Abortion resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifeoma Anaya, M.D.[2]

Synonyms and keywords: Miscarriage; termination

Overview

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.

Causes

Life Threatening Causes

• Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
  • Ruptured ectopic pregnancy
  • Blunt abdominal trauma with hemodynamic instability

Common Causes

• Unknown
• Chromosomal abnormalities such as:
  • Trisomies
  • Molar pregnancies
  • Blighted ovum
• Congenital anomalies
• Infections
• 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

Diagnosis

• Shown below is an algorithm summarizing the diagnosis of Abortion.

Female of reproductive age, gestation <20weeks, bleeding per vagina, +/-pelvic pain

Targeted history and examination, β-HCG,CBC, type and screen

Hemodynamically stable?

No

Yes

IV access and fluid resuscitation, move to the ED and send consult to OBGYN

Signs of peritonitis?

Yes

No

Pelvic ultrasound

Intrauterine

Extrauterine, confirmed ectopic?

Surgery. Stabilise if need be

Yes

Threatened abortion; viable preganancy+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

Uncertain

Serial prpogesterone, 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

Treat accordingly

Surgery

Uncertain

β-HCG every 2-3 days, repeat ultrasound weekly till viability is ascertained

Treatment

• Shown below is an algorithm summarising the treatment of abortion.

Viable pregnancy?

Yes

No

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

Yes

No

Counsel on expectant management

Consent

Decline

Follow-up with serial β-HCG

Uterine evacuation or medical treatment

Uterine evacuation and stabilise patient

Do's

• 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.

Don'ts

• Contraindications to conservative management/use of uterotonic drugs are:
  • Severe blood loss leading to anemia
  • Septicemia or pelvic infections
  • Shock
  • Equivocal diagnosis of abortion/desired pregnancy
  • Presence of bleeding disorder
  • Ectopic pregnancy
  • Molar pregnancy
  • Adverse reaction to uterotonic agents
  • >12 weeks uterine volume
• Surgical management is contraindicated in the following settings:
  • Presence of bleeding disorder that has not been corrected
  • Unconfirmed diagnosis of abortion

References

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