Eduovisual
Pregnancy, Childbirth & Puerperium
Spontaneous abortion: types and management
— Clinically recognized pregnancy loss occurs in 10–20% of pregnancies; including biochemical losses, the rate approaches 30%.
— 80% of SABs occur in the first trimester (<12 weeks).
— Risk rises sharply with maternal age: ~10% at age 20–30, ~25% at 35, ~50% at 40, ~80% at ≥45.
— First trimester: ~50% from fetal aneuploidy (trisomy 16 most common karyotype, but 45,X and triploidy frequent). Other: luteal phase insufficiency, uncontrolled diabetes, thyroid disease, antiphospholipid syndrome (APS), uterine anomalies, infection (TORCH, listeria, syphilis).
— Second trimester: more often maternal/anatomic — cervical insufficiency, müllerian anomalies, submucosal fibroids, APS, thrombophilias, chronic disease.
— Any first- or early second-trimester vaginal bleeding ± cramping in a confirmed or suspected pregnancy.
— Loss of pregnancy symptoms (breast tenderness, nausea) in an early gestation.
— Inappropriately rising β-hCG (<35% rise in 48 h) or absent fetal cardiac activity at expected milestones.
Board pearl: A patient with ≥3 consecutive losses (or 2 with workup justified) meets criteria for recurrent pregnancy loss — trigger evaluation for APS, karyotype of both partners, uterine imaging, TSH, HbA1c, and prolactin. Single sporadic losses do not warrant a workup beyond Rh status and emotional support.
— Threatened abortion: vaginal bleeding, closed os, viable IUP on US. ~50% progress normally.
— Inevitable abortion: bleeding + cramping, dilated os, products still in uterus, no tissue passed yet.
— Incomplete abortion: partial tissue passage, dilated os, retained products on US (heterogeneous endometrial contents >15 mm).
— Complete abortion: all POC expelled, closed os, empty uterus on US (endometrial stripe <15 mm), bleeding/cramping resolving, β-hCG falling.
— Missed abortion: fetal demise retained in utero, closed os, no bleeding, loss of fetal cardiac activity or empty gestational sac (anembryonic/"blighted ovum").
— Septic abortion: any of the above + infection (fever, foul discharge, tender uterus, leukocytosis) — often after instrumentation or unsafe abortion.
— LMP and gestational age — anchor every decision.
— Quantify bleeding (pads/hour, clots, tissue passage — ask patient to bring tissue if possible).
— Cramping severity, shoulder pain or syncope (suspect ectopic).
— Prior pregnancies, prior losses, prior D&C/cervical procedures (LEEP, cone → cervical insufficiency).
— Medical: diabetes, thyroid, APS, SLE, thrombophilia, hypercoagulable history.
— Medications, substances (cocaine, tobacco, alcohol, NSAIDs, misoprostol misuse).
— Rh status of patient and partner — drives RhoGAM decision.
— Trauma, IPV screening, recent instrumentation.
Key distinction: Threatened = bleeding + closed os + viable fetus; inevitable = bleeding + open os, fetus may still be viable but loss is unavoidable. The cervical os exam is the pivot point on Step 3 vignettes — read carefully whether the os is "closed," "dilated," or "POC visible at os."
Step 3 management: Always screen for intimate partner violence during pregnancy loss evaluations; abuse escalates during pregnancy and is a missed cause of trauma-related loss.
— Tachycardia, hypotension, orthostasis → suspect hemorrhagic shock or ruptured ectopic; resuscitate before workup.
— Fever ≥38°C with bleeding → septic abortion until proven otherwise.
— Suprapubic tenderness suggests uterine source.
— Peritoneal signs (rebound, guarding) or shoulder-tip pain (Kehr sign from hemoperitoneum irritating diaphragm) → ruptured ectopic, surgical emergency.
— Fundal height assessment if >12 weeks (palpable above pubic symphysis at 12 wk, at umbilicus at 20 wk).
— Quantify bleeding and identify source (cervical, vaginal, uterine).
— Inspect os: closed vs open, presence of products of conception protruding (immediate gentle removal with ring forceps relieves vasovagal cervical shock from POC stretching the os and stops reflex bradycardia/hypotension).
— Look for foul discharge → infection.
— Note any cervical lesions, polyps, lacerations (rule out other bleeding source).
— Assess cervical dilation (key for classifying type).
— Uterine size versus gestational age — small-for-dates suggests missed/incomplete or wrong dating.
— Adnexal mass or cervical motion tenderness → ectopic or PID/septic abortion.
CCS pearl: In a hypotensive bleeding pregnant patient, the first three orders are: two large-bore IVs, type & cross 2 units PRBCs, and stat transvaginal ultrasound + quantitative β-hCG. Resuscitate with crystalloid while preparing for the OR if ectopic or hemorrhagic SAB is suspected. Do not delay OB consult to finish lab workup.
Board pearl: Cervical shock — a vasovagal response to POC distending the internal os — presents with bradycardia + hypotension despite minimal blood loss. Remove the tissue with ring forceps and symptoms resolve; do not assume hypovolemia and over-resuscitate.
— Quantitative serum β-hCG — establishes pregnancy, trends with serial values, anchors US interpretation.
— CBC — baseline hemoglobin, leukocytosis (sepsis).
— Blood type and Rh — drives Rh(D) immunoglobulin decision.
— Coagulation panel and fibrinogen if heavy bleeding or suspected DIC (especially missed abortion retained >4 weeks or septic abortion).
— Urinalysis ± urine culture; cervical GC/CT if risk factors or septic picture.
— Type & cross if hemodynamically unstable or surgical management planned.
— Gestational sac visible at β-hCG ~1,500–2,000 mIU/mL (discriminatory zone).
— Yolk sac at ~5.5 weeks (sac >10 mm without yolk sac is abnormal).
— Fetal pole at ~6 weeks; cardiac activity by ~6.5 weeks (CRL ≥7 mm without heartbeat = nonviable).
— Mean sac diameter ≥25 mm without embryo = anembryonic pregnancy (missed abortion).
— Retained products: heterogeneous endometrial contents, often with vascularity on Doppler.
— Empty uterus + β-hCG above discriminatory zone → presume ectopic until proven otherwise.
— Normal IUP: rise ≥35% in 48 h (older "doubling" rule replaced by 2013 ACOG criteria).
— Plateau or <35% rise → abnormal pregnancy (ectopic or failing IUP).
— Falling β-hCG with empty uterus → completed SAB or resolving ectopic — still must follow to zero.
Step 3 management: In suspected complete abortion, document the patient to zero β-hCG with weekly trends. A premature stop risks missing an undiagnosed ectopic masquerading as completed miscarriage.
Board pearl: A single β-hCG value cannot distinguish IUP from ectopic; trends + ultrasound do.
— Not routine after a first sporadic loss.
— Indicated for recurrent pregnancy loss (≥2–3) — identifies aneuploidy as cause and informs prognosis. Microarray preferred over standard karyotype (avoids maternal cell contamination, higher resolution).
— Antiphospholipid syndrome: lupus anticoagulant, anticardiolipin IgG/IgM, anti-β2 glycoprotein I — repeat positive at 12 weeks for diagnosis.
— Parental karyotypes — balanced translocations (Robertsonian) in ~3–5%.
— Uterine cavity assessment: saline infusion sonohysterogram, hysteroscopy, or 3D US — identify septate uterus, submucosal fibroids, Asherman, polyps.
— TSH (overt and subclinical hypothyroidism), HbA1c, prolactin.
— Inherited thrombophilia panel (factor V Leiden, prothrombin G20210A) — only if personal/family VTE history; not routine in RPL alone.
— Endometrial biopsy and TORCH titers are not recommended.
— MRI pelvis if müllerian anomaly suspected and US ambiguous (distinguishes septate from bicornuate uterus — septate is correctable, bicornuate generally is not).
— HSG if also evaluating tubal patency for subfertility.
— Confirm chorionic villi in expelled tissue — absence raises concern for ectopic.
— Molar pregnancy: "snowstorm" US, β-hCG often >100,000, theca lutein cysts, hyperemesis — send tissue for histology.
Key distinction: Septate uterus = hysteroscopic resection improves live birth rates; bicornuate uterus = surgery rarely improves outcomes. Misclassification changes management entirely.
Board pearl: APS is the only proven, treatable cause of RPL with a clear intervention — low-dose aspirin + prophylactic LMWH in the next pregnancy.
— Expectant management
— Medical management (misoprostol ± mifepristone)
— Surgical management (suction D&C / manual vacuum aspiration)
— Hemodynamic stability: unstable → surgical, immediately.
— Infection: septic abortion → prompt surgical evacuation + IV antibiotics.
— Gestational age and POC volume: large retained tissue or >12 wks → surgical preferred.
— Patient preference, access, distance from hospital, prior experience.
— Coagulopathy or anticoagulation → surgical with correction.
— Threatened abortion: expectant; pelvic rest, avoid heavy activity, return precautions for heavy bleeding/cramping/fever. No bed rest — not evidence-based. Repeat US in 1–2 weeks. Progesterone supplementation only benefits women with prior SAB and current first-trimester bleeding (modest evidence).
— Inevitable/incomplete: expectant, medical, or surgical based on stability and preference.
— Missed abortion: all three options reasonable; medical or surgical often preferred since spontaneous expulsion may take weeks and carries DIC risk if prolonged.
— Complete abortion: supportive, confirm β-hCG to zero, RhoGAM if Rh-negative.
— Septic abortion: emergent suction D&C + broad-spectrum IV antibiotics (ampicillin + gentamicin + clindamycin or metronidazole).
— Give 300 μg if Rh-negative and unsensitized; 50 μg acceptable if <12 weeks per some guidelines, but 300 μg is standard US practice.
Step 3 management: All three options are equally safe for stable early pregnancy loss — present them with shared decision-making. Document the conversation.
CCS pearl: For septic abortion, order antibiotics, IV fluids, type & cross, OB consult, and OR within minutes — every hour of delay increases mortality.
— Mifepristone 200 mg PO → 24 hours later → Misoprostol 800 μg vaginally (or buccal).
— Combined regimen yields ~84% complete expulsion vs 67% with misoprostol alone — preferred when mifepristone is accessible.
— 800 μg vaginally, may repeat dose in 24–48 h if no expulsion.
— Alternative: 600 μg sublingual.
— Mifepristone: progesterone receptor antagonist → decidual breakdown, cervical softening, sensitization to prostaglandins.
— Misoprostol: PGE1 analog → uterine contractions, cervical ripening.
— NSAIDs (ibuprofen 600–800 mg) for cramping — does not reduce misoprostol efficacy.
— Antiemetics (ondansetron) — misoprostol causes nausea/vomiting/diarrhea in ~25%.
— Opioids rarely needed; offer for severe pain.
— Expect heavy bleeding and clots within 2–6 hours of misoprostol; cramping peaks early then tapers.
— Bleeding continues lighter for 1–2 weeks.
— Return precautions: soaking >2 pads/hour for 2 consecutive hours, fever >38°C, severe pain unresponsive to meds, foul discharge, syncope.
— Follow-up US or β-hCG in 1–2 weeks to confirm completion.
— Hemodynamic instability, suspected ectopic, IUD in place (remove first), severe anemia, coagulopathy, allergy, active pelvic infection.
Board pearl: Mifepristone + misoprostol is also the regimen for induced abortion up to 70 days — but for SAB it is only the misoprostol portion that is FDA-approved; mifepristone use for SAB is off-label but evidence-based and ACOG-endorsed.
Step 3 management: Always provide Rh(D) immune globulin to Rh-negative patients undergoing medical management before tissue passage.
— Hemodynamic instability or hemorrhage
— Septic abortion
— Failed medical management (~10–15%)
— Patient preference (immediate completion)
— Coagulopathy / on anticoagulation
— Concurrent need for diagnostic tissue (suspected molar pregnancy, GTD)
— Manual vacuum aspiration (MVA): office-based, syringe-driven, <10–12 weeks, local paracervical block. Efficacy ~98%, shorter recovery, lower cost.
— Electric suction D&C: OR-based, similar efficacy, used for later gestations or larger uterus.
— Sharp curettage: historic, largely replaced by suction; reserved for adjunct after suction.
— Cervical preparation: misoprostol 400 μg buccal/vaginal 2–4 h pre-op softens cervix, reduces injury risk — especially for nulliparous or >12 wk.
— Prophylactic antibiotics: doxycycline 200 mg PO preoperatively reduces post-procedure infection.
— Anesthesia: paracervical block ± IV sedation or general for OR.
— Confirm uterine size and position; ultrasound guidance reduces perforation risk.
— Dilate cervix progressively; aspirate gently; confirm gritty sensation of evacuated cavity.
— Send tissue for pathology — confirms chorionic villi, screens for molar disease.
— Bleeding lighter than medical management, resolves over 1–2 weeks.
— Resume normal activity in 24–48 h; avoid intercourse/tampons 1–2 weeks.
— RhoGAM if Rh-negative.
— Contraception counseling — ovulation can occur within 2 weeks.
— Uterine perforation (~0.1%), cervical laceration, hemorrhage, infection, retained POC, Asherman syndrome (intrauterine adhesions — present later as amenorrhea/infertility).
CCS pearl: After suction D&C for septic abortion, continue IV antibiotics until afebrile 48 h, then transition to oral doxycycline 14 days.
Board pearl: Vignette of secondary amenorrhea + infertility after D&C = Asherman syndrome → diagnose with hysteroscopy, treat with adhesiolysis.
— SAB risk rises steeply: 25% at 35, 50% at 40, 80% at ≥45 — driven by oocyte aneuploidy.
— Counsel about baseline elevated risk before loss occurs.
— Offer expanded carrier screening and cell-free fetal DNA in next pregnancy.
— Pre-conception evaluation: HbA1c, TSH, BP optimization, folic acid 400–800 μg/day (4 mg if prior NTD or diabetes).
— Increased SAB and preeclampsia risk with eGFR <60 or significant proteinuria.
— Avoid NSAIDs for cramping if CKD — use acetaminophen.
— Dose-adjust misoprostol? Not generally needed; renal clearance minimal contribution.
— Methotrexate (used for ectopic, not SAB) is contraindicated in renal impairment.
— Mifepristone metabolized hepatically (CYP3A4) — use caution in severe hepatic disease; no formal dose adjustment but avoid in chronic adrenal failure (it's an anti-glucocorticoid).
— Acute fatty liver of pregnancy, HELLP — if SAB occurs in this context, manage the systemic disease first.
— Hold warfarin/DOACs; bridge to LMWH if needed.
— Surgical management preferred over medical to control bleeding.
— Time procedure when anticoagulation effect is minimal (skip 1–2 LMWH doses pre-op).
— Severe baseline anemia (Hgb <8) → surgical management to limit duration of blood loss; transfuse before procedure if symptomatic or Hgb <7.
Step 3 management: Pre-conception optimization is higher-yield than any post-loss workup for most patients — control DM (HbA1c <6.5%), thyroid (TSH 0.5–2.5), BMI, and substance use before the next pregnancy.
Board pearl: Use acetaminophen, not NSAIDs, for SAB-related cramping in CKD, peptic ulcer disease, or third-trimester pregnancy.
— Diagnostic criteria: ≥1 clinical (vascular thrombosis OR pregnancy morbidity: ≥3 consecutive losses <10 wks, ≥1 loss ≥10 wks, or severe preeclampsia/IUGR <34 wks) + persistent antibodies ≥12 weeks apart.
— Treatment in next pregnancy: low-dose aspirin (81 mg) + prophylactic LMWH (e.g., enoxaparin 40 mg SQ daily) from positive pregnancy test through 6 weeks postpartum.
— Therapeutic-dose anticoagulation if prior thrombosis.
— Overt hypothyroidism doubles SAB risk; treat to TSH <2.5 preconception and first trimester.
— Subclinical hypothyroidism with positive anti-TPO: treat with levothyroxine — evidence mixed but ACOG/ATA endorse.
— Poor periconceptional glucose control (HbA1c >10) increases SAB risk 2–3×. Target HbA1c <6.5% preconception.
— Continue metformin/insulin; transition oral agents to insulin if needed.
— History: painless cervical dilation with second-trimester loss, prior cone/LEEP, müllerian anomaly.
— Management in next pregnancy: history-indicated cerclage at 12–14 weeks, or US-indicated cerclage if cervical length <25 mm before 24 weeks with prior preterm birth.
— Vaginal progesterone if short cervix without prior loss.
— Higher rates of incomplete prenatal care; ensure confidentiality, screen for IPV, STI testing, contraception counseling.
— Increased risk of cesarean scar pregnancy — mimics SAB but is a dangerous variant; diagnose with TVUS showing gestational sac in scar niche; refer to MFM.
Key distinction: Cervical insufficiency = painless dilation in 2nd trimester → cerclage. Preterm labor = painful contractions → tocolytics. Both can cause 2nd-trimester loss but management differs entirely.
Board pearl: APS + low-dose aspirin + LMWH improves live birth rate from ~20% to ~70% — one of the highest-yield interventions in obstetrics.
— Hemorrhage: most common serious complication; defined as soaking >2 pads/h for ≥2 hours or hemodynamic compromise. Treat with uterotonics (misoprostol 800 μg, methylergonovine 0.2 mg IM if no HTN, oxytocin), uterine massage, urgent suction D&C.
— Retained products of conception: persistent bleeding, β-hCG plateau, US with echogenic endometrial contents. Treat with repeat misoprostol or suction D&C.
— Infection / endometritis: fever, foul discharge, uterine tenderness — broad-spectrum antibiotics (ampicillin + gentamicin + clindamycin/metronidazole) and surgical evacuation if retained tissue.
— Septic abortion → septic shock, ARDS, DIC, renal failure — ICU-level care; remember Clostridium perfringens as a classic post-abortion sepsis pathogen with massive intravascular hemolysis.
— DIC: especially with prolonged retention of dead fetus (>4 weeks) — release of thromboplastin. Monitor fibrinogen, platelets, PT/PTT. Treat underlying SAB urgently.
— Uterine perforation (surgical complication): suspect with sudden pain, hypotension, loss of resistance during dilation. Manage with laparoscopy if hemodynamic concern; observation if small fundal perforation.
— Cervical injury / hematometra.
— Asherman syndrome: intrauterine adhesions after aggressive curettage → secondary amenorrhea, infertility, recurrent loss. Diagnose with hysteroscopy.
— Rh sensitization if RhoGAM omitted → hemolytic disease of fetus/newborn in subsequent pregnancies.
— Psychological: depression, anxiety, PTSD, grief — affect up to 30–50% of women post-SAB, often underrecognized.
CCS pearl: Post-abortion sepsis with gas in the uterus on imaging, jaundice, hemoglobinuria, and shock → Clostridium perfringens. Treat with immediate hysterectomy + IV penicillin + clindamycin — antibiotics alone will not save the patient.
Board pearl: RhoGAM omission is a classic Step 3 litigation/quality scenario — always document Rh status and prophylaxis.
— Hemodynamic instability unresponsive to fluids
— Septic shock, suspected clostridial infection
— DIC with active hemorrhage
— Uterine perforation with intra-abdominal bleeding
— Suspected ruptured ectopic
— Confirmed or suspected SAB beyond first trimester
— Suspected ectopic, molar pregnancy, or cesarean scar pregnancy
— Septic abortion
— Recurrent pregnancy loss
— Failed medical management
— Müllerian anomaly or cervical insufficiency requiring planning
— Recurrent loss with APS, thrombophilia, or known anomaly
— Prior cervical insufficiency requiring cerclage planning
— Comorbid medical conditions (SLE, severe DM, CKD)
— Heavy bleeding requiring monitoring/transfusion
— IV antibiotics for endometritis/septic abortion
— Pain uncontrolled with oral medication
— Inability to follow up or safety concerns at home
— Surgical management requiring observation
— Hemodynamically stable threatened, complete, or uncomplicated incomplete SAB
— Patients on outpatient medical management — provide clear return precautions and 24-hour contact number
— Social work for grief support, IPV screening
— Mental health referral for severe distress or prior depression/anxiety
— Genetics for confirmed parental translocation or recurrent loss
Step 3 management: In any Step 3 vignette of a stable patient with confirmed SAB, the next best step is rarely "admit" — it's usually shared decision-making with three management options and RhoGAM if Rh-negative.
CCS pearl: Time-sensitive orders in septic abortion (within 1 hour): blood cultures × 2, lactate, broad-spectrum IV antibiotics, 30 mL/kg crystalloid, OB consult, OR booking. Do not wait for surgery to start antibiotics.
— Must be excluded in every first-trimester bleed.
— Classic triad: amenorrhea, vaginal bleeding, abdominal pain.
— Risk factors: prior ectopic, PID, tubal surgery, IUD in situ, IVF, smoking.
— Diagnosis: β-hCG above discriminatory zone with empty uterus on TVUS; tubal ring or adnexal mass.
— Management: unstable → salpingectomy; stable with small unruptured ectopic (β-hCG <5,000, no cardiac activity, mass <3.5 cm) → methotrexate (single or two-dose). Follow β-hCG to zero.
— Complete mole (46,XX paternal, no fetal tissue) and partial mole (69,XXY triploid with fetal parts).
— Vignette: β-hCG >100,000, hyperemesis, early preeclampsia (<20 wks), uterus large for dates, theca lutein cysts, "snowstorm"/"cluster of grapes" on US.
— Management: suction D&C (preferred over medical), serial β-hCG to zero, contraception for 6–12 months (avoid IUD until β-hCG zero), monitor for gestational trophoblastic neoplasia (~15–20% of complete moles).
— Crescent-shaped hypoechoic collection between chorion and uterine wall; small ones often resolve. Larger (>25% of sac) increase SAB risk. Manage expectantly.
— Light spotting around expected menses with rising β-hCG and viable IUP — reassurance.
— Coexisting IUP + ectopic — rare (~1/30,000 natural, ~1/100 IVF). Don't be falsely reassured by an IUP if pain or adnexal mass present.
Key distinction: β-hCG >100,000 + theca lutein cysts + snowstorm US = molar; β-hCG plateau + empty uterus + adnexal mass = ectopic; β-hCG appropriately rising + IUP + bleeding = threatened SAB or subchorionic hematoma.
Board pearl: After molar evacuation, pregnancy is contraindicated for 6–12 months because a new pregnancy's β-hCG would mask the rising β-hCG of GTN.
— Cervicitis (GC, chlamydia, trichomoniasis) — friable cervix on exam; treat infection.
— Cervical polyps — bleeding with intercourse; usually benign.
— Cervical cancer — should not be missed; perform Pap if overdue, biopsy suspicious lesions.
— Vaginal trauma — ask about IPV.
— Light spotting at 4–6 weeks may be normal.
— Von Willebrand disease, ITP, anticoagulation — bleed easily; quantify and correct.
— Placenta previa: painless bright red bleeding, abnormal placental position on US. No digital exam.
— Placental abruption: painful dark bleeding, rigid tender uterus, fetal distress, hyperactive contractions. Risk factors: HTN, cocaine, trauma, prior abruption.
— Vasa previa: rupture of fetal vessels during membrane rupture, fetal exsanguination, dark bleeding with sudden fetal decelerations. Emergent C-section.
— Uterine rupture: sudden severe pain, loss of fetal station, hemodynamic collapse — especially with prior C-section or oxytocin use.
— Preterm labor with bloody show, cervical insufficiency with painless dilation.
— UTI may cause dysuria and microscopic hematuria; rule out by UA.
Key distinction: Painless late-pregnancy bleeding → previa. Painful rigid uterus → abruption. Sudden fetal bradycardia + membrane rupture + dark bleeding → vasa previa. Do not confuse abruption (maternal blood, fetus may be okay) with vasa previa (fetal blood, baby exsanguinates fast).
Board pearl: Any second-trimester bleeding warrants TVUS first, not digital exam — to avoid catastrophic hemorrhage if previa is present.
— Rh(D) immunoglobulin if Rh-negative, given before discharge.
— Ibuprofen or acetaminophen for cramping; short opioid course rarely needed.
— Iron supplementation if Hgb <11, oral ferrous sulfate 325 mg daily–TID.
— Antibiotics completed if endometritis (doxycycline 14 days).
— Contraception: ovulation may return in 2 weeks; offer all methods. IUD/implant can be placed immediately if no infection.
— Soaking ≥2 pads/h for 2 hours, fever ≥38°C, foul discharge, severe pain unresponsive to NSAIDs, syncope, persistent bleeding >2 weeks.
— 1–2 weeks: clinical visit ± TVUS to confirm completion, repeat β-hCG until negative (especially after molar — weekly until zero × 3, then monthly × 6 months).
— 4–6 weeks: wellness/grief check-in, contraception, preconception counseling for those desiring another pregnancy.
— Optimize comorbidities (HbA1c <6.5, TSH 0.5–2.5, BP <140/90).
— Folic acid 400–800 μg/day (4 mg if prior NTD or on antiepileptics).
— Smoking cessation, alcohol abstinence, healthy BMI.
— Vaccinations: MMR, varicella, Tdap, influenza, COVID — update before conception (live vaccines avoided in pregnancy).
— Address medications: switch teratogens (ACEi/ARB, warfarin, isotretinoin, valproate) to pregnancy-safe alternatives.
— Timing: most clinicians advise waiting 1–3 months before attempting again, though physiologically conception is safe after one normal cycle.
— APS → ASA + LMWH next pregnancy.
— Septate uterus → hysteroscopic resection.
— Cervical insufficiency → cerclage planning.
— Diabetes/thyroid → tight control preconception.
Step 3 management: Folic acid + comorbidity optimization + medication review is the universal preconception bundle — applicable to every Step 3 vignette involving future pregnancy planning.
Board pearl: Single sporadic SAB does not decrease future fertility or live birth rate — counsel reassuringly.
— β-hCG to undetectable: typically 4–6 weeks for first-trimester loss. Persistent or rising β-hCG suggests retained POC, GTN, or undiagnosed ectopic — re-image and refer.
— CBC at 1–2 weeks if significant blood loss.
— Pelvic ultrasound if heavy or prolonged bleeding to rule out retained tissue.
— Menses return in 4–8 weeks; persistent amenorrhea raises Asherman concern → hysteroscopy.
— Discuss all options; LARC (IUD, implant) can be placed at the post-procedure visit or immediately after surgical management if no infection.
— Combined hormonal methods safe immediately postpartum loss (no VTE elevation as in term postpartum).
— Up to 50% of women experience clinically significant grief or depressive symptoms after SAB; up to 20% develop major depression or PTSD.
— Validate the loss — avoid minimizing language ("at least it was early").
— Use patient-preferred terminology (some prefer "miscarriage," some "baby," some "pregnancy loss").
— Screen with PHQ-9 / GAD-7 at follow-up visits.
— Acknowledge partner's grief — refer for couples counseling if needed.
— Religious or cultural rituals — offer chaplaincy, time with tissue if desired.
— Resources: support groups (Share Pregnancy & Infant Loss Support), online communities, mental health referral.
— Pelvic rest 1–2 weeks (no intercourse, tampons, douching).
— Resume exercise as tolerated; return to work in 1–7 days depending on procedure and emotional state.
— Some patients need extended leave for grief — provide FMLA documentation as appropriate.
Step 3 management: Schedule a dedicated emotional follow-up visit at 4–6 weeks, separate from the medical β-hCG follow-up. Empathic continuity is associated with better mental health outcomes and patient satisfaction.
Board pearl: Persistent amenorrhea after D&C = think Asherman → hysteroscopy. Persistent rising β-hCG after molar = GTN → chemotherapy referral.
— All three management options (expectant, medical, surgical) must be offered with risks/benefits in a stable patient. Document the discussion.
— Capacity to consent: standard adult capacity assessment. Adolescents — most states allow minors to consent to pregnancy-related care; check jurisdictional law.
— Language-concordant care: use professional interpreters, not family.
— Management of spontaneous abortion is medically and legally distinct from induced abortion, but in restrictive-state vignettes, clinicians and patients have faced delays due to ambiguity.
— Ectopic pregnancy and septic abortion are not considered "abortions" under any current state law — emergent treatment is mandated under EMTALA. Do not delay life-saving care for legal review.
— Mifepristone access varies; document medical indication clearly.
— Screen for IPV — trauma during pregnancy can cause loss and indicates escalation of abuse.
— Suspected unsafe induced abortion with infection — provide compassionate care, no legal obligation to report an adult patient's pregnancy decisions in most US jurisdictions (verify locally); patient confidentiality protected under HIPAA.
— Pediatric patients with pregnancy: assess for sexual abuse, mandatory reporting if statutory.
— Patients discharged on misoprostol must have 24-hour access to a clinician — bleeding can be severe and patients may panic. Provide written instructions and direct phone line.
— RhoGAM omission is a sentinel safety event — build it into order sets.
— β-hCG follow-up loss = missed ectopic = malpractice exposure.
— Disposition of fetal tissue — some states require burial/cremation options; respect patient wishes.
— Use neutral, validating language.
Step 3 management: In a vignette involving a restrictive-state patient with incomplete septic abortion, the answer is always immediate evacuation and antibiotics — EMTALA preempts state restrictions when maternal life is threatened.
Board pearl: Document RhoGAM administration, β-hCG follow-up plan, and emotional support discussion — these are the three most commonly omitted items on SAB charts.
— 1st trimester: chromosomal (~50%, trisomy 16 most common but lethal).
— 2nd trimester: anatomic, infection, cervical insufficiency, APS.
— CRL ≥7 mm without cardiac activity
— Mean sac diameter ≥25 mm without embryo
— No embryo with cardiac activity ≥2 weeks after gestational sac without yolk sac
— No embryo with cardiac activity ≥11 days after gestational sac with yolk sac
Board pearl: "Snowstorm + theca lutein cysts + hyperemesis + early preeclampsia" = complete mole. "Empty uterus + β-hCG >2,000 + adnexal mass + shoulder pain" = ruptured ectopic.
— Diagnosis: threatened abortion.
— Best next step: reassurance, pelvic rest, repeat US in 1–2 weeks, RhoGAM if Rh-negative. NOT bed rest, NOT progesterone routinely.
— Diagnosis: cervical shock from inevitable abortion.
— Best next step: ring forceps removal of POC — symptoms resolve immediately.
— Diagnosis: ruptured ectopic.
— Best next step: OR for salpingectomy (not methotrexate — patient unstable).
— Diagnosis: complete molar pregnancy.
— Best next step: suction D&C, then weekly β-hCG; contraception 6–12 months.
— Diagnosis: missed abortion.
— Best next step: offer expectant, medical (mife + miso), or surgical management. Stable patient — no single right answer except shared decision-making.
— Diagnosis: APS.
— Treatment in next pregnancy: low-dose aspirin + prophylactic LMWH.
— Diagnosis: Asherman syndrome.
— Best next step: hysteroscopy with adhesiolysis.
— Diagnosis: clostridial septic abortion.
— Best next step: IV PCN + clindamycin + emergent hysterectomy.
Board pearl: When the os is closed and fetus is viable → threatened, observe. When the os is open → inevitable/incomplete, intervene. When β-hCG is high and uterus is empty → ectopic or mole — never assume completed SAB.
Spontaneous abortion management hinges on classifying the subtype by cervical os, ultrasound, and β-hCG, then offering hemodynamically stable patients shared decision-making among expectant, medical (mifepristone + misoprostol), and surgical (suction D&C) options — while never forgetting RhoGAM, ruling out ectopic, escalating immediately for septic or hemorrhagic presentations, and providing emotional support plus preconception optimization for the next pregnancy.
Board pearl: A single sporadic miscarriage requires no workup beyond Rh status and emotional support; only after ≥2–3 consecutive losses does the ASRM recurrent pregnancy loss panel become indicated — and APS is the only proven, treatable cause with a clear, high-impact intervention for the next pregnancy.