Passage of a live fetus between 20 weeks and 36 weeks/6 days
Abortions are classified as follows:
- Early or late
- Spontaneous or induced for therapeutic or elective reasons
- Spontaneous abortion is further classified based on history and physical exam findings
Classification of abortion | |
Early | Abortion before 12 weeks gestation |
Late | Abortion between 12 and 20 weeks gestation |
Spontaneous | Noninduced abortion |
Induced | Termination of pregnancy for medical or elective reasons |
Therapeutic | Termination of pregnancy because the woman’s life or health is endangered or because the fetus is dead or has malformations incompatible with life |
Threatened | Vaginal bleeding occurring before 20 weeks gestation without cervical dilation and indicating that spontaneous abortion may occur |
Inevitable | Vaginal bleeding or rupture of the membranes accompanied by dilation of the cervix |
Incomplete | Expulsion of some products of conception |
Complete | Expulsion of all products of conception |
Recurrent or habitual | ≥ 2 to 3 consecutive spontaneous abortions |
Missed | Undetected death of the fetus before 20 weeks of gestation, with products of conception remaining intrauterine |
Septic | Serious infection of the uterine contents during or shortly before or after an abortion |
Recurrent, spontaneous abortions: 2-3 or more consecutive spontaneous abortions
- Genetic testing of parents
- Thyroid (hypo and hyper)
- Autoimmune (SLE and anticardiolipin antibodies)
Spontaneous abortion:
- More than 80 percent of spontaneous abortions occur in the first 12 weeks
- Sixty percent of abortions are due to chromosomal abnormalities with the next largest category is unknown
- Increased risk with:
- Parity: the more often you are pregnant the more likely you are to have an abortion
- Increased risk of maternal (35 +) and paternal age (45 +)
- Women who conceive within 3 months of a term birth
- Cigarette smoking
- Use of certain drugs (cocaine, alcohol)
- A poorly controlled chronic disorder (e.g., diabetes, hypertension, overt thyroid disorders) in the mother
Diagnose by ↓ βHG and classification based on ultrasound findings
- Transvaginal ultrasonography is the cornerstone of the evaluation of bleeding in early pregnancy
- The US demonstrates inappropriate development or interval growth, poorly formed/unformed fetal pole, fetal demise
- The βHG should double every 48 hours in a viable intrauterine pregnancy
- Blood type and Rh status necessary tests to preclude Rh sensitization in the mother
Classification of spontaneous abortion | |||
Type | Vaginal Bleeding | Cervix Open | POC passed |
Threatened | Yes | No | No |
Inevitable | Yes | Yes | No |
Incomplete | Yes | Yes | Partial |
Complete | Yes | Yes | Yes |
Missed | No | No | No |
Traditionally managed by D&C only, monitor progress with B-HCG levels or ultrasound examination
- Comprehensive management of early pregnancy loss includes addressing the emotions of women and their partners, inquiring about future plans for pregnancy, and offering contraceptive or preconception planning as appropriate
Elective abortion:
- Medical abortion: Mifepristone and Misoprostol up to first 7-9 weeks LMP
- Suction Curettage: safest and most effective for 12 weeks or less. Surgical procedure 3-12 weeks LMP. local anesthesia on the cervix
- Surgical Curettage (D&C) Aspiration: a surgical abortion up to 16 weeks LMP
- Dilation and Evacuation (D&E) up to 18 weeks outpatient
- Induction of labor with intraamniotic installation after 16 weeks
- Induction of labor with vaginal prostaglandins after 16 weeks
Spontaneous abortion is defined as loss of pregnancy before 20 weeks gestation. Excessive bleeding before 20 weeks gestation in a pregnant women may indicate a nonviable fetus. Types of spontaneous abortion include threatened, inevitable, incomplete, complete, and missed. Identifying the type of spontaneous abortion is critical for determining subsequent treatment. Interventions include promoting bed rest and providing emotional support. Since fluid imbalance may occur in spontaneous abortion, monitoring for hemorrhage includes saving the patient’s pads and linens. The administration of RhoGAM may be necessary for Rh- women exposed to R+ blood of nonviable fetuses. Dilation & curettage and cerclage may be done to remove fetal tissue from inside the uterus.
Spontaneous abortion types | Play Video + Quiz |
Spontaneous abortion overview | Play Video + Quiz |
Question 1 |
uterine intramural myomata | |
progesterone deficiency elevated serum beta HCG | |
tobacco use | |
controlled diabetes |
Question 2 |
come to your office first thing in the morning for an evaluation | |
take some ibuprofen and see you at her next scheduled prenatal visit | |
rush to the emergency department because of suspected ectopic pregnancy | |
rush to the emergency department for an immediate dilation and curettage (D& C) | |
call an obstetrician-gynecologist to schedule an outpatient consultation |
Question 3 |
missed abortion | |
recurrent spontaneous abortion | |
complete abortion | |
incomplete abortion | |
inevitable abortion |
Question 4 |
expectant management | |
uterine aspiration | |
medical management with vaginal misoprostol | |
exploratory laparoscopy | |
serial β-human chorionic gonadotropin (β-hCG) measurements |
Question 5 |
Threatened abortion Hint: Threatened abortion is characterized by bleeding in the first trimester without loss of fluid or tissue. | |
Inevitable abortion | |
Incomplete abortion Hint: Complete abortion refers to a documented pregnancy that spontaneously passes all of the products of conception. | |
Incomplete abortion Hint: Incomplete abortion is when the cervical os is open and allows passage of blood. The products of conception may remain in utero or may partially extrude through the open os. |
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