Threatened miscarriage: evaluation and management

Abstract

Threatened miscarriage-vaginal bleeding before 20 gestational weeks-is the commonest complication in pregnancy, occurring in about a fifth of cases.w1 Miscarriage is 2.6 times as likely, 1 and 17% of cases are expected to present complications later in pregnancy. 2Although general practitioners and gynaecologists often see this condition, management of threatened miscarriage is mostly empirical. Bed rest is routinely recommended, and about a third of women presenting with threatened miscarriage are prescribed drugs. However, two thirds of the general practitioners recommending this do not believe it affects outcome. In this review, we present available evidence on the initial evaluation and management of threatened miscarriage, focusing mainly on the first trimester of pregnancy and primary healthcare settings. Sources and selectionWe searched literature in English with Medline (January 1965 to April 2004), Embase (January 1980 to April 2004), and the Cochrane database using the keywords "threatened" and "abortion" or "miscarriage" and "pregnancy" and "first trimester" or "early" and "bleeding". We scanned abstracts and got the full text of relevant articles. We also scanned the references of retrieved articles. The more recent or randomised, prospective, or large studies focusing on women with symptoms of threatened miscarriage were primarily cited; we excluded studies on recurrent pregnancy loss or women without symptoms, unless otherwise stated. EvaluationBleeding in the first trimester can originate from the uterus, cervix, or vagina, or it can be extragenital. Thorough physical examination is essential to differentiate between genital and extragenital causes. After exclusion of extragenital causes, several parameters have been associated with prognosis (table 1). HistoryOlder women are at increased risk of miscarriage in the general population.w3 A prospective study on women with threatened abortion reported that women older than 34 years had an odds ratio of 2.3 for miscarriage, however, the 95% confidence interval was wide (0.76 to 7.10), and the contribution of maternal age in regression analysis was not significant (P = 0.13). 4 Having had previous miscarriages is also associated with increased risk in future pregnancies, especially in older women, w4 whereas data from the general population show that the rate of fetal loss declines with advancing gestational age.

Does progesterone therapy increase nuchal translucency in women with threatened miscarriage?

“…It occurs in about a fifth of all pregnancies and approximately half of them will be lost. Progesterone is an essential hormone for the continuation of pregnancy and is prescribed in 13-40% of women with threatened miscarriage, according to the literature [8]. Some authors suggested that progesterone reduced the abortion rate in women with threatened miscarriage [7].…”

Vaginal Bleeding Before 20 Weeks Gestation Due to Placental Abruption Leading to Disseminated Intravascular Coagulation and Fetal Loss After Appearing to Satisfy Criteria for Routine Threatened Abortion: A Case Report and Brief Review of the Literature

“…Several review articles and book chapters also exist at present concerned primarily with the evaluation, management, and treatment of threatened abortion (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12). The American College of Emergency Physicians has begun to develop a clinical policy statement and evaluation algorithms to aid in the evaluation of threatened abortion (1,9 -11).…”

“…These will enable Emergency Physicians to treat these patients with improved diagnostic accuracy after observations in the past of falling well "short of reasonable standards" (23). These evaluation parameters insist that a history and physical examination, sonographic evaluation, and laboratory testing of maternal serum biochemistry be the mainstay of evaluation in these patients (8). On pelvic examination, if the os is open or products of conception are seen, the diagnosis of inevitable miscarriage is made, and after counseling the patient, OB/GYN consultation is scheduled while inhouse or as an outpatient after discharge (9).…”

“…The causes of vaginal bleeding before 20 weeks gestation are numerous, however, abortion (threatened, inevitable, incomplete, complete, septic, and missed) and ectopic pregnancy comprise Ͼ 95% of these (2). Several review articles and book chapters also exist at present concerned primarily with the evaluation, management, and treatment of threatened abortion (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12). Evaluation algorithms and clinical policy statements state that when a sonogram demonstrates a viable intrauterine fetus in a case of threatened abortion, and the bleeding is less than one pad per hour, the mother can safely be sent home on pelvic precautions without an Obstetrics and Gynecology (OB/GYN) consult or coagulation studies while in-house (1,9,10).…”

Lifestyle Risk Factors Associated with Threatened Miscarriage: A Case-Control Study

“…Threatened miscarriage, defined as vaginal bleeding before the 20th week of gestation, occurs in about 20% of pregnancies [1]. One in three women with threatened miscarriage subsequently suffers a complete miscarriage [2].…”