gynecology and obstetrics
Spontaneous Abortion
Treatment of Spontaneous Abortion
For threatened abortion, observation For inevitable, incomplete, or missed abortions, observation or surgical or medical uterine evacuation If the mother is Rh-negative, Rho(D) immune globulin Pain medication as needed Emotional support Forthreatened abortion,treatment is observation, but clinicians may periodically evaluate the woman's symptoms or do ultrasonography to check fetal status. No evidence suggests that bed rest decreases risk of subsequent completed abortion. Forinevitable, incomplete, or missed abortions,treatment is waiting for spontaneous passage of products of conception, management with medications, or uterine evacuation. , expectant management is an option, but this approach is not recommended during the second trimester due to limited safety studies and risk of hemorrhage ( Treatment references ). Expectant management has an 80% success rate for complete expulsion within 8 weeks, with symptomatic women having better outcomes than asymptomatic women. Bleeding and cramping may occur, and patients should be counseled about when to return to the healthcare facility if symptoms are severe or to confirm passage of gestational tissue. Ultrasound and reported symptoms are used to confirm passage of gestational tissue; in a patient with a previous ultrasound that showed a gestational sac, a follow-up ultrasound with no gestational sac is the most common criterion for complete expulsion. For patients who cannot return for ultrasound confirmation, triaging via telemedicine and/or home urine pregnancy tests may be useful. If complete expulsion is not achieved within a reasonable time, medical management or surgery may be necessary. is available ( Treatment references ). Spontaneous abortions that are not completely expelled with expectant management or medications require surgical uterine evacuation. Also, some women may prefer surgical evacuation due to more immediate completion and less need for follow-up care. Traditionally, uterine evacuation was performed with sharp curettage alone. However, Instrumental evacuation is now favored due to superior outcomes and can be completed in an office setting with local anesthesia and/or sedation in first trimester loss patients. Urgent surgical evacuation may be needed in cases of hemorrhage, hemodynamic instability, or infection. Ifcomplete abortionseem likely based on symptoms and/or ultrasound, further management with medications or uterine evacuation is typically not required. Uterine evacuation may be needed if bleeding occurs and/or if other signs indicate that products of conception may be retained. Pain medications should be given, as appropriate. Prevention is given if the pregnant patient is Rh-negative. After aspontaneous abortion,parents may feel grief or guilt. They should be given emotional support and, in most cases of spontaneous abortions, reassured that their actions were not the cause. Formal counseling or support groups may be made available if appropriate. 1.American College of Obstetricians and Gynecologists (ACOG): ACOG Practice Bulletin No. 200: Early pregnancy loss.Obstet Gynecol132(5):e197–e207, 2018. doi:10.1097/AOG.0000000000002899 2.Zhang J, Gilles JM, Barnhart K, et al: A comparison of medical management withmisoprostoland surgical management for early pregnancy failure.N Engl J Med353(8):761-769, 2005. doi:10.1056/NEJMoa044064 3.Schreiber CA, Creinin MD, Atrio J, et al:Mifepristonepretreatment for the medical management of early pregnancy loss.N Engl J Med378(23):2161-2170, 2018. doi:10.1056/NEJMoa1715726 