Threatened Abortion
Threatened Abortion
Definition (WHO)
• It is pregnancy-related bloody vaginal
discharge or frank bleeding during the first
half of pregnancy
• < 20 weeks
• Without cervical dilatation.
HOW TO IDENTIFY?
• During early pregnancy with lower abdominal pain,
and/or vaginal bleeding.
• Nearly 25% of pregnant women have some degree of
vaginal bleeding during the first two trimesters and
about 50% of these progress to an actual abortion.
• The bleeding in a threatened abortion is mild to
moderate.
• The abdominal pain may present as intermittent
cramps.
• Miscarriage is 2.6 times as likely, and 17% of cases are
expected to present complications later in pregnancy
ETIOLOGY
Fetal factors Maternal factors
Maternal infection
Chromosomal Chronic illness
abnormalities.
Extremes of weight
Maternal lifestyle choices
including alcohol, tobacco,
and illicit drug use
EPIDEMIOLOGY
Occur in all races
Women who bear children at an older age.
Increased parity
Previously had a miscarriage
PATHOPHYSIOLOGY
A threatened abortion occurs when a pregnant patient at less than 20 weeks
gestation, presents with vaginal bleeding.
The cervical os is closed on physical exam. The patient may also experience
abdominal cramping and pain.
Vaginal bleeding usually begins first followed by cramping abdominal pain
hours to days later.
Bleeding is the most predictive risk factor for pregnancy loss.
More than half of threatened abortions will abort.
The risk of spontaneous abortion, in a patient with a threatened abortion, is
less if fetal cardiac activity is present.
WHO ARE AT RISK?
Bacterial or viral
infection during Trauma to the abdomen
pregnancy
Advanced maternal age Exposure to certain
(over age 35) medications or chemicals
Other risk factors for a
threatened abortion
include obesity and
uncontrolled diabetes.
Evaluation
Bleeding in the first trimester can originate
from the uterus, cervix, or vagina, or it can be
extra- genital.
Thorough physical examination is essential to
differentiate between genital and extra-
genital causes.
HISTORY AND
PHYSICAL EXAMINATION
• Stable vital signs
• Hypotension – profuse bleeding
• P/A – soft , nontender
• P/V - mild to moderate bleeding/blood stained discharge
seen
• No adnexal tenderness, Os is closed
• Ultrasonography – site of pregnancy, any sub- chorionic
bleeding/haematoma, viability
• Once a threatened abortion is diagnosed, the patient
should be warned not to have sexual intercourse and to go
on bed rest.
DIAGNOSIS
• Measurement of beta-human chorionic gonadotropin
(beta-HCG)
• A beta-HCG level of 1500 lu/ml to -2000 lu/ml is
associated with a gestational sac on ultrasound.
• A beta-HCG doubles in 48 hours in 85% of
intrauterine pregnancies.
• Beta-HCG is usually detectable the first nine to 11
days following ovulation and reaches 200 IU/ml at
the expected time of menses.
Ultrasound
• Transvaginal ultrasound may be used
• To locate the pregnancy and determine if the
fetus is viable.
• Rule out an ectopic pregnancy and to evaluate
for retained products of conception.
• A yolk sac is typically seen at 36 days, and a
heartbeat is seen on ultrasound at approximately
45 days after the last menstruation.
INVESTIGATIONS
• HAEMOGRAM
• BLOOD GROUP RH TYPE
• SICKLING
• BLOOD SUGAR
• URINE ROUTINE
• HIV
• HBSAG
• TSH
• SOS OTHER INVESTIGATIONS
TREATMENT / MANAGEMENT
• Patients with a threatened abortion should be managed
expectantly until their symptoms resolve.
• Patients should be monitored for progression to an inevitable,
incomplete, or complete abortion.
• Analgesia will help relieve pain from cramping.
• Bed rest has not been shown to improve outcomes but
commonly is recommended. Physical activity precautions and
abstinence from sexual intercourse are also commonly advised.
• Repeat pelvic ultrasound weekly until a viable pregnancy is
confirmed or excluded.
• A miscarriage cannot be avoided or prevented, and the patients
should be educated as such.
• Intercourse and tampons should be avoided to decrease the chance of
infection.
• A warning should be given to the patient to return to the emergency
department if there is heavy bleeding or if the patient is experiencing light
headedness or dizziness.
• Heavy bleeding is defined as more than one pad per hour for six hours.
• The patient should also be given instructions to return if they experience
increased pain or fever.
• All patients with vaginal bleeding who are Rh-negative should be treated
with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12
weeks, the likelihood of fetal blood mixture is small in the first trimester.
• A smaller RhoGam dose can be considered in the first trimester. A dose of 50
micrograms to 150 micrograms has been recommended. A full dose can also
be used. Rhogam should ideally be administered before discharge.
• Maternal general diseases (diabetes, hypothyroidism)
and infections should be treated accordingly.
• The most common entity to be treated in this category is
luteal phase deficiency. Progesterone is the most
important hormone for the maintenance of an early
human pregnancy.
• Besides progesterone administration, human chorionic
gonadotropin (HCG) also is the logical endocrine
treatment of choice. In the pregnant woman HCG
stimulates and optimizes hormonal production in the
corpus luteum
Progesterone's
physiological role
• is to prepare the uterus for the implantation of the
embryo, enhance uterine quiescence and suppress
uterine contractions, - preventing rejection of the
embryo.
• Inadequate secretion of progesterone in early
pregnancy has been linked to the aetiology of
miscarriage and progesterone supplementation has
been used as a treatment for threatened
miscarriage to prevent spontaneous pregnancy
loss.
ROLE OF PROGESTERONE
• Progesterone induces secretory changes in the lining
of the uterus, which are important for implantation of
the fertilised ovum
• it modulates the immune response of the mother to
prevent rejection of the embryo through a protein
called progesterone induced blocking factor (PIBF),
which is produced by the lymphocytes
• and it enhances uterine quiescence and suppresses
uterine contractions
• DOSE – 200 MG TDS/QID
• Exposure to environmental toxicants should be avoided -
The contribution of environmental, physical and chemical
agents to the incidence of spontaneous abortion is
controversial.
• They may be abortifacient even if they are not teratogenic.
• Paternal leukocyte immunotherapy - unexplained repeated
spontaneous abortion. This therapeutic approach is
considered experimental, as there may be some significant
risks.
• Maternal antiphospholipid antibodies positive – advice
Administration of corticosteroids with low doses of aspirin
PATIENT EDUCATION
FOR HEALTHY PREGNANACY
• It’s difficult to prevent a miscarriage, but certain
behaviors can help support a healthy pregnancy.
• These include:
• not drinking alcohol
• not smoking cigarettes
• not using illegal drugs
• minimizing consumption of caffeine
• avoiding exposure to toxic chemicals or harsh cleaning solutions
• promptly treating any viral or bacterial infections that occur
• taking prenatal vitamins, such as folic acid
• exercising at least two hours per week as per
SUMMARY
• POINTS One in five pregnancies is complicated by vaginal bleeding
before 20 weeks' gestation
• A large empty gestational sac, discrepancy between gestational age
and crown to rump length, fetal bradycardia or absence of fetal heart
activity at presentation, advanced maternal age, history of recurrent
pregnancy loss, a maternal serum progesterone < 45 nmol/l or low
maternal serum hCG or inhibin A are adverse prognostic factors
• Fetal heart activity and lack of adverse prognostic factors conveys a
favourable prognosis
• Although bed rest and progesterone supplements are often advised,
little evidence supports their effectiveness Give anti-Rh D immune
globulin to non-sensitised women with symptoms near, at, or after 12
gestational weeks
Favourable prognostic factors
• Adverse prognostic factors
• History Advancing gestational age Maternal age >34 years
• Increasing number of previous miscarriagesw
• Sonography Fetal heart activity at presentation Fetal
bradycardia Discrepancy between gestational age and crown
to rump length Empty gestational sac >15-17mm Maternal
serum biochemistry Normal levels of these markers Low β
hCGvalues Free β hCG value of 20ng/m2 β hCG increase <66%
in 48 hrsw9* Bioactive/immunoreactive ratio hCG <0.5w7
Progesterone <45 nmol/l in 1st trimester Inhibin A <0.553
multiples ofmedian CA125 level ≥43.1 U/mL in 1st trimester
CLINICAL FEATURES
• The patient, having amenorrhea, complains of:
• (1) Slight bleeding per vaginam
• (2) Pain: Usually painless; there may be mild backache or
dull pain in lower abdomen
• The uterus and cervix feel soft.
• Digital examination reveals closed external os
• Differential diagnosis includes – cervical ectopy – polyps
or carcinoma – ectopic pregnancy – molar pregnancy
• Ultrasound is diagnostic; Pelvic examination is avoided
when USG is available
Management & Prognosis
• Rest: Patient should be in bed for few days until
bleeding stops
• Relief of pain: Diazepam 5 mg BD
• 80% of pregnancies with threatened abortions go
on until term
• If a live fetus is seen on USG, pregnancy is likely
to continue in over 95% cases.
• If pregnancy continues, there is increased
frequency of preterm labor, placenta previa &
IUGR
