TREATMENT
Medical Care: No effective therapy is available for a threatened intrauterine abortion.
Bed rest, although often advocated, is not effective.
Do not administer progesterone or sedatives. In the majority of instances of threatened abortions that ultimately result in complete abortion, the embryo is already dead; thus, the administration of progesterone drugs is ineffective and only prolongs the natural course of abortion.
Institute appropriate counseling for all patients. A sympathetic attitude and continuing support and follow-up care are important to patients. This includes a tactful explanation about the pathologic process and favorable prognosis when the pregnancy is viable.
Treat any vaginal infections.
Surgical Care: Continued observation is indicated as long as the cervix remains closed, bleeding and cramping are mild, QhCG levels are increasing normally, and a normal embryo/fetus is visualized on follow-up sonogram images. The prognosis worsens with (1) progressively increasing bleeding and cramping, (2) QhCG levels that fall or level off, (3) failure to find sonographic evidence of embryonic/fetal growth, (4) fetal bradycardia, and (5) size smaller than appropriate for dates.
When the pregnancy is confirmed nonviable because the cervical os is dilated or excessive bleeding is present, perform suction curettage. This prevents delayed hemorrhage and infection related to retention of necrotic tissue. It also diminishes the chances for the development of disseminated intravascular coagulation, a rare but potentially life-threatening complication associated with the retention of a dead conceptus for longer than 4 weeks.
In women with minimal intrauterine tissue based on ultrasound images, waiting for spontaneous passage of the products of conception is possible (expectant management).
Currently, evidence is insufficient to support medical therapy (prostaglandins and antiprogesterones) for spontaneous abortions.
MEDICATION
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Drug Category: Oxytocic agents –
Enhance uterine contractility after evacuation and diminish bleeding.
Drug Name
Oxytocin (Pitocin, Syntocinon) -- Promotes contractility of uterine smooth muscle by increasing intracellular calcium. Most effective at or near term. In early pregnancy, high doses produce uterine contractions. Diminishes bleeding after surgical uterine evacuation.
Adult Dose
10-60 U in 1000 mL (NS, D5RL, or LR) IV infusion, titrate to control uterine atony (125-200 mL/h)
Pediatric Dose
<12>12 years: Administer as in adults
Contraindications
Documented hypersensitivity; pregnant patients with severe toxemia, unfavorable fetal positions, and contracting uterus with hypertonic or hyperactive patterns; labor for which vaginal delivery should be avoided, such as invasive cervical carcinoma, cord presentation or prolapse, active herpes genitalis, total placenta previa, and vasa previa
Interactions
Pressor effect of sympathomimetics may increase when used concomitantly with oxytocic drugs, causing postpartum hypertension; inhalation anesthetics may produce adverse cardiovascular effects; cyclopropane may induce hypotension, maternal sinus bradycardia, or abnormal atrioventricular rhythms
Pregnancy
X - Contraindicated in pregnancy
Precautions
Overstimulated uterus can be hazardous to mother and fetus; uterine hypersensitivity may induce hypertonic contractions, even with appropriate administration; intrinsic antidiuretic effect at high doses given over a prolonged period can cause water intoxication
Drug Name
Methylergonovine (Methergine) -- Ergot alkaloid that acts directly on uterine smooth muscle, producing increased tone, frequency, and amplitude of contractions and decreased bleeding.
Adult Dose
0.2 mg PO q4h for 6 doses0.2 mg IM/IV, repeat q2-4h prn
Pediatric Dose
Not established
Contraindications
Documented hypersensitivity; pregnancy; induction of labor; threatened spontaneous abortion; toxemia; hypertension
Interactions
Concurrent administration of vasoconstrictors or other ergot alkaloids may produce additive effect (ie, additive peripheral vasoconstriction with dopamine associated with peripheral ischemia and gangrene)
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in sepsis, obliterative vascular disease, or hepatic or renal insufficiency
Drug Category: Immunoglobulins –
Suppress immune response and antibody formation.
Drug Name
Rho (D) Immune Globulin (RhoGAM) -- Suppresses immune response of nonsensitized Rho (D)–negative women exposed to fetal Rho (D)–positive blood following a fetomaternal hemorrhage (ie, abdominal trauma, amniocentesis, abortion, ectopic pregnancy, 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 3 mo
Interactions
Alters response to live virus vaccines (ie, measles, mumps, rubella, varicella)
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in thrombocytopenia, bleeding disorders, or IgA deficiency
FOLLOW-UP
Further Inpatient Care:
Inpatient treatment includes suction curettage for inevitable and complete abortions.
Laparoscopy or laparotomy is available for patients with ectopic pregnancies who are not candidates for methotrexate.
Patients undergoing suction curettage should be observed for 4-6 hours and then discharged if stable.
Further Outpatient Care:
A follow-up visit with an obstetrician/gynecologist should be scheduled for within 1 week.
Serial QhCG levels and TVS evaluations may be required.
If spontaneous abortion occurs, the patient should be seen within 1 week.
Allow sufficient time for counseling.
Etiologies and prognosis can be addressed further at this point.
Include a sensitively approached focus on the patient's emotional reactions.
In/Out Patient Meds:
For patients who are Rh-negative and at less than 13 weeks’ gestation, administer RhoGAM at 50 mcg intramuscularly.
If the patient undergoes suction curettage, any of the following may be administered if needed:
Methergine (0.2 mg PO q4h 6 times) - To diminish postevacuation uterine bleeding
Ibuprofen (800 mg PO q6h prn) - For analgesia
Doxycycline (100 mg PO bid for 4-7 d) - For prophylaxis
Iron supplementation - For anemia
Contraception agent, if desired
Deterrence/Prevention:
Contraceptive counseling
Complications:
Preexisting anemia may make patients more susceptible to hypovolemic shock.
Potential complications from suction curettage include hemorrhage and uterine perforation with possible injury to bowel, bladder, ureter, and uterine artery.
Other complications include the following:
Postabortion bleeding
Retained products of conception
Hematometra
Depression
Anesthesia complications
Prognosis:
In women who have had 1 prior miscarriage, the rate of spontaneous abortion in a subsequent pregnancy is approximately 20%. In women who have had 3 consecutive losses, the rate is 50%.
The live-birth rate after documentation of fetal cardiac activity at 5-6 weeks of gestation in women with 2 or more unexplained spontaneous abortions is approximately 77%.
Patients can be reassured that in most cases, spontaneous abortions do not recur.
Evidence of an association between threatened abortion and birth defects is limited and inconsistent. One epidemiologic study found an increased risk of birth defects (polydactyly, undescended testicle, and hypospadias) in the follow-up observation of patients with threatened abortion. Another study looking at perinatal outcome of pregnancies continuing after threatened abortion found no significant difference in preterm deliveries, low birth weight, and overall perinatal outcome.
Patient Education:
Advise patients to return for follow-up care upon the occurrence of any of the following symptoms:
Profuse vaginal bleeding and/or severe abdominal cramping
Severe pelvic pain
Temperature higher than 38°C (100.4°F)
Passage of tissue
MISCELLANEOUS
Medical/Legal Pitfalls:
Failure to diagnose pregnancy: Every woman of reproductive age with lower abdominal pain and/or vaginal bleeding should have a pregnancy test.
Failure to diagnose an ectopic pregnancy: An ectopic pregnancy must be excluded in every pregnant woman with abdominal pain and/or vaginal bleeding. With early diagnosis, ectopic pregnancy in a patient who is stable can be treated nonsurgically.
Failure to provide important follow-up care: In patients who are being monitored with serial QhCG titers and sonograms, documenting a contact person with telephone number and address is prudent in the event that the patient is lost to follow-up.
Failure to prevent isoimmunization: Unsensitized Rh-negative women should receive the appropriate dose of RhoGAM.
Failure to assess the true intensity of hemorrhage: External bleeding may not accurately reflect total blood loss. Blood can be concealed in the vagina or uterus, or a hemoperitoneum may exist.
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