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Abortion, Spontaneous, Emergency Medicine

Basics

Description

- Inevitable abortion: Vaginal bleeding, cervical os is open; products of conception (POC) have not been expelled - Incomplete abortion: Vaginal bleeding, cervical os is open with partial passage of some POC and some retained POC - Complete abortion: Vaginal bleeding, cervical os closed, complete passage of POC; no surgical or medical intervention - Missed abortion: Fetal demise with no uterine activity to expel - Septic abortion: Spontaneous abortion complicated by intrauterine infection - Recurrent spontaneous abortion: 3 or more consecutive pregnancy losses

- Medications: - Misoprostol - Methotrexate - NSAIDs

- Multiple previous elective abortions - Previous early pregnancy loss - Toxins - Uterine abnormalities (e.g., leiomyoma, uterine adhesions, congenital anomalies)

- Last menstrual period (LMP) - Obstetric history: - Parity - Risk factors for pregnancy loss - Prenatal care

- Pelvic exam: - Determine whether the internal cervical os is opened or closed - Amount of bleeding - Presence of POC - Presence of adnexal tenderness or peritoneal irritation can be consistent with an ectopic pregnancy

- Bimanual exam to determine the size of the uterus: - Size of an orange: 6-8 wk - Fundus at the symphysis pubis: 12 wk - Fundus at the umbilicus: 16-20 wk

- 2nd- and 3rd-trimester vaginal bleeding: - Placenta previa - Placental abruption

- Stable patients: - Unstable patients: - Oxygen, IV fluids via 2 large-bore IVs, cardiac monitor - Transfuse PRBC if patient does not stabilize after 2-3 L of crystalloid - Gynecologic consultation immediately - Oxytocin or methylergonovine may be necessary to control hemorrhage - These patients are at high risk for having ruptured ectopic pregnancies and may need emergent operative intervention

- Surgical management: - Dilation and curettage (D&C) or evacuation, removal of POC at the cervical os to help decrease bleeding and cramping - Less unplanned hospital admissions, curettages, and blood transfusions - The confirmation of POC by pathology rules out ectopic pregnancy

  • Spontaneous termination of a <20 wk intrauterine pregnancy
  • Synonyms: Early pregnancy loss, miscarriage
  • Occurs in up to 15-20% of recognized pregnancies (most common complication of early pregnancy)
  • Vaginal bleeding in the 1st trimester seen in about 25% of pregnant patients:50% of these women will eventually mis-carry
  • Definitions:Threatened abortion: Vaginal bleeding, cervical os is closed, viable intrauterine pregnancy confirmed:50% of women seen in the ED for threatened abortion will eventually miscarryInevitable abortion: Vaginal bleeding, cervical os is open; products of conception (POC) have not been expelledIncomplete abortion: Vaginal bleeding, cervical os is open with partial passage of some POC and some retained POCComplete abortion: Vaginal bleeding, cervical os closed, complete passage of POC; no surgical or medical interventionMissed abortion: Fetal demise with no uterine activity to expelSeptic abortion: Spontaneous abortion complicated by intrauterine infectionRecurrent spontaneous abortion: 3 or more consecutive pregnancy losses

Etiology

  • Chromosomal abnormalities of the fetus
  • Uterine abnormalities
  • Risk factors include:Increased age of both the mother and fatherIncreased parityAlcohol useCigarette smokingCocaine useConception within 3-6 mo after deliveryChronic maternal disease:Poorly controlled diabetesAutoimmune diseaseCeliac diseaseIntrauterine deviceMaternal BMI < 18 or >25 kg/m2Maternal infections:Bacterial vaginosisMycoplasmosisHerpes simplexToxoplasmosisListeriosisChlamydia/gonorrheaHIVSyphilisParvovirus B19MalariaCMVRubellaMedications:MisoprostolMethotrexateNSAIDsMultiple previous elective abortionsPrevious early pregnancy lossToxinsUterine abnormalities (e.g., leiomyoma, uterine adhesions, congenital anomalies)

Diagnosis

Signs and Symptoms

History

  • Last menstrual period (LMP)
  • Obstetric history:ParityRisk factors for pregnancy lossPrenatal care
  • Abdominal pain, cramping
  • Vaginal bleeding:DurationAmount of bleeding (quantify by number of pads used, compare with normal menstrual period for patient)Passage of clots
  • Dizzy, syncope

Physical Exam

  • Determine hemodynamic status of patient:Pregnant patients in late 1st trimester have an increased blood volumeCan lose substantial amount of blood before having abnormal vital signs
  • Pelvic exam:Determine whether the internal cervical os is opened or closedAmount of bleedingPresence of POCPresence of adnexal tenderness or peritoneal irritation can be consistent with an ectopic pregnancy
  • Bimanual exam to determine the size of the uterus:Size of an orange: 6-8 wkFundus at the symphysis pubis: 12 wkFundus at the umbilicus: 16-20 wk

Essential Workup

  • Pregnancy test as below
  • Imaging as below

Diagnosis Tests & Interpretation

Lab

  • Confirm pregnancy with a urine or serum test:Urine pregnancy test: Most are positive at β-hCG levels of 25-50 mIU/mL ~1 wk gestational age and remain positive 2-3 wk after induced or spontaneous abortions
  • CBC
  • Rapid hemoglobin determination: Type and Rh
  • Type and cross-match for woman with low Hct or signs of active blood loss
  • Quantitative β-hCG
  • Any POC passed should be sent to pathology for confirmation

Imaging

  • Transvaginal ultrasound (TVS):Gestational sac seen at 5 wkCardiac activity seen at 6.5 wk
  • Transabdominal ultrasound (TAS):Gestational sac at 6 wkCardiac activity seen at 8 wk
  • Discriminatory zone: Level of β-hCG where a normal IUP should be detected:1,500-2,000 for TVS6,500 for TAS

Differential Diagnosis

  • Positive pregnancy test with vaginal bleeding:CervicitisEctopic pregnancyMolar pregnancyPregnancy of unknown location (PUL)Septic abortionsSubchorionic hemorrhageTrauma
  • 2nd- and 3rd-trimester vaginal bleeding:Placenta previaPlacental abruption

Treatment

Pre-Hospital

  • IV fluids, oxygen, and cardiac monitor
  • Monitor vital signs and transport
  • Cautions:Patients with spontaneous abortion/vaginal bleeding can have severe hemorrhage and present in shock, especially at >12 wkBP drops during the 2nd trimester of pregnancy with an average of 110/70

Initial Stabilization/Therapy

  • Stable patients:
  • Unstable patients:Oxygen, IV fluids via 2 large-bore IVs, cardiac monitorTransfuse PRBC if patient does not stabilize after 2-3 L of crystalloidGynecologic consultation immediatelyOxytocin or methylergonovine may be necessary to control hemorrhageThese patients are at high risk for having ruptured ectopic pregnancies and may need emergent operative intervention

Ed Treatment/Procedures

  • Threatened abortion:Pelvic rest, close follow-up with obstetricsPatients <6.5 wk pregnant with no documented cardiac activity by vaginal US need to be followed with serial β-hCG to assess the viability of the fetus and to rule out ectopic pregnancy
  • Inevitable and incomplete abortions:Expectant management:Successful in up to 85%Increased risk of unplanned surgical intervention and blood loss as compared to surgical managementMedical management:MisoprostolSuccessful in up to 85%Surgical management:Dilation and curettage (D&C) or evacuation, removal of POC at the cervical os to help decrease bleeding and crampingLess unplanned hospital admissions, curettages, and blood transfusionsThe confirmation of POC by pathology rules out ectopic pregnancy
  • Complete abortion:May treat with methylergonovine or oxytocin if bleeding is heavyIf quantitative β-hCG is <1,000 and the US is negative, may follow-up with obstetrics for serial β-hCG to confirm the levels are decreasing
  • Missed abortion:These patients are at risk for disseminated intravascular coagulation (DIC), especially if fetus is retained >4-6 wkObtain CBC, PT/PTT, fibrin-split products (FSP), and fibrinogen levelsThese patients may be followed closely as outpatients if stable with an early, confirmed IUP and no evidence of DICPatients may choose to have a D&C at a later date or miscarry at home with medication or no intervention; this decision should be made in consultation with OB/GYN

Medication

First Line

  • RHO immunoglobulin in Rh-negative women:50 Ојg for women with threatened or complete abortion at <12 wk300 Ојg for women with threatened or complete abortion at ≥12 wk
  • Patients need RhoGAM administration within 72 hr to prevent future isoimmunization
  • Misoprostol 800 Ојg vaginally if medical management is chosen in consultation with OB/GYN
  • Repeat dose required in 48 hr

Second Line

Usually given in consultation with OB/GYN: пїЅ

  • Oxytocin: 20 IU in 1,000 mL of NS at a rate of 20 mIU/min titrated to decrease bleeding; may repeat for a max. dose of 40 mIU/min
  • Methylergonovine: 0.2 mg IM/PO QID for bleeding

Follow-Up

Disposition

Admission Criteria

  • Suspected unstable ectopic pregnancy (see "Ectopic Pregnancy"пїЅ)
  • Hemodynamically unstable patients with hypovolemia or anemia
  • DIC
  • Septic abortions
  • Suspected gestational trophoblastic disease

Discharge Criteria

  • D&Cs can be done in the ED for incomplete and inevitable abortions, and patients may be discharged home if stable after 2-3 hr
  • Some early inevitable miscarriages can be discharged to complete their miscarriages at home without a D&C
  • Discharge with pain medications and close OB/GYN follow-up
  • Patients with threatened abortions should be told to avoid strenuous activity
  • Pelvic rest (i.e., "nothing in the vagina"пїЅ during active bleeding; may increase risk of infection)
  • Patients should be instructed to return to the ED for any increase in bleeding, dizziness, or temperature >100.4 пїЅF
  • Patients and their partners should be counseled that early pregnancy loss is common and that it is not anyones fault

Followup Recommendations

Patients with positive pregnancy tests and vaginal bleeding with or without abdominal pain should be followed by OB/GYN. пїЅ

Pearls and Pitfalls

  • Recognize the possibility of ectopic pregnancy
  • Patients with spontaneous abortion may have clinically significant blood loss

Additional Reading

  • Huancahuari пїЅN. Emergencies in early pregnancy. Emerg Med Clin North Am. 2012;30:837-847.
  • Martonffy пїЅAI, Rindfleisch пїЅK, Lozeau пїЅAM, et al. First trimester complications. Prim Care. 2012;39:71-82.
  • Marx пїЅJA, Hockberger пїЅRS, Walls пїЅRM, et al. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009.
  • Prine пїЅLW, MacNaughton пїЅH. Office management of early pregnancy loss. Am Fam Physician. 2011;84:75-82.

See Also (Topic, Algorithm, Electronic Media Element)

  • Ectopic Pregnancy
  • Vaginal Bleeding

Codes

ICD9

  • 634.90 Spontaneous abortion, without mention of complication, unspecified
  • 634.91 Spontaneous abortion, without mention of complication, incomplete
  • 634.92 Spontaneous abortion, without mention of complication, complete
  • 632 Missed abortion
  • 634.9 Spontaneous abortion without mention of complication

ICD10

  • O02.1 Missed abortion
  • O03.4 Incomplete spontaneous abortion without complication
  • O03.9 Complete or unspecified spontaneous abortion without complication

SNOMED

  • 17369002 Spontaneous abortion (disorder)
  • 156072005 Incomplete miscarriage (disorder)
  • 156073000 Complete miscarriage (disorder)
  • 59363009 Inevitable abortion
  • 16607004 Missed abortion (disorder)
  • 19169002 Spontaneous abortion in first trimester (disorder)
  • 85116003 Spontaneous abortion in second trimester (disorder)