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Spontaneous abortion: ManagementAuthorsTogas Tulandi, MD, MHCMHaya M Al-Fozan, MDSection Editor

Robert L arbieri, MDDe!uty EditorSandy " Fal#, MDDisclosuresAll to!ics are u!dated as ne$ e%idence beco&es a%ailable and our!eer re%ie$ !rocessis co&!lete'Literature re%ie$ current through( Se! )*+' This to!ic last u!dated( abr )., )*+)'

/0TR1D2CT/10 3 S!ontaneous abortion, also #no$n as &iscarriage, re4ers to a!regnancy that ends s!ontaneously be4ore the 4etus has reached a %iable gestational age'The &anage&ent o4 di44erent ty!es o4 s!ontaneous abortion $ill be discussed here'

1ther as!ects o4 s!ontaneous abortion, including the clinical &ani4estations anddiagnosis o4 the di44erent ty!es o4 abortion, are re%ie$ed se!arately' 5See 6S!ontaneousabortion( Ris# 4actors, etiology, clinical &ani4estations, and diagnostic e%aluation6'7

THREATE0ED A1RT/10 3 8o&en $ith threatened abortion ha%e traditionallybeen &anaged e9!ectantly until their sy&!to&s resol%e, a de4initi%e diagnosis o4non%iable !regnancy can be &ade, or there is !rogression to an ine%itable, inco&!lete,or co&!lete abortion'

The use o4 !rogestins to reduce the ris# o4 &iscarriage a&ong $o&en $ith threatened

abortion is contro%ersial' A &eta-analysis that included 4our rando&ized trials $ith atotal o4 .)+ $o&en 4ound that the rate o4 s!ontaneous abortion $as statisticallysigni4icantly lo$er $ith !rogestin treat&ent co&!ared $ith !lacebo or no treat&ent 5+.%ersus ): !ercent; relati%e ris# *'

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SEBT/C A1RT/10 3 Sus!ected se!tic abortion $ith retained !roducts o4 conce!tionshould be &anaged by(

Stabilizing the !atient

1btaining blood and endo&etrial cultures

Bro&!tly ad&inistering !arenteral broad s!ectru& antibiotics 5eg, clinda&ycin=** &g e%ery eight hours and genta&icin< &g#g daily $ith or $ithouta&!icillin) g e%ery 4our hours; or a&!icillin and genta&icin and &etronidazole

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A co&!lete abortion theoretically should not reuire thera!y, but co&!lete abortionsgenerally cannot be reliably distinguished 4ro& inco&!lete abortions either clinically orultrasonogra!hically' As a result, so&e !ro%iders !er4or& suction curettage in all o4these !atients @=' Due to a !ossible ris# o4 intrauterine adhesions, $e do not ad%ocatethis a!!roach' /n addition, treat&ent o4 intrauterine adhesions is not al$ays 4ollo$ed by

a !regnancy' 5See GSurgical &anage&entGbelo$ and 6/ntrauterine adhesions6'7

The surgical &anage&ent o4 co&!lete abortion is not based u!on data 4ro& co&!arati%etrials' /t see&s clear that surgery is necessary 4or $o&en $ith e9cessi%e bleeding,unstable %ital signs, or ob%ious signs o4 in4ection' 8hether the uterus should bee%acuated in unco&!licated cases needs to be deter&ined by studies that co&!are%arious treat&ent a!!roaches and consider the ty!e o4 &iscarriage 5inco&!lete orco&!lete7, the gestational age, and the clinical status and !re4erences o4 the &other' /nour e9!erience, i4 the ultrasound sho$s an e&!ty uterus and the bleeding is &ini&al, no4urther action is needed'

/0C1MBLETE, /0E/TALE, A0D M/SSED A1RT/10 3 8o&en $ith aninco&!lete, ine%itable, or &issed abortion docu&ented by ultrasound e9a&ination can

be &anaged surgically, &edically, or e9!ectantly' Syste&atic re%ie$s o4 rando&izedclinical trials o4 surgical, &edical, and e9!ectant &anage&ent o4 $o&en $ith 4irsttri&ester &issed or inco&!lete abortion generally concluded that all o4 the thera!ies$ere e44ecti%e, but co&!lete e%acuation $ithin . hours $as &ore li#ely $ith surgicalthan &edical &anage&ent and &ore li#ely $ith &edical than e9!ectant &anage&ent@+*-+)' These analyses $ere li&ited by &issing data, di44erent a!!roaches to &edicaland e9!ectant &anage&ent, and nonstandardized outco&es' Maor co&!lications $erein4reuent 4or all o4 the &ethods, and !atient satis4action could not be assessed'

Subseuent to these syste&atic re%ie$s, a rando&ized trial 5M/ST7 co&!aring surgical,&edical, and e9!ectant &anage&ent o4 4ailed !regnancy in +)** $o&en re!orted thatthe incidence o4 in4ection $as ) to !ercent 4or all three grou!s @+; thus, the ris# o4in4ection is not an i&!ortant %ariable in choosing the thera!eutic a!!roach'

Surgical &anage&ent 3 The con%entional treat&ent o4 4irst or early second tri&ester4ailed !regnancy is dilatation and curettage 5DIC7 or dilatation and e%acuation 5DIE7to !re%ent !otential he&orrhagic and in4ectious co&!lications 4ro& the retained

!roducts o4 conce!tion @+.' This !rocedure carries anesthesia ris#s and co&!licationssuch as uterine !er4oration, intrauterine adhesions, cer%ical trau&a, and in4ection, $hich

&ight lead to subseuent in4ertility or ecto!ic !regnancy @+

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based on a &eta-analysis that 4ound $o&en gi%en !eriabortal antibiotics had a .)!ercent lo$er ris# o4 in4ection @+=' These trials in%ol%ed $o&en undergoing inducedabortion, but it is li#ely si&ilar bene4its $ould be obser%ed 4or $o&en undergoingsurgical e%acuation o4 a 4ailed !regnancy' Ho$e%er, the only rando&ized trial thate%aluated antibiotic !ro!hyla9is be4ore curettage 4or inco&!lete abortion did not

obser%e a signi4icant decrease in 4ebrile &orbidity @)*'

Medical treat&ent 3 The a%ailability o4 e44ecti%e &edical thera!ies 4or inducingabortion has created ne$ o!tions 4or $o&en $ho $ant to a%oid surgery and in areas$here surgical inter%ention is not !ractical' Miso!rostol5a !rostaglandin E+ analog7 isthe &ost co&&only used such agent' /ts sa4ety and e44ecti%eness ha%e been established

by &ulti!le rando&ized and controlled trials @)+,))' The ad%antages o4 &iso!rostolo%er other drugs 5including !rostaglandin E)7 are its lo$ cost @), lo$ incidence o4side e44ects $hen gi%en intra%aginally, stability at roo& te&!erature, and readya%ailability' The ris# o4 a &aor co&!lication is rare'

The e44icacy o4 &iso!rostol4or &edical &anage&ent o4 !regnancy 4ailure in the 4irsttri&ester $as illustrated in a large, $ell-designed trial in $hich :

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The o!ti&u& dose and route and 4reuency o4 ad&inistration ha%e not been established'/n a consensus !a!er by an e9!ert grou! con%ened by the 8orld Health 1rganization in)**?, t$o di44erent regi&ens o4 &iso!rostol$ere !ro!osed @(

For &issed abortion J ** &cg !er %agina& 1R :** &cg sublingually 5each o4

these is a single dose7 For inco&!lete abortion J :** &cg orally 5single dose7

1ur !re4erence is to use &iso!rostol.** &cg !er %agina& e%ery 4our hours 4or 4ourdoses to ta#e ad%antage o4 the increased e44ecti%eness o4 the %aginal route $hile&ini&izing the ris# o4 side e44ects, $hich are dose and route de!endent' The e9!ulsionrate is ?* to =* !ercent $ithin ). hours; thus, so&e $o&en $ill still reuire surgicale%acuation' Ho$e%er, the i&&ediate, short-ter&, and &ediu&-ter& &edicalco&!lications associated $ith &iso!rostol use are signi4icantly lo$er than $ith surgery@)'

A co&bination o4 a !rogesterone antagonist 5&i4e!ristone7 and &iso!rostol5.** &cgorally7 has also been used @=' Due to lo$ seru& !rogesterone le%els in $o&en $ithabnor&al !regnancy @.*, the %alue o4 adding a !rogesterone antagonist is uestionableand e9!ensi%e' This hy!othesis $as su!!orted by a !ros!ecti%e cross-o%er trial and arando&ized controlled trial, both o4 $hich re!orted that &iso!rostol alone or aco&bination o4 &iso!rostol and &i4e!ristone had si&ilar success rates in treat&ent o4early !regnancy 4ailure @.+,.)' 5See 6Thera!eutic use and ad%erse e44ects o4

!rogesterone rece!tor antagonists and selecti%e !rogesterone rece!tor &odulators6'7

Batients $ho are treated &edically are instructed to go to the e&ergency de!art&ent i4they de%elo! e9cessi%e bleeding' Tissues that are !assed %aginally should be !laced in acontainer and brought to the hos!ital 4or analysis'

The long-ter& conce!tion rate and !regnancy outco&e are si&ilar 4or $o&en $houndergo &edical or surgical e%acuation 4or early !regnancy 4ailure @.'

Methotre9ateis not used in &anage&ent o4 s!ontaneous abortion'

Second tri&ester 3 Second tri&ester abortion is associated $ith higher rates o4co&!lications than 4irst tri&ester abortion @..' For e9a&!le, u! to +* !ercent o4$o&en undergoing induced &edical abortion $ill reuire hos!italization 4or &edical,

social, or geogra!hical reasons @.

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noninter%ention @++' Rando&ized trials co&!aring &edical &anage&ent to EM ha%ere!orted si&ilar rates o4 success4ul e%acuation @

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on se%eral 4actors, including the sco!e o4 costs considered in the analysis and theco&&unity in $hich the costs are incurred @:-::'

B1STA1RT/10 CARE A0D C120SEL/0 3 8o&en are ad%ised to &aintain!el%ic rest 5ie, nothing !er %agina7 until t$o $ee#s a4ter e%acuation or !assage o4 the

!roducts o4 conce!tion, at $hich ti&e