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Threatened Abortion

Abortion Following Threatened Abortion

Threatened abortion is a term that comprises of spotting within the first 20 weeks of gestation without cervical dilation, and may lead to spontaneous miscarriage. It occurs in 10-25% of all pregnancies, and the cause often remains unknown. Vaginal bleeding may be accompanied by abdominal pain, and the diagnosis is made clinically and by ultrasonography. Therapy consists of treating the underlying cause, observation, and the management of accompanying diseases.


Presentation

The main feature of threatened abortion is the presence of vaginal bleeding, or sometimes spotting may be encountered as well. Other symptoms include abdominal pain or cramping, back aches, or period pains, which may be overlooked, as they commonly appear during regular pregnancy. Not all threatened abortions progress to miscarriage. However, the chances are high in women that present with threatened abortion with an open cervix.

Abdominal Pain
  • Women with mild abdominal cramping received amoxicillin plus erythromycin for 1 week; those with severe abdominal pain received amoxicillin plus clindamycin for 1 week.[ncbi.nlm.nih.gov]
  • Remain calm in the face of danger First, take time to calm down even if you experience bleeding or have lower abdominal pains in the first 20 weeks of pregnancy.[baby-pedia.com]
  • Factors that may contribute to miscarriage include A genetic problem with the fetus Problems with the uterus or cervix Chronic diseases, such as polycystic ovary syndrome Signs of a miscarriage include vaginal spotting, abdominal pain or cramping, and[icdlist.com]
  • Vaginal bleeding during pregnancy, especially with abdominal pain, should always be reported to a doctor.[allegiancehealth.org]
Suprapubic Pain
  • Abdominal examination: Suprapubic pain and tenderness. Abdominal rigidity and distension indicates peritonitis. Local examination: Offensive vaginal discharge. Minimal inoffensive vaginal discharge is often associated with severe cases.[gfmer.ch]
Chloasma
  • […] buttocks) (complete) (frank) 652.2 cardiovascular disease (conditions classifiable to 390 - 398 , 410 - 429 ) 648.6 cerebrovascular disorders (conditions classifiable to 430 - 434 , 436 - 437 ) 674.0 cervicitis (conditions classifiable to 616.0 ) 646.6 chloasma[icd9data.com]
Scotoma
  • A 30-year-old woman who had received a 2-week course of high dose intramuscular progestogen for a threatened abortion presented with a paracentral scotoma in her right eye and occlusion of a small arteriole adjacent to the macula.[ncbi.nlm.nih.gov]
First Trimester Bleeding
  • First trimester bleeding with visible fetal heart beat appears to associate significantly with higher subsequent spontaneous abortion rate than those without.[ncbi.nlm.nih.gov]
  • Patients with first trimester bleeding had a significantly higher percentage of low implantation sites (25.8%) than the controls (4.8%).[journals.lww.com]
  • Clinical evaluation of women with first trimester bleeding involves looking for evidence of: Inevitable abortion Incomplete abortion Ectopic pregnancy Gestational trophoblastic disease Other miscellaneous causes for bleeding, including cervical/vaginal[brooksidepress.org]
  • There are signs to look for in cases of first-trimester bleeding: Is the patient shocked through blood loss? If so, pelvic and speculum examination are indicated: Are there products of conception in the cervical canal? (Remove with sponge forceps.)[patient.info]
  • Sonography in first trimester bleeding. J Clin Ultrasound . 2008 Jul-Aug. 36(6):352-66. [Medline] . Nakhai-Pour HR, Broy P, Sheehy O, et al.[emedicine.medscape.com]
Pelvic Pain
  • Threatened Abortion There is bleeding and sometimes pelvic pain but the cervix is closed and ultrasound indicates an ongoing pregnancy within the uterus. Inevitable Abortion The pregnancy is not continuing.[2womenshealth.com]
  • pain); Ultrasound proof of viable singleton intrauterine pregnancy (positive foetal heart beat); Gestation week 6 weeks (5 w 1d) and Closed uterine cervix; At the first case of threatened abortion in the current pregnancy.[clinicaltrials.gov]
  • Without treatment, these symptoms may be followed in several days or weeks by severe pelvic pain, shoulder pain (due to blood from a ruptured ectopic pregnancy pressing on the diaphragm), faintness, dizziness, nausea or vomiting.[nairaland.com]
  • Symptoms and Signs Symptoms of spontaneous abortion include crampy pelvic pain, bleeding, and eventually expulsion of tissue. Late spontaneous abortion may begin with a gush of fluid when the membranes rupture. Hemorrhage is rarely massive.[merckmanuals.com]
Uterine Tenderness
  • Such infections are characterized by fever, chills, uterine tenderness and occasionally, peritonitis. The responsible bacteria are usually a mixed group of Strep, coliforms and anaerobic organisms.[brooksidepress.org]
  • Diffuse uterine tenderness, adnexal tenderness, or both may be present. Threatened miscarriage is defined by the absence of passing/passed tissue and the presence of a closed internal cervical os.[emedicine.medscape.com]
Uterine Cramps
  • Abstract Threatened abortion is associated with bleeding and/or uterine cramping while the cervix is closed. This stage of abortion may progress to spontaneous incomplete or complete abortion.[ncbi.nlm.nih.gov]

Workup

The diagnosis of threatened abortion is made during a clinical examination when the absence of cervical dilation is observed in the setting of vaginal bleeding. Other forms of abortion (incomplete, inevitable) almost always include the presence of cervical dilation. However, ultrasonography (either abdominal or vaginal) is a recommended diagnostic procedure to evaluate the status of the fetus (the fetus may be expelled in the case of missed abortion, which can also present without cervical dilation) [10]. Additionally, levels of beta-hCG should be measured, but results may be inconclusive. It is important to obtain a diagnosis early so that appropriate steps can be taken in terms of therapy, and in the case of recurrent miscarriage, several diagnostic tools should be included, such as genetic testing, evaluation of hormonal status, and other tests [11].

Progesterone Decreased
  • Estrogen and progesterone continue to be secreted in large amounts by the placenta up to the time of delivery Progesterone decreases estrogen-driven endometrial proliferation and leads to the development of a secretory endometrium (Figure 40–3), and the[slideshare.net]

Treatment

The main therapeutic principle in threatened abortion is observation and treatment of the underlying cause, in order to prevent the development of miscarriage. Several factors, such as bed rest and avoidance of sexual intercourse have been recommended by certain studies, but with inconclusive results [12].

Management of accompanying illnesses, such as diabetes mellitus, hypothyroidism, is vital in minimizing the risk of pregnancy loss. Infections in early pregnancy should be treated appropriately, and screening of bacterial vaginosis with proper antibiotic therapy has resulted in reduced rates of miscarriages [13]. The Antiphospholipid syndrome has also been established as a potential cause of pregnancy loss, and therapy consists of heparin combined with aspirin. Environmental factors, such as alcohol consumption and cigarette smoking, should be ceased or avoided, as well as drug abuse and increased caffeine intake.

Supplemental therapy with progesterone is a topic of debate across the world since numerous studies have implicated progesterone, as well as dydrogesterone (a synthetic analog of progesterone) supplementation to be beneficial for threatened miscarriage [14]. However, more evidence is necessary to prove that it is beneficial and that it can be used in general practice.

Prognosis

About 30% of all threatened abortions end in eventual miscarriage and pregnancy loss, which is why it is of vital importance to establish the diagnosis promptly, and identify possible factors which may contribute to pregnancy loss. Inevitable, incomplete or complete abortion can be emotionally debilitating for couples, especially for women who experience recurrent miscarriages.

Etiology

The exact causes of threatened abortion are not always identified, and it may commonly remain unknown. However, several theories have been proposed:

  • Infectious etiology - viral pathogens, such as parvovirus, rubella virus, cytomegalovirus, as well as herpes virus have been implicated as causative agents of miscarriages and recurrent pregnancy loss.
  • Environmental factors - use of drugs such as cocaine, caffeine, alcohol abuse, as well as cigarette smoking, have been established as factors that contribute to pregnancy loss.
  • Genetic defects - numerous pregnancies end because of chromosomal abnormalities, and defects in fetal development.

Numerous maternal factors have been proposed to be of influence to the fetus, including genital tract and uterine abnormalities, endocrine factors (reduced levels of progesterone and human chorionic gonadotropin (beta - hCG), poorly controlled diabetes mellitus, disorders of the thyroid gland, as well as other conditions, such as antiphospholipid syndrome, both acquired and hereditary thrombophilias, and trauma.

Epidemiology

It is estimated that threatened abortion occurs in about 20-25% of all pregnancies, and is associated with an increased rate of fetal loss. Namely, miscarriage rates in women with threatened abortion are much higher (ranging from 15-50%) compared to women in whom this condition did not develop (between 2-7% of pregnancies result in miscarriage).

Risk factors for threatened abortion, but for other types of abortion as well, have been proposed and include:

  • Prior miscarriage
  • Older age (> 35)
  • Drug and alcohol abuse
  • Presence of maternal diseases (e.g. diabetes mellitus, thyroid dysfunction)
  • Cigarette smoking
  • Hormonal disbalance (reduced levels of progesterone and beta-hCG)
  • Infection during early pregnancy
Sex distribution
Age distribution

Pathophysiology

The pathogenesis of threatened abortion is incompletely understood, as it primarily depends on the underlying cause, but several studies have implicated that progesterone levels are one of the key factors in maintaining a normal pregnancy [5] [6]. Progesterone maintains the structure and function of the uterus, as well as cervical competency, and it has been established that sufficient levels of progesterone induce lymphocytic production of progesterone-induced blocking factor (PIBF), which shows anti-abortive properties in animal models [7]. PIBF also performs other important functions during pregnancy, such as modulation of maternal immune response to mediate the reaction to the fetus, as well as relaxation of uterine smooth muscles [8], indicating that progesterone therapy may be a valid approach in women with threatened abortion. However, there is still no concrete evidence for progesterone use in general practice, and more studies need to be performed to solidify these findings [9].

Prevention

Prevention of threatened miscarriage is directed at maintaining good prenatal care, which consists of regular check-ups, avoiding toxins that may harm the fetus, including alcohol, cigarettes, and certain drugs that have proven harmful effects to the fetus, while caffeine should be completely avoided, and intake of this compound should be reduced to a minimum; and management of accompanying conditions, such as diabetes, hypothyroidism, or autoimmune disorders should be done.

Summary

Threatened abortion is a term that implies vaginal bleeding before reaching 20 weeks of gestation, but without cervical dilation, and may lead to preterm delivery, low birth weight, or it may lead to fetal death and loss of pregnancy [1]. The cause often remains unknown, but several factors have been proposed, including infectious, genetic and environmental. Risk factors for threatened abortion have been proposed, such as cigarette smoking, uterine abnormalities, previous miscarriages, use of certain drugs, reduced levels of progesterone, increased age, as well as other illnesses and conditions. Threatened abortion is estimated to occur in about 20% of early gestations, and about 50% of them will progress to miscarriage, with the majority of threatened miscarriages occurring between 14 and 20 weeks of gestation [2]. Clinical presentation of threatened abortion, in addition to vaginal bleeding, may include abdominal pain and backache [3]. The diagnosis can be made by clinical examination and abortion criteria, while ultrasonography is used to confirm the diagnosis, through recognizing the fetus and evaluation of vital signs. Treatment of threatened abortion includes supportive therapy, correction and proper management of other accompanying illnesses and conditions, and observation. Because of the psychological burden, it carries [4], proper prenatal care and avoidance of risk factors that may harm the fetus are recommended, to avoid pregnancy loss, and in the case of recurrent miscarriages, extensive evaluation should be conducted to identify the cause.

Patient Information

Threatened abortion is a term used to describe the presence of vaginal bleeding within the first 20 weeks of pregnancy, but without cervical dilation. It is important to note that threatened abortion does not imply pregnancy loss, it is rather a predisposing condition which may lead to miscarriage. Threatened abortion occurs in about a quarter of all pregnancies, and rates of miscarriage range from 15-50%, depending on numerous factors. Smoking, alcohol and drug abuse, age over 35 years, uterine abnormalities, poor monitoring and management of accompanying illnesses (such as diabetes mellitus) and prior miscarriages are all proposed as risk factors. The exact cause of threatened abortion is not known, while several factors have been mentioned. Infection by certain viruses has been proposed as a potential cause, while genetic defects, genital, and uterine abnormalities, as well as environmental factors, are also considered. However, the exact cause often remains unknown.

Symptoms of threatened abortion include spotting (light bleeding from the vagina), abdominal pain or cramping, back aches, while period pains may also be observed. The majority of symptoms are commonly encountered in normal pregnancy, but whenever there is the presence of bleeding, an immediate visit to the physician is necessary to identify the possible case, because threatened abortion may lead to pregnancy loss.

The diagnosis can be made during clinical examination, while ultrasound can be performed (either abdominal or vaginal) to assess the status of the fetus. In the case of recurrent pregnancy loss, a detailed diagnostic workup should be performed, including genetic testing, and evaluation of hormonal status. Treatment of threatened abortion should be directed at the underlying cause, if discovered, while supportive measures, such as bed rest and avoidance of sexual intercourse have been proposed, but a clear benefit has not been established. Supplemental use of progesterone is a topic of many discussions, because of the key roles this hormone has during pregnancy, but more evidence is necessary for this method to be used in everyday practice. Management of underlying illnesses, such as diabetes, hypothyroidism, or autoimmune diseases, should be performed, while prevention measures include proper prenatal care with regular check-ups, avoidance of risk factors that may harm the fetus, and proper management of accompanying illnesses.

References

Article

  1. Weiss JL, Malone FD, Vidaver J, et al. Threatened abortion: A risk factor for poor pregnancy outcome, a population-based screening study. Am J Obstet Gynecol. 2004;190(3):745–50.
  2. Siriwachirachai T, Piriyasupong T. Effect of Dydro-gesterone on Treatment of Threatened Miscarriage: A Systematic Review and Meta-Analyses. Thai J Obstet Gynaecol. 2011;19:97–104.
  3. Pandian RU. Dydrogesterone in threatened miscarriage: a Malaysian experience. Maturitas. 2009;65(1):S47–50.
  4. Lok IH, Neugebauer R. Psychological morbidity following miscarriage. Best Pract Res Clin Obstet Gynaecol. 2007;21(2):229–47.
  5. Daya S. Luteal support: progestogens for pregnancy protection. Maturitas. 2009;65(1):S29–34.
  6. Palagiano A, Bulletti C, Pace MC, DE Ziegler D, Cicinelli E, Izzo A. Effects of vaginal progesterone on pain and uterine contractility in patients with threatened abortion before twelve weeks of pregnancy. Ann N Y Acad Sci. 2004;1034:200–10.
  7. Kalinka J, Szekeres-Bartho J. The impact of dydrogesterone supplementation on hormonal profile and progesterone-induced blocking factor concentrations in women with threatened abortion. Am J Reprod Immunol. 2005;53(4):166–71.
  8. Miranda S, Litwin S, Barrientos G, et al. Dendritic cells therapy confers a protective microenvironment in murine pregnancy. Scand J Immunol. 2006;64(5):493–9.
  9. Wahabi HA, Abed Althagafi NF, Elawad M. Pro-gestogen for treating threatened miscarriage. Cochrane Database Syst Rev. 2007;3:CD005943.
  10. Sotiriadis A, Papatheodorou S, Makrydimas G. Threatened miscarriage: evaluation and management. BMJ. 2004;329(7458):152–5.
  11. Potdar N, Konje JC. The endocrinological basis of recurrent miscarriages. Curr Opin Obstet Gynecol. 2005;17(4):424–8.
  12. Qureshi NS. Treatment options for threatened miscarriage. Maturitas. 2009;65(1):S35–41.
  13. Duan L, Yan D, Zeng W, Yang X, Wei Q. Effect of progesterone treatment due to threatened abortion in early pregnancy for obstetric and perinatal outcomes. Early Hum Dev. 2010;86(1):41–3.
  14. Tien JC, Tan TY. Non-surgical interventions for threatened and recurrent miscarriages. Singapore Med J. 2007;48(12):1074–90.

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Last updated: 2018-06-22 04:17