The 20-week mark during pregnancy is considered the point of fetal viability. Pregnant women <20 weeks gestation who experience bleeding may be experiencing a miscarriage or spontaneous abortion. Factors such as chromosomal abnormalities, endocrine imbalances, systemic disorders, and genetic mutations may lead to an early pregnancy loss occurring before 12 weeks gestation. A late miscarriage occurring between 12 and 20 weeks gestation may be caused by advanced maternal age, reproductive tract abnormalities, obesity, inadequate nutrition, and stress.
Identifying the type of spontaneous abortion is critical in determining appropriate subsequent treatment. Types of spontaneous abortion include threatened, inevitable, incomplete, complete, and missed.
For threatened spontaneous abortion, bed rest is recommended for 24-48 hours following symptoms of bleeding and cramping. Instruct the patient to avoid intercourse for the next 2 weeks. Bed rest is also recommended in patients experiencing inevitable spontaneous abortion if there is no pain, fever, or bleeding.
During a spontaneous abortion, monitoring the patient for hemorrhage is critical for timely interventions of maintaining fluid balance. Instruct the patient to save and measure the amount of blood on pads. Administer IV fluids or blood as needed.
Since the patient may experience excessive bleeding during a spontaneous abortion, saving pads and linens is important to monitor the amount of bleeding.
RhoGAM is indicated to suppress the immune response in nonsensitized Rh-negative women who are exposed to Rh-positive fetal blood cells. Rh- women experiencing spontaneous abortion may be exposed to Rh-positive blood of the nonviable fetus and require RhoGAM to prevent complications (refer to the Picmonic on "RhoGAM").
Dilation and curettage (D&C) is a surgical procedure involving the dilation of the cervix to facilitate the insertion of a suction curette to scrape the uterine walls to remove uterine contents. The procedure is done to remove the tissue of the nonviable fetus from inside the uterus. Prior to D&C, a full history is obtained and a pelvic examination is conducted. After the removing the uterus, oxytocin may be administered to prevent hemorrhage.
A cervical cerclage or cervical stitch is done in patients with cervical insufficiency in which the cervix shortens prematurely and leads to a late miscarriage. A strong suture is inserted around the cervix between weeks 12 to 14 and removed toward the end of the pregnancy or it may be left in place and a cesarean birth performed, if the woman anticipates another pregnancy.
A spontaneous abortion is a traumatic experience for many pregnant women. Assessing the woman's reaction to the experience and providing emotional support is critical during this time of emotional grief of the loss of pregnancy.
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