incomplete abortion

Definition:
In an incomplete abortion , parts of the fetus or placental material is retained within the uterus. Typical symptoms include vaginal bleeding and lower abdominal cramping.

In most cases, a surgical intervention called curettage is performed to remove the remaining material from the uterus. The goal of this treatment is to prevent prolonged bleeding or infection.


Background: The most common complication of pregnancy is spontaneous abortion, which occurs in an estimated 10-15% of pregnancies. Spontaneous abortions are categorized as threatened, inevitable, incomplete, complete, or missed. Spontaneous abortions can be classified further as sporadic or recurrent. By definition, an incomplete abortion is the partial expulsion of the products of conception before the 20th week of gestation.


Pathophysiology: The timing of miscarriage suggests the pathophysiology of a spontaneous abortion. Genetic anomalies (eg, trisomies); hormonal abnormalities; and infectious, immunologic, and environmental factors usually result in first-trimester pregnancy loss. Anatomic factors usually are associated with second-trimester pregnancy loss. Factor XIII deficiency and a complete or partial deficiency of fibrinogen are associated with recurrent spontaneous abortions.


Frequency:


In the US: Many pregnancies are not viable. According to estimates, 50% of pregnancies terminate spontaneously before the first missed menstrual period; these abortions usually are not clinically recognized. Spontaneous abortion typically is defined as a clinically recognized (ie, by blood test or ultrasound) pregnancy loss before 20 weeks' gestation.
Mortality/Morbidity: Surveillance data from 1987 through 1990 reveal a total of 1459 pregnancy-related deaths in the US. Spontaneous and induced abortions accounted for 5.6% of these deaths.

Race: Surveillance data for pregnancy-related deaths from 1987 through 1990 demonstrate more deaths due to ectopic pregnancy and spontaneous and induced abortion among African American women than among Caucasian women. Fourteen percent of pregnancy-related deaths among black women were due to ectopic pregnancies; 7% were due to abortions. Among white women, data show that 8% of pregnancy-related deaths were due to ectopic pregnancies; 4% were due to abortions.

Age:

Age and increased parity affect a woman's risk of miscarriage. In women younger than 20 years, miscarriage occurs in an estimated 12% of pregnancies. In women older than 20 years, miscarriage occurs in an estimated 26% of pregnancies.
Age primarily affects the oocyte. When oocytes from young women are used to create embryos for transfer to older recipients, implantation and pregnancy rates mimic those seen in younger women. The number of miscarriages and chromosomal anomalies decreases, suggesting that the uterus is not responsible for poor outcomes in women of advanced reproductive age.

History: Although classified as different entities, incomplete and inevitable miscarriages present in a similar clinical fashion and have similar treatment. An inevitable abortion involves continuous and progressive dilation of the cervix without expulsion of the products of conception before the 20th week of gestation.

The patient history should include the following:
Last menstrual period (LMP)
Estimated length of gestation
Ultrasound results, if previously performed
Bleeding (eg, degree, duration, presence/passage of tissue): Bleeding may be quantified roughly by the number of pads soaked per hour or day. An average pad absorbs approximately 20-30 mL of blood.
Physical:

Vital signs should be within reference ranges unless infection is present or hemorrhage has caused hypovolemia.
The abdomen usually is soft and nontender.
On pelvic examination, products of conception may be partially present in the uterus, may protrude from the external os, or may be present in the vagina. Bleeding and cramping usually persist.
The cervix appears dilated and effaced.
Bimanual examination reveals an enlarged and soft uterus.
Causes:

Genetic factors

Approximately 5% of spontaneous abortions occur because of genetic factors.

Trisomy chromosomes commonly are encountered, with trisomy 16 accounting for approximately a third of chromosomal abnormalities in early pregnancy.
Anatomic factors: Congenital or acquired anatomic factors are reported to occur in 10-15% of women who have recurrent spontaneous abortions.
Congenital anatomic lesions include müllerian duct anomalies (eg, septate uterus, diethylstilbestrol [DES]-related anomalies). Müllerian duct lesions usually are found in second-trimester pregnancy loss.
Anomalies of the uterine artery with compromised endometrial blood flow are congenital.
Acquired lesions include intrauterine adhesions (ie, synechiae), leiomyoma, and endometriosis.
Endocrine factors

Endocrine factors potentially contribute to recurrent abortion in 10-20% of cases.
Luteal phase insufficiency (ie, abnormal corpus luteum function with insufficient progesterone production) is implicated as the most common endocrine abnormality contributing to spontaneous abortion.
Hypothyroidism, hypoprolactinemia, poor diabetic control, and polycystic ovarian syndrome are contributive factors in pregnancy loss.
Infectious factors
Presumed infectious etiology may be found in 5% of cases.
Bacterial, viral, parasitic, fungal, and zoonotic infections are associated with recurrent spontaneous abortion.
Immunologic factors
Immunologic factors may contribute in up to 60% of recurrent spontaneous abortions.
Both the developing embryo and the trophoblast may be considered immunologically foreign to the maternal immune system.
Antiphospholipid antibody syndrome generally is responsible for more second-trimester pregnancy losses than first-trimester losses.
Miscellaneous factors
Miscellaneous factors may account for up to 3% of recurrent spontaneous abortions.
Other contributing factors implicated in sporadic and recurrent spontaneous abortions include environment, drugs, placental abnormalities, medical illnesses, and male-related causes.


Lab Studies:


Complete blood count with differential
Blood type and Rh factor
Qualitative and quantitative human chorionic gonadotropin-beta
Factor XIII and fibrinogen
Imaging Studies:


Ultrasound is useful in evaluation of incomplete abortion.
An incomplete abortion may demonstrate a variety of sonographic findings as follows:
The gestational sac may be misshaped or collapsed, or it may be intact, containing a nonliving embryo. In addition, an irregular complex mass within the endometrial or endocervical canal may be present.
Echogenic material or debris within the endometrial canal may represent retained products of conception or clotted blood.
First-trimester molar pregnancies may simulate an incomplete abortion, with echogenic material within the endometrial cavity that has no characteristic vesicles or cysts.
Intrauterine fluid collections may represent pseudogestational sacs found in ectopic pregnancies.
Studies suggest no statistically significant relationship between the initial presence of a gestational sac or endometrial thickness and the success rate or expectant management.
Procedures:


Transabdominal ultrasound of the pelvis provides an overall view of the pelvic structures. A full bladder is required as a sonographic window.
Endovaginal ultrasound gives a detailed view of the endometrium of the uterus, ovaries, adnexa, and cul-de-sac. An empty bladder is required for optimal imaging.


Prehospital Care:

Maintain routine universal precautions in view of potentially heavy vaginal bleeding.
Encourage the patient to bring any passed tissue to the hospital for evaluation.
Emergency Department Care:

Treat all patients with vaginal bleeding of any etiology as follows:
Determine hemodynamic stability and treat instability.
Determine pregnancy status (qualitative and quantitative).
Pelvic ultrasonography may be useful in clinically classifying spontaneous abortion. Determination of Rh status and hematocrit usually is indicated.
In most cases, vacuum or suction curettage can be performed in the outpatient setting or the ED.
The treatment goal is evacuation of the uterus to prevent complications such as further hemorrhage and/or infection.
Consultations:

Obstetrics/gynecology consultation is indicated.


Further Inpatient Care:


If bleeding cannot be controlled in the ED, transfer the patient to the operating room (OR) for examination. Anesthetize the patient and perform uterine evacuation.
Further Outpatient Care:


After curettage, observe the patient for 4-6 hours. If stable, the patient can be discharged.
Administer the standard dose of Rho(D) immune globulin (ie, 300 mcg) to women who are Rh-negative to prevent Rh immunization.
Send products of conception for pathologic evaluation.
Complications:


Potential complications include septic abortion and hypovolemic or septic shock.
Preexisting anemia may make patients more susceptible to hypovolemic shock.
Patients with HIV infection who are undergoing curettage may have a higher rate of procedure-related complications but no increase in infectious morbidity.
Prognosis:


The prognosis for a successful pregnancy depends upon the etiology of previous spontaneous abortions.
Correction of an endocrine abnormality in women with recurrent abortion has the best prognosis for a successful pregnancy (>90%).
In women with an unknown etiology of prior pregnancy loss, the probability of achieving successful pregnancies is 40-80%.
The live-birth rate after documentation of fetal cardiac activity at 5-6 weeks of gestation in women with 2 or more unexplained spontaneous abortions is approximately 77%.
Patient Education:


Advise patients to return to the ED upon occurrence of symptoms such as the following:
Profuse vaginal bleeding
Severe pelvic pain
Temperature above 38°C (100.4°F)
Patients may experience intermittent menstrual-like flow and cramps during the following week. The next menstrual period usually occurs in 4-5 weeks.
Patients can resume regular activities when able but should refrain from intercourse and douching for approximately 2 weeks