Early pregnancy loss: Clinical sciences

Pregnancy loss, also known as miscarriage or abortion, is the loss of an intrauterine pregnancy up to 19 weeks 6 days, and when it occurs in the first trimester, it’s called early pregnancy loss. Early pregnancy loss is common and approximately half are caused by fetal chromosomal abnormalities.

There are several different types of early pregnancy loss defined by patient symptoms, open versus closed cervical os, and if there has been passage of products of conception, or POC. Incomplete abortion with hemorrhage and septic abortions can cause patients to be unstable, while missed, threatened, inevitable, and complete abortions typically occur in stable patients.

Your first step in evaluating a patient presenting with a chief concern suggesting early pregnancy loss is to perform a CABCDE assessment to determine if they are stable or unstable. If your patient is unstable, start with acute management. Control the hemorrhage if present and stabilize the airway, breathing, and circulation. You may need to intubate the patient. Then, obtain IV access and continuously monitor their vital signs.

Next, obtain a focused history, physical exam, and labs including hCG, CBC, and blood type with crossmatch in case a transfusion is needed. Also, get a bedside pelvic ultrasound focusing on the uterine contents, which will help with the diagnosis. However, don’t delay treatment while waiting for the diagnosis, since hypovolemic or septic shock can be life-threatening!

Alright, history might reveal heavy vaginal bleeding, painful uterine cramping, and possible syncope. Vital signs will likely show hypotension and tachycardia. On pelvic exam, you may observe profuse bleeding coming from the cervical os. On closer inspection, the cervical os will be open, and you might see POC protruding from the os.

When it comes to labs, you’ll usually find a positive hCG, and possibly anemia. Keep in mind that the CBC may not accurately reflect the degree of blood loss, as hemorrhage can rapidly evolve and it takes time for lab values to reflect that. Finally, the pelvic ultrasound might reveal a gestational sac or retained POC, and no evidence of ectopic pregnancy. These findings are consistent with an incomplete abortion, which is when there is passage of some, but not all POC.

Here’s a clinical pearl! Distinguishing between early pregnancy loss and ectopic pregnancy might be difficult. If you have any suspicion of ectopic pregnancy in an unstable patient, call gynecologic surgery for consultation.

As for the treatment, start IV fluid resuscitation and prepare to give blood products. Obtain a gynecologic surgical consult and then move your patient to the OR for a suction dilation and curettage, or D&C. This will evacuate the POC from the uterus, which should stop the bleeding. Ultrasound guidance might be necessary to ensure the uterus is completely evacuated. Finally, if your patient is Rh-negative, give them Rh-immune globulin within 72 hours.

Now let’s talk about unstable patients with a septic abortion, which occurs when retained POC becomes infected, leading to sepsis. Your patient will report a fever, possible syncope, and they may likely have uterine cramping or pain. A key feature to keep in mind is a recent history of early pregnancy loss or elective abortion. On physical exam, you will likely note hypotension, tachycardia, and fever at or above 38 degrees Celsius. There will also be a purulent cervical discharge and uterine tenderness.

Now, labs will likely show a positive hCG, and pelvic ultrasound will usually show retained POC, but keep in mind a negative HCG and a normal pelvic ultrasound do not rule out septic abortion!

Start treatment with IV fluid resuscitation, and administer broad-spectrum IV antibiotics, such as piperacillin-tazobactam, or the combination of ampicillin, gentamicin, and clindamycin. Finally, obtain a gynecologic surgery consultation for a suction D&C, and administer Rh Immune Globulin if your patient is Rh-negative.

Alright, let's go back and talk about stable patients. Your first step here is to obtain a focused history and physical, as well as hCG and blood type, especially if they don’t already know they are pregnant.