How to manage a patient with a threatened abortion or spontaneous miscarriage?

Management of Threatened Abortion or Spontaneous Miscarriage

For patients with threatened abortion or spontaneous miscarriage, immediate assessment of hemodynamic stability, followed by appropriate management based on clinical presentation is recommended, with consideration for anti-D immunoglobulin administration in Rh-negative women.

Initial Assessment

Clinical Evaluation

• Assess for:
  • Amount and pattern of vaginal bleeding
  • Presence of abdominal pain or cramping
  • Vital signs (blood pressure, heart rate) to determine hemodynamic stability
  • Cervical status (open vs. closed)
  • Presence of tissue passage

Diagnostic Testing

• Perform transvaginal ultrasound to:
  • Confirm intrauterine pregnancy
  • Assess fetal viability (cardiac activity)
  • Rule out ectopic pregnancy
  • Evaluate for retained products of conception
• Obtain quantitative β-hCG level
• Check blood type and Rh status
• Consider complete blood count if significant bleeding

Management Algorithm

For Threatened Abortion (Bleeding with Closed Cervix and Viable Pregnancy)

1. Provide reassurance and counseling about prognosis

   • Approximately 15% of clinically recognized pregnancies end in spontaneous abortion 1
   • 50-60% of spontaneous abortions are due to chromosomal abnormalities 1

2. Consider progesterone supplementation

   • Evidence suggests progesterone may reduce the rate of spontaneous miscarriage (RR 0.53; 95% CI 0.35 to 0.79) 2
   • Options include vaginal progesterone 90-200mg daily 3

3. Recommend pelvic rest and limited activity until bleeding resolves

   • Avoid sexual intercourse
   • Avoid strenuous physical activity

4. Schedule follow-up within 1-2 weeks for repeat ultrasound

For Incomplete/Inevitable Abortion (Open Cervix or Non-Viable Pregnancy)

1. Discuss management options:

   • Expectant management: allowing natural completion of the miscarriage
   • Medical management: using medications to complete the process
   • Surgical management: uterine evacuation (vacuum aspiration or D&C)

2. For expectant management:

   • Appropriate for hemodynamically stable patients
   • Counsel about expected bleeding and cramping
   • Provide pain management options
   • Arrange follow-up within 1-2 weeks to confirm complete expulsion

3. For medical management:

   • Offer misoprostol (typically 800 mcg vaginally)
   • Provide pain management
   • Arrange follow-up within 1-2 weeks to confirm complete expulsion

4. For surgical management:

   • Indicated for:
     • Heavy bleeding with hemodynamic instability
     • Patient preference
     • Failed expectant or medical management
     • Evidence of infection

Rh Immunoglobulin Administration

• Administer anti-D immunoglobulin (RhIg) to all Rh-negative, unsensitized women with threatened abortion or spontaneous miscarriage 4
• Recommended dose: 50 μg within 72 hours of bleeding onset 4
• If 50 μg dose unavailable, a 300 μg dose is acceptable 4
• This is critical to prevent Rh alloimmunization which could affect future pregnancies 4

Emotional Support and Follow-up

• Provide emotional support and acknowledge the psychological impact of pregnancy loss 5
• Express empathy, listen actively, and normalize the experience to mitigate guilt and self-blame 5
• Consider referral to pregnancy loss support organizations if needed
• Schedule follow-up appointment to:
  • Confirm complete expulsion of pregnancy tissue
  • Address emotional concerns
  • Discuss contraception if desired
  • Provide preconception counseling when appropriate

Special Considerations

• For patients with recurrent miscarriages, consider evaluation for:

  • Uterine anatomical abnormalities
  • Endocrine disorders (thyroid dysfunction, diabetes)
  • Antiphospholipid syndrome
  • Genetic factors

• If IUD is present with confirmed pregnancy:

  • Remove IUD if strings are visible to reduce risk of spontaneous abortion, septic abortion, and preterm delivery 4
  • If strings are not visible, perform ultrasound to locate the IUD 4

Pitfalls and Caveats

• Do not assume ectopic pregnancy is ruled out based on low β-hCG levels alone; ectopic pregnancies can present at any β-hCG level 4
• Avoid delaying ultrasound when β-hCG is below discriminatory threshold as ectopic pregnancy rupture can occur at very low β-hCG levels 4
• Do not withhold RhIg in Rh-negative women with threatened abortion, as fetomaternal hemorrhage can occur even with minimal bleeding 4
• Recognize that threatened abortion may have significant psychological impact requiring appropriate emotional support 5