Threatened abortion: Vaginal bleeding of o Presence of blood clots or

any degree during early pregnancy is tissue may be an important

considered to represent a threatened sign indicating progression of
abortion, although such bleeding is very spontaneous abortion.
common. Approximately a fourth of all
pregnant women have some degree of o Abdominal pain usually is
vaginal bleeding during the first 2 located in the suprapubic area
trimesters. About half of these cases or in one or both lower
progress to an actual miscarriage. Bleeding quadrants.
and pain accompanying threatened abortion
o Pain may radiate to the lower
usually are not very intense. Threatened
back, buttocks, genitalia, and
abortion rarely presents with severe vaginal
perineum.
bleeding. On vaginal examination, the
cervical os is closed and no cervical motion  Other symptoms, such as fever or
tenderness or tissue is found. Diffuse uterine chills, are more characteristic of a
tenderness and/or adnexal tenderness may septic abortion.
be present. Threatened abortion is defined
by the absence of passing/passed tissue and  Consider any woman of childbearing
the presence of a closed cervix. These age with vaginal bleeding pregnant
findings differentiate threatened abortion until proven otherwise.
from later stages of abortion.
Physical

Immediately evaluate patients who are

History experiencing hemodynamic instability or
severe vaginal bleeding, including
 Patients with spontaneous abortion orthostatic vital signs and abdominal and
usually present to the ED with pelvic examinations. Initiate emergency
vaginal bleeding and/or abdominal fluid resuscitation in cases of orthostatic
pain. hypotension.
o Vaginal bleeding may vary  Pelvic examination should focus on
from slight spotting to a determining the source of bleeding.
severe life-threatening
hemorrhage. Quantification o Blood from cervical os
of the amount of bleeding is
o Intensity of bleeding
very important. The patient's
history should reflect the o Presence of clots or tissue
number of pads or tampons fragments
used.
 o Cervical motion tenderness o Chronic maternal health
(presence increases suspicion factors
for ectopic pregnancy)
 Maternal insulin-
o State of cervical os: Open dependent diabetes
indicates inevitable or mellitus (IDDM): As
incomplete abortion; closed many as 30% of
indicates threatened abortion. pregnancies in women
with IDDM result in
o Uterine size and tenderness, spontaneous abortion,
as well as adnexal tenderness predominantly in
or masses patients with poor
glucose control in the
Causes
first trimester.
 Embryonic abnormalities account for
 Severe hypertension
80-90% of first-trimester
miscarriages.  Renal disease
o Chromosomal abnormalities  Systemic lupus
are the most common cause erythematosus (SLE)
of spontaneous abortion.
 Hypothyroidism and
o More than 90% of cytogenic hyperthyroidism
and morphologic errors are
eliminated through o Acute maternal health factors
spontaneous abortion.
 Infections (eg,
o Chromosomal abnormalities rubella,
have been found in more than cytomegalovirus
75% of fetuses aborted in the [CMV], and
first trimester. mycoplasmal
ureaplasmal, listerial,
o The rate of chromosomal toxoplasmal
abnormalities increases with infections)
age, with a steep increase in
women older than 35 years.  Trauma

o Severe emotional shock

 Maternal factors account for the
majority of second-trimester  Diseases and abnormalities of the
abortions. These factors can be reproductive system
divided into 4 categories.
 o Congenital or acquired bleeding, with or without
uterine defects abdominal cramps, during the
first trimester of pregnancy.
o Fibroids When the symptoms indicate
a miscarriage is possible, the
o Cervical incompetence
condition is called a
o Abnormal placental "threatened abortion." (This
development refers to a naturally occurring
event, not medical abortions
o Grand multiparity or surgical abortions.)

 Exogenous factors Miscarriage occurs in just a

small percentage of women
o Caffeine
who have vaginal bleeding
o Alcohol during pregnancy.

o Tobacco

o Cocaine Causes

A small number of pregnant women have

some vaginal bleeding, with or without
Alternative Names abdominal cramps, during the first trimester
Threatened miscarriage; of pregnancy. When the symptoms indicate
Threatened spontaneous a miscarriage is possible, the condition is
abortion; Abortion - called a "threatened abortion." (This refers
threatened; Threatened to a naturally occurring event, not medical
abortion abortions or surgical abortions.)

Definition of Miscarriage - Miscarriage occurs in just a small

threatened: percentage of women who have vaginal
bleeding during pregnancy.
A threatened miscarriage is a
condition that suggests a For more information, see: Miscarriage
miscarriage might take place
before the 20th week of Back to TopSymptoms
pregnancy.
Symptoms of a threatened miscarriage
Causes, incidence, and risk include:
factors:
 Abdominal cramps with or without
A small number of pregnant vaginal bleeding
women have some vaginal
  Vaginal bleeding during the first 20 there is a luteal phase defect, progesterone
weeks of pregnancy (last menstrual should not be used.
period was less than 20 weeks ago)
Back to TopOutlook (Prognosis)
Note: During an actual miscarriage, low
back pain or abdominal pain (dull to sharp, Many women with threatened miscarriage
constant to intermittent) typically occurs, go on to have a normal pregnancy.
and tissue or clot-like material may pass
from the vagina.

Back to TopExams and Tests

Abdominal or vaginal ultrasound may be

done to check the baby's development, heart
beat, and amount of bleeding. A pelvic exam
will be done to check the cervix.

The following blood tests may be

performed:

 Beta HCG (quantitative) test over a

period of days or weeks to confirm
whether the pregnancy is continuing
 Complete blood count (CBC) to
determine amount of blood loss
 Serum HCG to confirm pregnancy
 White blood count (WBC) with
differential to rule out infection

Back to TopTreatment

You may be told to avoid or restrict some

forms of activity, or you may need complete
bed rest. Not having sexual intercourse is
usually recommended until the warning
signs have disappeared.

The use of progesterone is controversial. It

might relax smooth muscles, including the
muscles of the uterus. However, it also
might increase the risk of an incomplete
abortion or an abnormal pregnancy. Unless