Abortion, Spontaneous, Emergency Medicine

Basics

Description

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 miscarry
- 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

Etiology

Chromosomal abnormalities of the fetus
Uterine abnormalities
Risk factors include:
- Increased age of both the mother and father
- Increased parity
- Alcohol use
- Cigarette smoking
- Cocaine use
- Conception within 3-6 mo after delivery
- Chronic maternal disease:
  - Poorly controlled diabetes
  - Autoimmune disease
  - Celiac disease
- Intrauterine device
- Maternal BMI < 18 or >25 kg/m2
- Maternal infections:
  - Bacterial vaginosis
  - Mycoplasmosis
  - Herpes simplex
  - Toxoplasmosis
  - Listeriosis
  - Chlamydia/gonorrhea
  - HIV
  - Syphilis
  - Parvovirus B19
  - Malaria
  - CMV
  - Rubella
- Medications:
  - Misoprostol
  - Methotrexate
  - NSAIDs
- Multiple previous elective abortions
- Previous early pregnancy loss
- Toxins
- Uterine abnormalities (e.g., leiomyoma, uterine adhesions, congenital anomalies)

Diagnosis

Signs and Symptoms

History

Last menstrual period (LMP)
Obstetric history:
- Parity
- Risk factors for pregnancy loss
- Prenatal care
Abdominal pain, cramping
Vaginal bleeding:
- Duration
- Amount 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 volume
- Can lose substantial amount of blood before having abnormal vital signs
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

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

Differential Diagnosis

Positive pregnancy test with vaginal bleeding:
- Cervicitis
- Ectopic pregnancy
- Molar pregnancy
- Pregnancy of unknown location (PUL)
- Septic abortions
- Subchorionic hemorrhage
- Trauma
2nd- and 3rd-trimester vaginal bleeding:
- Placenta previa
- Placental 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 wk
- BP drops during the 2nd trimester of pregnancy with an average of 110/70

Initial Stabilization/Therapy

Stable patients:
- IV
- Pelvic exam
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

Ed Treatment/Procedures

Threatened abortion:
- Pelvic rest, close follow-up with obstetrics
- Patients <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 management
- Medical management:
  - Misoprostol
  - Successful 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 cramping
  - Less unplanned hospital admissions, curettages, and blood transfusions
  - The confirmation of POC by pathology rules out ectopic pregnancy
Complete abortion:
- May treat with methylergonovine or oxytocin if bleeding is heavy
- If 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 wk
- Obtain CBC, PT/PTT, fibrin-split products (FSP), and fibrinogen levels
- These patients may be followed closely as outpatients if stable with an early, confirmed IUP and no evidence of DIC
- Patients 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 μg for women with threatened or complete abortion at <12 wk
- 300 μg for women with threatened or complete abortion at ≥12 wk
Patients need RhoGAM administration within 72 hr to prevent future isoimmunization
Misoprostol 800 μg 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: �

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"�)
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"� 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 �F
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. �

Pearls and Pitfalls

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

Additional Reading

Huancahuari �N. Emergencies in early pregnancy. Emerg Med Clin North Am. 2012;30:837-847.
Martonffy �AI, Rindfleisch �K, Lozeau �AM, et al. First trimester complications. Prim Care. 2012;39:71-82.
Marx �JA, Hockberger �RS, Walls �RM, et al. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009.
Prine �LW, MacNaughton �H. Office management of early pregnancy loss. Am Fam Physician. 2011;84:75-82.

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)

Home

Erectile Dysfunction

Doctor123.org