Early pregnancy loss / spontaneous abortion

Rationale

Early pregnancy loss or spontaneous abortion (miscarriage) is common. Patient presentation is commonly with a threatened abortion. Spontaneous abortion occurs most frequently in the first trimester. When recurrent, spontaneous abortion can be associated with infertility. Spontaneous abortion can result in grief.

Causal Conditions

(list not exhaustive)

The cause is usually not determined but may include the following:

1. Genetic factors (e.g., chromosomal abnormalities)
2. Reproductive tract abnormalities (e.g., uterine anomalies)
3. Prothrombotic factors (e.g., thrombophilia)
4. Endocrinologic factors (e.g., polycystic ovary syndrome)
5. Immunologic factors (e.g., antiphospholipid syndrome)

Key Objectives

Given a patient with a threatened abortion, the candidate will clarify the status of the pregnancy, identify any complications, and initiate an appropriate management plan. Particular attention should be paid to supportive counselling of parents and to appropriate investigation in cases of recurrent spontaneous abortion.

Enabling Objectives

Given a patient with threatened abortion, the candidate will

1. list and interpret critical clinical findings, including
   1. the results of a thorough obstetric history;
   2. the results of a physical examination, with an emphasis on the status of the pregnancy (e.g., speculum examination, evidence of an ectopic pregnancy); and
   3. signs of urgent complications (e.g., hemodynamic instability);
2. list and interpret critical investigations, including
   1. transvaginal ultrasonography;
   2. laboratory investigations when appropriate (e.g., maternal antibody screen, complete blood count, β-human chorionic gonadotropin); and
   3. proper investigation regarding recurrent abortion (e.g., antiphospholipid antibody screen, karyotype, hysterosalpingography); and
3. construct an effective initial management plan, including
   1. emergent management in case of hemodynamic instability (e.g., ruptured ectopic pregnancy);
   2. referral for surgical evacuation or medical management (e.g., incomplete or missed abortion) if necessary;
   3. counselling (e.g., grief, fertility implications, contraception); and
   4. referral for specialized care if indicated (e.g., serious hemorrhage, recurrent abortion).