Each option has its own risks and benefits. With all three, infection and need for transfusion are uncommon. However, misoprostol and expectant care are associated with unpredictable bleeding, and some women will undergo unscheduled curettage. Expectant management of spontaneous incomplete abortion has failure rates that approximate 25 percent in randomized trials (Nadarajah, 2014; Nielsen, 1999; Trinder, 2006). Some observational studies have shown failure rates of 10 to 15 percent (Blohm, 2003; Casikar, 2012; Luise, 2002). Medical therapy carries failure rates of 5 to 30 percent (Dao, 2007; Shochet, 2012; Trinder, 2006). In many studies for this, an oral misoprostol dose of 600 1g has been used (American College of Obstetricians and Gynecologists, 2009). Alternatively, an 800-l1g vaginal or a 400-1g oral or sublingual misoprostol dose is suitable. Last, curettage usually results in a quick resolution that is 95-to 100-percent successful. However, it is invasive and not necessary for all women.
At times, complete expulsion of the entire pregnancy may ensue, and the cervical os subsequently closes. A history of heavy bleeding, cramping, and passage of tissue is typical. Patients are encouraged to bring in passed tissue, in which a complete gestation should be discerned from blood clots or a decidual cast. he latter is a layer of endometrium in the shape of the uterine cavity that when sloughed can appear as a collapsed sac (Fig. 19-2, p. 373).
If an expelled complete gestational sac is not identified, transvaginal sonography is performed to diferentiate a complete abortion from threatened abortion or ectopic pregnancy. Characteristic findings of a complete abortion include a minimally thickened endometrium without a gestational sac. However, this does not guarantee a recent uterine pregnancy. Condous and associates (2005) described 152 women with heavy bleeding, an empty uterus with endometrial thickness < 15 mm, and a diagnosis of completed miscarriage. Six percent were subsequently found to have an ectopic pregnancy. Thus, a complete abortion cannot be surely diagnosed unless: (1) true products of conception are seen grossly or (2) unless sonography confidently documents first an intrauterine pregnancy and then later an empty cavity. In unclear settings, serial serum hCG level measurements aid clariication. With complete abortion, these levels drop quickly (Table 18-2).
This describes dead products of conception that have been retained for days or weeks in the uterus with a closed cervical os. Diagnosis is imperative prior to intervention and avoids interruption of a potentially live IUP. Transvaginal sonography is the primary tool.
TABLE 18-2. Percentage Decline of Initial Serum
FIGURE 18-1 Transvaginal sonogram displays a large anechoic sac consistent with an anembryonic gestation. Calipers measure uterine length and anteroposterior thickness in a sagittal plane.
aThe percentage decline is given as the expected decline.
The minimum expected decline in parentheses is the 95th percentile value. Declines less than this minimum may reflect retained either intrauterine or extrauterine trophoblast.
Data from Barnhart, 2004a; Chung, 2006.