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ManagementofSpontaneousAbortion
CRAIGP.GRIEBEL,M.D.,JOHNHALVORSEN,M.D.,THOMASB.GOLEMON,M.D.,andANTHONYA.DAY,M.D.,UniversityofIllinoisCollegeofMedicine
atPeoria,Peoria,Illinois
AmFamPhysician.2005Oct172(7):12431250.
Spontaneousabortion,whichisthelossofapregnancywithoutoutsideinterventionbefore20weeksgestation,affectsupto20percentof
recognizedpregnancies.Spontaneousabortioncanbesubdividedintothreatenedabortion,inevitableabortion,incompleteabortion,missed
abortion,septicabortion,completeabortion,andrecurrentspontaneousabortion.Ultrasonographyishelpfulinthediagnosisofspontaneous
abortion,butothertestingmaybeneededifanectopicpregnancycannotberuledout.Chromosomalabnormalitiesarecausativein
approximately50percentofspontaneousabortionsmultipleotherfactorsalsomayplayarole.Traditionaltreatmentconsistingofsurgical
evacuationoftheuterusremainsthetreatmentofchoiceinunstablepatients.Recentstudiessuggestthatexpectantormedicalmanagementis
appropriateinselectedpatients.Patientswithacompletedspontaneousabortionrarelyrequiremedicalorsurgicalintervention.Forwomenwith
incompletespontaneousabortion,expectantmanagementforuptotwoweeksusuallyissuccessful,andmedicaltherapyprovideslittle
additionalbenefit.Whenpatientsareallowedtochoosebetweentreatmentoptions,alargepercentagewillchooseexpectantmanagement.
Expectantmanagementofmissedspontaneousabortionhasvariablesuccessrates,butmedicaltherapywithintravaginalmisoprostolhasan80
percentsuccessrate.Physiciansshouldbeawareofpsychologicissuesthatpatientsandtheirpartnersfaceaftercompletingaspontaneous
abortion.Womenareatincreasedriskforsignificantdepressionandanxietyforuptooneyearafterspontaneousabortion.Counselingto
addressfeelingsofguilt,thegriefprocess,andhowtocopewithfriendsandfamilyshouldbeprovided.
Spontaneousabortionreferstopregnancylossatlessthan20weeksgestationintheabsenceofelectivemedicalorsurgicalmeasurestoterminatethe
pregnancy.Thetermmiscarriageissynonymousandoftenisusedwithpatientsbecausethewordabortionisassociatedwithelectivetermination.
Spontaneouspregnancylosshasbeenrecommendedtoavoidthetermabortionandacknowledgetheemotionalaspectsoflosingapregnancy.1Another
emotionallyneutraltermisearlypregnancyfailure.2
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SORT:KEYRECOMMENDATIONSFORPRACTICE
CLINICALRECOMMENDATION

EVIDENCE
RATING

REFERENCES

Thepossibilityofectopicpregnancyshouldbeconsideredwhentransvaginalultrasonographyrevealsanemptyuterusandthequantitative
serumhumanchorionicgonadotropinlevelisgreaterthan1,800mIUpermL(1,800IUperL).

Transvaginalultrasoundshouldbeperformedinthefirsttrimesterofpregnancywhenincompleteabortionissuspectedandisextremely
reliableinidentifyingintrauterineproductsofconception.

7,8

Expectantmanagementshouldbeconsideredforwomenwithincompletespontaneousabortions.Ithasan82to96percentsuccessrate
withouttheneedforsurgicalormedicalintervention.

1722,24

Whenmisoprostol(Cytotec)isusedtotreatwomenwithamissedspontaneousabortion,itshouldbegivenvaginallyratherthanorally.

27

Patientswhohavehadaspontaneousabortionshouldbegiventheopportunitytochooseatreatmentoption.

28

A50mcgdoseofRho(D)immuneglobulin(Rhogam)shouldbeadministeredtoRhnegativepatientswhohaveathreatenedabortionor
havecompletedaspontaneousabortion.

Physiciansshouldbealerttothedevelopmentofpsychologicsymptomsthatfrequentlyoccurfollowingspontaneousabortion(e.g.,
depression,anxiety).

3134

A=consistent,goodqualitypatientorientedevidenceB=inconsistentorlimitedqualitypatientorientedevidenceC=consensus,diseaseorientedevidence,usualpractice,
expertopinion,orcaseseries.ForinformationabouttheSORTevidenceratingsystem,seepage1154orhttp://www.aafp.org/afpsort.xml(http://www.aafp.org/afpsort.xml).

Forclinicalpurposes,spontaneousabortionoftenissubdividedintothreatenedabortion,inevitableabortion,incompleteabortion,missedabortion,septic
abortion,recurrentspontaneousabortion,andcompleteabortion(Table1).
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TAL1
SpontaneousAbortion:DefinitionsofSubcategories
Completeabortion:allproductsofconceptionhavebeenpassedwithouttheneedforsurgicalormedicalintervention

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Incompleteabortion:some,butnotall,oftheproductsofconceptionhavebeenpassedretainedproductsmaybepartofthefetus,placenta,ormembranes
Inevitableabortion:thecervixhasdilated,buttheproductsofconceptionhavenotbeenexpelled
Missedabortion:apregnancyinwhichthereisafetaldemise(usuallyforanumberofweeks)butnouterineactivitytoexpeltheproductsofconception
Recurrentspontaneousabortion:threeormoreconsecutivepregnancylosses
Septicabortion:aspontaneousabortionthatiscomplicatedbyintrauterineinfection
Threatenedabortion:apregnancycomplicatedbybleedingbefore20weeksgestation

Incidence
Approximately20percentofpregnantwomenwillhavesomebleedingbefore20weeksgestation,androughlyonehalfofthesepregnancieswillendin
spontaneousabortion.3Upto20percentofrecognizedpregnancieswillendinmiscarriage.However,whenwomenwerefollowedwithserialserumhuman
chorionicgonadotropin(hCG)measurements,theactualmiscarriageratewasfoundtobe31percent.4Manypregnanciesarelostspontaneouslybeforea
womanrecognizesthatsheispregnant,andtheclinicalsignsofmiscarriagearemistakenforaheavyorlatemenses.

Diagnosis
Threatenedabortionisdefinedbyvaginalbleedinginawomanwithaconfirmedpregnancy.Firsttrimesterbleedinginapregnantwomanhasanextensive
differentialdiagnosis(Table2)andshouldbeevaluatedwithafullhistoryandphysicalexamination.Laboratorytestsshouldincludepotassiumhydroxideand
wetprepmicroscopyofanyvaginaldischarge,completebloodcount,bloodtypingandRhtesting,andquantitativeserumhCGtesting.Gonorrheaand
chlamydiatestingalsoshouldbeconsidered.Ultrasonographyiscrucialinidentifyingthestatusofthepregnancyandverifyingthatthepregnancyis
intrauterine.WhentransvaginalultrasonographyrevealsanemptyuterusandthequantitativeserumhCGlevelisgreaterthan1,800mIUpermL(1,800IU
perL),anectopicpregnancyshouldbeconsidered.5Whentransabdominalultrasonographyisperformed,anemptyuterusshouldraisesuspicionofan
ectopicpregnancyifquantitativehCGlevelsaregreaterthan3,500mIUpermL(3,500IUperL).Auterusfoundtobeemptyonultrasoundexaminationmay
signalacompletedspontaneousabortion,butthediagnosisisnotdefinitiveuntilectopicpregnancyisexcluded.Ifanultrasoundexaminationfindsan
intrauterinepregnancy,ectopicpregnancyisunlikely,althoughheterotopicpregnancyhasbeenreported(i.e.,simultaneousintrauterineandectopic
pregnancies).5Theriskforspontaneousabortiondecreasesfrom50to3percentwhenafetalheartbeatisidentifiedonultrasoundexamination.1
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TAL2
DifferentialDiagnosisofFirstTrimesterVaginalBleeding
Cervicalabnormalities(e.g.,excessivefriability,malignancy,polyps,trauma)
Ectopicpregnancy
Idiopathicbleedinginaviablepregnancy
Infectionofthevaginaorcervix
Molarpregnancy
Spontaneousabortion
Subchorionichemorrhage
Vaginaltrauma

Whentheclinicalexaminationrevealsadilatedcervix,spontaneousabortionisinevitable.However,cervicalevaluationisnotreliablefordistinguishing
betweencompleteandincompleteabortion.6,7Transvaginalultrasonographyshouldbeperformedandisextremelyreliableforfindingproductsof
conception,witha90to100percentsensitivityand80to92percentspecificity.7,8
Amissedspontaneousabortionusuallyisdiagnosedbyroutineultrasonographyorwhenanultrasoundscanisobtainedbecausethesymptomsandphysical
signsofpregnancyareregressing.Figure1presentsanalgorithmfordiagnosingspontaneousabortion.1
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Figure1.
Algorithmforthediagnosisofspontaneouspregnancyloss.(ED=emergencydepartmenthCG=humanchorionicgonadotropin.)
AdaptedwithpermissionfromScrogginsKM,SmuckerWD,KrishenAE.Spontaneouspregnancyloss:evaluation,management,andfollowupcounseling.PrimCare
200027:157.

EtiologyandRiskFactors
Chromosomalabnormalitiesareadirectcauseofspontaneousabortion.Onemetaanalysis9foundthatachromosomalabnormalityoccursin49percentof
spontaneousabortions.Autosomaltrisomywasthemostcommonlyidentifiedanomaly(52percent),followedbypolyploidy(21percent)andmonosomyX
(13percent).9Mostchromosomalabnormalitiesthatresultinspontaneousabortionarerandomevents,suchasmaternalandpaternalgametogenesis
errors,dispermy,andnondisjunction.Structuralabnormalitiesofindividualchromosomes(e.g.,translocations,inversions)werereportedin6percentof
womenwhohadspontaneousabortions,andapproximatelyonehalfoftheseabnormalitieswereinherited.9Chromosomalabnormalitiesaremorelikelyto
beassociatedwithrecurrentspontaneousabortion,butareuncommoneveninthatinstance(4to6percent).9
RiskfactorsforspontaneousabortionarelistedinTable3.1,1014However,otherfactorsarenotablefortheirlackofassociationwithmiscarriage.One
study15thatexaminedtheinfluenceofstressonearlypregnancylossfailedtofindaclearassociation.Marijuanause,likewise,hasnotbeenprovento
increasetheriskforspontaneousabortion.11Sexualactivityalsodoesnotelevateriskinwomenwithuncomplicatedpregnancies.
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TAL3
RiskFactorsforSpontaneousAbortion
Advancedmaternalage
Alcoholuse
Anestheticgasuse(e.g.,nitrousoxide)
Caffeineuse(heavy)
Chronicmaternaldiseases:poorlycontrolleddiabetes,celiacdisease,autoimmunediseases(particularlyantiphospholipidantibodysyndrome)

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Cigarettesmoking
Cocaineuse
Conceptionwithinthreetosixmonthsafterdelivery
Intrauterinedeviceuse
Maternalinfections:bacterialvaginosismycoplasmosis,herpessimplexvirus,toxoplasmosis,listeriosis,chlamydia,humanimmunodeficiencyvirus,syphilis,parvovirusB19,
malaria,gonorrhea,rubella,cytomegalovirus
Medications:misoprostol(Cytotec),retinoids,methotrexate,nonsteroidalantiinflammatorydrugs
Multiplepreviouselectiveabortions
Previousspontaneousabortion
Toxins:arsenic,lead,ethyleneglycol,carbondisulfide,polyurethane,heavymetals,organicsolvents
Uterineabnormalities:congenitalanomalies,adhesions,leiomyoma

Informationfromreferences1and10through14.

Treatment
Dilatationandcurettageisthetraditionaltreatmentforspontaneousabortionmanualvacuumaspirationisanothersurgicaloption.Promptsurgical
evacuationoftheuterushasbeenrecommendedinthepastbecauseoftheriskforinfectionandconcernsaboutcoagulationdisordersthatresultfrom
retainedproductsofconception.1,2However,theneedforimmediatesurgicalevacuationinallpatientswithaspontaneousabortionhasbeenquestioned.
Manyrecentstudies1624haveexaminedtheoutcomesofexpectantandmedicalmanagementforwomenwithspontaneousabortions.
Promptsurgicalevacuationoftheuterusisthetreatmentofchoicewhenthepatientisunstablebecauseofheavybleedingorhasevidenceofaseptic
abortion.Patientchoiceisanotherreasontoproceedwithsurgicalevacuation.
Somewomenmayhavealreadycompletedaspontaneousabortionbythetimetheypresentforclinicalevaluation.Iftheultrasoundexaminationshowsan
emptyuterusandevaluationoftheexpelledtissueconfirmsthepresenceofproductsofconception,nofurtheractionisneededintheseinstances,patients
haveacompletedspontaneousabortionandcanbemanagedexpectantly.16Iftheproductsofconceptionarenotphysicallyconfirmedwhentheuterusis
empty,anectopicpregnancymustberuledout.
Manystudies1724havecomparedexpectantmanagement,medicaltherapy,andsurgicalmanagementforwomenwithincompletespontaneousabortion.
Expectantmanagementprovedtobesuccessful,withnoneedforsurgicalinterventionin82to96percentofwomen.1722,24Mostpatientswhohadsurgical
interventionwerefollowedexpectantlyfortwoweeksbeforeinterventionwasrecommended.17,19,21Medicaltherapywithmisoprostol(Cytotec)or
mifepristone(Mifeprex)doesnotconfersignificantadditionalbenefit.23Theaveragetimetocompletionofthemiscarriagewasninedays.20
Inwomenwithmissedspontaneousabortions,expectantmanagementhasavariablebutgenerallylowersuccessratethanmedicaltherapy,rangingfrom16
to76percent.17,20,25,26Incontrast,medicaltherapyformissedspontaneousabortionresultsinhighsuccessratesforcompletionofaspontaneousabortion
withoutsurgicalintervention.Onestudy25foundthatpatientshadan80percentsuccessrateafterusing800mcgofmisoprostol,administeredintravaginally
andrepeatedafterfourhours,ifnecessary.Intravaginaladministrationofmisoprostolcauseslessdiarrheathanoraladministration.27
Patientpreferencesshouldbeconsideredwhenchoosingatreatmentforspontaneousabortion.Physiciansshoulddiscusstheavailableoptionsandthe
evidencetosupporteachoptionwiththepatient.Thereisevidencetosuggestthatwomenwhoaregiventheopportunitytochooseatreatmentoptionhave
bettersubsequentmentalhealththanwomenwhoarenotallowedtochoosetheirtherapy.28However,patientsexpresslesshappinesswiththemodeof
treatmenttheyreceiveandarelesswillingtohavethesamecareagainwhentheybeginwithnoninvasivemanagementandlaterrequiresurgical
intervention.29Whenpatientsareallowedtochoosetheirtherapy,38to75percentchooseexpectantmanagement.20,26,30
AnalgorithmformanagingwomenwithspontaneousabortionispresentedinFigure2.1A50mcgdoseofRho(D)immuneglobulin(Rhogam)shouldbe
giventopatientswhoareRhnegativeandhaveathreatenedabortionorhavecompletedaspontaneousabortion.5
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Figure2.
Algorithmforthemanagementofspontaneouspregnancyloss.(hCG=humanchorionicgonadotropin.)
AdaptedwithpermissionfromScrogginsKM,SmuckerWD,KrishenAE.Spontaneouspregnancyloss:evaluation,management,andfollowupcounseling.PrimCare
200027:161.

PsychologicIssuesAfterSpontaneousAbortion
Physiciansshouldrecognizethepsychologicissuesthataffectapatientwhoexperiencesaspontaneousabortion.Althoughtheliteraturelacksgood
evidencetosupportpsychologiccounselingforwomenafteraspontaneousabortion,itisthoughtthatpatientswillhavebetteroutcomesiftheseissuesare
addressed.Thepatientandherpartnermaybedealingwithfeelingsofguilt,andtheytypicallywillgothroughagrievingprocessandhavesymptomsof
anxietyanddepression.
Womenwhohaveaspontaneousabortionfrequentlystrugglewithguiltoverwhattheymayhavedonetocauseorpreventtheloss.Physiciansshould
addresstheissueofguiltwiththeirpatientsandallayanyconcernsthattheymayhavecausedthespontaneousabortion.
Physiciansshouldencouragethepatientandherpartnertoallowthemselvestogrieve.Thewomanandherpartnermaygrievedifferentlyspecifically,they
maygothroughthestagesofgriefindifferentordersoratdifferentrates.Theyalsoshouldbeawarethatfriendsandfamilymembersmaynotrecognizethe
magnitudeoftheirloss.Friendsandfamilymembersmayignorethesubjectofmiscarriage,ortheymaymakewellmeaningcommentsthattrytominimize
theevent.Connectingthecouplewithacounselorwhohasexperienceinhelpingcouplescopewithpregnancylossmaybebeneficial.Manyhospitalsoffer
programsthatprovidefollowupcareandliteraturetothewomanandherpartner.Twonationalorganizations,theCompassionateFriends
(http://www.compassionatefriends.org(http://www.compassionatefriends.org)telephone:8779690010)andSHAREPregnancyandInfantLossSupport,Inc.
(http://www.nationalshareoffice.com(http://www.nationalshareoffice.com)telephone:8008216819),providesupportforwomenandtheirpartnersastheyprogress
throughthegrievingprocessafteramiscarriage.
Moststudies3134havefoundthatasignificantpercentageofwomenexperiencepsychiatricsymptomsintheweekstomonthsafterspontaneousabortion.
Womenwhowerefoundtobeespeciallypronetothesesymptomsarechildlessandhavelostawantedpregnancy.31Onestudy28showedthatwomenwho
aremanagedexpectantlyhavebetteroverallmentalhealth12weeksafteraspontaneousabortion.
Physiciansshouldrealizetheimportanceofprovidingcarethatissensitivetothemedicalandpsychologicaspectsofacouplewhoexperiencesspontaneous
abortion.Manypatientsreportdissatisfactionwiththemedicalcaretheyreceive.35,36TheAdvancedLifeSupportinObstetrics5providercourseofferedby
theAmericanAcademyofFamilyPhysicianssummarizesissuestodiscusswithwomenandtheirpartnersafteraspontaneousabortion(Table4).5
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TAL4
PointstoCoverwithWomenandTheirPartnersAfterSpontaneousAbortion
Acknowledgeandattempttodispelguilt
Acknowledgeandlegitimizegrief
Assesslevelofgriefandadjustcounselingaccordingly
Counselhowtotellfamilyandfriendsofthemiscarriage
Includethepatientspartnerinpsychologiccare
Providecomfort,empathy,andongoingsupport
Reassureaboutthefuture
Warnabouttheanniversaryphenomenon

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Informationfromreference5.

TheAuthors
CRAIGP.GRIEBEL,M.D.,isclinicalassistantprofessoranddirectorofobstetricsandgynecologyattheUniversityofIllinoisCollegeofMedicineatPeoria
familymedicineresidencyprogramatMethodistMedicalCenter.Dr.GriebelreceivedhismedicaldegreefromtheUniversityofMissouriSchoolofMedicine,
Columbia,andcompletedhisresidencyatQuadCitiesGenesisFamilyPracticeResidencyPrograminDavenport,Iowa.
JOHNHALVORSEN,M.D.,istheThomasandEllenFosterchairandprofessoroffamilymedicineattheUniversityofIllinoisCollegeofMedicineatPeoria.
Healsoisassociatedeanforcommunityhealth.HereceivedhismedicaldegreefromOhioStateUniversitySchoolofMedicineandPublicHealth,Columbus,
andcompletedafamilymedicineresidencyattheUniversityofMinnesotaMedicalSchoolatHennepinCountyMedicalCenter,Minneapolis.
THOMASB.GOLEMON,M.D.,isexecutivedirectoroftheUniversityofIllinoisCollegeofMedicineatPeoriafamilymedicineresidencyprogramatMethodist
MedicalCenter.HereceivedhismedicaldegreefromtheUniversityofTexasSouthwesternMedicalSchool,Dallas,andcompletedafamilymedicine
residencyatTheMedicalCenterinColumbus,Ga.
ANTHONYA.DAY,M.D.,isassistantexecutivedirectoroftheUniversityofIllinoisCollegeofMedicineatPeoriafamilymedicineresidencyprogramat
MethodistMedicalCenter.HereceivedhismedicaldegreefromtheUniversityofIowaRoyJ.andLucilleA.CarverCollegeofMedicine,IowaCity,and
completedafamilymedicineresidencyattheUniversityofIllinoisCollegeofMedicineatRockford.
AddresscorrespondencetoCraigP.Griebel,M.D.,DepartmentofFamilyandCommunityMedicine,UniversityofIllinoisCollegeofMedicineatPeoria,815
MainSt.,SuiteC,Peoria,IL61602(email:cgriebel@mmci.org(mailto:cgriebel@mmci.org)).Reprintsarenotavailablefromtheauthors.
Authordisclosure:Nothingtodisclose.

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MembersofvariousfamilymedicinedepartmentsdeveloparticlesforPracticalTherapeutics.ThisarticleisoneinaseriescoordinatedbytheDepartment
ofFamilyPracticeattheUniversityofIllinoisCollegeofMedicineatChicagoRockford.CoordinatoroftheseriesisEricHenley,M.D.

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