Early pregnancy loss: Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:49

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.

Unstable patient0:49–1:44

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.

Incomplete abortion1:44–3:37

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.

Septic abortion3:37–4:53

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.

Stable Patient4:53–5:43

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.Patients might present with vaginal bleeding and uterine cramping, or they might be completely asymptomatic and be presenting for their initial prenatal visit.
The most important risk factor for early pregnancy loss is advanced maternal age, meaning older than 35 years, due to the increased potential for fetal chromosomal abnormalities.
Other risk factors include having a previous pregnancy loss, or medical conditions like diabetes or obesity. On labs, you can expect to find a positive hCG.
If your patient is experiencing these symptoms, you should suspect early pregnancy loss and order a pelvic ultrasound. Okay, let’s start with a missed abortion.

Missed abortion5:43–8:45

This is when an early pregnancy loss occurs without any symptoms and is often discovered incidentally. If you perform a cervical exam, the os will be closed.
As for the ultrasound, there are very specific findings to make the diagnosis of a missed abortion. These include a crown-rump length of 7 mm or greater without cardiac activity; or a mean gestational sac diameter of 25 mm, and no embryo.
This is called an anembryonic gestation, also known as the blighted ovum. If your patient had an ultrasound earlier in the pregnancy, an early loss is confirmed by the absence of an embryo with a heartbeat 2 weeks or more after a previous ultrasound showed a gestational sac without a yolk sac; or by the absence of an embryo with a heartbeat 11 days or more after an ultrasound that showed a gestational sac with a yolk sac.
These signs are very important to ensure you don’t misdiagnose a viable pregnancy, such as when menstrual dates are inaccurate and the gestational age is less than anticipated.
Now that you have made the diagnosis of a missed abortion, let's talk about treatment options, which will vary depending on how far along the pregnancy is, what medical complications the patient may have, and what your patient desires.
A diagnosis of a missed abortion can be shocking to your patient and you should offer empathy and support. They might need some time to decide how they want to proceed.
First, you can offer expectant management, which is exactly what it sounds like. It’s waiting to see if the body expels the pregnancy tissue without any intervention.
Within up to 8 weeks, expectant management should achieve complete expulsion in the majority of patients. This is okay to do as long as there are no signs of infection or hemorrhage, but use caution with expectant management if your patient is closer to the end of the first trimester as it may be more difficult to pass spontaneously.The second option is medical management with high dose vaginal misoprostol alone, or with the addition of oral mifepristone.
Similar to expectant management, this is a good option for many patients as long as there are no signs of infection or hemorrhage because it can shorten the time to complete expulsion in those who prefer to avoid surgery.
The third treatment option is surgical by performing a suction D&C. Your patient might prefer surgical management to avoid experiencing the passage of POC, which can be traumatic.
Surgical treatment is preferred in those patients with severe anemia or bleeding disorders, to avoid the possibility of hemorrhage during spontaneous expulsion.
Finally, remember to administer Rh immune globulin to your patients if their blood type is Rh-negative!Alright, let’s move on to threatened abortion.

Threatened abortion8:45–9:26

These patients report vaginal bleeding, possibly accompanied by uterine cramping, but no passage of POC. On exam, you may see uterine bleeding from the cervix, but the cervical os is closed.
A pelvic ultrasound will reveal evidence of an intrauterine pregnancy. Treatment is with expectant management and pelvic rest, meaning refraining from sexual intercourse, the use of tampons, or placement of anything within the vagina.
Don’t forget to give Rh immune globulin if your patient is Rh-negative.The next type of early pregnancy loss is inevitable abortion.

Inevitable abortion9:26–10:07

This type presents with vaginal bleeding, likely associated with uterine cramping, but on exam, the cervical os will be open.
A pelvic ultrasound will reveal evidence of an intrauterine pregnancy, but passage of POC is imminent. Treatment is again with expectant management and Rh immune globulin if your patient is Rh-negative.
Here’s a clinical pearl! Patients should be educated on when to return for medical evaluation, including if they soak two maxi pads per hour for 2 consecutive hours, or if they develop a fever.Finally, a complete abortion is when there has been complete passage of POC.

Complete abortion10:07–10:39

Your patient will likely have had vaginal bleeding and uterine cramping that may still be present. On exam, the cervical os will be closed and pelvic ultrasound will reveal an absence of a gestational sac, although the endometrium may still appear thickened.
As for the treatment, it involves expectant management and Rh immune globulin if your patient is Rh-negative.Alright, as a quick recap… Early pregnancy loss is when a pregnancy fails in the first trimester.

Review10:39–11:25

Unstable patients need rapid stabilization with IV fluids; possibly blood transfusion if hemorrhaging; IV antibiotics if septic abortion is present; as well as surgical management with suction D&C.
On the other hand, stable patients with early pregnancy loss can have either a missed, threatened, inevitable, or complete abortion.
Treatment for threatened, inevitable, and complete abortions typically involves expectant management, while missed abortions can be treated with expectant management; medical management with misoprostol alone or with the addition of mifepristone; or surgical management with suction D&C.