Jessica M. Ciaburri
History of present illness
A 24-year-old gravida 2, para 1 woman presents to the urgent care clinic after she began having vaginal bleeding and pelvic pain the previous night. She comes with her partner and reports that she had a positive home pregnancy test approxi- mately two weeks prior. She is tearful and asks,“Do you think I’m losing the baby?”She is a healthy adult with a benign past medical history and in the past carried a pregnancy to term without complications.
Her vaginal bleeding is similar to a heavy menstrual cycle and she is changing a pad every two hours. She has pain in the suprapubic region and describes it as a cramping sensation.
The patient has not tried any over-the-counter pain relievers, as she was unsure if these would be harmful to her fetus. The review of systems is negative for fever or chills, nausea, vomiting, or dysuria.
Physical examination
General appearance:Alert-and-oriented woman who is tearful
Vital signs:
Temperature: 37.0°C Pulse: 98 beats/min
Blood pressure: 110/65 mmHg Respiratory rate: 18 breaths/min Oxygen saturation: 100% on room air HEENT:Unremarkable
Neck:Supple
Cardiovascular:Regular rate and rhythm without rubs, murmurs, or gallops
Lungs:Clear to auscultation bilaterally
Abdomen:Soft, nondistended, normal bowel sounds, tender to palpation in the suprapubic region without associated rebound or guarding
Pelvic:
Speculum: Moderate amount dark red blood and tissue/
clot in vaginal vault
Bimanual: Cervix 1 cm dilated, no cervical motion tenderness, uterus ~8 weeks’size, anteverted, nontender, bilateral adnexa nontender
Extremities:No clubbing, cyanosis, or edema Neurologic:Nonfocal
Laboratory studies:
Urine pregnancy test: Positive
Quantitative beta-hCG: 3500 mIU/mL Hb: 11.0 g/dL (normal 12–16 g/dL) Blood type and Rh: O negative Urinalysis: Negative
How would you manage this patient?
This patient is experiencing a spontaneous abortion, defined as a loss of a pregnancy at less than 20 weeks without medical intervention–synonymous with miscarriage. Hemorrhage into the decidua basalis, followed by necrosis of the early pregnancy tissue, usually accompanies an early miscarriage.
As the gestational sac and placental tissue detach from the uterine wall, contractions occur in an effort to expel the preg- nancy tissue. With an incomplete abortion, the internal cer- vical os opens to allow passage of blood. The fetus and placenta may remain entirely in utero or may partially extrude through the dilated os. In addition to the above physical examination findings and laboratory values, imaging using transvaginal ultrasound will help to confirm the diagnosis and aid the clinician in helping the patient choose an appropriate manage- ment strategy (Fig. 29.1).
When choosing a treatment strategy,first and foremost the hemodynamic stability of the patient should be assessed. Signs such as hypotension, tachycardia, heavy vaginal bleeding, fever, or altered mental status necessitate immediate action on the part of the practitioner to begin fluid resuscitation, administer blood products and antibiotics as indicated, and transport the patient emergently to the operating room for definitive surgical management. In our patient, there is time to discuss treatment options to find the best management strategy to help her cope physically and emotionally with her loss. The approach to managing early pregnancy loss should be individualized, as current literature supports relatively equal efficacy of medical and surgical treatments [1].
A Cochrane review completed in November 2012 sought to review data from available randomized control trials com- paring medical treatment with expectant care or surgery for incomplete abortion before 24 weeks. Twenty studies were included, encompassing 4208 women. Ultimately, it was determined that in pregnancies less than or equal to 13 weeks’ gestation, success rates were high for all treatment options.
The conclusion statement suggested that medical treatment
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
with misoprostol and expectant care are both acceptable alter- natives to surgical evacuation given the availability of health service resources to support all three approaches [1].
Once a nonviable pregnancy has been identified, manage- ment focuses not only on the evacuation of products of conception but also on the patient’s personal feelings about the pregnancy and beginning the grief process. Studies have documented that women who are given a choice in how to deal with their miscarriage have improved psychological health [2].
Expectant management
For women with incomplete abortions less than 12 weeks’
gestation expectant management has been shown to have approximately a 50% success rate in various randomized con- trol trials [1]. Expectant management is often a safe initial treatment option. The patient should be given precautions regarding signs and symptoms of infection (fever, chills, foul smelling vaginal discharge, severe abdominal pain) and hem- orrhage (weakness, dizziness, heavy vaginal bleeding with clots, using one pad per hour) along with instructions to seek medical evaluation if these occur. A follow-up appointment should be scheduled for 10–14 days later to reassess [3].
Medical management
The most common choice for medical management of an incomplete abortion is the prostaglandin E1 analog, misopros- tol. Study data has not clearly identified one misoprostol regimen or route to be superior to the others. Current accepted misoprostol regimens include a single dose of either 600 àg orally, 800 àg vaginally, or 400 àg sublingually [4]. Depending on the study, the success rates of completing the spontaneous abortion medically range from 71 to 99%. Misoprostol given by the vaginal route is generally preferred given that serum
levels remain higher for a longer period of time, and uncom- fortable gastrointestinal side effects including nausea, vomiting, and diarrhea are minimized. It is reasonable to prescribe a pretreatment dose of an anti-emetic. Patients should be coun- seled regarding expected side effects of bleeding and cramping pelvic pain. Passage of tissue should occur within 48–72 hours of medical therapy, and if this is unsuccessful, then surgical management is warranted [4].
Surgical management
In the past, surgical management of incomplete abortion with suction dilation and curettage was the gold standard.
Surgical treatment is definitive and predictable, with a near 100% success rate in completing early pregnancy failures. But dilation and curettage is also invasive and carries additional risks, including uterine perforation, cervical laceration, hem- orrhage, incomplete removal of pregnancy tissue, infection, and Asherman syndrome [3]. Surgical management is the recommended treatment course for gestations greater than or equal to 12 weeks. Antibiotic prophylaxis is needed to decrease infection risk. A common antimicrobial regimen is: Doxycy- cline 100 mg PO prior to procedure and 200 mg PO post- procedure. Broad spectrum antibiotic coverage is needed if a septic abortion is suspected.
Additional considerations
Within 72 hours of identifying a spontaneous abortion, Rh-negative women should receive a 50 àg dose of anti-D immune globulin (RhoGAM®). Following miscarriage as many as 5% of women will become isoimmunized without it [5]. It is important to provide a comforting environment for patients experiencing early pregnancy loss. It may be helpful to provide them with local resources for support groups and
Fig. 29.1 Transvaginal ultrasound.
Case 29: Abdominal pain and vaginal bleeding in a 24-year-old woman
reputable websites such as the March of Dimes (www.march- ofdimes.com), which can help them through the grieving pro- cess. It is also essential to begin a dialogue about the patient’s desire for future conception. Women under age 35 have approximately a 10% chance of spontaneous abortion with any given pregnancy; this is not increased after a single early pregnancy loss [3]. If desired an appropriate contraceptive should be initiated.
Key teaching points
An incomplete abortion is defined by an open internal cervical os accompanied by vaginal bleeding. The fetus and placenta may remain in utero or partially extrude through the dilated os.
If signs of hemodynamic instability or acute sepsis are identified in a patient with an incomplete abortion, urgent surgical management is indicated.
In hemodynamically stable, afebrile women at less than or at 12 weeks’gestation, it is prudent to counsel the patient and allow her to choose between expectant, medical, and surgical management given the high success rates for completion of the abortion with all three treatment plans.
Women choosing expectant management should be followed up in clinic within 10–14 days to determine whether or not the abortion has completed spontaneously.
The preferred route for misoprostol administration is 800 àg placed vaginally. This route greatly decreases irritating gastrointestinal side effects.
Surgical management with suction dilation and curettage is nearly 100% effective and is the recommended treatment modality for gestations greater than 12 weeks.
Administration of RhoGAM to Rh-negative women experiencing a spontaneous abortion should be done within 72 hours to prevent isoimmunization.
References
1. Neilson JP, Gyte GML, Hickey M, Vazquez JC, Dou L. Medical treatments for incomplete miscarriage.Cochrane Database Syst Rev2013, Issue 3. Art.
No.: CD007223. DOI: 10.1002/
14651858.CD007223.pub3.
2. Wieringa-De Waard M, Hartman EE, Ankum WM, et al. Expectant
management versus surgical evacuation infirst trimester miscarriage: health- related quality of life in randomized and non-randomized patients.Hum Reprod 2002;17(6):1638–42.
3. Puscheck EE, Lucidi RS.Early Pregnancy Loss. Available athttp://
reference.medscape.com/article/
266317-overview.
4. Allen R, O’Brien BM. Uses of misoprostol in obstetrics and gynecology.Rev Obstet Gynecol2009;
2(3):159–68.
5. American College of Obstetricians and Gynecologists. Prevention of Rh D alloimmunization. Practice Bulletin No. 4.Obstet Gynecol1999;5:1–7.
Reaffirmed 2010.