What is the treatment for preventing miscarriage in a confirmed pregnancy?

Management of Threatened Abortion in Confirmed Pregnancy

For confirmed pregnancies with threatened abortion, management should include bed rest, folic acid supplementation, uterine sedatives, and hormonal treatment with progesterone until 28 weeks of gestation to prevent miscarriage. 1

Understanding Threatened Abortion

Threatened abortion is characterized by vaginal bleeding and/or uterine cramping with a closed cervix during early pregnancy. It is the most common complication in the first half of pregnancy, with approximately 15-20% of clinically recognized pregnancies experiencing this condition.

Risk Factors for Miscarriage

Several factors increase the risk of progression from threatened abortion to complete miscarriage:

• Maternal age >33 years 2
• Low body mass index ≤20 kg/m² 2
• Low serum progesterone levels ≤12 ng/ml 2
• High stress levels 2
• Presence of subchorionic hematoma, especially >20 cm² 1
• Previous history of miscarriage 3
• Smoking and alcohol consumption 3

Initial Assessment

When a patient presents with threatened abortion:

1. Confirm intrauterine pregnancy with pelvic ultrasound
2. Assess for presence and size of subchorionic hematoma
3. Check quantitative hCG levels
4. Evaluate for signs of infection or other complications
5. Determine Rh status

Treatment Protocol

First-Line Management

• Complete bed rest until 48 hours after cessation of bleeding 1
• Folic acid supplementation 1
• Uterine sedatives to reduce cramping 1
• Progesterone supplementation until 28 weeks of gestation 1

Progesterone Therapy

Progesterone is the most important hormone for early pregnancy maintenance and is the logical endocrine treatment of choice for threatened abortion 4. It helps maintain the decidua and may have immunomodulatory effects that prevent rejection of the fetal allograft.

Anti-D Immunoglobulin

The American College of Emergency Physicians recommends administering 50 μg of anti-D immunoglobulin to Rh-negative women in all cases of documented first-trimester loss of established pregnancy to prevent Rh-D alloimmunization 5.

Monitoring and Follow-up

• Regular ultrasound monitoring to assess fetal viability and growth
• Serial hCG measurements to ensure appropriate rise
• Monitor for signs of complete abortion or infection
• Watch for complications in continuing pregnancies:
  • Intrauterine growth restriction (occurs in ~13.2% of cases) 1
  • Antepartum hemorrhage (occurs in ~7.5% of cases) 1
  • Preterm premature rupture of membranes (occurs in ~5.7% of cases) 1
  • Intrauterine fetal demise (occurs in ~5.7% of cases) 1

Special Considerations

Subchorionic Hematoma

Subchorionic hematoma is found in approximately 42.9% of threatened abortion cases 1. Larger hematomas (>20 cm²) are associated with higher rates of spontaneous abortion. These patients require more intensive monitoring.

Recurrent Miscarriage

For patients with history of recurrent miscarriage, additional evaluation may be needed:

• Chromosomal analysis
• Uterine cavity assessment
• Antiphospholipid antibody testing
• Endocrine evaluation

Prognosis

With appropriate treatment including bed rest, uterine sedatives, folic acid supplementation, and hormonal support, approximately 75.8% of threatened abortions will continue to term 1. About 17.1% may progress to spontaneous abortion during initial management, and another 7.1% may abort on subsequent follow-up 1.

Psychological Support

Psychological consequences of miscarriage include increased risk of anxiety, depression, and post-traumatic stress disorder 3. Appropriate counseling and emotional support should be provided regardless of pregnancy outcome.