What are the treatment options for symptoms of an impending miscarriage, such as vaginal bleeding or abdominal cramps?

Symptoms and Treatment Options for Impending Miscarriage

The primary treatment options for symptoms of an impending miscarriage include expectant management, medical management with misoprostol, and surgical management, with expectant management being the first-line approach for 7-14 days after diagnosis unless there are risk factors for hemorrhage. 1

Clinical Presentation of Impending Miscarriage

• Vaginal bleeding is the most common symptom, reported in approximately 80% of cases 2
• Abdominal pain or cramping often accompanies the bleeding 1, 3
• The severity of bleeding can be assessed by how quickly sanitary pads become saturated - changing a pad soaked with blood more than once per hour indicates heavy bleeding requiring immediate referral 1
• A period of anxiety, change in mental status, or sensation of doom may precede more severe complications 4

Diagnostic Approach

• Transvaginal ultrasound is the standard test to assess pregnancy viability and should be the first diagnostic step 1, 5
• Transabdominal ultrasound assessment is the preferred initial imaging procedure, followed by transvaginal ultrasound if needed for better visualization 4
• Digital pelvic examination should be avoided until placenta previa, low-lying placenta, and vasa previa have been excluded by ultrasound in patients with second or third-trimester bleeding 4, 5
• History and physical examination are essential for assessing miscarriage or preterm labor in cases of painful vaginal bleeding 4

Treatment Options

Expectant Management

• First-line approach for 7-14 days after diagnosis of miscarriage 1
• Success rates of 66-91% depending on the type of miscarriage 6
• Most women will miscarry spontaneously during this time and need no further treatment 1
• Complications include hemorrhage requiring blood transfusion in 1-2% of cases 6
• Not appropriate if there are risk factors for hemorrhage or if the woman is at increased risk from the effects of hemorrhage 1

Medical Management

• Misoprostol is the primary medication used for medical management of miscarriage 1, 6
• Success rates of 81-95% for complete termination of pregnancy 6
• Vaginal administration is the most effective route with fewest side effects 6
• Side effects include nausea (more common with misoprostol than with surgical management), vomiting, and diarrhea 7
• Curettage is needed in 5-20% of cases after medical management 6
• Caution: Misoprostol can induce or augment uterine contractions and may cause hyperstimulation of the uterus, potentially leading to uterine tetany, impaired uteroplacental blood flow, or uterine rupture 8

Surgical Management

• Suctional curettage has a success rate of 97-98% 6
• Associated risks include anesthesia-related complications (0.2%), uterine perforation (0.1%), and need for repeat curettage (2-3%) 6
• Indicated in cases of infection, marked and persistent bleeding, hemodynamic instability, or pre-existing coagulopathy 6

Special Considerations

Rhesus Status

• If a pregnancy is ≤12 weeks' gestation and the woman is rhesus negative, she will require anti-D prophylaxis if there are symptoms of bleeding 1
• The recommended dose of anti-D immunoglobulin is 50 μg for first-trimester pregnancies 4

Risk Factors for Miscarriage

• Advanced maternal and paternal age 1
• Being underweight or overweight 1
• Smoking and high alcohol consumption 1
• Low serum levels of progesterone or human chorionic gonadotrophin (hCG) 3
• Heavy bleeding 3
• Early gestational age 3
• Empty gestational sac of >15-17 mm diameter 3

Prognostic Indicators

• The amount of vaginal bleeding correlates with risk of pregnancy loss 1
• Low serum levels of progesterone or hCG indicate higher risk of miscarriage 3
• Ultrasound findings such as empty gestational sac >15-17 mm provide valuable prognostic information 3

Follow-up Recommendations

• If symptoms resolve after confirmation of a viable intrauterine pregnancy, no immediate further action is needed 1
• If symptoms worsen or persist beyond 14 days, a repeat referral should be made for further assessment 1
• If expectant or medical management fails, subsequent treatment with misoprostol or curettage is indicated 6