5.6: Pregnancy that does not result in a Child

Learning Objectives

By the end of this section, learners will be able to

• Identify emergencies associated with miscarriages
• Outline typical history, physical, and laboratory evaluation of miscarriages
• Summarize the management options available for miscarriages
• Describe interprofessional team strategies for improving care coordination and communication to patients undergoing miscarriage

5.6.1 Miscarriage

5.6.1.1 Introduction

Spontaneous abortion or miscarriage is defined as the loss of pregnancy less than 20 weeks gestation. The American College of Obstetricians and Gynecologists (ACOG) estimates it is the most common form of pregnancy loss. It is estimated that as many as 26% of all pregnancies end in miscarriage and up to 10% of clinically recognized pregnancies.⁶² Moreover, 80% of early pregnancy loss occurs in the first trimester.⁶³ The risk of miscarriage decreases after 12 weeks gestation.

The terms miscarriage and abortion are used interchangeably. The term abortion refers to a termination of a pregnancy either natural or induced. There are several terms that describe different states of pregnancy loss. These terms include threatened, inevitable, complete, and missed abortion. Threatened abortion is the presence of vaginal bleeding in early pregnancy, but on pelvic exam, the cervical os is closed, and the transvaginal ultrasound shows a viable fetus.⁶⁴ Inevitable abortion is when there is vaginal bleeding, but on the pelvic exam, the cervical os is open, meaning that the fetus or products of conception are expected to pass through the cervix in the near future. On transvaginal ultrasound, there can be either be a viable fetus or not.⁶⁵ Complete abortion is when there is initially vaginal bleeding and passing of products of conception through the cervix. On transvaginal ultrasound, there would be no remaining products of conception in the uterus. A missed abortion refers to when there was vaginal bleeding and perhaps some passage of tissue or products of conception. On pelvic exam, the cervical os would be closed. On transvaginal ultrasound, there would be retained products of conception, and there would not be a viable fetus.

Watch this video

Video 5.3 - Ultrasound

MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2020 Jun 24]. "Ultrasound." [updated Jan 22, 2022]

5.6.1.2 Etiology

The most common cause of spontaneous pregnancy loss in the first trimester is chromosomal abnormalities. In most cases, it is too early to determine the exact cause of the abnormality. The risk of early pregnancy loss decreases with increasing gestational age and is relatively low after 15 weeks gestation in a genetically normal fetus.⁶⁶

5.6.1.3 Epidemiology

The risk of miscarriage is multivariate, and while some maternal risk factors tend to be more important than others, there is no one predictor of future pregnancy loss. Maternal age is an important predictor of the risk of miscarriage. In women aged 20 to 30, the risk of miscarriage at less than 20 weeks gestation is 8.9%. This increases to 74.7% for women over 40.⁶⁷ Another important predictor in the risk of early pregnancy loss is prior obstetrical history. The risk of miscarriage in a future pregnancy is approximately 20% after 1 miscarriage, 28% after 2 consecutive miscarriages, and 43% after 3 or more consecutive miscarriages.⁶⁸

Maternal comorbidities such as thrombophilia, antiphospholipid antibody syndrome, extremes of maternal weight, and hypertension also increase the risk of miscarriage. Additional maternal risk factors have been identified such as cigarette smoking, large amounts of caffeine use, trauma, and malnutrition.⁶⁹

5.6.1.4 History and Physical

Signs of early pregnancy loss vary and can often be confused with complications or symptoms of a normal intrauterine pregnancy as well as ectopic pregnancy. Most commonly patients present with pelvic and abdominal cramping with or without vaginal bleeding and a positive pregnancy test or missed or abnormal menstrual cycle.

5.6.1.5 Evaluation

The most important determination when evaluating a pregnant patient with symptoms of miscarriage is whether or not this is a true loss, an ectopic pregnancy, molar pregnancy, or a viable pregnancy with complications.

Ultrasound is the gold standard for examining intrauterine contents and viability. This, paired with a quantitative human chorionic (hCG) hormone level, can help determine viability. hCG levels should double in 48 hours on serial exams.⁷⁰

At hCG levels between 1000 to 2000, it has been determined that transvaginal ultrasound (TVUS) is the most sensitive study for identifying intrauterine contents such as a gestational sac with or without a fetus or embryo. There have been multiple studies that reveal a correlation between hCG levels and the stage of embryonic development seen on ultrasound. For instance, at a range of serum hCG between 800 to 1500 UI/I, a 1 to 3 mm gestational sac should be visible on TVUS. A yolk sac should be detectable within the range hCG level of 4500 to 7500 UI/I, with fetal heart motion visible at a range of 8650 to 12,200 U/I.⁷¹

Cardiac activity should be identifiable at a crown-rump length of 5 mm or greater.⁷²

Findings suggestive of but not definitive of early pregnancy loss on transvaginal ultrasound are a crown-rump length (CRL) of 7 mm or greater without fetal cardiac activity or an empty gestational sac with no embryo of 16 to 24 mm or greater in diameter.⁷³

The American College of Obstetricians and Gynecologists (ACOG), therefore, recommends serial hCG levels as well as serial ultrasounds to determine viability.⁷⁴

5.6.1.6 Treatment/Management

Treatment options include expectant management, medication, or surgical interventions.

Decisions are often made jointly with the patient and the obstetrician as to which path to choose. As long as patients are hemodynamically stable and do not require emergency surgery, there is no difference in long-term outcomes when comparing these treatment options.

Expectant management is typically limited to those miscarrying in the first trimester because of lack of studies beyond that timeframe and presumed increased risk of bleeding complications beyond that. Approximately 80% of patients achieve complete passage of intrauterine contents within 8 weeks. ⁷⁵

Medical management can be used in the absence of contraindications, including severe anemia, bleeding disorders, or infection.⁷⁶ Misoprostol, a prostaglandin analog, is given in 1 or 2 doses to achieve induced passage of intrauterine contents. Misoprostol can be taken in the oral form, sublingually, or as a vaginal suppository. Most women will achieve complete expulsion within 3 days, and very few need subsequent uterine curettage.

Surgical evacuation is another option in the treatment of early pregnancy loss and is achieved either with sharp curettage or suction curettage. Surgical evacuation is preferred in women who present with hemorrhage, hemodynamic instability, or signs of infection because these conditions require urgent treatment.⁷⁷ This is also the preferred method of treatment for women with comorbid conditions such as cardiovascular disease, infection, severe anemia, or bleeding disorders.

Success rates for surgical evacuation reach 99%⁷⁸. The risk of complications among all 3 treatment options remains low and is equivocal in patients without comorbid conditions or contraindications to one form or another. Hemorrhage and infection appear to be the 2 most common complications across all three treatment types.

Another important consideration that must be taken into account when evaluating pregnant females with complaints consistent with miscarriage is their Rh status. This is important because the fetus could differ in Rh type from the mother. If mother and fetus have different Rh types, this sets up a scenario where the mother could be exposed to a differing Rh from exposure to the fetal blood type. This could cause the mother to produce antibodies against the different Rh to which it was exposed. These antibodies can then cross the placenta and affect the fetus. This can present serious consequences to the fetus and cause the fetus to develop a high output cardiac failure state known as hydrops fetalis, which is nearly 100% fatal. All women who have a blood type that is Rh(D) negative who are diagnosed with early pregnancy loss and have not been sensitized should receive Rh(D)-immune globulin 50 micrograms (or 300 micrograms if available) to prevent alloimmunization. Rh(D)-immune globulin should be administered as early as possible, within 72 hours, of diagnosis of miscarriage and immediately following surgical intervention.

To date, there exists no proven strategy to prevent early pregnancy loss. Suggestions such as pelvic rest and hormone administration have not been proven. However, some physicians advocate progestin administration early to women who have experienced multiple prior miscarriages. Anticoagulants or aspirin administration has only been proven to be beneficial in women with antiphospholipid antibody syndrome^.79

5.6.1.7 Differential Diagnosis

The differential for early pregnancy loss includes ectopic pregnancy, viable pregnancy with implantation bleeding, molar pregnancy, and viable pregnancy with complications. There are also non-uterine causes of bleeding that can be mistaken for miscarriage such as vaginal trauma.

5.6.1.8 Deterrence and Patient Education

Patient education is important in early pregnancy loss as this can be an emotionally difficult diagnosis. Patient education should focus on maternal health and preparing for future pregnancy. There has been no data to support delaying conception after an early pregnancy loss to prevent subsequent miscarriage or complications.⁸⁰Although most physicians recommend abstaining from vaginal intercourse for 1 to 2 weeks after the passage of tissues, there is no data to support this recommendation.⁸¹

Patients should also be provided with education regarding contraception after a miscarriage including the use of an intrauterine device or hormonal contraception as both have been deemed safe for use immediately following an early pregnancy loss.⁸²

It is important to provide each Rh(D) negative patient education on alloimmunization and risk of future pregnancy with regards to receiving Rh(D) immune globulin.

Most importantly, while there are no proven strategies to reduce the risk of subsequent pregnancy loss after a miscarriage, patient education on maternal health is important. Patients should be provided with education on managing blood pressure, extremes of weight, and cigarette smoking cessation.

5.6.1.9 Enhancing Healthcare Team Outcomes

Treating patients who experience pregnancy loss requires close coordination between all members of the care team. Follow-up care with an obstetrician needs to be coordinated. Clear and concise discharge instructions need to be given to the patient. This experience for the patient can be very emotionally taxing and must be handled with extreme compassion and sensitivity.

Pearls and Other Issues

• Miscarriage is the loss of a pregnancy before 20 weeks gestation.
• Before 12 weeks gestation, most pregnancy loss is due to chromosomal abnormalities.
• Maternal health such as high blood pressure, obesity, and cigarette smoking may increase the risk of miscarriage.
• Advanced maternal age has been proven to increase the risk of miscarriage with risks as high as 74% for women over age 40.
• It is important to evaluate using transvaginal ultrasound to determine whether or not a pregnancy is viable.
• For women with no comorbid conditions, all 3 miscarriage treatment options (medical, surgical, or expectant management) have been proven equally safe and effective.

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5.6.2 Abortion

Learning Objectives

• Describe options available to a patient with a positive pregnancy test
• Explain the methods of abortion available and describe the pros and cons of each method
• Outline the steps of medical abortion, identify complications, and explain how these can be managed
• Review steps of aspiration or surgical abortion, identify complications, and explain how these can be managed

5.6.2.1 Introduction

Abortion is one of the common procedures performed among women. In the US, in 2014, 1 in 5 pregnancies ended in abortion, and 1 in 4 women are estimated to have an abortion in their lifetimes.⁸³ Globally, 1 in 4 pregnancies ends in abortion. It is important that all providers understand the prevalence of abortion, the options available, the safety, the restrictions, and the access issues associated with abortion to be able to provide safe and optimal quality of care to the patients. This activity reviews the options available to the patient when they have a positive pregnancy test, describes the various methods of safe abortion care, outlines the indications and contraindications of the various methods of abortion, explains the techniques of performing an abortion, and outlines the complications and steps that help manage these complications.

A committee of the National Academies of Sciences, Engineering, and Medicine reviewed the data available and confirmed in their report in 2018 that all forms of abortion, including medication and aspiration abortion, are safe and effective and that the only factors decreasing safety are those decreasing access.84 First trimester abortions pose no long-term risk of infertility, ectopic pregnancy, spontaneous abortion, or breast cancer. Abortion does not pose a hazard to a patient’s mental health.⁸⁵

Abortion can be completed with medication or by a procedure which is often called surgical abortion or aspiration abortion. The reasons for terminating a pregnancy may be maternal factors or fetal indications. Preabortion workup often includes obtaining a complete blood count, coagulation profile, type and crossmatch, sexually transmitted infection screen, human chorionic gonadotropin levels, and a pelvic ultrasound to confirm that the pregnancy is intrauterine. Medication abortion can be completed at home. The aspiration abortion is usually performed in a clinic or hospital under local anesthesia, with or without conscious sedation.⁸⁶

5.6.2.2 Anatomy and Physiology

Understanding the normal anatomy of the female genital tract helps manage complications of medication abortion and performing the aspiration or surgical abortion.

5.6.2.3 Indications

According to the National Abortion Federation 2020 Clinical Policy Guidelines for Abortion Care, any patient choosing to have an abortion must be counseled in a nonjudgmental manner about their options. The patient’s desires must be explored, and options including continuing the pregnancy, parenting, adoption, and termination of pregnancy should be discussed during this time. If the patient desires to end the pregnancy, then the benefits, risks, and details of the process need to be discussed.

Early medication abortion is noninvasive, avoids the risks of a surgical procedure and anesthesia, and can be done up to 11 weeks. It allows for more privacy and control for the patient. It usually involves the use of medications such as mifepristone and misoprostol, and rarely, methotrexate.⁸⁷ Medication abortion after the first trimester can also be performed safely and effectively by trained clinicians in settings that are equipped to support the patient. Induced fetal demise may be necessary for later gestational ages.

Aspiration or surgical abortion involves a procedure and the use of instruments in the vagina, cervix, and uterus to remove the pregnancy. The procedure is usually short. Aspiration abortion might be needed if medication abortion fails or the woman bleeds heavily during the medication abortion. According to the 2020 National Abortion Federation Clinical Policy Guidelines for Abortion Care, the incidence of aspiration after medication abortion is 2-9% for >63 days LMP and even less to less than 1 to 3% when the second dose of misoprostol is used. The other indication for aspiration or surgical abortion is suspected molar pregnancy.⁸⁸

5.6.2.4 Contraindications

Contraindications to medication abortion include:

• IUD in place - may be removed before the medication abortion
• Allergy to medication used
• Chronic adrenal failure, especially in patients who are on long-term systemic corticosteroid therapy
• Suspected ectopic pregnancy
• Hemorrhagic disorders
• Anticoagulant therapy, excluding aspirin
• Hemodynamic instability
• Inherited porphyria

Anemia, seizures, asthma on steroid inhalers, obesity, breastfeeding, HIV or AIDs, and sexually transmitted infection are not considered contraindications.

Exercise care in case of any coagulopathy or any other bleeding disorder, but these are not contraindications for surgical or aspiration abortion. In case the products of conception are not confirmed on the aspirate after a surgical abortion, trend the HCG levels to ensure ectopic pregnancy or pregnancy of unknown location is ruled out and treated if this is the case.

5.6.2.5 Equipment

Equipment used for aspiration abortion includes:

• Vacuum single valve aspirator/Manual vacuum aspirator plus
• Locking 60 cc syringe
• Cannula
• Specimen cup
• Standard Graves speculum
• Single tooth tenaculum
• Ring forceps with cotton
• Small polyp forceps
• Pratt cervical dilators
• Gauze
• Curette

5.6.2.6 Preparation

• Medical Abortion

Once the pregnancy test is positive and the patient has opted for abortion, take the following steps to ensure the patient is eligible for medication abortion.

Confirm the last menstrual period (LMP) and estimate the gestational age(GA). The first day of LMP alone is an accurate means of estimating the gestational age through the mid-first trimester. If the LMP is not known or unreliable, obtain an ultrasound to date the pregnancy. There is no need for an ultrasound prior to medication abortion in all cases^.89

Take a detailed medical history from the patient, including allergies, review of medical conditions, medications, and substance use. Complete a physical exam if indicated by the patient’s history and symptoms. Patients choosing medication abortion with a definite LMP do not need a pelvic exam. The pelvic and bimanual exams may be performed prior to the procedure. Patients with no medical conditions do not need routine pre-abortion lab testing. Labs that are recommended include glucose for patients with Insulin Dependent Diabetes Mellitus, INR for those on anticoagulants (warfarin) beyond 12 weeks of GA, rhesus D testing for consenting patients beyond 56 days from LMP and unknown Rh status, hemoglobin and hematocrit only for those with history or symptoms of anemia, gonorrhea and chlamydia testing for those at increased risk or less than 25 years of age. When clinical dating is uncertain, an ultrasound scan is performed to confirm the location and viability of the pregnancy. Combined mifepristone/misoprostol regimens are more effective than misoprostol alone or methotrexate/misoprostol.⁹⁰

According to the National Abortion Federation (NAF) 2020 guidelines, after counseling the patient about the methods and the pros and cons of the procedure, determine pregnancy dating and eligibility for medication abortion by one of the following.

1. LMP< or = 77 days from the anticipated date of mifepristone use and
   1. First positive pregnancy test was less than 6 weeks ago
   2. No ectopic risk factors, including previous ectopic pregnancy, history of Pelvic Inflammatory Disease, Intra Uterine Device in place at the time of conception, bleeding since LMP, or unilateral pelvic pain
   3. Regular menses with no hormonal contraception use 2 months prior to LMP
2. LMP and physical examination, including a bimanual examination if needed
3. Pelvic ultrasound to date the pregnancy

Ensure the patient has no contraindications for medication abortion. Obtain signed informed consent, including the manufacturer’s patient agreement and medication guide from the patient, after discussing the risks involved in medication abortion and the side effects of the medication.

Side effects of mifepristone mainly include vaginal bleeding. Side effects of misoprostol include nausea, vomiting, diarrhea, low-grade fever, and muscle aches that resolve within 6 hours of use. If the mifepristone or misoprostol are vomited after less than 15 to 30 minutes of use, repeating the dosing can be considered. Antiemetic medications can help manage nausea and vomiting. Vaginal bleeding usually starts 4 to 6 hours after misoprostol use and can be heavy with clots. Patients bleeding heavier than 2 pads per hour or for over 2 hours need to be evaluated by the clinician. Bleeding lasts from 1 to 45 days. Patients need to be informed of the risks, including heavy bleeding that may need additional doses of misoprostol, NSAIDs, the need for aspiration in some cases, the small risk for endometritis, failure of medication abortion needing additional doses of misoprostol or aspiration, and teratogenicity of misoprostol. The patient’s phone number or email is confirmed. Lastly, transportation for follow-up is ensured.

• Surgical Abortion

After taking a detailed medical history, pregnancy must be confirmed, and gestational age must be assessed. Ultrasound is often used to confirm the location of the pregnancy. Baseline vitals, including pulse and blood pressure, must be performed for all, and a physical exam for those indicated by patient symptoms and history. Confirm and arrange all the instruments required for the procedure ahead of time.

5.6.2.7 Technique

• Medical Abortion - Mifepristone/Misoprostol protocol

Mifepristone - one 200mg tablet is swallowed on day 1 in the clinic or at home. Misoprostol can be administered in the following routes

1. Buccally: Four 200mcg tablets are placed between gum and cheek for 30 minutes and swallowed thereafter, 24 to 48 hours after mifepristone administration.
2. Vaginal: Four 200mcg tablets of misoprostol can also be placed in the vagina 6 to 48 hours after the mifepristone
3. Sublingual: Two to four 200mcg tablets of misoprostol under the tongue for 30 minutes

According to the NAF 2020 guidelines, if a patient is > 63 days from LMP, a second dose of 800mcg misoprostol can be administered 4 hours after the first dose. If the patient more than 70 days from LMP, a second dose of 800mcg misoprostol is recommended 4 hours after mifepristone.

NSAIDs help pain management for the patient while at home,⁹¹ and the routine prescription of opiates is not necessary. A short prescription for opiates may be prescribed in case NSAIDs are not tolerated or cannot be used due to an allergy. Prophylactic antibiotics are not routinely recommended for medical abortion. Contraception can be discussed if the patient is willing to engage at this time.

The patient is instructed to contact the provider if

1. Bleeding heavily, soaking 2 or more pads in 2 or more consecutive hours
2. Severe pain that is not responding to the medication prescribed
3. Fever of more than 100.4 degrees Fahrenheit (38 C) for more than 24 hours after misoprostol
4. No bleeding within 24 hours of misoprostol
5. Nausea, vomiting, diarrhea, abdominal pain more than 24 hours after misoprostol

According to the NAF 2020 guidelines, an ultrasound is not needed to confirm the completion of a successful abortion if using clinical history and home pregnancy tests.92 It can be performed by checking baseline serum HCG on the day of mifepristone and one after misoprostol. A decrease of hCG of 50% from baseline by 72 hours, 60% by 4-5 days,⁹³ and 80% by 7 days from initiating treatment94 are confirmative of a successful MAB. It can also be confirmed by ultrasound examination before and after medication administration. An absence of the gestational sac or embryo confirms the success of the abortion.

According to the NAF 2020 guidelines, when methotrexate and misoprostol are used, an evidence-based regimen of oral or intramuscular methotrexate followed in three to five days with vaginal misoprostol is recommended for gestations up to 63 days.

• Surgical/Aspiration Abortion

Aspiration abortion is performed up to 16 weeks.

Technique: Don gloves, perform a bimanual examination, and confirm the uterine position and size. Confirm you have all the equipment you need. Adjust table and light, insert the speculum, and evaluate and collect samples for infection screening and testing. Apply the antiseptic solution to the cervix. Administer a paracervical block if the patient is awake. Place the tenaculum on the cervix. Dilate the cervix to the size of the cannula you will be using (gestational age in weeks + or - 1 to 2 mm). The cervix is dilated using tapered dilators like Pratt or Denniston dilators.⁹⁵ Misoprostol can also be used for cervical preparation prior to the procedure.⁹⁶ Osmotic dilators are used when cervical dilation is expected to be difficult. Insert cannula through the cervix with gentle but firm traction on the cervix using the tenaculum. Connect the aspirator to the cannula. The procedure is completed by aspiration of the uterus using a manual or electric vacuum and not by sharp curettage. The procedure is considered complete when the uterus is empty. Ultrasound can be used to confirm the completion of the procedure. Remove the tenaculum and the speculum. Check for the adequacy of the products of conception. If molar pregnancy is suspected, send the tissue to the pathologist for examination. Inform the patient of the complete procedure and the recovery process. The procedure usually takes 5 to 10 minutes, and antibiotics are given at the end of the procedure to avoid infection.

Dilatation and evacuation are performed beyond 16 weeks by experienced clinicians in appropriate clinical settings. Intravenous access should be established prior to the procedure. If induced fetal demise is used, appropriate evidence-based protocols must be followed. Osmotic dilators including Dilapan and laminaria, misoprostol, mifepristone, and or other cervical agents are used to achieve adequate dilation. Osmotic dilators may be placed in the cervix prior to the procedure. All instruments entering the uterine cavity must be sterile. Ultrasound should be used during the procedure to locate fetal parts, visualize instruments, and verify the completion of the procedure, thus reducing the risk of uterine perforation and shortening the procedure.⁹⁷ Uterotonics must be used to help control uterine bleeding during and after the procedure.

5.6.2.8 Complications

Complications of Medication abortion⁹⁸ and the management options when these arise include the following:

1. Heavy bleeding and or severe cramping.
   1. Repeat misoprostol/NSAIDs
   2. Uterine aspiration
   3. Blood transfusion99
2. Failure of medication abortion
   1. Uterine aspiration
   2. Repeat misoprostol100
3. Infection - endometritis (fever>24 hours after misoprostol, abdominal and pelvic pain, vaginal discharge, uterine/adnexal tenderness)
   1. Uterine aspiration if retained pregnancy tissue in the uterus and antibiotics per CDC guidelines
   2. Immediate admission to the hospital will be required if hemodynamically unstable and aggressive treatment with antibiotics.
4. Ectopic pregnancy
   1. Treat or refer for the next steps

5.6.2.9 Aspiration Abortion 101

1. Vasovagal episode
   1. Cool compresses
   2. Elevate legs above the chest
   3. Isometric extremity contractions
   4. Atropine IM 0.4mg or 0.2mg IV, max dose 2mg
2. Heavy bleeding - remember 6 Ts102
   1. Tone - Uterine massage and consider uterotonics like methergine, misoprostol
   2. Tissue - Ensure there is no retained tissue in the uterus
   3. Trauma - Identify the source of bleeding and address it, especially cervical and vaginal tears
   4. Thrombin - review the history of bleeding and consider additional tests like CBC, coagulation tests, clotting test
   5. Treatment - Consider IV fluid bolus and uterine tamponade with a foley’s catheter bulb
   6. Transfer - to the hospital if need be, monitor vitals closely

5.6.2.10 Perforation

1. Stop the suction, examine the contents of the aspirate for omentum, bowel, products of conception
2. If stable, continue and complete the procedure under ultrasound guidance. Consider uterotonics and antibiotics. Observe for 1.5 to 2 hours post-procedure.
3. If the patient is unstable, transfer
4. Incomplete abortion
   1. Offer misoprostol or
   2. Reaspiration if bleeding, in pain or have signs of infection
5. Accumulation of blood in the uterus post-procedure - patient usually complains of pain and rectal pressure, and this is usually accompanied by hypotension and or vasovagal syncope
   1. Uterine aspiration or uterotonics
6. Endometritis (fever, pain, vaginal discharge, leukocytosis)
   1. Antibiotics per the CDC PID regimen
   2. Ultrasound +/- aspiration procedure
   3. Test for gonorrhea and chlamydia
7. Ectopic Pregnancy - suspect if POC inadequate at the time
   1. Transfer to hospital for treatment with methotrexate vs. surgical management

5.6.2.11 Clinical Significance

Any patient with a positive pregnancy test should be counseled about thier options at the time of the consultation in a nonjudgemental manner. Abortion is an overall safe and effective procedure. Providers should be aware of the prevalence of abortion, the restrictions, and the access issues associated with abortion and strive to provide safe care to patients seeking an abortion.

5.6.2.12 Enhancing Healthcare Team Outcomes

Abortion is safer when the laws regarding abortion are less restrictive and in countries where the gross national income is higher. The stigma associated with abortion is another recognized barrier to accessing safe abortion and can contribute to the maternal mortality rate worldwide. Overall, ensuring women have better access to reproductive health care, including modern methods of contraception, can ensure the care provided is safe and help reduce maternal and infant mortality rates.

Glossary Terms

Alloimmunization

immune response to foreign antigens after exposure to genetically different cells or tissues

Anemia

condition in which the body does not have enough healthy red blood cells. Red blood cells provide oxygen to body tissues

Anticoabulants

agents that prevent BLOOD CLOTTING

Antiemetic

drug used to prevent NAUSEA or VOMITING

Antiphospholipid antibody syndrome

condition in which the immune system mistakenly creates antibodies that attack tissues in the body

Aspirate

aspiration means to draw in or out using a sucking motion

Buccally

buccal means relating to or located in the cheeks

Cannula

short, hollow cylinders or tubes for insertion into a canal, vessel, or body cavity

Cervical os

opening between the cervix and the corpus

Coagulopathy

blood's ability to coagulate (form clots) is impaired

Coagulation

process of the interaction of BLOOD COAGULATION FACTORS that results in an insoluble FIBRIN clot

Comorbid

diseases or medical conditions that are simultaneously present in a patient

Contrainidcations

specific situation in which a medicine, procedure, or surgery should not be used because it may be harmful to the person

Curretage

scraping, usually of the interior of a cavity or tract, for removal of new growth or other abnormal tissue, or to obtain material for tissue diagnosis. It is performed with a curet (curette), a spoon-shaped instrument designed for that purpose

Dilipan

mechanical cervical dilator designed for gentle and predictable cervical ripening in the induction of labor

Dilation

first stage of childbirth, involving an increase in cervical diameter

Ectopic pregnancy

implantation of an embryo outside of the uterus

Endometritis

inflammation of the ENDOMETRIUM, usually caused by intrauterine infections. Endometritis is the most common cause of postpartum fever

Foley catheter

medical device that helps drain pee from your bladder

Hematocrit

Hematocrit is a blood test that measures how much of a person's blood is made up of red blood cells. This measurement depends on the number of and size of the red blood cells

Hemodynamics

movement and the forces involved in the movement of the blood through the CARDIOVASCULAR SYSTEM

Hemoglobin

protein in red blood cells that carries oxygen

Hemorrhagic disorders

hemorrhage is the medical term for bleeding. It most often refers to excessive bleeding. Hemorrhagic diseases are caused by bleeding, or they result in bleeding (hemorrhaging)

Human chorionic hormone (hCG)

hormone produced primarily by syncytiotrophoblastic cells of the placenta during pregnancy

Hydrops fetalis

occurs when abnormal amounts of fluid build up in two or more body areas of a fetus or newborn; it is a symptom of underlying problems

Incidence

the number of new cases of a condition, symptom, death, or injury that develop during a specific time period, such as a year. Incidence shows the likelihood that a person in a certain population will be newly affected by that condition in a specific period of time

Intravenous

means "within a vein;" most often it refers to giving medicines or fluids through a needle or tube inserted into a vein - this allows the medicine or fluid to enter your bloodstream right away

IUD

intrauterine device (IUD) is a small plastic T-shaped device used for birth control; it is inserted into the uterus where it stays to prevent pregnancy

MAB

medical abortion

Methodrexate

antineoplastic antimetabolite with immunosuppressant properties; it is an inhibitor of TETRAHYDROFOLATE DEHYDROGENASE and prevents the formation of tetrahydrofolate, necessary for synthesis of thymidylate, an essential component of DNA

Mifepristone

Mifepristone (Korlym) is used to treat hyperglycemia (high blood sugar) in people with a certain type of Cushing's syndrome in which the body makes too much cortisol (a hormone) and who have failed surgery or cannot have surgery to treat this condition

Misoprostol

used to prevent ulcers in people who take certain arthritis or pain medicines, including aspirin, that can cause ulcers; it protects the stomach lining and decreases stomach acid secretion

Molar pregnancy

rare complication of pregnancy involving unusual growth of cells called trophoblas

Obstetrician

qualified medical professionals who specialize in OBSTETRICS - a medical-surgical specialty concerned with management and care of women during pregnancy, parturition, and the puerperium

Opiates

drugs used to treat pain

Ostmoci dilators

medical implements used to dilate the uterine cervix by swelling as they absorb fluid from surrounding tissue

Paracervical block

nerve block used during obstetric and gynecologic procedures

Porphyria

group of rare disorders that result from a buildup of natural chemicals called porphyrins in the body

Prevalence

total number of cases of a given disease in a specified population at a designated time; it is differentiated from INCIDENCE, which refers to the number of new cases in the population at a given time

Prophylactic

medicine or course of action used to prevent disease

Prostaglandin

group of compounds derived from unsaturated 20-carbon fatty acids, primarily arachidonic acid, via the cyclooxygenase pathway; they are extremely potent mediators of a diverse group of physiological processes

Rh status

blood-type classification based on the presence or absence of the antigen Rh on the erythrocyte membrane surface

Syncope

loss of consciousness for a short period of time

Tenaculum

surgical instrument, usually classified as a type of forceps

Teratogenecity

ability to cause defects in a developing fetus

Thrombophilia

disorder of HEMOSTASIS in which there is a tendency for the occurrence of THROMBOSIS

Uterotonics

medication used to induce contraction or greater tonicity of the uterus to prevent or reduce hemorrhage

Vasovagal syncope

loss of consciousness due to a reduction in blood pressure that is associated with an increase in vagal tone and peripheral vasodilation

Footnotes

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