Abortion resident survival guide
|Abortion Resident Survival Guide Microchapters|
Synonyms and keywords: Approach to miscarriage; Approach to pregnancy termination, Abortion workup, Abortion management
Abortion refers to pregnancy loss occurring before 20 weeks of gestation. Without external intervention is known as Spontaneous abortion. An example of a life-threatening cause that may result in death or permanent disability within 24 hours if left untreated is a ruptured Ectopic pregnancy. Other causes include chromosomal abnormalities, infections, cervical anomalies, etc. Ultrasound, β-HCG, and progesterone levels are helpful in confirming diagnosis and treatment could be conservative, medical, or surgical depending on the cause, presentation, and/or patient's preference. Administer Rhogam to Rh (D) negative mothers, and counsel, accordingly if pregnancy is subsequently desired. Medical management is contraindicated in conditions like severe anemia, bleeding disorders, etc while surgical intervention is not indicated with an unconfirmed diagnosis of spontaneous abortion.
Life Threatening Causes
- Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
- Chromosomal abnormalities such as:
- Congenital anomalies
- Cervical insufficiency
- Abnormalities of the reproductive system e.g. uterine malformations, fibroids especially submucosal.
- Behavioural/lifestyle causes such as illicit drug and alcohol use, smoking
- Environmental such as exposure to radiation
- Uncontrolled chronic diseases (Diabetes, Hypertension, Hypo/Hyperthyroidism, Antiphospholipid syndrome, etc)
- Iatrogenic such as amniocentesis, chorionic villus sampling
|Female of reproductive age, gestation <20weeks, bleeding per vagina, +/-pelvic pain|
|Targeted history and examination, β-HCG,CBC, type and screen|
|IV access and fluid resuscitation, move to the ED and send consult to OBGYN||Signs of peritonitis?|
|Intrauterine||Extrauterine, confirmed ectopic?|
|Surgery. Stabilise if need be|
|Threatened abortion; viable pregnancy+closed cervix||Missed abortion; non-viable pregnancy+closed cervix||Inevitable abortion; viable pregnancy+open cervix||Incomplete abortion; Retained Products of Conception+closed cervix||Complete abortion; empty uterus+closed cervix|
|Serial progesterone, β-HCG, ultrasound|
|Ectopic Pregnancy||↑β-HCG >66% in 48hrs,normal ultrasound, progesterone >25ng/ml||Progesterone <5ng/ml, β-HCG ↓ or ↔, non-viability on ultrasound||β-HCG equivocal, ultrasound not diagnostic, progesterone 5-25ng/ml|
|β-HCG every 2-3 days, repeat ultrasound weekly till viability is ascertained|
|Threatened abortion||Missed, incomplete or inevitable abortion|
|Weekly check ups till bleeding ceases, administer Rhogam[Rhο(D)] immunoglobulin if indicated, watch out for oligohydramnios, IUGR and preterm labor|
|Any complications? E.g.pain, hemorrhage, sepsis|
|Counsel on expectant management|
|Follow-up with serial β-HCG||Uterine evacuation or medical treatment|
|Uterine evacuation and stabilise patient|
- Administer Rhogam to Rh (D) negative mothers and counsel accordingly if pregnancy is subsequently desired.
- Counsel/Reassure patients and their partners when they are available on how to deal with guilt, the grieving process, and handling friends and family.
- Reversible risk factors can be addressed professionally.
- Reassure when the cause is unknown.
- Contraindications to conservative management/use of uterotonic drugs are:
- Surgical management is contraindicated in the following settings:
- Creinin MD, Schwartz JL, Guido RS, Pymar HC (2001). "Early pregnancy failure--current management concepts". Obstet Gynecol Surv. 56 (2): 105–13. doi:10.1097/00006254-200102000-00024. PMID 11219590.
- Scroggins KM, Smucker WD, Krishen AE (2000). "Spontaneous pregnancy loss: evaluation, management, and follow-up counseling". Prim Care. 27 (1): 153–67. doi:10.1016/s0095-4543(05)70153-6. PMID 10739462.