12.5 Spontaneous & Recurrent Abortion: Recognition & Management

12.5 Spontaneous & Recurrent Abortion: Recognition & Management

High-Yield Core Concept: The OBGYN syllabus lists Abortions and Intra-Uterine Growth Retardation under high-risk pregnancy. CMS stems hinge on classifying the miscarriage by the state of the cervical os, recognising septic abortion, and knowing the work-up of recurrent loss.

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1. Definitions & Classification

Abortion = expulsion or extraction of a fetus before 20 weeks gestation or weighing <500 g.

Clinical triad of miscarriage: bleeding + cramping lower-abdominal pain + (closed or open) cervix. Always record the state of the os — it determines the diagnosis.

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2. Septic Abortion

Most often follows unsafe/illegal induced abortion but complicates any retained products. Causative organisms include E. coli, anaerobes, Gram-negative bacilli, Clostridium.

Clinical: fever, tachycardia, foul-smelling vaginal discharge, uterine tenderness, abdominal guarding; may progress to septic shock, ARDS, renal failure, DIC.

Management (emergency):

1. Resuscitate — IV fluids, oxygen, haemodynamic monitoring; blood for CBC, cross-match, coagulation, cultures.
2. Broad-spectrum IV antibiotics early (e.g. ampicillin/ceftriaxone + gentamicin + metronidazole, or a carbapenem in severe sepsis).
3. Uterine evacuation (suction or D&E) once stable; oxytocin to reduce blood loss.
4. Supportive ICU care for shock, ARDS, DIC; hysterectomy if uterine necrosis/perforation uncontrolled.

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3. Recurrent (Habitual) Abortion

Defined as ≥3 consecutive spontaneous abortions. Causes:

Work-up: parental karyotype, TSH, anticardiolipin + lupus anticoagulant (repeat 12 weeks apart), pelvic ultrasound/hysteroscopy/SIS for uterine anatomy, cervical length surveillance if cervical incompetence.

Antiphospholipid syndrome criteria: ≥3 consecutive losses <10 weeks, or ≥1 loss ≥10 weeks, or severe pre-eclampsia/ placental insufficiency, plus persistent positive antiphospholipid antibodies. Treatment: low-dose aspirin + unfractionated/LMWH heparin in pregnancy improves live-birth rate.

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4. Molar Pregnancy (Hydatidiform Mole)

A cause of bleeding in early pregnancy that must not be missed. Complete mole (all paternal DNA, no fetus) and partial mole (triploid, partial fetal tissue).

Clinical: first-trimester bleeding, uterus large for dates, excessive vomiting (hyperemesis, high β-hCG), passage of vesicles, bilateral theca-lutein cysts, early pre-eclampsia.

USG: 'snowstorm' appearance, absent fetal cardiac activity (complete).

Management: suction evacuation (careful, oxytocin running to avoid perforation/embolisation), send products for histology, then serial β-hCG follow-up until undetectable and for 6 months thereafter to detect persistent trophoblastic disease / choriocarcinoma; reliable contraception during surveillance.

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5. Differential: Bleeding + Pain in Early Pregnancy

Always consider ectopic pregnancy — abdominal pain, vaginal bleeding, amenorrhoea, adnexal tenderness/mass, and a β-hCG below the discriminatory zone (~1,500–2,000 IU/L) with no intrauterine gestation on transvaginal USG. A closed cervix with mild bleeding may mimic threatened abortion; adnexal tenderness or a mass and a positive pregnancy test with an empty uterus mandate ectopic assessment.

6. Cervical Incompetence & Threatened Abortion Management in Detail

Cervical incompetence (cervical insufficiency) is a distinct, surgically-treatable cause of second-trimester loss that candidates must not confuse with first-trimester miscarriage. The classic history is painless, progressive cervical dilation and expulsion of a live fetus in the second trimester with minimal cramping, often recurrent. Risk factors include prior cervical surgery (cone biopsy), trauma (dilation, MTP), and connective-tissue disorders.

Management — cervical cerclage (Shirodkar/McDonald suture):

• History-indicated (prophylactic) at 12–14 weeks after one or more prior second-trimester losses.
• Ultrasound-indicated when serial transvaginal scans show cervical shortening (<25 mm) before 24 weeks.
• Rescue/emergency when dilation is detected on examination but membranes are unruptured — lower success.
• Cerclage is removed at 36–37 weeks (or earlier if labour/PPROM/infection) and is contraindicated with active bleeding, infection, ruptured membranes or a fetus already non-viable.

Threatened abortion with viable pregnancy — light bleeding, closed os, fetal cardiac activity present. Management is reassurance, pelvic rest and avoidance of heavy exertion; progesterone supplementation has limited evidence and is reserved for a history of recurrent loss. Most threatened abortions resolve and proceed to a live birth. Anti-D for Rh-negative women. Arrange ultrasound to confirm viability and exclude subchorionic haematoma.

Worked scenario: a woman with two prior painless mid-trimester losses at 18 weeks presents at 11 weeks wanting prevention — history-indicated cervical cerclage at 12–14 weeks is the evidence-based choice, distinguishing her cervical incompetence from recurrent first-trimester miscarriage (which would prompt antiphospholipid screening instead).

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Key Takeaways for the CMS Candidate

• State of the cervical os defines threatened vs inevitable vs incomplete miscarriage — the favourite discriminator.
• Septic abortion = emergency: antibiotics + evacuation + ICU support.
• Recurrent loss = ≥3 consecutive; the treatable cause is antiphospholipid syndrome → aspirin + heparin.
• Molar pregnancy → suction + 6-month serial β-hCG surveillance for choriocarcinoma.
• Bleeding + pain + empty uterus on USG → exclude ectopic.