PowerPoint Outline: Spontaneous Abortion
Slide 1: Modern Terminology and Classification
Use "Early Pregnancy Loss (EPL)" instead of outdated terms like "pregnancy failure" or "blighted ovum" 1, 2
Four main clinical presentations:
- Threatened abortion: Vaginal bleeding with closed cervix and viable fetus (cardiac activity present) 2, 3
- Inevitable abortion: Vaginal bleeding with cervical dilatation but no tissue expulsion yet 2, 3
- Incomplete abortion: Partial expulsion of products of conception with retained intrauterine tissue 2, 3
- Missed abortion (Embryonic/Fetal Demise): Confirmed fetal death without spontaneous expulsion 1, 2
Additional category: Complete abortion - complete expulsion of all products of conception 2, 3
Slide 2: Etiology and Risk Factors
Chromosomal abnormalities account for 50-60% of spontaneous abortions 2, 3
Other major causes include: 2
- Maternal endocrine disorders
- Infections
- Anatomic uterine factors
- Toxin exposure
Fetomaternal hemorrhage occurs in approximately 32% of spontaneous abortions - critical for Rh prophylaxis 2
Slide 3: Diagnostic Criteria - Ultrasound Findings
Society of Radiologists in Ultrasound 2025 Consensus Criteria 1:
Diagnostic of EPL (Embryonic/Fetal Demise):
Concerning for EPL (uncertain prognosis):
Use term "cardiac activity" instead of "heartbeat," "heart motion," or "viable" 1
Slide 4: Clinical Presentation by Type
- Vaginal bleeding (spotting to moderate)
- Closed cervix on examination
- Cramping pain (mild to moderate)
- Fetus with cardiac activity on ultrasound
- Vaginal bleeding (moderate to heavy)
- Open/dilated cervix
- Cramping pain (moderate to severe)
- Gestational sac visible in cervical canal or lower uterine segment
- Vaginal bleeding (variable, can be profuse)
- Open cervix with tissue passage
- Retained intrauterine tissue with internal vascularity on ultrasound
- Cramping pain
- Minimal or no bleeding initially
- Closed cervix
- Absence of pregnancy symptoms
- Confirmed embryonic/fetal demise on ultrasound
Slide 5: Diagnostic Workup
Essential Studies 2:
- Transvaginal ultrasound - primary diagnostic modality
- Serial β-hCG measurements - levels fail to rise appropriately or decrease in EPL 2
- Complete blood count - assess for anemia from bleeding 4
- Blood type and Rh status - mandatory for all patients 2, 4
Signs of Infection Requiring Urgent Action 2, 5:
- Maternal tachycardia
- Purulent cervical discharge
- Uterine tenderness
- Do NOT wait for fever to diagnose infection 2, 5
Slide 6: Management of Threatened Abortion
- Expectant management is appropriate 3
- Pelvic rest (avoid intercourse, tampons, douching) 3
- Monitor for progression to inevitable or incomplete abortion 3
- Rh-negative women require 50 μg anti-D immunoglobulin 2, 4
- Serial ultrasound to confirm ongoing viability 1
- Counsel that 50% of threatened abortions progress to complete loss 3
Slide 7: Management of Inevitable Abortion
Surgical evacuation is the definitive treatment 2, 4:
- Vacuum aspiration preferred over sharp curettage - less blood loss and pain 4, 6
- Perform urgently if profuse bleeding present 4
- Can be performed as outpatient procedure if hemodynamically stable 4, 6
Medical management alternative 2:
- Misoprostol 800 mcg vaginally
- Success rate lower than surgical approach
- Higher risk of prolonged bleeding (28.3% vs 9.1% surgical) 4
Rh prophylaxis mandatory: 50 μg anti-D immunoglobulin for Rh-negative women 2, 4
Slide 8: Management of Incomplete Abortion
Three Evidence-Based Options 2, 4:
1. Surgical Evacuation (Gold Standard for Moderate-Severe Bleeding) 4:
- Vacuum aspiration preferred
- Lowest complication rates: hemorrhage 9.1%, infection 1.3%, retained tissue 1.3%
- Immediate resolution
- Misoprostol 600-800 mcg vaginally single dose
- Success rate 91.5% in first trimester
- Higher bleeding risk (28.3%), infection risk (23.9%), retained tissue (17.4%)
3. Expectant Management (Up to 2 Weeks) 2, 3:
- Variable success rates
- Significantly higher maternal morbidity (60.2% vs 33.0% with active management) 2
- Intrauterine infection risk 38.0% vs 13.0% with active care 2
Slide 9: Indications for Hospitalization (Incomplete Abortion)
Absolute Indications 4:
- Severe bleeding with hemodynamic instability
- Signs of intrauterine infection (tachycardia, purulent discharge, uterine tenderness)
- Gestational age >12 weeks
- Hemoglobin <7 g/dL or need for transfusion
Relative Indications 4:
- History of preterm labor or PPROM
- Significant distance from hospital
- High-risk coexisting medical conditions
- End-stage renal disease
Safe Outpatient Criteria 4:
- Stable vital signs
- No infection signs
- Mild-moderate controlled bleeding
- Gestational age ≤12 weeks
Slide 10: Management of Missed Abortion
Expectant management is ABSOLUTELY CONTRAINDICATED 2, 5:
- Risk of intrauterine infection increases with time
- Risk of coagulopathy with prolonged retention
- Risk of maternal sepsis 2, 5
Recommended Management by Gestational Age 2, 5:
<9 weeks: Medical or surgical options
9-12 weeks: Surgical evacuation preferred
- Dilation and evacuation (D&E) 2
>12 weeks: D&E is procedure of choice 2
Critical Safety Point: If infection suspected, initiate broad-spectrum antibiotics immediately and proceed with urgent evacuation without waiting for confirmatory tests 2, 5
Slide 11: Critical Pitfalls to Avoid
- Wait for fever to diagnose infection - look for tachycardia, purulent discharge, uterine tenderness
- Delay definitive treatment waiting for laboratory results if infection suspected
- Use expectant management in confirmed missed abortion
- Administer methylergonovine BEFORE complete uterine evacuation (causes sustained contraction trapping retained tissue) 5
- Forget Rh prophylaxis in Rh-negative women
- Initiate broad-spectrum antibiotics immediately if infection suspected
- Proceed with urgent evacuation without delay
- Administer 50 μg anti-D immunoglobulin to ALL Rh-negative women
- Provide contraceptive counseling immediately (ovulation resumes in 2-4 weeks) 2
Slide 12: Rh Immunoprophylaxis - Universal Requirement
ALL Rh-negative women with any type of spontaneous abortion must receive anti-D immunoglobulin 2, 4, 5:
- Dose: 50 μg for abortion/miscarriage 2, 4
- Rationale: Fetomaternal hemorrhage occurs in 32% of spontaneous abortions 2
- Timing: Administer as soon as diagnosis confirmed
- Consequence of omission: Alloimmunization affecting future pregnancies 4
Slide 13: Complications and Their Management
- May require transfusion if Hgb <7 g/dL
- Surgical evacuation has lowest bleeding risk (9.1%)
- Oxytocin slow IV infusion (<2 U/min) AFTER complete evacuation 5
- More common with incomplete or missed abortion
- Broad-spectrum antibiotics + urgent surgical evacuation
- Intrauterine infection rate: 38% expectant vs 13% active management
Long-term Complications 2:
- Asherman syndrome (intrauterine adhesions) from aggressive/repeated curettage
- Alloimmunization if Rh prophylaxis omitted
Uterine Perforation 2:
- Rare complication of surgical procedures
- Higher risk with sharp curettage vs vacuum aspiration
Slide 14: Psychological Considerations and Follow-up
Psychological Impact 3:
- Women at increased risk for depression and anxiety up to 1 year post-abortion
- Address feelings of guilt and grief process
- Provide guidance on coping with friends and family
- Confirm complete resolution clinically and/or with ultrasound
- Immediate contraceptive counseling - ovulation resumes within 2-4 weeks 2
- Combined hormonal contraceptives or implants can start immediately 2
- If contraception started within 7 days, no backup method needed 2
- Monitor for signs of retained tissue or infection
- Prognosis for subsequent pregnancy is good (except recurrent abortion) 3, 8
Slide 15: Key Takeaways - Management Algorithm
Threatened Abortion: Expectant + Rh prophylaxis 2, 3
Inevitable Abortion: Surgical evacuation (vacuum aspiration) + Rh prophylaxis 2, 4
- Stable, minimal bleeding, <12 weeks → Medical or expectant options
- Moderate-severe bleeding OR >12 weeks → Surgical evacuation
- Any infection signs → Antibiotics + urgent surgical evacuation
Missed Abortion: Active evacuation ONLY (never expectant) + Rh prophylaxis 2, 5
- <12 weeks: Medical or surgical
12 weeks: D&E
Universal: 50 μg anti-D immunoglobulin for ALL Rh-negative women 2, 4, 5