MEDICAL TREATMENT :
No effective therapy is available for a threatened intrauterine abortion.
Bed rest, although often advocated, is not effective. No consistent evidence shows that bed rest can affect pregnancy outcome in threatened abortion. However, it is not harmful and may provide the patient with some emotional comfort.
In general, most do not administer progesterone or sedatives. In most instances of threatened abortions that ultimately result in complete abortion, the embryo is already dead; thus, the administration of progesterone drugs is ineffective and only prolongs the natural course of abortion. However, progesterone (vaginal administration) may be indicated in unique circumstances, including viable pregnancies achieved with advanced reproductive technology or patients with a history of an inadequate luteal phase. Studies have shown that although progesterone administration may not necessarily change the outcome of threatened abortion, it may help reduce the severity of symptoms such as pain from cramping and uterine contractions.
Institute appropriate counseling for all patients. A sympathetic attitude and continuing support and follow-up care are important to patients. This includes a tactful explanation about the pathologic process and favorable prognosis when the pregnancy is viable.
Treat any vaginal infections.
SURGICAL CARE : Continued observation is indicated as long as the cervix remains closed, bleeding and cramping are mild, QhCG levels are increasing normally, and a normal embryo/fetus is visualized on follow-up sonogram images.
The prognosis worsens with (1) progressively increasing bleeding and cramping, (2) QhCG levels that fall or level off, (3) failure to find sonographic evidence of embryonic/fetal growth, (4) fetal bradycardia, and (5) size smaller than appropriate for dates.
When the pregnancy is confirmed nonviable based on transvaginal ultrasonography or because the cervical os is dilated or excessive bleeding is present, perform suction curettage. This prevents delayed hemorrhage and infection related to retention of necrotic tissue. It also diminishes the chances for the development of disseminated intravascular coagulation, a rare but potentially life-threatening complication associated with the retention of a dead conceptus for longer than 4 weeks.
In women with minimal intrauterine tissue based on ultrasonographic images, waiting for spontaneous passage of the products of conception is possible (expectant management). If complete abortion does not occur within this waiting period, ensure adequate counseling regarding risks of infection, bleeding, disseminated intravascular coagulation, and chance of requiring surgical intervention (suction curettage).
Currently, evidence is insufficient to support medical therapy (prostaglandins and progesterone receptor inhibitors) for spontaneous abortions.
DRUG TREATMENT :
HORMONE THERAPY :
- PROGESTERONE : Progesterone supplementation may be given PO, IM, or vaginally. Oral progesterone is metabolized rapidly in the liver, and the metabolites have little effect on endometrial activity. Vaginal progesterone is the drug of choice for luteal phase deficiency; this is due to the close proximity of the uterus to where the medication is delivered. Vaginal gel 8% or suppository either qd or bid regimen can be used with good patient tolerability and similar efficiency. Treatment begins 2 days after spontaneous ovulation as determined by an ovulation predictor kit or the day after medically induced ovulation during infertility treatment protocols