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{{WikiDoc CMG}}; {{AE}}  
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{{SK}}
{{WikiDoc CMG}}; {{AE}} {{Ifeoma Anaya}}
 
{{SK}} Approach to miscarriage; Approach to pregnancy termination, Abortion workup, Abortion management
==Overview==
==Overview==
This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.
[[Abortion]] refers to [[pregnancy]] loss occurring before 20 weeks of [[gestation]]. Without external intervention is known as [[Spontaneous abortion]]. An example of a life-threatening cause that may result in death or permanent [[disability]] within 24 hours if left untreated is a ruptured [[Ectopic pregnancy]]. Other causes include [[chromosomal abnormalities]], [[infections]], [[cervical]] anomalies, etc. [[Ultrasound]], β-HCG, and [[progesterone]] levels are helpful in confirming [[diagnosis]] and [[treatment]] could be conservative, [[medical]], or [[surgical]] depending on the cause, [[presentation]], and/or patient's preference. Administer Rhogam to [[Rh (D) disease|Rh (D)]] negative mothers, and counsel, accordingly if pregnancy is subsequently desired. [[Medical]] management is [[contraindicated]] in conditions like severe [[anemia]], [[bleeding disorders]], etc while [[surgical]] intervention is not indicated with an unconfirmed [[diagnosis]] of [[spontaneous abortion]].


==Causes==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
 
* [[Life threatening cause 1]]
*Life-threatening causes include conditions that may result in death or permanent [[disability]] within 24 hours if left untreated.
* [[Life threatening cause 2]]
**Ruptured [[ectopic pregnancy]]
* [[Life threatening cause 3]]
**Blunt [[abdominal trauma]] with [[hemodynamic instability]]


===Common Causes===
===Common Causes===
* [[Common cause 1]]
 
* [[Common cause 2]]
*Unknown
* [[Common cause 3]]
*[[Chromosomal abnormalities]] such as:
* [[Common cause 4]]
**[[Trisomies]]
* [[Common cause 5]]
**[[Molar pregnancy]]
**[[Blighted ovum]]
*[[Congenital anomalies]]
*[[Infections]]
*Cervical insufficiency
*Abnormalities of the [[reproductive system]] e.g. [[uterine]] [[malformations]], [[fibroids]] especially [[submucosal]].
*[[Behavioural]]/[[lifestyle]] causes such as illicit drug and [[Alcohol, Drug Abuse, and Mental Health Services Block Grant|alcohol]] use, [[smoking]]
*[[Environmental Health Perspectives|Environmental]] such as exposure to [[radiation]]
*Uncontrolled [[chronic diseases]] ([[Diabetes]], [[Hypertension]], Hypo/[[Hyperthyroidism]], [[Antiphospholipid syndrome]], etc)
*[[Iatrogenic]] such as [[amniocentesis]], [[chorionic villus sampling]]


==Diagnosis==
==Diagnosis==
Shown below is an algorithm summarizing the diagnosis of <nowiki>[[disease name]]</nowiki> according the the [...] guidelines.
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | A01 | | | A01= }}
{{familytree | | | | |!| | | | }}
{{familytree | | | | B01 | | | B01= }}
{{familytree | | |,|-|^|-|.| | }}
{{familytree | | C01 | | C02 | C01= | C02= }}


*Shown below is an algorithm summarizing the [[diagnosis]] of [[Abortion]].<ref name="pmid11219590">{{cite journal| author=Creinin MD, Schwartz JL, Guido RS, Pymar HC| title=Early pregnancy failure--current management concepts. | journal=Obstet Gynecol Surv | year= 2001 | volume= 56 | issue= 2 | pages= 105-13 | pmid=11219590 | doi=10.1097/00006254-200102000-00024 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11219590  }} </ref> <ref name="pmid10739462">{{cite journal| author=Scroggins KM, Smucker WD, Krishen AE| title=Spontaneous pregnancy loss: evaluation, management, and follow-up counseling. | journal=Prim Care | year= 2000 | volume= 27 | issue= 1 | pages= 153-67 | pmid=10739462 | doi=10.1016/s0095-4543(05)70153-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10739462  }} </ref>
{{familytree/start}}
{{familytree | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | |A01=[[Female]] of [[reproductive]] [[age]], [[gestation]] <20weeks, [[bleeding]] per [[vagina]], +/-[[pelvic]] [[pain]]}}
{{familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |B01=Targeted [[history]] and [[examination]], β-HCG,[[CBC]], [[type]] and [[screen]]}}
{{familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |C01=[[Hemodynamically]] stable?}}
{{familytree | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | I01 | | | | | | | | | | I02 | | | | | | | | | | | | | | | | | | | | | | |I01=No|I02=Yes}}
{{familytree | | |!| | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | D01 | | | | | | | | | | D02 | | | | | | | | | | | | | | | | | | | | | | |D01=[[IV access]] and [[fluid]] [[resuscitation]], move to the ED and send [[consult]] to OBGYN|D02=[[Signs]] of [[peritonitis]]?}}
{{familytree | | |!| | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | |!| | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | |!| | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | |!| | | | | |,|-|-|-|-|-|^|-|-|-|-|.| | | | | | | | | | | | | | | | | }}
{{familytree | | |!| | | | | J01 | | | | | | | | | J02 | | | | | | | | | | | | | | | | | |J01=Yes|J02=No}}
{{familytree | | |`|-|-|-|-|-|'| | | | | | | | | | |!| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | E02 | | | | | | | | | | | | | | | | | |E02=[[Pelvic]] [[ultrasound]] }}
{{familytree | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | F01 | | | | | | | | | | F02 | | | | | | | | | | | |F01=[[Intrauterine]]|F02=[[Extrauterine]], confirmed [[ectopic]]? }}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | G01 | | | | | | | | | | |G01=[[Surgery]]. Stabilise if need be}}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | | | | | | | | | | | | H02 | | | | | | | | | | | | | | | | |H02=Yes}}
{{familytree | | | | | |!| | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | | | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | }}
{{familytree | | | | | |!| | | | | |!| | | |!| | | |!| | | |!| | | |!| | | | | | | | | }}
{{familytree | | | | | |!| | | | | L01 | | L02 | | L03 | | L04 | | L05 | | | | | | | | | |L01=Threatened [[abortion]]; [[viable]] [[pregnancy]]+closed [[cervix]]|L02=Missed [[abortion]]; non-viable [[pregnancy]]+closed [[cervix]]|L03=Inevitable [[abortion]]; viable [[pregnancy]]+open [[cervix]]|L04=Incomplete [[abortion]]; Retained Products of [[Conception]]+closed [[cervix]]|L05=Complete [[abortion]]; empty [[uterus]]+closed [[cervix]]}}
{{familytree | | | | | H01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |H01=Uncertain }}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | M01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |M01=Serial [[progesterone]], β-HCG, [[ultrasound]] }}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | |,|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | N01 | | N02 | | N03 | | N04 | | | | | | | | | | | | | | | | | | | | | | | | |N01=[[Ectopic Pregnancy]]|N02=↑β-HCG >66% in 48hrs,normal [[ultrasound]], [[progesterone]] >25ng/ml|N03=[[Progesterone]] <5ng/ml, β-HCG ↓ or ↔, non-viability on [[ultrasound]]|N04=β-HCG equivocal, [[ultrasound]] not [[diagnostic]], [[progesterone]] 5-25ng/ml}}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | |!| | | |`| R01 |'| | | |!| | | | | | | | | | | | | | | | | | | | | | | |R01=[[Treat]] accordingly }}
{{familytree | O01 | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | |O01=[[Surgery]] }}
{{familytree | | | | | | | | | | | | | P01 | | | | | | | | | | | | | | | | | | | | | | |P01=Uncertain }}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | Q01 | | | | | | | | | | | | | | | | | | | | | | |Q01=β-HCG every 2-3 days, repeat [[ultrasound]] weekly till viability is ascertained }}
{{familytree/end}}
{{familytree/end}}


==Treatment==
==Treatment==
Shown below is an algorithm summarizing the treatment of <nowiki>[[disease name]]</nowiki> according the the [...] guidelines.
 
{{familytree/start |summary=PE diagnosis Algorithm.}}
*Shown below is an algorithm summarising the [[treatment]] of [[abortion]].<ref name="pmid10739462">{{cite journal| author=Scroggins KM, Smucker WD, Krishen AE| title=Spontaneous pregnancy loss: evaluation, management, and follow-up counseling. | journal=Prim Care | year= 2000 | volume= 27 | issue= 1 | pages= 153-67 | pmid=10739462 | doi=10.1016/s0095-4543(05)70153-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10739462  }} </ref>
{{familytree | | | | | | | | A01 |A01= }}  
{{Family tree/start}}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{Family tree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |A01=Viable [[pregnancy]]?}}
{{familytree | | | B01 | | | | | | | | B02 | | |B01= |B02= }}
{{Family tree | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | |!| | | | | | | | | |!| }}
{{Family tree | | | | | | B01 | | | | | | B02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | |B01=Yes|B02=No}}
{{familytree | | | C01 | | | | | | | | |!| |C01= }}
{{Family tree | | | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | |,|-|^|.| | | | | | | | |!| }}
{{Family tree | | | | | | C01 | | | | | | C02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | |C01=[[Threatened abortion]]|C02=Missed, incomplete or inevitable [[abortion]]}}
{{familytree | D01 | | D02 | | | | | | D03 |D01= |D02= |D03= }}
{{Family tree | | | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | |!| | | | | | | | | |,|-|^|.| }}
{{Family tree | | | | | | D01 | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |D01=Weekly check ups till [[bleeding]] ceases, administer Rhogam[Rhο(D)] [[immunoglobulin]] if indicated, watch out for [[oligohydramnios]], [[IUGR]] and [[preterm]] [[labor]]}}
{{familytree | E01 | | | | | | | E02 | | | E03 |E01= |E02= |E03= }}
{{Family tree | | | | | | | | | | | | | | J01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |J01=Any complications? E.g.[[pain]], [[hemorrhage]], [[sepsis]]}}
{{familytree | | | | | | | | | | |!| | | | |!| }}
{{Family tree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | F01 | | | F02 |F01= |F02= }}
{{Family tree | | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree/end}}
{{Family tree | | | | | | | | | | E01 | | | | | | E02 | | | | | | | | | | | | | | | | | | | | | | | | |E01=Yes|E02=No}}
{{Family tree | | | | | | | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |!| | | | | | | F01 | | | | | | | | | | | | | | | | | | | | | | | |F01=Counsel on expectant management}}
{{Family tree | | | | | | | | | | |!| | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |!| | | G01 | | | | | | G02 | | | | | | | | | | | | | | | | | | | | |G01=[[Consent]]|G02=Decline}}
{{Family tree | | | | | | | | | | |!| | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |!| | | H01 | | | | | | H02 | | | | | | | | | | | | | | | | | | | | |H01=Follow-up with [[serial]] β-HCG|H02=[[Uterine]] evacuation or [[medical]] [[treatment]]}}
{{Family tree | | | | | | | | | | K01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |K01=Uterine evacuation and [[stabilise]] [[patient]]}}
{{Family tree/end}}


==Do's==
==Do's==
* The content in this section is in bullet points.
 
*Administer Rhogam to Rh (D) negative mothers and counsel accordingly if [[pregnancy]] is subsequently desired.
*Counsel/Reassure [[patients]] and their partners when they are available on how to deal with guilt, the grieving process, and handling friends and family.
*Reversible [[risk factors]] can be addressed professionally.
*Reassure when the cause is unknown.


==Don'ts==
==Don'ts==
* The content in this section is in bullet points.
 
*Contraindications to conservative management/use of uterotonic [[drugs]] are:
**Severe [[blood]] loss leading to [[anemia]]
**[[Septicemia]] or [[pelvic]] [[infections]]
**[[Shock]]
**Equivocal [[diagnosis]] of [[abortion]]/desired [[pregnancy]]
**Presence of [[bleeding disorder]]
**[[Ectopic pregnancy]]
**[[Molar pregnancy]]
**Adverse reaction to uterotonic agents
**>12 weeks uterine volume
*[[Surgical]] management is contraindicated in the following settings:
**Presence of [[bleeding disorder]] that has not been corrected
**Unconfirmed [[diagnosis]] of [[abortion]]


==References==
==References==
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{{Reflist|2}}
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Latest revision as of 04:27, 31 July 2021


Abortion Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifeoma Anaya, M.D.[2]

Synonyms and keywords: Approach to miscarriage; Approach to pregnancy termination, Abortion workup, Abortion management

Overview

Abortion refers to pregnancy loss occurring before 20 weeks of gestation. Without external intervention is known as Spontaneous abortion. An example of a life-threatening cause that may result in death or permanent disability within 24 hours if left untreated is a ruptured Ectopic pregnancy. Other causes include chromosomal abnormalities, infections, cervical anomalies, etc. Ultrasound, β-HCG, and progesterone levels are helpful in confirming diagnosis and treatment could be conservative, medical, or surgical depending on the cause, presentation, and/or patient's preference. Administer Rhogam to Rh (D) negative mothers, and counsel, accordingly if pregnancy is subsequently desired. Medical management is contraindicated in conditions like severe anemia, bleeding disorders, etc while surgical intervention is not indicated with an unconfirmed diagnosis of spontaneous abortion.

Causes

Life Threatening Causes

Common Causes

Diagnosis

 
 
 
 
 
 
 
Female of reproductive age, gestation <20weeks, bleeding per vagina, +/-pelvic pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Targeted history and examination, β-HCG,CBC, type and screen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemodynamically stable?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IV access and fluid resuscitation, move to the ED and send consult to OBGYN
 
 
 
 
 
 
 
 
 
Signs of peritonitis?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pelvic ultrasound
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intrauterine
 
 
 
 
 
 
 
 
 
Extrauterine, confirmed ectopic?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgery. Stabilise if need be
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Threatened abortion; viable pregnancy+closed cervix
 
Missed abortion; non-viable pregnancy+closed cervix
 
Inevitable abortion; viable pregnancy+open cervix
 
Incomplete abortion; Retained Products of Conception+closed cervix
 
Complete abortion; empty uterus+closed cervix
 
 
 
 
 
 
 
 
 
 
 
 
 
Uncertain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serial progesterone, β-HCG, ultrasound
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ectopic Pregnancy
 
↑β-HCG >66% in 48hrs,normal ultrasound, progesterone >25ng/ml
 
Progesterone <5ng/ml, β-HCG ↓ or ↔, non-viability on ultrasound
 
β-HCG equivocal, ultrasound not diagnostic, progesterone 5-25ng/ml
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat accordingly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Uncertain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
β-HCG every 2-3 days, repeat ultrasound weekly till viability is ascertained
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

 
 
 
 
 
 
 
 
 
Viable pregnancy?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Threatened abortion
 
 
 
 
 
Missed, incomplete or inevitable abortion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weekly check ups till bleeding ceases, administer Rhogam[Rhο(D)] immunoglobulin if indicated, watch out for oligohydramnios, IUGR and preterm labor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Any complications? E.g.pain, hemorrhage, sepsis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Counsel on expectant management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consent
 
 
 
 
 
Decline
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow-up with serial β-HCG
 
 
 
 
 
Uterine evacuation or medical treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Uterine evacuation and stabilise patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • Administer Rhogam to Rh (D) negative mothers and counsel accordingly if pregnancy is subsequently desired.
  • Counsel/Reassure patients and their partners when they are available on how to deal with guilt, the grieving process, and handling friends and family.
  • Reversible risk factors can be addressed professionally.
  • Reassure when the cause is unknown.

Don'ts

References

  1. Creinin MD, Schwartz JL, Guido RS, Pymar HC (2001). "Early pregnancy failure--current management concepts". Obstet Gynecol Surv. 56 (2): 105–13. doi:10.1097/00006254-200102000-00024. PMID 11219590.
  2. 2.0 2.1 Scroggins KM, Smucker WD, Krishen AE (2000). "Spontaneous pregnancy loss: evaluation, management, and follow-up counseling". Prim Care. 27 (1): 153–67. doi:10.1016/s0095-4543(05)70153-6. PMID 10739462.