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ESSENTIALS OF DIAGNOSIS
Intrauterine pregnancy at less than 20 weeks.
Low or falling levels of hCG.
Bleeding, midline cramping pain.
Open cervical os.
Complete or partial expulsion of products of conception.
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GENERAL CONSIDERATIONS
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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.
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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.
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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.
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A. Symptoms and Signs
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1. Threatened abortion
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Bleeding or cramping occurs, but the pregnancy continues. The cervix is not dilated.
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2. Inevitable abortion
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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.
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Products of conception are completely expelled. Pain ceases, but spotting may persist. Cervical os is closed.
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4. Incomplete abortion
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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.
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The pregnancy has ceased to develop, but the conceptus has not been expelled. Symptoms of pregnancy disappear. ...