19-08: Spontaneous Abortion

About three-fourths of spontaneous abortions occur before the 16th week; of these, three-fourths occur before the 8th week. Almost 20% of all clinically recognized pregnancies terminate in spontaneous abortion.

More than 60% of spontaneous abortions result from chromosomal defects due to maternal or paternal factors; about 15% appear to be associated with maternal trauma, infections, dietary deficiencies, diabetes mellitus, hypothyroidism, the lupus anticoagulant-anticardiolipin-antiphospholipid antibody syndrome, or anatomic malformations. There is no reliable evidence that abortion may be induced by psychic stimuli such as severe fright, grief, anger, or anxiety. In about one-fourth of cases, the cause of abortion cannot be determined. There is no evidence that video display terminals or associated electromagnetic fields are related to an increased risk of spontaneous abortion.

It is important to distinguish women with a history of incompetent cervix from those with more typical early abortion. Characteristically, incompetent cervix presents as “silent” cervical dilation (ie, with minimal uterine contractions) in the second trimester. When the cervix reaches 4 cm or more, active uterine contractions or rupture of the membranes may occur secondary to the degree of cervical dilation. This does not change the primary diagnosis. Factors that predispose to incompetent cervix are a history of incompetent cervix with a previous pregnancy, cervical conization or surgery, cervical injury, diethylstilbestrol (DES) exposure, and anatomic abnormalities of the cervix. Prior to pregnancy or during the first trimester, there are no methods for determining whether the cervix will eventually be incompetent. After 14–16 weeks, ultrasound may be used to evaluate the internal anatomy of the lower uterine segment and cervix for the funneling and shortening abnormalities consistent with cervical incompetence.

A. Symptoms and Signs

1. Threatened abortion

Bleeding or cramping occurs, but the pregnancy continues. The cervix is not dilated.

2. Inevitable abortion

The cervix is dilated and the membranes may be ruptured, but passage of the products of conception has not yet occurred. Bleeding and cramping persist, and passage of the products of conception is considered inevitable.

3. Complete abortion

Products of conception are completely expelled. Pain ceases, but spotting may persist. Cervical os is closed.

4. Incomplete abortion

The cervix is dilated. Some portion of the products of conception remains in the uterus. Only mild cramps are reported, but bleeding is persistent and often excessive.

5. Missed abortion

The pregnancy has ceased to develop, but the conceptus has not been expelled. Symptoms of pregnancy disappear. There may be a brownish vaginal discharge but no active bleeding. Pain does not develop. The cervix is semifirm and slightly patulous; the uterus becomes smaller and irregularly softened; the adnexa are normal.

B. Laboratory Findings

Pregnancy tests show low or falling levels of hCG. A CBC should be obtained if bleeding is heavy. Determine Rh type, and give Rh_o(D) immune globulin if Rh-negative. All tissue recovered should be assessed by a pathologist and may be sent for genetic analysis in selected cases.

C. Ultrasonographic Findings

The gestational sac can be identified at 5–6 weeks from the last menstruation, a fetal pole at 6 weeks, and fetal cardiac activity at 6–7 weeks by transvaginal ultrasound. Serial observations are often required to evaluate changes in size of the embryo. Diagnostic criteria of early pregnancy loss are a crown-rump length of 7 mm or more and no heartbeat or a mean sac diameter of 25 mm or more and no embryo.

The bleeding that occurs in abortion of a uterine pregnancy must be differentiated from the abnormal bleeding of an ectopic pregnancy and anovulatory bleeding in a nonpregnant woman. The passage of hydropic villi in the bloody discharge is diagnostic of hydatidiform mole.

A. General Measures

1. Threatened abortion

Bed rest for 24–48 hours followed by gradual resumption of usual activities has been offered in the past. Studies do not support that this strategy is beneficial. Abstinence from sexual activity has also been suggested without proven benefit. Data are lacking to support the administration of progestins to all women with a threatened abortion. If during the patient’s evaluation, an infection is diagnosed (ie, urinary tract infection), it should be treated.

2. Missed abortion

This calls for counseling regarding the fate of the pregnancy and planning for its elective termination at a time chosen by the patient and clinician. Management can be medical or surgical. Each has risks and benefits. Medically induced first-trimester termination with prostaglandins (ie, misoprostol given vaginally or orally in a dose of 200–800 mcg) is safe, effective, less invasive, and more private than surgical intervention; however, if it is unsuccessful or if there is excessive bleeding, a surgical procedure (dilation and curettage) may still be needed. Patients must be counseled about the different therapeutic options.

B. Surgical Measures

1. Incomplete or inevitable abortion

Prompt removal of any products of conception remaining within the uterus is required to stop bleeding and prevent infection. Analgesia and a paracervical block are useful, followed by uterine exploration with ovum forceps or uterine aspiration. Regional anesthesia may be required.

2. Cerclage and restriction of activities

A cerclage is the treatment of choice for incompetent cervix, but a viable intrauterine pregnancy should be confirmed prior to placement of the cerclage.

A variety of suture materials including a 5-mm Mersilene tape or No. 2 nonabsorbable monofilament suture can be used to create a purse-string type of stitch around the cervix, using either the McDonald or Shirodkar method. Cerclage should be undertaken with caution when there is advanced cervical dilation or when the membranes are prolapsed into the vagina. Rupture of the membranes and infection are specific contraindications to cerclage. Cervical cultures for N gonorrhoeae, C trachomatis, and group B streptococci should be obtained before elective placement of a cerclage. N gonorrhoeae and C trachomatis should be treated before placement.

• Patient with history of two second-trimester losses.

• Vaginal bleeding in a pregnant patient that resembles menstruation in a nonpregnant woman.

• Patient with an open cervical os.

• No signs of uterine growth in serial examinations of a pregnant patient.

• Leakage of amniotic fluid.

• Open cervical os.

• Heavy vaginal bleeding.

• Leakage of amniotic fluid.