History: Women may report vaginal bleeding, cramping, and the passing of large blood clots or tissue. These symptoms may be accompanied by low abdominal pain that radiates to the back, buttocks, and vaginal area. There may also be a gush of fluid from the rupture of the amniotic sac. Additionally, there may no longer be signs of pregnancy such as breast tenderness or nausea. It is important to keep in mind that the woman may not know that she is pregnant. A history of prior pregnancies, spontaneous abortion, infection, chronic illnesses, and surgeries is usually obtained. Physical exam: Pelvic examination must assess the source and intensity of bleeding, open or patent cervix, tenderness on cervical motion, uterine size and tenderness, and presence of any mass on or near the uterus. A miscarriage is confirmed if the pelvic exam reveals a dilated cervix and tissue protruding through the cervix, indicating imminent expulsion of tissue. An abdominal exam is performed to assess for any signs that may indicate other abdominal pathology such as distension, enlarged liver or spleen, and areas of tenderness. The examination must address possible ectopic pregnancy or rupture of an ovarian cyst, which may be detected by tenderness on only one side of the abdomen. The characteristics of bowel sounds help rule out acute abdomen not associated with pregnancy. Measuring vital signs can be important if excess bleeding is present, which can alter blood pressure and fluid balance (hemodynamic instability).
A missed abortion can be suspected if pregnancy symptoms (tender breasts and nausea) have disappeared and no symptoms of spontaneous abortion are present. The most common sign of a missed abortion is a uterus that is smaller than expected. Tests: A pregnancy test is usually done. Blood tests that measure quantitative levels of human chorionic gonadotropin (hCG) may be done and then repeated in several days to see if the level is increasing or decreasing; besides confirming pregnancy, this test is important in distinguishing whether bleeding is related to pregnancy or another cause. If the passed tissue is recovered, laboratory analysis (histopathologic examination) can determine if it is of fetal origin. A complete blood count (CBC) will be done to evaluate degree of blood loss. A white blood cell (WBC) count with differential can rule out potential infection. Coagulation tests (platelet count, fibrinogen level, prothrombin time and partial thromboplastin time) may be done if significant bleeding or CBC suggest hematologic disease or possible disseminated intravascular coagulation (DIC). Blood chemistries may be done to evaluate fluid imbalances due to bleeding, and kidney and liver function. Blood typing, antibody screening, and crossmatching may be done to prepare for possible transfusion, if needed, and to determine if an Rh negative mother should receive Rho (D) immune globulin (RhoGAM) to avoid sensitization for future pregnancies. Urinalysis may be done to rule out urinary tract infection.
Abdominal or vaginal ultrasound imaging may be used to evaluate and confirm any of the stages of miscarriage and rule out ectopic pregnancy or gynecologic problems.
If the individual has experienced habitual abortion, evaluation may include genetic studies and other special tests to determine the reason, tests to rule out chronic infections or hormonal dysfunction, and x-rays of the uterus and fallopian tubes (hysterosalpingography). |