Abortion is the loss of a pregnancy before 24 weeks' gestation. 20-40% of pregnancies miscarry, mostly in the first trimester. Most present with bleeding PV. Diagnosis may not be straightforward (consider ectopics): have a low threshold for doing an ultrasound scan. Pregnancy tests remain +ve for several days after fetal death.
Management of early pregnancy bleeding
Consider the following:
- Is she shocked? There may be blood loss, or products of conception in the cervical canal (remove them with sponge forceps).
- Has pain and bleeding been worse than a period? Have products of conception been seen? (Clots may be mistaken for products.)
- Is the os open? The external os of a multigravida usually admits a fingertip.
- Is uterine size appropriate for dates?
- Is she bleeding from a cervical lesion and not from the uterus?
- What is her blood group? If RhD-ve does she need anti-D?
If symptoms are mild and the cervical os is closed it is a threatened abortion. Rest is advised but probably does not help. 75% will settle. Threatened abortion (especially second trimester) is associated with risk of subsequent preterm rupture of membranes and preterm delivery so book mother at a hospital with good neonatal facilities.
If symptoms are severe and the os is open it is an inevitable abortion or, if most of the products have already been passed, an incomplete abortion. If bleeding is profuse, consider ergometrine 0.5mg IM. If there is unacceptable pain or bleeding, or much retained tissue on ultrasound, arrange evacuation of retained products of conception (ERPC). Expectant management is used when the volume of retained products is small eg <15mm across on transvaginal scan; when 15-50mm, medical management eg with mifepristone may be offered (benefit may not be conclusive).17
Missed abortion
The fetus dies but is retained. There has usually been bleeding and the uterus is small for dates. Confirm with ultrasound. Mifepristone and misoprostol may be used to induce uterine evacuation if the uterus is small but 50% will require surgical evacuation if uterine products are >5cm2 in the trans- verse plane; >6cm2 in the sagittal plane.1 Surgical evacuation is required for larger uteruses.
Mid-trimester abortion
This is usually due to mechanical causes, eg cervical incompetence (rapid, painless delivery of a live fetus), uterine abnormalities; or chronic maternal disease (eg DM, SLE). An incompetent cervix can be strengthened by a cervical encirclage suture at ~16 weeks of pregnancy. It is removed prior to labour.
After a miscarriage
Miscarriage may be a bereavement. Give the parents space to grieve, and to ask why it happened and if it will happen again. Fetal products should be incinerated but if the mother requests alternative disposal (eg to bury herself) her wishes should be respected.1
Most early pregnancy losses are due to aneuploidy and abnormal fetal development; 10% to maternal illness, eg pyrexia. 2nd trimester loss may be due to infection, eg CMV. Bacterial vaginosis has been implicated. Most subsequent pregnancies are normal although at increased risk.
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