Management of Spontaneous Abortion

Spontaneous abortion is a condition commonly encountered in family medicine. Indeed spontaneous abortion, defined as a loss of pregnancy without outside intervention, before 20 weeks of gestation, affects up to 20% of recognized pregnancies. When one factors in unrecognized pregnancies, the loss rate may be as high as 31%.¹

There are several types of spontaneous abortion - threatened abortion, inevitable abortion, incomplete abortion, missed abortion, septic abortion, complete abortion, and recurrent spontaneous abortion. Management will vary depending on the type of abortion.

The types can be defined as:

• Threatened abortion: a pregnancy complicated by bleeding before 20 weeks' gestation
• Inevitable abortion: the cervix has dilated, but the products of conception have not been expelled
• Incomplete abortion: some, but not all, of the products of conception have been passed; retained products may be part of the fetus, placenta, or membranes
• Missed abortion: a pregnancy in which there is a fetal demise (usually for a number of weeks) but no uterine activity to expel the products of conception
• Septic abortion: a spontaneous abortion that is complicated by intrauterine infection
• Complete abortion: all products of conception have been passed without the need for surgical or medical intervention
• Recurrent spontaneous abortion: three or more consecutive pregnancy losses

Vaginal bleeding in the first trimester has many potential causes, including:

• Cervical abnormalities (e.g., excessive friability, malignancy, polyps, trauma)
• Ectopic pregnancy
• Idiopathic bleeding in a viable pregnancy
• Infection of the vagina or cervix
• Molar pregnancy
• Spontaneous abortion
• Subchorionic hemorrhage
• Vaginal trauma

A clinical examination should be performed and if examination reveals a dilated cervix, spontaneous abortion is inevitable.

Ultrasound examination should also be performed to asses the contents of the uterus and to rule out ectopic pregnancy.

Blood typing should be conducted to determine the patient's Rh status and the patient should be treated with immune globulin if there is a question of Rh incompatibility.

In the past dilatation and curettage was the traditional treatment for spontaneous abortion. It is now felt that expectant and medical management have a significant role to play.

Women who have already completed a spontaneous abortion (examination shows an empty uterus and the expelled tissue contain products of conception) can be managed expectantly. However, If the products of conception are not physically confirmed when the uterus is empty, an ectopic pregnancy must be ruled out.

Expectant treatment has been found to be successful in 82-96% of women with incomplete spontaneous abortions. In fact, most patients requiring surgical treatment had been followed expectantly for 2 weeks before intervention was recommended. Medical therapy with misoprostol (Cytotec) does not confer significant additional benefit. The average time to completion of the miscarriage is nine days.^2,3,4,5

Expectant management has a variable but generally lower success rate than medical therapy in women with missed spontaneous abortions. For these patients, medical therapy results in high success rates for completion of a spontaneous abortion without surgical intervention. One study found that patients had an 80 percent success rate after using 800 mcg of misoprostol, administered intravaginally and repeated after four hours, if necessary.⁶

Surgical intervention is the treatment of choice for patients with septic spontaneous abortion or for those patients who are unstable because of heavy bleeding.

It is important to involve the patient in decision making with respect to which form of therapy to choose. There is evidence to suggest that women who are given the opportunity to choose a treatment option have better subsequent mental health than women who are not allowed to choose their therapy.⁷

Family physicians should recognize that treatment of the patient with spontaneous abortion does not end with the termination of the pregnancy. Psychological support is also important. Patients often feel guilty about the loss and are concerned that something they did may have caused the abortion. They need support during the grieving process and the family physician can help by recognizing the importance of this process and by helping to involve the partner and family. Referral to a counsellor may be helpful. Women who are childless and have lost a wanted pregnancy are especially at risk.

- John Hickey

Thanks to Dr. Penny Fuller, Staff Obstetrician and Gynecologist at St. Martha's Regional Hospital in Antigonish Nova Scotia for reviewing the draft copy of this article.

1. Wilcox AJ, Weinberg CR, O'Connor JF, Baird DD, Schlatterer JP, Canfield RE, et al. Incidence of early loss of pregnancy. N Engl J Med 1988;319:189-94. (Level 3 evidence)
2. Blohm F, Friden B, Platz-Christensen JJ, Milsom I, Nielsen S, Expectant management of first-trimester miscarriage in clinical practice. Acta Obstet Gynecol Scand 2003;82:654-8. (Level 3 evidence)
3. Luise C, Jermy K, Collons WP, Bourne TH. Expectant management of incomplete, spontaneous first-trimester miscarriage: outcome according to initial ultrasound criteria and value of follow-up visits. Ultrasound Obstet Gynecol 2002;19:580-2. Abstract
4. Nielsen S, Hahlin M, Platz-Christensen J. Randomised trial comparing expectant with medical management for first trimester miscarriages. Br J Obstet Gynaecol 1999;106:804-7. (Level 3 evidence)
5. Geyman JP. Oliver LM, Sullivan SD. Expectant medical or surgical treatment of spontaneous abortion in first trimester of pregnancy? A pooled quantitative literature evaluation. J Am Board Fam Pract 1999;12:55-64. (Level 3 evidence)
6. Wood SL, Brain PH. Medical management of missed abortion: a randomized clinical trial [published correction appears in Obstet Gynecol 2002;100:175]. Obstet Gynecol 2002;99:563-6. (Level 3 evidence)
7. Wieringa-De Waard M, Hartman EE, Ankum WM, Reitsma JB, Bindels PJ, Bonsel GJ. Expectant management versus surgical evacuation in first trimester miscarriage: health-related quality of life in randomized and non-randomized patients. Hum Reprod 2002;17:1638-42. (Level 3 evidence)

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