What are the physical consequences for a woman after a missed abortion?

Physical Consequences of a Missed Abortion

A missed abortion causes significant physical consequences including infection risk, hemorrhage, and potential for sepsis, with maternal morbidity occurring in up to 60% of cases when expectant management is chosen rather than medical or surgical intervention. 1

Definition and Classification

• A missed abortion is defined as an in utero death of the embryo or fetus before 20 weeks of gestation with retained conception products, where the cervix remains closed and there is often little to no bleeding 2, 3
• It may also be referred to as a blighted ovum or an anembryonic pregnancy 2
• Ultrasound examinations typically reveal an empty gestational sac or an embryo/fetus lacking cardiac activity 4

Immediate Physical Consequences

• Vaginal bleeding, which can vary from light spotting to heavy hemorrhage, affecting up to 23.1% of women with expectant management 1
• Abdominal cramping and pain, particularly in the hypogastric region 5
• Retained products of conception, which can lead to incomplete abortion if not fully expelled 6
• Risk of intraamniotic infection (clinical chorioamnionitis), occurring in up to 38% of women who choose expectant management 1

Potential Complications

• Infection risk increases significantly with duration of retained products, with intraamniotic infection being the most common complication (38.0% with expectant management versus 13.0% with abortion care) 1, 7
• Hemorrhage requiring transfusion can occur in severe cases, with postpartum hemorrhage more than doubled with expectant management (23.1%) compared to abortion care (11.0%) 1
• Sepsis has been reported in up to 6.8% of cases, with higher rates associated with expectant management 1
• Maternal death, though rare, has been reported with an incidence rate of 45 per 100,000 patients with expectant management of previable PPROM 1
• Endometritis can develop as a post-infectious complication 1

Progression of Complications

• The median interval between membrane rupture and first signs of infection is approximately 5 days, but once infection is identified, clinical deterioration can be rapid (median time to death of 18 hours) 1
• Infection can lead to systemic inflammatory response syndrome and septic shock if not promptly treated 1
• Uterine contractions and bleeding may occur spontaneously as the body attempts to expel the products of conception 6

Management Outcomes

• With expectant management, 37% of women experience maternal morbidity without fetal survival, 23% have maternal morbidity with fetal survival, 24% have no maternal morbidity and no fetal survival, and only 16% avoid maternal morbidity with fetal survival 1
• Medical management with misoprostol has high efficacy rates (80-93%) for complete evacuation without surgical intervention 8, 4
• Surgical evacuation remains the treatment of choice for unstable patients or when medical management fails 3

Long-term Physical Consequences

• Risk of Asherman syndrome (intrauterine adhesions) increases with multiple or aggressive curettage procedures 9, 5
• Rh-negative women require Rh immunoglobulin to prevent Rh alloimmunization, as approximately 32% of spontaneous abortions present with fetomaternal hemorrhage 5, 6
• Potential impact on future fertility, though most women can have successful pregnancies after a missed abortion 3

Comparison of Management Approaches

• Surgical evacuation has lower risk of hemorrhage (9.1%) compared to medical abortion (28.3%) 9
• Infection rates are lower with surgical methods (1.3%) than with medical abortion (23.9%) 9
• Retained tissue requiring additional procedures is less common with surgical methods (1.3%) than with medical abortion (17.4%) 9
• Vaginal administration of misoprostol shows higher success rates and shorter induction-to-expulsion intervals compared to oral administration for medical management 4

Important Considerations

• The risk of maternal morbidity is significantly higher with expectant management (60.2%) compared to abortion care (33.0%) 9
• Infection risk increases substantially after 18 hours of ruptured membranes 7
• Prompt recognition and treatment of infection is crucial, as clinical deterioration can be rapid once infection is established 1
• Psychological impact, including depression and anxiety, can persist for up to one year after spontaneous abortion 3