MANAGEMENT OF THREATENED ABORTION

Dr. Bushra Hasan Khan

JR-1

Department of Pharmacology

JNMC, AMU, Aligarh.

Threatened Abortion

A clinical entity where the process of abortion has

started, but has not progressed to a state where recovery

is impossible.

The clinical diagnosis of threatened abortion is

presumed when a bloody vaginal discharge appears

through a closed cervical os during the first half of

pregnancy.

Threatened Abortion is the most common complication

in the first half of pregnancy.

Its incidence varies between 20-25%.

Miscarriage is 2.6 times as likely

17% of cases are expected to present complications later

in pregnancy.

ETIOLOGY

Embryonic abnormalities

Maternal factors

Anatomic factors

Endocrine factors

Infectious factors

Immunologic factors

CLINICAL FEATURES

The pregnant patient complains of :

• Bleeding per vaginum

• Pain

INVESTIGATIONS

Blood

Urine

Pelvic examination

Ultrasonography

Transvaginal Sonography

Well formed gestational sac

Observation of fetal cardiac activity

With these there is about 98% chance of continuation of

pregnancy.

Sonography can usually differentiate between an intrauterine

pregnancy (viable or non-viable), a molar

pregnancy, or an inevitable abortion.

Serum Progesterone value

25 ng/ml or more – a viable pregnancy in about

95% cases

Serial serum beta HCG level

20 ng/ml or more – viable pregnancy

To assess the level of fetal well being

Adverse Prognostic factors in cases of Threatened Abortion

A large empty gestational sac

Discrepancy : gestational age and crown to rump length

Fetal bradycardia or absence of fetal heart activity

Advanced maternal age

History of recurrent pregnancy loss

Maternal serum Progesterone < 25 ng/ml or

low maternal serum hCG

Complications

These fetuses are at increased risk for intrauterine

growth retardation, preterm delivery, low birthweight,

and perinatal death.

Maternal risks include antepartum hemorrhage, manual

removal of the placenta, and cesarean delivery.

Management

Bed rest

Paracetamol

Progesterone therapy

hCG therapy

Tocolytic agents

“There is insufficient evidence of high quality that

supports a policy of bed rest in order to

prevent miscarriage in women with confirmed fetal

viability and vaginal bleeding in first half of pregnancy”.

Progesterone therapy

Oral micronized Progesterone : 200mg OD or BD.

Vaginal progesterone suppositories : 200mg OD or BD.

Progesterone vaginal gel : 100mg two or three times/day

Intramuscular Progesterone : Injection in oil given as

50mg /day.

• “Use of progestogens is effective in the treatment of threatened

miscarriage with no evidence of increased rates of pregnancy-

induced hypertension or antepartum haemorrhage as harmful

effects to the mother, nor increased occurrence of congenital

abnormalities on the newborn”.

•“However, the analysis was limited by the small number and

the poor methodological quality of eligible studies (four studies)

and the small number of the participants (421), which limit the

power of the meta-analysis and hence of this conclusion”.

“The current evidence does not support the routine use

of hCG in the treatment of threatened miscarriage”.

Tocolytics

Adrenergic receptor agonists

Ca2+ channel blockers

Oxytocin-receptor antagonist: Atosiban

Nitric oxide donors

Magnesium sulphate

Cycloxygenase inhibitors

Sites of action of tocolytic drugs in the uterine myometrium

Ritodrine

Started as 50 µg/min i.v. infusion

Rate of infusion is increased every 10 minutes till

uterine contractions cease or maternal heart rate

rises to 120/min.

Contractions can also be kept suppressed by 10 mg i.m.

4-6 hourly followed by 10 mg oral 4-6 hourly.

Side effects & contraindications

Tachycardia, Hypotension, Pulmonary Edema.

Hypergylycemia, Hypokalemia.

Anxiety, Restlessness, Headaches.

Fetal pulmonary edema.

Neonate may develop hypoglycemia and ileus.

Its use is contraindicated if mother is diabetic, having

heart disease, or receiving beta blockers.

Ca2+ channel blockers

Relative to Beta2 adrenergic agonists, Nifedipine is more

likely to improve fetal outcomes and less likely to cause

maternal side effects.

Oral Nifedipine 10 mg repeated once or twice after

20-30 min, followed by 10 mg, 6 hourly has been used.

Nifedipine: side effects

Maternal flushing

Headache, Dizziness, Nausea

Transient hypotension and Tachycardia, Palpitations.

Fetal hypoxia associated with maternal

Hypotension.

Oxytocin receptor antagonists

Atosiban : a peptide analogue of Oxytocin

Competitively inhibits the interaction of Oxytocin with

its membrane receptor on uterine cellsdecreases the

frequency of uterine contractions.

Intravenous use

6.75 mg bolus, followed by 300µg/min infusion for 3

hours. Then 100µg/hour for upto 45 hours.

Nitroglycerine

Nitric oxide is a potent vasodilator and smooth muscle

relaxant.

The major adverse effect is maternal hypotension.

Dose; 50-200µg intravenously.

Can consider repeating dose after 1-4 minutes if

inadequate response occurs.

Magnesium Sulphate

Administered intravenously ; 4-6 g loading dose,

then 2-4 g/hour titrated to uterine response and

maternal toxicity.

Two reviews demonstrate magnesium sulphate to be

ineffective as a tocolytic.

Side effects of magnesium sulphate

Maternal flushing,

Sweating,

Respiratory depression,

Bradycardia,

Myocardial depression,

Loss of deep tendon reflexes,

Neuromuscular blockade.

“There is insufficient evidence to support

the use of uterine muscle relaxant drugs

for women with threatened miscarriage”.

“Any such use should be restricted to the

context of randomised trials”.

Cycloxygenase inhibitor

Indomethacin

Use is controversial.

Anti-D Immunoglobulin

The Rh-negative woman is given anti-D

immunoglobulin following abortion.

This practice is controversial with threatened abortion

because it lacks evidence-based support (American

College of Obstetricians and Gynecologists, 1999;

Weissman and associates, 2002).