Newer recommendations are that mifepristone be given orally prior to the administration of vaginal misoprostol for the medical management of missed abortions.

 – Dr. Hughey

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APGO educational topic number 16
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spontaneous abortion spontaneous
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abortion is the loss of a pregnancy
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before 20 weeks gestation it affects up
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to 20% of recognized pregnancies note
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that medically the term abortion refers
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to miscarriage this differs from the
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terms elective therapeutic or induced
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abortions which will be addressed in a
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separate video approximately 80% of
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spontaneous abortions occur in the first
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12 weeks of a pregnancy the objectives
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of this video are to review the
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differential diagnosis for first
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trimester vaginal bleeding and to
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differentiate the types causes
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complications and treatment options for
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continuous abortion the differential
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diagnosis for vaginal bleeding in the
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first trimester includes spontaneous
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abortion viable intrauterine pregnancy
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and ectopic pregnancy when a woman
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presents with vaginal bleeding in the
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first trimester therefore it is
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essential to first determine the
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location of the pregnancy and whether
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the pregnancy will ultimately be viable
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serial beta HCG values and transvaginal
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ultrasound tests give us diagnostic
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information to help us make the
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diagnosis over a 48-hour period the beta
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HCG values should rise at least 50% if
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the beta HCG decreases over a 48-hour
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period and the pregnancy is not a viable
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pregnancy this could be a spontaneous
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abortion or it could still be an ectopic
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pregnancy the rule of tens is a simple
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way of remembering some important beta
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HCG landmarks the beta HCG peaks at
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approximately 10 weeks
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assuming gestational age at
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approximately 100,000 it then decreases
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and that term it’s about 10,000 on
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transvaginal ultrasound a gestational
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sac can usually be identified around
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four and a half to five weeks estimated
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gestational age a yolk sac between five
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and six weeks and a fetal pull with
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cardiac activity between five and a half
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to six weeks there are four definitions
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that are important to remember
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pertaining to spontaneous abortion for a
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complete abortion all of the products
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have been passed without the need for
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any intervention and the cervix is
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closed in an incomplete abortion some
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but not all of the products have passed
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and the cervix is open in an inevitable
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abortion the cervix is dilated but the
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products of consumption have not been
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passed in a missed abortion there has
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been a fetal demise usually for a number
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of weeks but the products have not been
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expelled the most common causes
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spontaneous abortion in the first
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trimester is
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chromosomal abnormalities 50% of
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recognized early spontaneous abortions
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are attributed to chromosomal
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abnormalities most of which are
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trisomies increasing maternal age will
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thus increase the risk of chromosome
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abnormalities which will thus increase
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the risk of spontaneous abortion
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compared to first trimester abortions
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second trimester abortions are less
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likely to be caused by chromosomal
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abnormalities and can be caused by
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maternal systemic disease abnormal
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placentation or other anatomic
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considerations other risk factors are
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less well defined and are much less
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common and include a history of
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spontaneous abortion smoking having an
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IUD in place and uncontrolled diabetes
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of note moderate caffeine consumption is
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not a risk factor for miscarriage and
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this brings up an important point that
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many patients need reassurances that
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drinking moderate coffee having sex or
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exercising did not contribute to their
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miscarriage many women need to go
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through a grieving process after a
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pregnancy loss and it is important to
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provide appropriate support for this
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process there are three options when a
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woman has a spontaneous abortion
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expectant management is fine and some
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women may want to see if their body will
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spontaneously miscarry surgical
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evacuation of the pregnancy can be
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performed with either a dilation and
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curettage in the operating room or a
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manual vacuum aspiration in a clinic
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setting the third treatment option is
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medical management which can be
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performed in the first trimester with
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vaginal misoprostol remember that if a
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patient is Rh negative she will need a
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rhogam injection to protect against I so
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immunization in future pregnancies let’s
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conclude by discussing possible
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complications from spontaneous abortion
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hemorrhage may occur around the time of
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spontaneous passage of the pregnancy or
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related to surgical evacuation of the
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pregnancy if a patient presents with
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heavy vaginal bleeding with retained
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products of consumption then a surgical
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evacuation should be performed under
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metritis after spontaneous evacuation or
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spontaneous passage of the pregnancy
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should be treated with oral
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broad-spectrum antibiotics it is very
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rare now for a patient to develop a
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septic abortion for this was much more
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prevalent in the past before the
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legalization of elective terminations
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the signs and symptoms of a septic
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abortion are fevers chills lower
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abdominal discomfort and foul-smelling
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vaginal discharge this concludes the
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aapko video on spontaneous abortion we
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reviewed the important diagnostic
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criteria and therapeutic options for
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this common
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addition in women