Spontaneous abortion considered Clinical and therapeutic approach

by Claudia Ravaldi

Spontaneous abortion is unfortunately a very frequent occurrence that occurs in 10 to 20% of all clinically recognized pregnancies.

In this document, the authors Margaret Mascherpa, Laura Avagliano, Francesca Angelini, Nicole Decurti, Claudia Ravaldi and Alfredo Vannacci take stock of the clinical and psychological aspects to consider when receiving this painful diagnosis, so that every woman can undertake the most appropriate therapeutic path. to its real needs.

Spontaneous abortion is unfortunately a very frequent occurrence that occurs in 10 to 20% of all clinically recognized pregnancies.

Spontaneous abortion can have two types of course: complete miscarriage and presumed miscarriage.

In complete spontaneous abortion there is the spontaneous and complete expulsion of the gestational chamber and the embryo out of the uterus.

This process can have a variable duration over time (hours or days) and manifests itself with the appearance of menstrual-like blood loss and cramp-like contractions that lead to expulsion.

Spontaneous abortion, on the other hand, is a “silent” event, which often occurs without clear external signals, without cramping pains and bleeding.

Sometimes the woman may suspect that the evolution of pregnancy has stopped due to the disappearance of the most common symptoms such as nausea or breast tension.

In these cases the abortion is diagnosed at the time of the gynecological check-up, through the ultrasound visualization of the absence of the fetal heartbeat, often “out of the blue”.

Whether it is complete or deemed, spontaneous abortion, especially when pregnancy is desired, is a traumatic event that can have psychically important sequelae, both in the woman and in the couple.

The appearance of bleeding alarms women and can trigger a profound “anticipatory mourning”, which persists even if the losses are interrupted and the pregnancy continues.

The diagnosis of suspected abortion made during a routine check-up is often doubly traumatic because it is completely unexpected and unexpected .

Knowing that it happens to many women or that in theory it could happen to all of them does not lessen the distress, shock and bewilderment after diagnosis.

This psychic state requires a correct ability to manage the event on the part of the operators and the people around the couple.

The woman should be able to take appropriate time to discuss possible procedures clearly and comprehensively with the caregiver.

It becomes essential to provide the mother and the couple with comprehensive medical information, making sure that all the information given has been well understood.

The role of hospital staff is critical for parents to use their coping skills to make the decision that works best for them II.

In approaching the woman and the couple, the operator must have in mind that even if the loss is premature, when a pregnancy is interrupted the event marks the end of a dream, of a project destined to remain unfinished forever III.

This paper focuses on the different ways of treating suspected abortion when diagnosed within the first trimester of pregnancy (up to the 12th week of gestation).

In internal abortion, the gestational chamber is still ultrasonographically visible inside the uterus.

On the basis of the gestational period in which the pregnancy was interrupted, the ultrasound picture may show: – a gestational chamber with an average diameter of 25 mm “empty” that is without embryo and yolk sac (the so-called “blighted ovum”); – a gestational chamber containing one or more embryos / fetuses without heartbeat, but with dimensions for which the heart should already be formed, visible and functioning, or with vertex-sacrum lengths of the embryo of at least 7 mm on ultrasound transvaginal (10 mm if transabdominal).

For measurements lower than those indicated above, it is necessary to carry out an ultrasound check at a distance of at least 7 days IV.

Following the diagnosis of complete abortion, no medical therapeutic approaches are necessary, but psychological support and a follow-up appointment are required to redefine the incident with your caregivers.

Following the diagnosis of internal abortion, in addition to psychological support, appropriate medical counseling is instead necessary to understand how it is best to proceed so that the abortion can end in a safe way for the woman’s health.

The treatments that can be undertaken in the face of a suspected abortion are threeV:

• the waiting behavior;

• drug therapy;

• surgical therapy.

Each option has advantages and disadvantages and the choice of the type of approach depends a lot on the context in which you find yourself.

There are no mandatory and fixed rules: the approach should be agreed between the doctor and the patient and modulated on the basis of the clinical-objective data, the needs / preferences of the woman and the availability of the healthcare facility (the English guidelines, for example, advise against waiting behavior where it is not possible to guarantee medical assistance 24 hours a day) IX.

Waiting behavior

Waiting for the expulsion to occur spontaneously is a valid option where the woman is in good general health conditions.

In these cases, waiting behavior is a safe treatment option, so much so that English guidelines propose it as the first choice following the diagnosis of abortionIX.

Spontaneous expulsion usually occurs in the days following the diagnosis of internal abortion; sometimes there may be longer waits, even a few weeks VIII.

It is very important to be able to offer appropriate supportive counseling to women who choose wait-and-see behavior.

“Letting go of that pregnancy and that child” is a real work of mourning that takes place inside your body: this specific characteristic of abortion and stillbirth is associated with profound suffering, which it is necessary to recognize and know how to deal with. , so as to allow over time the rebuilding of confidence in oneself, in one’s body and in one’s reproductive abilities VII.

It becomes essential to provide the couple with all the medical information and to provide for follow-ups to check the state of health, physical and psychological, of the woman to give her the opportunity to reassess the decision made by discussing with the care team.

In this regard, it is very important to inform the woman of the characteristics of the bleeding she will experience.

The blood flow may in fact be more abundant than normal menstrual flow and may be more painful, associated with uterine cramps. In addition, some clots may also be expelled.

The intensity of blood loss and pain can be proportional to the week in which the pregnancy ended.

It might be preferable to choose the waiting behavior in the event of early pregnancy interruptions rather than interruptions that occurred later in the week, but it is not a universal rule, also because much depends on the personal pain threshold and reproductive history of the woman.

The main advantage of the waiting procedure is to avoid the risks associated with the surgical procedure.

The “disadvantage” in this case is relative and subjective, because it is linked to the unpredictability of the waiting duration and to the home management of profuse bleeding. It should be considered that according to various guidelines VI, VII the success rate of the waiting procedure is slightly lower than in an active conduct.

In some cases, in fact, the waiting behavior can last so long as to involve the need to resort to active intervention in any case.

Pharmacological treatment

The rationale for the pharmacological treatment of presumed spontaneous abortion consists in obtaining a complete abortion through the use of drugs that involve the expulsion of the gestational chamber from the uterus.

The drugs used include preparations with a hormonal action (mifepristone: progesterone antagonist) and preparations with uterotonic capacity (that is, they stimulate the onset of uterine contractions and / or the maturation of the cervix: prostaglandin analogues, for example misoprostol or gemeprost). Basically we can divide drug therapy into two types of approach:

• Association of the two drugs: initial use of mifepristone, an anti-progestin drug, taken orally. It determines a modification of the receptivity of the decidua, the inner surface of the uterus in which the pregnancy is implanted. After 1-2 days from the intake of mifepristone we proceed with the intake of prostaglandins. This pharmacological protocol is comparable to that used in the voluntary termination of pregnancy.

• Use of only one drug: prostaglandins (misoprostol or gemeprost). The most used drug, as well as the most cited in scientific studies, is misoprostol administered vaginally, although oral intake is possible. However, dosages, treatment schedules and routes of administration are still extremely variable since the studies did not reveal an option clearly superior to the other IX.

This justifies the differences in therapeutic protocols that can be found in the various departments of gynecology. One of the most frequently applied protocols involves the administration of 800 mg of misoprostol. The uterine response can be achieved on the same day as taking the medicine. After waiting for a few days, an ultrasound check is carried out. If the complete expulsion of the product of conception has not been obtained, a new administration of the drug is carried out, followed by a wait of a few days and a subsequent ultrasound check. If after the third administration of the drug a complete abortion is not obtained, surgical treatment will be carried out. The advantage that medical treatment offers to women consists in obtaining, in most cases, complete expulsion, anticipating the times compared to the waiting procedure and avoiding surgery. The disadvantages are the unpredictability of the time of action of the drugs, the bleeding which – albeit slightly – is still greater than in surgical treatment VII and the lack of possibility to carry out a diagnostic examination on the embryo to search for the possible causes of the abortion.

Finally, in a limited number of cases, the treatment may not work, making it necessary to resort to surgery at a later time. Possible side effects of misoprostol, especially when taken by mouth include diarrhea, nausea and vomitingIX.

Surgical treatment

In technical terms we speak of “Revision of the Uterine Cavity” (RCU) or “hysterosuction”: the surgeon with special instruments (Hegar) dilates the cervical canal and then proceeds to the removal or aspiration of the abortion material from the uterus.

The operation takes place in the operating room under anesthesia or deep sedation, is of short duration and commonly takes place in the Day Hospital regime.

Surgery is not urgent and is generally scheduled based on the logistical availability of the department.

The advantages of surgical treatment are the speed of resolution of the internal abortion and the possibility of carrying out diagnostic tests on the material taken to identify the possible causes of the abortion. The disadvantages relate to the increased risk of complications related to the procedure. Complications are infrequent (settling around 2% of cases) and include lesions to the uterus (perforation of the wall, about 0.1% of cases) lesions of the cervix (about 1% of cases), bleeding complications, complications infectious and anesthetic X. Rarely, especially in the case of repeated uterine revision surgeries, longer-term complications such as adhesions between the inner walls of the uterus (Asherman’s syndrome) may also occur.

In summary, with the diagnosis of a presumed spontaneous abortion, three possible scenarios open up: waiting for expulsion to occur naturally, taking drugs with an abortive effect or surgery to revise the uterine cavity.

Each choice offers advantages and disadvantages and, depending on various factors, can be more or less effective. A treatment suitable for one woman does not necessarily work for another. The choice must be adequately discussed and personalized.

Psychological and relational aspects – The role of the midwife

The midwife has the task of providing the woman with all the information useful to understand what is happening to her body, through counseling aimed at giving support, bringing out any other stress factors and welcoming her emotions. The midwife stands next to the woman and reflects with her on the three options for intervention. The midwife has the task of supporting the woman during the diagnosis and in the subsequent decision-making process; its presence can be of great use to reactivate the internal resources of the woman and her psychological and physical skills, in order to face this experience in the best possible way.

The midwife offers a clear picture of possible short, medium and long-term intervention options and provides information on how to manage any residual symptoms of pregnancy, what to do when contraction pains and bleeding begin. In some hospital settings, it can also arrange for regular outpatient check-ups. In supporting the woman’s choices, the midwife informs her of the clinical and organizational characteristics of the chosen path: the pre- and post-operative procedure, the scheduling of visits and the date of admission and some important information relating to the “after”, such as management of histological and / or cytogenetic examination and the laws in force regarding burial. The midwife through counseling, empathy and active listening can accompany the woman on this path, support her in the elaboration of the grief and help her to express her emotions and her own experience.

The role of psychological counseling

The consequences of a loss, even a very early one, on the physical and psychological well-being of the woman and the couple should never be neglected or underestimated and all women should receive, together with medical assistance, also psychological and relational support. Psychological support is offered whenever the operators recognize the loss and respect the pain of the woman and the couple without minimizing it. Acknowledging and respecting the emotional investment made by the couple in that pregnancy and that child helps to properly initiate the grieving process. Each woman and each couple have their own story, which still makes the experience of pregnancy and loss unique. Being able to explore with the woman the significance she attaches to pregnancy and loss can be very important for grieving and future pregnancies. Healthcare professionals, doctors and midwives, should combine relational aspects with those more typical of their profession of diagnosis and treatment. Bereavement support should be part of clinical practice, as also highlighted by the World Health OrganizationXIV which invites each practitioner to recognize the loss suffered by the woman, to respect it and to offer support. No loss is “too small” and no loss should be mitigated, especially by healthcare professionals. Today we are used to considering spontaneous abortion a “non-event”, forgetting the subjective meaning that every pregnancy has for the expectant couple. The fact that pregnancy is terminated early does not make “everything easier”, quite the contrary. Spontaneous abortion interrupts an ongoing process in an abrupt and untimely way. Often the couple did not even have time to enter into a relationship with the managed baby, which is already all over. The void takes the place of the growing life. Mothers come to wonder if their love object really existed; for fathers, who have often seen only two positive lines on the pregnancy test, it is difficult to recognize, accept and motivate their feelings. In some contexts, suffering does not find the space to be seen, recognized and narrated by the couple. The task of those who assist parents, both physically and psychologically, is to recognize and legitimize pain, without minimizing, diminishing or labeling what they feel as excessive. Accepting the disbelief, denial and anger that can accompany the moments following the diagnosis of spontaneous abortion with an active listening, devoid of judgment and preconceptions is the basis of care also for these couples. After the first shock phase has passed, parents may feel the need to talk to someone about what happened, especially if they have to go back to the hospital to check on how the abortion is proceeding. For many couples it has proved useful to receive a small memory box, a memory box specially designed to collect the thoughts, dreams and wishes of these parents for their child and for that pregnancy experience interrupted too soon. Our culture still often considers it inappropriate to be in “mourning” for an abortion, because it is difficult to think of an embryo or fetus as “a loved one” XVI. Accepting the loss of someone who is not recognized and does not yet have a specific identity, if not the one created in the heart by their parents is a complex path that requires support in order to be processed in a healthy way.

Bibliographical references

I. ACOG Practice Bulletin No. 200: Early Pregnancy Loss. Obstet Gynecol. 2018; 132 (5): e197-e207.

II. Ravaldi C, Attending perinatal death. The role of hospital staff in supporting bereaved parents and family members. CiaoLapo ed. 2018

III. Ravaldi C, The broken dream, Editorial Graphic Workshop, 2016

IV. 2015 SIEOG Guidelines. Italian Society of Obstetric Gynecological Ultrasound. 2015. https://www.sieog.it/category/linee-guida/.

V. Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant, medical, or surgical? Results of randomized controlled trial (miscarriage treatment (MIST) trial). BMJ. 2006; 332 (7552): 1235-1240.

YOU. Ectopic pregnancy and miscarriage: diagnosis and initial management. NICE Guidel No 126. 2019.

VII. NICE Clinical Guideline. Ectopic pregnancy and miscarriage: R Coll Obstet Gynecol. 2012; December: 1-15.

VIII. Nanda K, Lopez LM, Grimes DA, Peloggia A, Nanda G. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev. March 2012. IX. Lemmers M, Verschoor MA, Kim BV, et al. Medical treatment for early fetal death (less than 24 weeks). Cochrane Database Syst Rev. June 2019.

X. White K, Carroll E, Grossman D. Complications from first-trimester aspiration abortion: a systematic review of the literature. Contraception. 2015; 92 (5): 422-438.

XI. Dreisler E, Kjer JJ. Asherman’s syndrome: current perspectives on diagnosis and management. Int J Womens Health. 2019; 11: 191-198.

XII. Luise C, Jermy K, May C, Costello G, Collins WP, Bourne TH. Outcome of expectant management of spontaneous first trimester miscarriage: observational study. BMJ. 2002; 324 (7342): 873-875.

XIII. Jurkovic D, Overton C, Bender-Atik R. Diagnosis and management of first trimester miscarriage. BMJ. 2013; 346 (jun19 2): f3676-f3676.

XIV. Abortion and stillbirth, why should we talk about it? The WHO document. https: // www.ciaolapo.it/index.php?option=com_k2&view=item&id=608:abortion-and-mortein-utero-because-we must-parlarne &Itemid=854

XV. Ravaldi C, Piccoli Principi, Editorial Graphic Workshop, 2011

XVI. Ravaldi C, The waiting death, Editorial Graphic Workshop, 2016

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