Complete Abortion 2

TREATMENT
Medical Care: A complete abortion usually needs no further treatment, medically or surgically.
In the situation in which a considerable amount of blood loss has occurred, iron therapy or transfusions may be indicated.
If the diagnosis in not correct, the patient is likely to continue to bleed and cramp for an incomplete or inevitable abortion. In these situations, a suction D&C is indicated. If the patient has any signs of infection, start antibiotics prior to the D&C.
An ectopic pregnancy may be treated medically or surgically, depending on the clinical scenario.
Medical therapy consists of methotrexate, which usually is administered in a dose of 50 mg/m2. The effectiveness of medical therapy depends on only applying it to patients who are appropriate candidates based on gestational age, hCG level, ectopic size, patient reliability, proximity to the office or hospital, and health.
Prior to administering the methotrexate, renal and liver function tests are measured and results should be normal. A CBC is warranted, and, if significant anemia exists, then medical therapy is not warranted.
The absolute limits for gestational age, hCG level, ectopic size, and the presence or absence of an embryonic heartbeat are debated in the literature. Despite the debate, the factors that decrease the likelihood of success are older gestational age, higher hCG, larger ectopic size, and the presence of a fetal heartbeat.
The author likes to use a rule of 3s because it is easy to remember. A patient who is less than 3 weeks from expected menses (7 wk from last menstrual period [LMP]), has an hCG level less than 3000 mIU/mL, and has an ectopic size less than 3 cm has a 95% chance of success with methotrexate.
On the day of injection and on days 4 and 7 after the injection, the hCG level is monitored. A 15% drop in the hCG level is expected between day 4 and day 7. From day 1 to day 4, a rise in the hCG level may occur. If a 15% drop in the hCG level occurs on day 7, then the patient is monitored with weekly hCG levels until the level is less than 5 mIU/mL.
Patients may have some cramping or discomfort on the side of the ectopic pregnancy as the hCG declines, but these symptoms should be mild. Typically, patients do not experience bleeding until the hCG level is low.
The authors encourage increased fluid intake to avoid some of the adverse effects of methotrexate. However, this dose of methotrexate is much smaller than that used to treat trophoblastic disease, and most patients have very little problem with taking it.
After methotrexate therapy for an ectopic pregnancy, any plateau or rising of hCG requires evaluation. In some situations, considering a second dose of methotrexate is possible. However, consider surgery as well.
Any symptoms suggesting ectopic rupture (eg, acute pain, rebound tenderness) should immediately direct the physician to the operating room.
Laparoscopy can still be considered if the patient is stable.
A linear salpingostomy with excision of the ectopic pregnancy or partial salpingectomy are the possible procedures.
If the patient is unstable, the same procedures are performed using a laparotomy.
For a complete abortion, the medical care is to treat any remaining anemia and to evaluate the blood type and treat the patient with RhoGAM when indicated.
Prehospital care: Monitor vital signs and provide fluid resuscitation if the patient is hemodynamically stable.
Emergency department care: If they know what to expect, most patients with complete abortions are not treated in the emergency department. Only those with significant blood loss go to the emergency department.
Patients with threatened, inevitable, incomplete, and ectopic pregnancies may go to the emergency department.
Patients with threatened abortions need an ultrasound to confirm the diagnosis and for reassurance. Usually, no other medical therapy is needed. These patients often are counseled to increase fluid intake, remain at bedrest, or add progesterone supplements. However, none of these treatments has been proven effective in a prospective randomized trial.
Abortion, Inevitable, Abortion, Incomplete, and Ectopic Pregnancy are discussed above and in separate articles.
Surgical Care: No surgical care is used for complete abortion.
Inevitable and incomplete abortions require a D&C.
A septic abortion requires antibiotic therapy prior to a D&C. An ectopic pregnancy only is treated medically for the appropriate candidates. The rest require surgery, consisting of linear salpingostomy or partial or complete salpingectomy via laparoscopy or laparotomy.
Consultations: Consult an obstetrician-gynecologist any time uncertainty about the diagnosis exists and to administer treatment.
Diet:
The patient's diet should be regular if the diagnosis truly is a complete abortion.
If any uncertainty about the diagnosis exists, keep the patient nothing by mouth (NPO) until certain that a surgical treatment is not necessary.
Activity: The patient should rest for a few days to 2 weeks for a complete abortion. The rest schedule needs to be adjusted if one of the other diagnoses is correct.

MEDICATION
For a complete abortion, no medication is likely to be needed. Usually, the uterus contracts well after expelling the entire contents and the cervix is closed. The risk for infection is minimal.
Drug Category: Immune globulins –
Used to suppress the immune system when the mother is Rh negative.
Drug Name
Rho (D) immune globulin (RhoGAM) -- Suppresses immune response of mother who is nonsensitized Rh O (D) negative exposed to Rh O (D) positive blood from the fetus as a result of a fetomaternal hemorrhage, abdominal trauma, amniocentesis, abortion, full-term delivery, or transfusion accident.
Adult Dose
<13>13 weeks' gestation: 300 mcg IM
Pediatric Dose
Administer as in adults
Contraindications
Documented hypersensitivity; patients who have received Rho (D)–positive blood within the last 3 mo
Interactions
None reported
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in thrombocytopenia, bleeding disorders, or IgA deficiency
Drug Category: Abortifacients –
Occasionally, the uterus does not contract well, and a clot may form in the uterine cavity. If the physician notes a boggy uterus after expulsion of the products of conception, the physician may consider methylergonovine in the appropriate candidate. In most cases in which a clot forms within the uterus, a surgical D&C finally is warranted.
Drug Name
Methylergonovine (Methergine) -- Acts directly on uterine smooth muscle, causing a sustained tetanic uterotonic effect that reduces uterine bleeding and shortens the third stage of labor.Administer IM during puerperium, delivery of placenta, or after delivering anterior shoulder. Also may be administered IV over no less than 60 sec, but should not be administered routinely because it may provoke hypertension or a stroke. Monitor blood pressure closely when administering IV.
Adult Dose
0.2 mg IM tid for 3 d
Pediatric Dose
Not established
Contraindications
Documented hypersensitivity; glaucoma; Tourette syndrome; anxiety
Interactions
Concurrent administration of methylergonovine with vasoconstrictors or other ergot alkaloids may produce additive effect
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in sepsis, obliterative vascular disease, or hepatic or renal insufficiency
Drug Name
Methotrexate (Rheumatrex) -- Antimetabolite that inhibits dihydrofolate reductase, thereby hindering DNA synthesis and embryonic cell reproduction.
Adult Dose
50 mg/m2 IM once
Pediatric Dose
Not established
Contraindications
Documented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia); renal insufficiency
Interactions
Oral aminoglycosides may decrease absorption and blood levels of concurrent oral methotrexate (MTX); charcoal lowers MTX levels; coadministration with etretinate may increase hepatotoxicity of MTX; folic acid or its derivatives contained in some vitamins may decrease response to MTX; probenecid, NSAIDs, salicylates, procarbazine, and sulfonamides (including TMP-SMZ) can increase MTX plasma levels; may decrease phenytoin plasma levels; may increase plasma levels of thiopurines
Pregnancy
D - Unsafe in pregnancy
Precautions
Has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; fatal reactions reported when administered concurrently with NSAIDs

FOLLOW-UP
Further Inpatient Care:
The follow-up should include monitoring hCG levels until they are less than 5 mIU/mL.
Further Outpatient Care:
With a complete abortion, measure the hCG level weekly until it is less than 5 mIU/mL in situations in which the products of conception were not evaluated by a physician (eg, the products were flushed down the toilet).
If the expelled products of conception are evaluated by a physician and confirmed to be intact and truly products of conception (not a clot), performing any further follow-up tests is not necessary.
Providing reassurance and routine gynecologic care is recommended.
Deterrence/Prevention:
Contraceptive counseling is warranted. Patients should avoid intercourse or use contraception until the hCG levels have become negative. Patients may wish to continue contraception until they are emotionally ready to try again to become pregnant.
Complications:
Complete abortions may be complicated by infection or accumulation of clot in the uterine cavity without expulsion due to uterine atony. Both of these complications are rare.
Occasionally, a decidual cast is passed and is mistaken for products of conception. In these cases, an ectopic pregnancy is likely.
Prognosis:
The prognosis is excellent. After one complete abortion, no increased risk exists for another one. Patients need reassurance. Tender loving care is proven effective therapy in one randomized recurrent pregnancy loss trial.
Patient Education:
The patient needs to hear that one miscarriage does not put her at increased risk for another miscarriage. Her next pregnancy is likely to last to term if she is young and has no other risk factors.
Advise the patient to return to the emergency department if any of the following symptoms occur:
Profuse vaginal bleeding
Severe pelvic pain
Temperature greater than 100°F
Patients may experience intermittent menstrual-like flow and cramps during the following week. The next menstrual period usually occurs in 4-5 weeks.
Patients may resume regular activities when able, but they should refrain from intercourse and douching for approximately 2 weeks.
MISCELLANEOUS
Medical/Legal Pitfalls:
Failure to diagnose correctly may occur in this situation. A presumed completed abortion may be an ectopic pregnancy with passage of clot where the clot was thought to be tissue. Missing an ectopic pregnancy can be a life-threatening situation. Be careful. If uncertainty exists regarding whether the passed tissue is tissue or a clot, have a pathologist evaluate it prior to sending the patient out.
If a suction D&C is performed, then a known complication in a small percentage of cases is Asherman syndrome or intrauterine synechiae. This situation may cause amenorrhea, infertility, or miscarriage in these patients in the future. Be gentle with the curettage, and, if there is difficulty, ultrasound guidance may be helpful. Do not forget that bleeding may be occurring due to DIC, which will not respond to a D&C but needs the missing factors replaced.
Perforation of the uterus may occur if a suction D&C is performed. Pregnant uteri are softer than the unpregnant state, and it is easier to perforate. Uterine perforation may occlude itself naturally because the uterus is a muscle that can undergo contraction and place its own pressure on the site until the bleeding stops. However, uncontrolled internal bleeding from a uterine perforation may require additional surgery, either a laparoscopy or laparotomy to control the bleeding. Occasionally, a hysterectomy may be the last resort to control the bleeding, which would eliminate the patient's ability to conceive in the future. Unrecognized uterine perforations may lead to significant internal bleeding that could be a life threat. Observe patients closely after a D&C and listen when patients complain of unusual symptoms (eg, shoulder pain, unexpectedly significant abdominal pain).
Misdiagnosis of an early intrauterine pregnancy for an ectopic pregnancy and administering methotrexate inappropriately may occur if the physician is not familiar with the laboratory and ultrasound department's discriminatory zone. Thinking about the patient's history and physical examination, differential diagnosis (including multiple gestation), the accuracy of the gestational age, the hCG level (and pattern of hCG levels if checked every 2 d), and ultrasound findings is very important in order to make an appropriate diagnosis. This is an area of rapidly growing malpractice in obstetrics and gynecology.