No intervention is necessary for patients with threatened abortion even if the bleeding is accompanied by low ab-dominal pain and cramping. If there is no evidence of sig-nificant abnormality on ultrasound evaluation, and if the pregnancy is found to be intact, the patient can be reassured and allowed to continue normal activities.
For an incomplete abortion, expectant, medical, and surgical management are all reasonable options, unless there is serious bleeding or infection. Surgical treatment is definitive and predictable but is invasive and not neces-sary for all women. Expectant and medical management may obviate curettage but are associated with unpre-dictable bleeding, and some women will need unscheduled surgery. In cases of significant pain, hemorrhage, or infec-tion, prompt completion of abortion—either medically or surgically—is warranted.
Immediate considerations include control of bleed-ing, prevention of infection, pain relief, and emotional support. Bleeding is controlled by ensuring that the prod-ucts of conception have been expelled or removed from the uterus. In cases of complete abortion, the uterus is small and firm, the cervix is closed, and ultrasound identi-fies an empty uterus. Curettage is a quick resolution that is almost 100% successful in completing early pregnancy losses. Hemostasis is enhanced through uterine contrac-tion stimulated by oral methylergonovine. Removal of the products of conception and vaginal rest (no tampons, douches, or intercourse) decrease the risk of infection. A mild analgesic may be required and should be offered. Rh-negative mothers should receive Rh immune globulin (RhoGAM). Chromosomal evaluation of spontaneous abortions is not recommended, unless there is a history of recurrent abortion.
Emotional support is important for both the short-and long-term well-being of both the patient and her partner. No matter how well-prepared a couple is for the possibility of pregnancy loss, the event is a significant dis-appointment and cause of stress. When appropriate, the couple should be reassured that the loss was not precipi-tated by anything that they did or did not do, and that there was nothing that they could have done to prevent the loss.
A follow-up office visit is generally scheduled for 2 to 6 weeks after the loss of a pregnancy. This is an appropri-ate time to evaluate uterine involution, assess the return of menses, and discuss reproductive plans. The causes (or lack of causes) of the pregnancy loss should also be reiter-ated. The impact of this loss on future childbearing should be discussed. A single pregnancy loss does not significantly increase the risk of future losses. Multiple pregnancy losses carry an increased risk for future pregnancies and warrant further evaluation for treatable etiologies.