Spontaneous abortion most often presents with vaginal bleeding in early pregnancy (< 20 weeks), with or without pelvic pain. Severe pain, heavy bleeding, passage of clots or tissue, and hypotension are possible. Symptoms that are not accompanied by passage of tissue or cervical dilation constitute a threatened abortion. Uterine cramping with progressive cervical dilation indicates an inevitable abortion. Partial passage of products of conception (POC) with intrauterine retention of some tissue is an incomplete abortion. Fever, leukocytosis, pelvic tenderness, and malodorous cervical discharge suggest a septic abortion. Completed abortion is characterized by the passage of confirmed POC, followed by resolution of bleeding and closure of the cervical os.
Spontaneous Abortion. Passage of tissue in a spontaneous abortion at 4 weeks. (Photo contributor: Lawrence B. Stack, MD.)
Spontaneous Abortion. Dilation of the cervical os with partial extrusion of tissue in the setting of an inevitable abortion. (Photo contributor: Robert Buckley, MD.)
Management and Disposition
Immediately obtain large-bore intravenous access and institute aggressive fluid resuscitation for any patient with severe pain, heavy bleeding, or hypovolemia. Also request cross-matched blood and urgent gynecologic consultation. Stable patients can undergo routine ED evaluation with complete blood count (CBC), human chorionic gonadotrophin (hCG), pelvic exam, and ultrasound (US). Send all identified tissue to pathology for definitive identification. Ectopic pregnancy must be ruled out by US, close clinical follow-up, and serial hCG testing. Administer anti-Rh immunoglobulin (RhoGAM) in all cases of vaginal bleeding where the mother is Rh negative.
Large blood clots or intrauterine decidual casts may be mistaken for POC, and their presence cannot be used to rule out ectopic pregnancy.
The passage of large clots usually indicates rapid, heavy bleeding.
Consider heterotopic pregnancy in patients with significant ongoing symptoms despite loss of previously identified viable early intrauterine pregnancy (IUP).
Septic abortion can lead to septic shock, acute respiratory distress syndrome, disseminated intravascular coagulation, and group A Streptococcus–induced toxic shock syndrome.
Decidual Cast. A decidual cast or organized clot may occasionally be mistaken for products of conception. (Photo contributor: Medical Photography Department, Naval Medical Center, San Diego, CA.)
Video 10-02: Free Fluid in Ectopic Pregnancy