Snapshot A 35-year-old G3P2 presents with vaginal bleeding and cramping pain at 12 weeks. An ultrasound was performed. (Threatened abortion) Introduction Defined as non-elective termination of pregnancy at < 20 weeks gestation Epidemiology occurs spontaneously in 15% of all pregnancies Causes chromosome abnormalities cause 50% of spontaneous abortions endocrine disease fibroids incompetent cervix infection Listeria, Mycoplasma, ToRCHeS chronic disease DM, SLE environmental factors toxins, radiation, smoking, ETOH Risk factors increased parity advanced maternal age advanced paternal age conception within three months of live birth single pregnancy loss does not significantly increase risk of further abortion Classification Threatened normal US with minimal bleeding and NO cervical dilation Missed abnormal US with NO bleeding or cervical dilation Inevitable abnormal US with bleeding and cervical dilation but no loss of products of conception Incomplete abnormal US with bleeding, a dilated cervix, and loss of some but not all products of conception Completed closed cervix on physical exam US shows empty uterus Presentation Symptoms vaginal bleeding and pain Evaluation Diagnosis vaginal bleeding and pain in first half of pregnancy is presumed to be threatened abortion unless another diagnosis can be made, including ectopic pregnancy cervical polyps cervicitis molar pregnancy Labs serum progesterone > 25 ng/mL corresponds to a normal intrauterine pregnancy < 5 ng/mL corresponds to a nonviable gestation b-hCG rate of increase used to measure the viability of a pregnancy in the 1st trimester threatened abortion should continue to have levels increase by >66% every 48 hours while a non-viable (e.g. inevitable abortion) Ultrasound presence of fetal heart rate can differentiate threatened from all other non-viable abortion types Hysterosalpingoram Treatment Observation alone indications threatened spontaneous abortion completed spontaneous abortion Scheduled surgical evacuation indications missed spontaneous abortion Emergency surgical evacuation indications inevitable spontaneous abortion incomplete spontaneous abortion technique suction curettage in 1st trimester dilation and evacuation (D&E) in 2nd trimester RhoGAM indicated when mother is Rh- and father is either Rh+ or unknown funtions to prevent isoimmunization from fetal-maternal blood contact as a result of the failed pregnancy see Rh disease topic