Spontaneous abortion, or miscarriage, is the loss of a pregnancy before 20 weeks, and most occur in the first trimester because of chromosomal problems. It is common, it is usually not caused by anything the patient did, and it needs both medical care and emotional support.
Key symptoms
- Vaginal bleeding, from spotting to heavy
- Cramping lower abdominal or back pain
- Passing tissue or clots
- Loss of pregnancy symptoms such as nausea or breast tenderness
What you find on exam
- Vital signs and signs of shock
- Speculum exam: cervical os open or closed, tissue at the os
- Uterine size and tenderness
- Fever or foul discharge suggests septic abortion
Tests
- Quantitative hCG, repeated if the location is unclear
- Transvaginal ultrasound to confirm location and viability
- Blood count, blood type and Rh
- Rule out ectopic pregnancy
Treatment basics
- Expectant management for stable patients who prefer it
- Medical management: mifepristone followed by misoprostol
- Uterine aspiration for heavy bleeding, infection or patient choice
- Rh immune globulin if Rh negative, per current guidance
- Grief support and clear return precautions
Red flags
- Bleeding that soaks 2 pads an hour for 2 hours, or shock
- Fever, foul discharge or uterine tenderness (septic abortion)
- One-sided pain with no pregnancy seen in the uterus: think ectopic
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.