Spontaneous Abortion

Patient at < 20 WGA with h/o thyroid disease, diabetes mellitus, immunologic/thrombophilic disorders, alcohol/tobacco abuse, and previous aneuploid fetus presents with bleeding per vagina. Extreme BMI (see notes), partially dilated cervix with products of conception noted on exam.

• Ultrasound shows uterine structural abnormality and embryo > 5 mm with no cardiac activity

• Treatment (select one of the following):

  • Expectant management

  • Medical management: Administer misoprostol 800 mcg vaginally and repeat dose if complete expulsion does not occur by day 3

  • Surgical management: Schedule procedure (see below)

• Schedule follow up in 2-4 weeks

  • Confirm negative urine beta-hCG

  • Evaluate for grief reaction vs. depression

  • Discuss modifying risk factors associated with spontaneous abortion

Notes

• Etiology

  • 50% of spontaneous abortions are due to chromosomal anomalies

  • Risk factors for spontaneous abortion:

    • Medical conditions: Hypothyroidism, hyperthyroidism, diabetes mellitus, autoimmune/thrombogenic conditions

    • Tobacco and/or excessive alcohol use

    • Extreme BMI, i.e. ≤ 18.5 or ≥ 40 kg/m^2

    • Structural abnormalities, e.g. uterine septum

• Spontaneous abortion classification is based on os position and product of conception (POC) location

  • Missed: Closed os, POC within uterus, fetal demise

  • Dilated os

    • Inevitable: POC within uterus

    • Incomplete: POC within cervical canal

    • Complete: POC expelled from cervix

• Treatment with intravaginal misoprostol has an 80% success rate

Medical Abortion

Mifepristone/Misoprostol Termination

Patient presents with unintended, undesired pregnancy at < 11 WGA and desires medical abortion.

• Following counseling about support services and adoption, patient elects to continue with medical abortion

• Positive pregnancy test per urine beta-hCG: Obtain ABO/Rh status and dating ultrasound

  • Intrauterine pregnancy < 11 WGA confirmed by ultrasound

  • Rh negative and > 8 WGA: Administer Rhogam prior to procedure

• Administer Mifepristone 200 mg now and misoprostol (Cytotec) 800 mcg buccally in 24 to 48 hours

• Patient counseled about contraception options

• Follow-up in two weeks for repeat urine beta-hCG and ultrasound to confirm elimination of intra-uterine pregnancy

Notes

• Mifepristone is a progesterone antagonist

• Misoprostol is a prostaglandin E1 analog

• Antibiotic prophylaxis is no longer required for medical abortions

Methotrexate Termination

Patient with confirmed ectopic pregnancy at < 7 WGA presents for treatment. No history of active pulmonary disease, peptic ulcer disease, chronic liver disease, immunodeficiency, alcohol abuse. Patient not currently breastfeeding. Lungs clear to auscultation bilaterally and no hepatomegaly on exam.

• Beta-hCG < 2,000 mIU/mL and Cr clearance > 50 mL/min

• Gestational sac < 3.5 cm with no embryonic cardiac activity

• Patient counseled about possibility for nausea/vomiting, abdominal/gastric pain, stomatitis following therapy

• Administer methotrexate 50 mg/m^2 IM

• Follow-up

  • Evaluate for 15% or greater beta-hCG decrease from day 4 to 7 s/p therapy

  • Continue weekly monitoring until beta-hCG reaches 0 mIU/mL

Notes

• Absolute contraindications

  • Active pulmonary disease, chronic liver disease, hematologic dysfunction, peptic ulcer disease, alcohol abuse

  • Patient currently breastfeeding

  • Creatinine clearance < 50 mL/min

• Efficacy

  • Success rate for starting beta-hCG < 1,000 mIU is 88% vs. 50% for starting beta-hCG > 3,000 mIU

  • 15 to 20% of women will require 2 doses

• Dose is calculated using body surface area

Surgical Abortion

Pre-Procedure

• Ability to perform procedure varies by facility and local legal restrictions: Generally performed up to 19 WGA. However, our outpatient clinic performs to 11+6 WGA, our local Planned Parenthood performs to 15+6 WGA, and our local tertiary care center performs until 23+6 WGA. Check with local providers/facilities before counseling your patient.

• Verify positive pregnancy test per urine beta-hCG prior to cervical preparation

• Cervical preparation: Recommended in all pregnancies > 12 WGA as it reduces risk of cervical injury, uterine perforation, and incomplete abortion

  • Administer misoprostol 400 micrograms vaginally 3-4 hours prior to procedure

  • Patient informed that she may experience bleeding/cramping following misoprostol placement

  • If bleeding occurs during preparation, perform surgical abortion immediately

• Administer analgesics, anxiolytics, and prophylactic antibiotics one hour prior to procedure, e.g.

  • Ibuprofen 800 mg PO

  • Diazepam 10 mg PO

  • Doxycycline 200 mg PO

Procedural Steps

1. Ask the woman to empty her bladder

2. Wash hands and use protective barriers

3. Perform a bimanual examination

4. Place the speculum

5. Perform cervical antiseptic preparation: Wipe cervix with non-alcoholic antiseptic solution starting at central cervical os and spiraling outward

6. Perform paracervical block using 1.0% lidocaine

   • Inject 1-2 mL where tenaculum will be placed (6 or 12 o’clock)

   • Stabilize cervix with tenaculum and inject 4 mL lidocaine at a depth of 2 cm at 4 locations along cervical/vaginal junction, i.e. at 2, 4, 8 and 10 o’clock

7. Assess cervical dilatation/dilate cervix if necessary

8. If greater than 12 WGA, perform amniotomy and aspirate amniotic fluid

9. Evacuate uterine contents (technique pending WGA)

   • For pregnancies < 12 WGA

     • The appropriate aspirator cannula size in millimeters is approximately the same as WGA (e.g. 12 mm cannula for 12 WGA)

     • The following signs during aspiration indicate that the uterus is empty: Red or pink foam in cannula with no more passage of tissue, gritty sensation as cannula passes over uterine surface, uterus contracts around cannula, patient feels intensified cramping or pain

   • For pregnancies > 12 WGA, procedure is termed dilation and evacuation (D&E)

     • Cannula size

       • > 12 WGA: Perform D&E with 14 mm cannula

       • > 16 WGA: Perform D&E with 16 mm cannula

     • Complete evacuation from lowest section of uterine cavity while holding cannula in horizontal position

10. Inspect the tissue

    • Products of conception (POC) should be visible including, villi, decidua, sac/membrane, and fetal parts after 9 WGA

    • Presence of grape-like villi in evacuated contents indicates likely molar pregnancy

    • If no POC are observed, consider incomplete abortion, spontaneous abortion, failed abortion, ectopic pregnancy, or anatomic abnormalities (e.g. bicornuate uterus)

11. Perform any concurrent procedures, e.g. cervical laceration repair or IUD placement

12. Recovery and discharge from the facility

Notes

• Osmotic dilators are an alternative method for cervical preparation

• Administration of NSAIDs (e.g. ibuprofen) does not interfere with action of prostaglandins (e.g. misoprostol)

• Prophylactic antibiotics

  • Reduce risk of post-procedural endometritis

  • Alternative to doxycycline: Azithromycin 500 mg x 1 dose

• Maximum lidocaine dose for a paracervical block: 4.5 mg/kg/dose

• Source: Clinical Practice Handbook for Safe Abortion