Background

Early pregnancy loss is estimated to occur in 10% of all clinically recognized

pregnancies, with about 80% occurring in the first trimester. [1] The term "abortion" is commonly
used to mean all forms of early pregnancy loss; however, due to the polarizing social stigma
assigned to this term, the term "miscarriage" is used here to indicate all forms of spontaneous
early pregnancy loss or potential loss. One of the common complications of pregnancy is
spontaneous miscarriage, which occurs in an estimated 5-15% of pregnancies. Spontaneous
miscarriages are categorized as threatened, inevitable, incomplete, complete, or missed, and can
be further classified as sporadic or recurrent (>3 occurrences).
Pathophysiology
The pathophysiology of a spontaneous miscarriage may be suggested by its timing.
Chromosomal defects are commonly seen in spontaneous miscarriages, especially those that
occur during 4-8 weeks' gestation. Genetic etiologies are common in early first-trimester loss but
may be seen throughout gestation. Trisomy chromosomes are the most common chromosomal
anomaly. Insufficient or excessive hormonal levels usually result in spontaneous miscarriage
before 10 weeks' gestation. Infectious, immunologic, and environmental factors are generally
seen in first-trimester pregnancy loss. Anatomic factors are usually associated with secondtrimester loss. Factor XIII deficiency and a complete or partial deficiency of fibrinogen are
associated with recurrent spontaneous miscarriage. [2]
A prospective study by Jayasena et al indicated that in in asymptomatic pregnant women
at 6 weeks gestation or more, low plasma levels of the hormone kisspeptin are associated with
an increased miscarriage risk. [3]
A spontaneous miscarriage is a process that can be divided into 4 stages, as follows:
threatened, inevitable, incomplete, and complete.
Latar
Belakang
keguguran dini diperkirakan terjadi di 10% dari seluruh kehamilan yang diakui secara klinis,
dengan sekitar 80% terjadi pada trimester pertama. [1] Istilah "aborsi" umumnya digunakan
untuk berarti semua bentuk kehilangan awal kehamilan; Namun, karena stigma sosial polarisasi
ditugaskan untuk istilah ini, istilah "keguguran" digunakan di sini untuk menunjukkan segala
bentuk kerugian awal kehamilan spontan atau potensi kerugian. Salah satu komplikasi umum
dari kehamilan adalah keguguran spontan, yang terjadi pada sekitar 5-15% kehamilan.
keguguran spontan dikategorikan sebagai terancam, tak terelakkan, tidak lengkap, lengkap, atau
tidak terjawab, dan dapat lebih diklasifikasikan sebagai sporadis atau berulang (> 3 kejadian).
patofisiologi
Patofisiologi keguguran spontan mungkin disarankan oleh waktu nya. cacat kromosom yang
biasa terlihat di keguguran spontan, terutama yang terjadi selama kehamilan 4-8 minggu. etiologi
genetik yang umum pada awal kerugian pada trimester pertama tapi dapat dilihat selama
kehamilan. kromosom trisomi adalah anomali kromosom yang paling umum. tingkat hormon
yang tidak mencukupi atau berlebihan biasanya mengakibatkan keguguran spontan sebelum usia

kehamilan 10 minggu. Menular, imunologi, dan faktor lingkungan umumnya terlihat pada
trimester pertama keguguran. faktor anatomi biasanya berhubungan dengan kehilangan trimester
kedua. Faktor defisiensi XIII dan defisiensi lengkap atau parsial dari fibrinogen berhubungan
dengan
keguguran
spontan
berulang.
[2]
Sebuah studi prospektif oleh Jayasena et al menunjukkan bahwa di dalam wanita hamil tanpa
gejala pada usia kehamilan 6 minggu atau lebih, kadar plasma rendah dari kisspeptin hormon
yang
terkait
dengan
risiko
keguguran
meningkat.
[3]
Keguguran spontan adalah sebuah proses yang dapat dibagi menjadi 4 tahap, sebagai berikut:
terancam,
tak
terelakkan,
tidak
lengkap,
dan
lengkap.
terancam
keguguran
perdarahan vagina, nyeri perut / panggul dari tingkat apapun, atau keduanya selama awal
kehamilan merupakan terancam keguguran. Sekitar seperempat dari semua wanita hamil
memiliki beberapa derajat perdarahan vagina selama 2 trimester pertama. Sekitar setengah dari
kasus-kasus ini berkembang menjadi keguguran yang sebenarnya. [4] Perdarahan dan nyeri
menyertai terancam keguguran biasanya tidak terlalu intens. terancam keguguran jarang
mengalami perdarahan vagina yang berat. Pada pemeriksaan vagina, os serviks internal tertutup
dan tidak ada gerak nyeri atau jaringan serviks ditemukan. Difus nyeri tekan uterus, adneksa,
atau keduanya mungkin hadir. terancam keguguran didefinisikan oleh tidak adanya passing /
jaringan berlalu dan kehadiran os serviks internal yang tertutup. Temuan ini membedakan
terancam keguguran dari tahap akhir keguguran.
Threatened miscarriage
Vaginal bleeding, abdominal/pelvic pain of any degree, or both during early pregnancy
represents a threatened miscarriage. Approximately a fourth of all pregnant women have some
degree of vaginal bleeding during the first 2 trimesters. About half of these cases progress to an
actual miscarriage. [4] Bleeding and pain accompanying threatened miscarriage is usually not very
intense. Threatened miscarriage rarely presents with severe vaginal bleeding. On vaginal
examination, the internal cervical os is closed and no cervical motion tenderness or tissue is
found. Diffuse uterine tenderness, adnexal tenderness, or both may be present. Threatened
miscarriage is defined by the absence of passing/passed tissue and the presence of a closed
internal cervical os. These findings differentiate threatened miscarriage from later stages of a
miscarriage.

Inevitable miscarriage
Vaginal bleeding is accompanied by dilatation of the cervical canal. Bleeding is usually
more severe than with threatened miscarriage and is often associated with abdominal pain and
cramping.
Incomplete miscarriage

Vaginal bleeding may be intense and accompanied by abdominal pain. The cervical os
may be open with products of conception being passed, or the internal cervical os may be closed.
Ultrasonography is used to reveal whether some products of conception are still present in the
uterus.
Complete miscarriage
Patients may present with a history of bleeding, abdominal pain, and tissue passage. By
the time the miscarriage is complete, bleeding and pain usually have subsided. Ultrasonography
reveals a vacant uterus. Diagnosis may be confirmed by observation of the aborted fetus with the
complete placenta, although caution is recommended in making this diagnosis without
ultrasonography because it can be difficult to determine if the miscarriage is complete.
terancam
keguguran
perdarahan vagina, nyeri perut / panggul dari tingkat apapun, atau keduanya selama awal
kehamilan merupakan terancam keguguran. Sekitar seperempat dari semua wanita hamil
memiliki beberapa derajat perdarahan vagina selama 2 trimester pertama. Sekitar setengah dari
kasus-kasus ini berkembang menjadi keguguran yang sebenarnya. [4] Perdarahan dan nyeri
menyertai terancam keguguran biasanya tidak terlalu intens. terancam keguguran jarang
mengalami perdarahan vagina yang berat. Pada pemeriksaan vagina, os serviks internal tertutup
dan tidak ada gerak nyeri atau jaringan serviks ditemukan. Difus nyeri tekan uterus, adneksa,
atau keduanya mungkin hadir. terancam keguguran didefinisikan oleh tidak adanya passing /
jaringan berlalu dan kehadiran os serviks internal yang tertutup. Temuan ini membedakan
terancam
keguguran
dari
tahap
akhir
keguguran.
keguguran
Inevitable
perdarahan vagina disertai dengan dilatasi saluran serviks. Perdarahan biasanya lebih parah
daripada dengan terancam keguguran dan sering dikaitkan dengan sakit perut dan kram.
keguguran
tidak
lengkap
perdarahan vagina mungkin intens dan disertai nyeri perut. Os serviks mungkin terbuka dengan
hasil konsepsi yang lulus, atau os serviks internal dapat ditutup. Ultrasonografi digunakan untuk
mengungkapkan apakah beberapa produk dari konsepsi masih ada di dalam rahim.
keguguran
lengkap
Pasien mungkin hadir dengan riwayat perdarahan, sakit perut, dan bagian jaringan. Pada saat
keguguran selesai, perdarahan dan nyeri biasanya telah mereda. Ultrasonography
mengungkapkan rahim kosong. Diagnosis dapat dikonfirmasi dengan pengamatan janin
digugurkan dengan plasenta lengkap, meskipun hati-hati dianjurkan dalam membuat diagnosis
ini tanpa ultrasonografi karena bisa sulit untuk menentukan apakah keguguran selesai.
Etiology
Causes of first- and second-trimester miscarriage
Embryonic abnormalities

Embryonic abnormalities account for 80-90% of first-trimester miscarriages. Note the following:

Chromosomal abnormalities are the most common cause of spontaneous miscarriage.

More than 90% of cytogenic and morphologic errors are eliminated through spontaneous
miscarriage.

Chromosomal abnormalities have been found in more than 75% of fetuses that miscarry
in the first trimester.

The rate of chromosomal abnormalities increases with age, with a steep increase in
women older than 35 years.

Trisomy chromosomes commonly are encountered, with trisomy 16 accounting for

approximately a third of chromosomal abnormalities in early pregnancy.

Maternal factors
Maternal factors account for the majority of second-trimester miscarriages, with advanced
age and a previous eary pregnancy loss as the most common risk factors. [1] Chronic maternal
health factors include the following:

Maternal insulin-dependent diabetes mellitus (IDDM): As many as 30% of pregnancies in

women with IDDM result in spontaneous miscarriage, predominantly in patients with
poor glucose control in the first trimester.

Severe hypertension

Renal disease

Systemic lupus erythematosus (SLE)

Hypothyroidism and hyperthyroidism

Acute maternal health factors include the following:

Infections (eg, rubella, cytomegalovirus [CMV], and mycoplasmal, ureaplasmal, listerial,

toxoplasmal infections)

Trauma

Severe emotional shock may also cause first- and second-trimester miscarriages.
Etiologi
Penyebab
pertama
dan
kedua
trimester
keguguran
kelainan
embrio
akun kelainan embrio untuk 80-90% keguguran pada trimester pertama. Perhatikan hal berikut:
Kelainan kromosom merupakan penyebab paling umum dari keguguran spontan. Lebih dari
90% dari cytogenic dan morfologis kesalahan dieliminasi melalui keguguran spontan.
Kelainan kromosom telah ditemukan di lebih dari 75% dari janin yang keguguran pada
trimester
pertama.
Tingkat kelainan kromosom meningkat dengan usia, dengan peningkatan tajam pada wanita
yang
lebih
tua
dari
35
tahun.
kromosom trisomi umum ditemui, dengan trisomi 16 terhitung sekitar sepertiga dari kelainan
kromosom
pada
awal
kehamilan.
faktor
ibu
memperhitungkan faktor ibu bagi mayoritas keguguran pada trimester kedua, dengan usia lanjut
dan kehilangan kehamilan eary sebelumnya sebagai faktor risiko yang paling umum. [1] kronis
faktor
kesehatan
ibu
adalah
sebagai
berikut:
Ibu insulin-dependent diabetes mellitus (IDDM): Sebanyak 30% dari kehamilan pada wanita
dengan hasil IDDM keguguran spontan, terutama pada pasien dengan kontrol glukosa yang
buruk
pada
trimester
pertama.

hipertensi
berat

Penyakit
ginjal

sistemik
lupus
eritematosus
(SLE)

Hypothyroidism
dan
hipertiroidisme
Faktor
kesehatan
ibu
akut
adalah
sebagai
berikut:
Infeksi (misalnya, rubella, cytomegalovirus [CMV], dan mikoplasma, ureaplasmal, listerial,
infeksi
toxoplasmal)

Trauma
shock emosional parah juga dapat menyebabkan pertama dan kedua trimester keguguran.
Other factors that may contribute to miscarriage
Exogenous factors include the following:

Alcohol

Tobacco

Cocaine and other illicit drugs

Anatomic factors include the following:

Congenital or acquired anatomic factors are reported to occur in 10-15% of women who have
recurrent spontaneous miscarriages.

Congenital anatomic lesions include mllerian duct anomalies (eg, septate uterus,
diethylstilbestrol [DES]-related anomalies). Mllerian duct lesions usually are found in
second-trimester pregnancy loss.

Anomalies of the uterine artery with compromised endometrial blood flow are congenital.

Acquired lesions include intrauterine adhesions (ie, synechiae), leiomyoma, and

endometriosis.

Other diseases or abnormalities of the reproductive system that may result in miscarriage
include congenital or acquired uterine defects, fibroids, cervical incompetence, abnormal
placental development, or grand multiparity.

Endocrine factors include the following:

Endocrine factors potentially contribute to recurrent miscarriage in 10-20% of cases.

Luteal phase insufficiency (ie, abnormal corpus luteum function with insufficient
progesterone production) is implicated as the most common endocrine abnormality
contributing to spontaneous miscarriage.

Hypothyroidism, hypoprolactinemia, poor diabetic control, and polycystic ovarian

syndrome are contributive factors in pregnancy loss.

Infectious factors include the following:

Presumed infectious etiology may be found in 5% of cases.

Bacterial, viral, parasitic, fungal, and zoonotic infections are associated with recurrent
spontaneous miscarriage.

Immunologic factors include the following:

Immunologic factors may contribute in up to 60% of recurrent spontaneous miscarriages.

Both the developing embryo and the trophoblast may be considered immunologically
foreign to the maternal immune system.

Antiphospholipid antibody syndrome generally is responsible for more second-trimester

pregnancy losses than first-trimester losses.

Miscellaneous factors
Miscellaneous factors may account for up to 3% of recurrent spontaneous miscarriages.
Other contributing factors implicated in sporadic and recurrent spontaneous abortions include
environment, drugs, placental abnormalities, medical illnesses, and male-related causes.
Gestational exposure to nonaspirin NSAIDs may increase the risk for miscarriage.
Nakhai-Pour et al identified 4705 women who had spontaneous abortions by 20 weeks' gestation.
Each case was matched to 10 control subjects (n=47,050) who did not have a spontaneous
abortion. In the women who had a miscarriage, 352 (7.5%) were exposed to a nonaspirin
NSAID, whereas NSAID exposure was lower (1213 exposed [2.6%]) in women who did not
have a miscarriage. [5]
On the other hand, a study by Daniel et al suggested that for the most part, gestational
exposure to nonaspirin NSAIDs does not increase the risk for spontaneous miscarriage. In a
study cohort that included 65,457 women who conceived during the study period, a total of 6508
(9.9%) experienced spontaneous miscarriage. Exposure to NSAIDs was not found to be an
independent risk factor for miscarriage, with the exception of indomethacin, which, the study
indicated, is significantly associated with spontaneous abortion following first-trimester
exposure. [6]
Faktor-faktor
lain
yang
dapat
berkontribusi
untuk
keguguran
Faktor
eksogen
adalah
sebagai
berikut:

Alkohol

Tembakau

Kokain
dan
lainnya
obat-obatan
terlarang
faktor
anatomi
adalah
sebagai
berikut:
faktor anatomi kongenital atau didapat dilaporkan terjadi pada 10-15% wanita yang mengalami
keguguran
spontan
berulang.
Lesi anatomi kongenital mencakup anomali duktus mullerian (misalnya, septate uterus,
dietilstilbestrol [DES] anomali -terkait). lesi saluran mullerian biasanya ditemukan di trimester
kedua
keguguran.
Anomali dari arteri uterina dengan aliran darah endometrium dikompromikan adalah bawaan.
Lesi Acquired termasuk adhesi intrauterine (yaitu, sinekia), leiomioma, dan endometriosis.
penyakit atau kelainan pada sistem reproduksi yang dapat mengakibatkan keguguran lainnya
termasuk cacat bawaan atau diperoleh rahim, fibroid, inkompetensi serviks, perkembangan
plasenta
yang
abnormal,
atau
besar
multiparitas.
faktor
endokrin
meliputi:
faktor endokrin berpotensi berkontribusi keguguran berulang pada 10-20% kasus.
insufisiensi fase luteal (yaitu, fungsi korpus luteum yang abnormal dengan produksi
progesteron cukup) yang terlibat sebagai kelainan endokrin yang paling umum berkontribusi
terhadap
keguguran
spontan.
Hipotiroidisme, hypoprolactinemia, kontrol diabetes yang buruk, dan sindrom ovarium
polikistik
merupakan
faktor
kontributif
dalam
keguguran.
faktor
infeksi
adalah
sebagai
berikut:


Diduga
etiologi
infeksi
dapat
ditemukan
pada
5%
kasus.
Bakteri, virus, parasit, jamur, dan infeksi zoonosis terkait dengan keguguran spontan berulang.
Faktor-faktor
imunologi
adalah
sebagai
berikut:
faktor imunologi dapat berkontribusi hingga 60% dari keguguran spontan berulang.
Kedua embrio berkembang dan trofoblas dapat dianggap imunologis asing untuk sistem
kekebalan
tubuh
ibu.
Sindrom antibodi antifosfolipid umumnya bertanggung jawab untuk lebih trimester kedua
keguguran
dibandingkan
kerugian
pada
trimester
pertama.
faktor
Miscellaneous
Faktor lain-lain dapat menjelaskan hingga 3% dari keguguran spontan berulang. Faktor lain yang
terlibat dalam aborsi spontan sporadis dan berulang termasuk lingkungan, obat-obatan, kelainan
plasenta, penyakit medis, dan penyebab yang berhubungan dengan laki-laki.
paparan Gestational untuk NSAID nonaspirin dapat meningkatkan risiko untuk keguguran.
Nakhai-Pour et al diidentifikasi 4705 perempuan yang melakukan aborsi spontan oleh kehamilan
20 minggu. Setiap kasus itu dicocokkan dengan 10 subjek kontrol (n = 47.050) yang tidak
memiliki aborsi spontan. Pada wanita yang mengalami keguguran, 352 (7,5%) yang terkena
NSAID nonaspirin, sedangkan paparan NSAID lebih rendah (1213 terkena [2,6%]) pada wanita
yang
tidak
mengalami
keguguran.
[5]
Di sisi lain, sebuah studi oleh Daniel et al menyarankan bahwa untuk sebagian besar, paparan
kehamilan untuk NSAID nonaspirin tidak meningkatkan risiko keguguran spontan. Dalam
kohort studi yang termasuk 65.457 wanita yang hamil selama masa studi, total 6508 (9,9%)
mengalami keguguran spontan. Paparan NSAID tidak ditemukan menjadi faktor risiko
independen untuk keguguran, dengan pengecualian indometasin, yang, studi menunjukkan,
secara signifikan berhubungan dengan aborsi spontan mengikuti paparan pada trimester pertama.
[6]

Epidemiology
United States statistics
Many pregnancies are not viable. According to estimates, 50% of pregnancies terminate
spontaneously before the first missed menstrual period; these miscarriages usually are not
clinically recognized. Spontaneous miscarriage is typically defined as a clinically recognized (ie,
by blood test, urine test, or ultrasonography) pregnancy loss before 20 weeks' gestation.
Approximately 5-15% of diagnosed pregnancies result in spontaneous miscarriage.
International

Some European investigators quote the rate of spontaneous miscarriage to be as low as 25%. Chinese researchers concluded that increased parental exposure to phenols is associated with
spontaneous abortion. [7]
Race- and age-related demographics
Surveillance data for pregnancy-related deaths demonstrate more deaths due to ectopic
pregnancy, spontaneous miscarriage, and induced abortion among African American women than
among white women. Eight percent of pregnancy-related deaths among black women were due
to ectopic pregnancies; 7% were due to miscarriages. Among white women, data show that 4%
of pregnancy-related deaths were due to ectopic pregnancies; 4% were due to miscarriages. [8, 9]
Age and increased parity affect a woman's risk of miscarriage. In women younger than 20
years, miscarriage occurs in an estimated 12% of pregnancies. In women older than 20 years,
miscarriage occurs in an estimated 26% of pregnancies.
Age primarily affects the oocyte. When oocytes from young women are used to create
embryos for transfer to older recipients, implantation and pregnancy rates mimic those seen in
younger women. The number of miscarriages and chromosomal anomalies decreases, suggesting
that the uterus is not responsible for poor outcomes in women of advanced reproductive age.
Diagnostic ConsiderationsImportant considerationsSpecial considerations
Perform pregnancy testing for every woman of childbearing age who presents with lower
abdominal pain, vaginal bleeding, or both. History alone is not sufficient to exclude pregnancy.
Pregnancy is possible even if the patient gives a history of a recent normal menstrual period,
lactation, or contraceptive use.
Rule out ectopic pregnancy. An ectopic pregnancy must be excluded in every pregnant
woman with abdominal pain, vaginal bleeding, or both during the first or second trimester.
Endometrial shedding, which clinically simulates miscarriage, may occur with an ectopic
pregnancy. This misdiagnosis is the greatest potential pitfall. An empty uterus on sonogram may
represent an ectopic pregnancy.
Prevent hemolytic disease of the newborn. Ascertain the blood type of every pregnant
patient with vaginal bleeding. If the patient is Rh-negative, administer RhoGAM to prevent
hemolytic disease of the newborn (see Medication).
Assess the intensity of hemorrhage. External bleeding may not accurately reflect total
hemorrhage. The patient, especially in the supine position, may collect large amounts of blood in
the vagina with minimal external bleeding. Similarly, a large quantity of retained blood may be
present in the uterine cavity and, in the case of ectopic pregnancy, in the peritoneal cavity.
Therefore, never rely on the external examination to assess the rate of hemorrhage in patients

with vaginal bleeding. Always perform a pelvic examination to look for blood collection in the
vagina, disproportionately tender uterus, and signs of peritoneal irritation.
Identify retained products of conception. Ultrasonography for the diagnosis of retained
products can yield false-positive rates, with one report of an overall false-positive rate of 34%.
Retained products may be more commonly found when an evacuation is performed after 15
weeks' gestation. Offer grief counseling to all patients after a miscarriage. Referral to a specialist
for determination of the cause of recurrent miscarriage may be indicated. [11]
Epidemiologi
Amerika
Serikat
statistik
Banyak kehamilan yang tidak layak. Menurut perkiraan, 50% dari kehamilan mengakhiri
spontan sebelum periode menstruasi pertama terjawab; keguguran ini biasanya tidak secara klinis
diakui. keguguran spontan biasanya didefinisikan sebagai klinis yang diakui (yaitu, dengan tes
darah, tes urine, atau ultrasonografi) keguguran sebelum usia kehamilan 20 minggu. Sekitar 515%
dari
kehamilan
didiagnosis
mengakibatkan
keguguran
spontan.
Internasional
Beberapa peneliti Eropa mengutip tingkat keguguran spontan menjadi serendah 2-5%. peneliti
Cina menyimpulkan bahwa peningkatan paparan orangtua untuk fenol dikaitkan dengan aborsi
spontan.
[7]
Race
dan
demografi
yang
berkaitan
dengan
usia
Data surveilans untuk kematian terkait kehamilan menunjukkan lebih banyak kematian akibat
kehamilan ektopik, keguguran spontan, dan aborsi di kalangan wanita Afrika Amerika dari
kalangan perempuan kulit putih. Delapan persen dari kematian terkait kehamilan di kalangan
perempuan kulit hitam adalah karena kehamilan ektopik; 7% adalah karena keguguran. Di antara
wanita kulit putih, data menunjukkan bahwa 4% dari kematian terkait kehamilan adalah karena
kehamilan
ektopik;
4%
adalah
karena
keguguran.
[8,
9]
Usia dan peningkatan paritas mempengaruhi risiko seorang wanita keguguran. Pada wanita yang
lebih muda dari 20 tahun, keguguran terjadi di diperkirakan 12% dari kehamilan. Pada wanita
yang lebih tua dari 20 tahun, keguguran terjadi di diperkirakan 26% dari kehamilan.
Umur terutama mempengaruhi oosit. Ketika oosit dari perempuan muda yang digunakan untuk
membuat embrio untuk transfer ke penerima yang lebih tua, implantasi dan kehamilan tarif
meniru yang terlihat pada wanita yang lebih muda. Jumlah keguguran dan anomali kromosom
menurun, menunjukkan bahwa rahim tidak bertanggung jawab atas hasil yang buruk pada wanita
usia
reproduksi
lanjut.
pertimbangan
diagnostik
ConsiderationsImportant
considerationsSpecial
Lakukan tes kehamilan bagi setiap wanita usia subur yang datang dengan nyeri perut bagian
bawah, perdarahan vagina, atau keduanya. Sejarah saja tidak cukup untuk mengecualikan
kehamilan. Kehamilan adalah mungkin bahkan jika pasien memberikan sejarah periode,
menyusui,
atau
penggunaan
kontrasepsi
menstruasi
normal
terakhir.
Mengesampingkan kehamilan ektopik. Kehamilan ektopik harus dikeluarkan pada setiap wanita

hamil dengan nyeri perut, perdarahan vagina, atau keduanya selama trimester pertama atau
kedua. penumpahan endometrium, yang secara klinis mensimulasikan keguguran, mungkin
terjadi dengan kehamilan ektopik. misdiagnosis ini adalah potensi perangkap terbesar. Rahim
kosong
pada
sonogram
dapat
mewakili
kehamilan
ektopik.
Mencegah penyakit hemolitik pada bayi baru lahir. Memastikan jenis darah setiap pasien hamil
dengan perdarahan vagina. Jika pasien Rh-negatif, mengelola RhoGAM untuk mencegah
penyakit
hemolitik
pada
bayi
baru
lahir
(lihat
Obat).
Menilai intensitas perdarahan. perdarahan eksternal mungkin tidak akurat mencerminkan jumlah
perdarahan. pasien, terutama dalam posisi terlentang, dapat mengumpulkan sejumlah besar darah
di vagina dengan perdarahan eksternal minimal. Demikian pula, jumlah besar darah
dipertahankan mungkin ada dalam rongga rahim dan, dalam kasus kehamilan ektopik, di rongga
peritoneal. Oleh karena itu, tidak pernah bergantung pada pemeriksaan luar untuk menilai tingkat
perdarahan pada pasien dengan perdarahan vagina. Selalu melakukan pemeriksaan panggul
untuk mencari koleksi darah di vagina, tidak proporsional uterus lembut, dan tanda-tanda iritasi
peritoneum.
Mengidentifikasi hasil konsepsi. Ultrasonografi untuk diagnosis produk tetap dapat
menghasilkan false positif, dengan satu laporan tingkat positif palsu keseluruhan 34%. produk
tetap dapat lebih umum ditemukan saat evakuasi dilakukan setelah usia kehamilan 15 minggu.
Menawarkan kesedihan konseling kepada semua pasien setelah keguguran. Rujukan ke spesialis
untuk penentuan penyebab keguguran berulang dapat diindikasikan. [11]
History
Patients with spontaneous miscarriage usually present to the ED with vaginal bleeding,
abdominal pain, or both. Note the following:

Vaginal bleeding may vary from slight spotting to a severe life-threatening hemorrhage.
The patient's history should include the number of pads or tampons used. Hasan et al
found that heavy bleeding in the first trimester, particularly when associated with
abdominal pain, is associated with higher risk of miscarriage. [10]

Presence of blood clots or tissue may be an important sign indicating progression of

spontaneous miscarriage.

Abdominal pain is usually located in the suprapubic area or in one or both lower
quadrants.

Pain may radiate to the lower back, buttocks, genitalia, and perineum.

The patient's history should also include the following:

Date of last menstrual period (LMP)

Estimated length of gestation

Sonogram results, if previously performed

Bleeding disorders

Previous miscarriage or elective abortions

Other symptoms, such as fever or chills, are more characteristic of a septic miscarriage or
abortion.
Consider any woman of childbearing age with vaginal bleeding pregnant until proven otherwise.
Physical
Pelvic examination should focus on determining the source of bleeding, such as the following:

Blood from cervical os

Intensity of bleeding

Presence of clots or tissue fragments

Cervical motion tenderness (presence increases suspicion for ectopic pregnancy)

Status of internal cervical os: open indicates inevitable or possibly incomplete

miscarriage; closed indicates threatened miscarriage.

Uterine size and tenderness, as well as adnexal tenderness or masses

Signs of threatened miscarriage include the following:

Vital signs should be within reference ranges unless infection is present or hemorrhage
has caused hypovolemia.

The abdomen usually is soft and nontender.

Pelvic examination reveals a closed internal cervical os. The bimanual examination is
unremarkable.

Signs of incomplete miscarriage include the following:

The cervix may appear dilated and effaced, or it may be closed.

Bimanual examination may reveal an enlarged and soft uterus.

On pelvic examination, products of conception may be partially present in the uterus,

may protrude from the external os, or may be present in the vagina. Bleeding and
cramping usually persist.

Signs of complete miscarriage: On pelvic examination, the cervix should be closed, and the
uterus should be contracted.
Signs of missed miscarriage include the following:

Vital signs usually are within reference ranges. Abdominal examination may or may not
reveal a palpable uterus. If palpable, the uterus usually is small for the presumed
gestational age.

Fetal heart tones are inaudible or unseen on sonogram.

The cervical os is closed upon pelvic examination. The uterus may feel soft and enlarged.

Sejarah
Pasien dengan spontan keguguran biasanya hadir ke ED dengan perdarahan vagina, nyeri
perut, atau keduanya. Perhatikan hal berikut:
Vaginal pendarahan mungkin berbeda dari bercak kecil untuk pendarahan yang
mengancam jiwa yang parah. riwayat pasien harus mencakup jumlah pembalut atau
tampon digunakan. Hasan et al menemukan bahwa perdarahan berat pada trimester
pertama, terutama bila dikaitkan dengan sakit perut, terkait dengan risiko yang lebih
tinggi keguguran. [10]
Kehadiran bekuan darah atau jaringan mungkin merupakan tanda penting yang
menunjukkan perkembangan keguguran spontan.
Nyeri perut biasanya terletak di daerah suprapubik atau di salah satu atau kedua kuadran
yang lebih rendah.
Nyeri dapat menyebar ke punggung bawah, bokong, genitalia, dan perineum.
riwayat pasien juga harus mencakup sebagai berikut:
Tanggal menstruasi terakhir (LMP)
Perkiraan panjang kehamilan
hasil sonogram, jika dilakukan sebelumnya
Gangguan perdarahan
Sebelumnya keguguran atau elektif aborsi
Gejala lain, seperti demam atau menggigil, merupakan ciri dari keguguran septik atau
aborsi.
Pertimbangkan setiap wanita usia subur dengan perdarahan vagina hamil sampai terbukti
sebaliknya.
Fisik
pemeriksaan panggul harus fokus pada menentukan sumber perdarahan, seperti berikut:
Darah dari os serviks
Intensitas perdarahan

 Keberadaan bekuan atau fragmen jaringan

Serviks gerak kelembutan (kehadiran meningkatkan kecurigaan untuk kehamilan
ektopik)
Status os serviks internal yang: terbuka menunjukkan keguguran tidak bisa dihindari
atau mungkin tidak lengkap; tertutup menunjukkan terancam keguguran.
Ukuran uterus dan nyeri, serta adneksa atau massa
Tanda-tanda terancam keguguran adalah sebagai berikut:
Tanda-tanda vital harus berada dalam rentang referensi kecuali infeksi hadir atau
perdarahan telah menyebabkan hipovolemia.
abdomen biasanya lembut dan tidak nyeri tekan.
Pemeriksaan panggul mengungkapkan os serviks internal yang tertutup. Pemeriksaan
bimanual biasa-biasa saja.
Tanda-tanda keguguran tidak lengkap meliputi berikut ini:
Serviks mungkin muncul melebar dan dihapuskan, atau mungkin ditutup.
Pemeriksaan bimanual dapat mengungkapkan rahim yang membesar dan lembut.
Pada pemeriksaan panggul, hasil konsepsi mungkin sebagian hadir dalam rahim,
mungkin menonjol dari os eksternal, atau mungkin ada dalam vagina. Perdarahan dan
kram biasanya bertahan.
Tanda-tanda keguguran lengkap: Pada pemeriksaan panggul, leher rahim harus ditutup,
dan rahim harus dikontrak.
Tanda-tanda keguguran terjawab adalah sebagai berikut:
Tanda-tanda vital biasanya berada dalam rentang referensi. Pemeriksaan abdomen
mungkin atau mungkin tidak mengungkapkan uterus teraba. Jika teraba, rahim biasanya
kecil untuk usia kehamilan yang diduga.
Nada jantung janin yang tak terdengar atau terlihat pada sonogram.
The os serviks ditutup pada pemeriksaan panggul. rahim mungkin merasa lembut dan
membesar.

Differential Diagnoses

Abortion Complications

Appendicitis

Dysfunctional Uterine Bleeding in Emergency Medicine

Dysmenorrhea

Emergent Management of Ectopic Pregnancy

Emergent Treatment of Endometriosis

Molar pregnancy

Ovarian Cysts

Ovarian Torsion

Pregnancy Trauma

Urinary Tract Infections in Pregnancy

Vaginitis

Prognosis
The prognosis for a successful pregnancy depends upon the etiology of previous spontaneous
miscarriages, the age of the patient, and the sonographic appearance of the gestation.
Correction of an endocrine abnormality in women with recurrent miscarriage has the best
prognosis for a successful pregnancy (>90%).
In women with an unknown etiology of prior pregnancy loss, the probability of achieving
successful pregnancies is 40-80%.
The live-birth rate after documentation of fetal cardiac activity at 5-6 weeks of gestation in
women with 2 or more unexplained spontaneous miscarriages is approximately 77%.
When the transvaginal pelvic sonogram shows an embryo of at least 8 weeks estimated
gestational age (EGA) and cardiac activity, the miscarriage rate for patients younger than 35
years is 3-5% and for those older than 35 years is 8%.
Unfavorable sonographic prognostic indicators are a fetal cardiac activity rate that is slower than
90 beats per minute, an abnormally shaped or sized gestational sac, and a large subchorionic
hemorrhage.
The overall miscarriage rate for patients older than 35 years is 14% and for patients younger than
35 years is 7%.
Mortality/Morbidity
Surveillance data suggest that spontaneous miscarriages and induced abortions accounted for
about 4% of pregnancy-related deaths in the United States. [8]
Complications
Potential complications of early pregnancy loss include septic miscarriage and hypovolemic or
septic shock.

Preexisting anemia may make patients more susceptible to hypovolemic shock.

Patients with HIV infection who are undergoing curettage may have a higher rate of procedurerelated complications but no increase in infectious morbidity.
Coagulation defects may be associated with a retained dead fetus.
Other possible complications include post miscarriage bleeding, retained products of conception,
and hematometra.
Patient Education
Advise patients to return to the ED upon occurrence of symptoms such as the following:

Profuse vaginal bleeding (more than 1 pad/hour)

Severe pelvic pain

Temperature above 38C (100.4F)

Patients may experience intermittent menstrual-like flow and cramps during the following
week. The next menstrual period usually occurs in 4-5 weeks.
Patients can resume regular activities when able to but should refrain from intercourse and
douching for approximately 2 weeks.
For patient education resources, see Pregnancy Center, as well as Bleeding During
Pregnancy, Miscarriage, Abortion, and Dilation and Curettage (D&C).
Prehospital Care
Maintain routine universal precautions in view of potentially heavy vaginal bleeding.
Emergency medical services (EMS) personnel should be aware of the potential for hemorrhagic
shock and should treat any hemodynamic instability.
Obtain vital signs and establish an intravenous line in all pregnant patients who have
abdominal pain and vaginal bleeding. If the patient is hypotensive, an intravenous bolus of
normal saline (NS) is indicated for hemodynamic stabilization.
Administer oxygen.
Encourage the patient to bring any passed tissue to the hospital for evaluation.
Diagnosis Banding
Komplikasi Aborsi
Apendisitis

 disfungsional uterus Pendarahan di Emergency Medicine

Dismenore
Muncul Manajemen Kehamilan ektopik
Muncul Pengobatan Endometriosis
kehamilan molar
Kista ovarium
ovarium Torsi
Trauma Kehamilan
Infeksi Saluran Kemih di Kehamilan
Vaginitis
Prognosa
Prognosis untuk kehamilan yang sukses tergantung pada etiologi keguguran spontan sebelumnya,
umur pasien, dan penampilan sonografi kehamilan tersebut.
Koreksi kelainan endokrin pada wanita dengan keguguran berulang memiliki prognosis yang
terbaik untuk kehamilan yang sukses (> 90%).
Pada wanita dengan etiologi yang tidak diketahui dari keguguran sebelumnya, kemungkinan
mencapai kehamilan yang sukses adalah 40-80%.
Tingkat hidup-lahir setelah dokumentasi aktivitas jantung janin pada 5-6 minggu kehamilan pada
wanita dengan 2 atau lebih dijelaskan keguguran spontan adalah sekitar 77%.
Ketika sonogram panggul transvaginal menunjukkan embrio minimal 8 minggu diperkirakan
usia kehamilan (EGA) dan aktivitas jantung, tingkat keguguran untuk pasien yang lebih muda
dari 35 tahun adalah 3-5% dan untuk orang-orang yang lebih tua dari 35 tahun adalah 8%.
Tidak menguntungkan indikator prognostik sonografi adalah jantung tingkat janin kegiatan yang
lebih lambat dari 90 denyut per menit, sebuah kantung kehamilan normal berbentuk atau
berukuran, dan pendarahan subkorionik besar.
Tingkat keguguran keseluruhan untuk pasien yang lebih tua dari 35 tahun adalah 14% dan untuk
pasien yang lebih muda dari 35 tahun adalah 7%.
Mortalitas / Morbiditas
Data surveilans menunjukkan bahwa keguguran spontan dan aborsi diinduksi menyumbang
sekitar 4% dari kematian terkait kehamilan di Amerika Serikat. [8]
komplikasi
Potensi komplikasi keguguran dini termasuk keguguran septik dan syok hipovolemik atau septik.
Sudah ada sebelumnya anemia dapat membuat pasien lebih rentan terhadap syok hipovolemik.
Pasien dengan infeksi HIV yang menjalani kuretase mungkin memiliki tingkat yang lebih tinggi
dari komplikasi prosedur terkait namun tidak ada peningkatan morbiditas infeksi.
cacat koagulasi dapat berhubungan dengan janin mati dipertahankan.
kemungkinan komplikasi lainnya termasuk perdarahan keguguran posting, produk konsepsi, dan
hematometra.
Pendidikan pasien
Menyarankan pasien untuk kembali ke ED pada terjadinya gejala seperti berikut:
berlimpah vagina perdarahan (lebih dari 1 pad / jam)
Nyeri panggul parah
Suhu di atas 38 C (100,4 F)
Pasien mungkin mengalami aliran menstruasi seperti intermiten dan kram selama minggu
berikutnya. Periode menstruasi berikutnya biasanya terjadi dalam 4-5 minggu.
Pasien dapat melanjutkan kegiatan rutin ketika mampu tetapi harus menahan diri dari hubungan

dan douching selama kurang lebih 2 minggu.

Untuk sumber daya pasien pendidikan, lihat Pusat Kehamilan, serta Pendarahan Selama
Kehamilan, Keguguran, Aborsi, dan Dilatasi dan kuretase (D & C).
Perawatan pra-rumah sakit
Menjaga kewaspadaan universal rutin dalam pandangan perdarahan vagina berpotensi berat.
layanan medis darurat (EMS) personil harus menyadari potensi syok hemoragik dan harus
memperlakukan setiap ketidakstabilan hemodinamik.
Mendapatkan tanda-tanda vital dan membangun jalur intravena pada semua pasien hamil yang
memiliki sakit perut dan pendarahan vagina. Jika pasien hipotensi, bolus intravena salin normal
(NS) diindikasikan untuk stabilisasi hemodinamik.
Berikan oksigen.
Dorong pasien untuk membawa jaringan yang keluar ke rumah sakit untuk evaluasi.

Emergency Department Care

Management
Treat all patients with vaginal bleeding of any etiology as follows:

Determine hemodynamic stability and treat instability. If the patient is in hemorrhagic

shock, treatment includes the Trendelenburg position, oxygen, aggressive fluid
resuscitation (at least 2 large-bore IV lines with lactated Ringer [LR] solution or normal
saline, wide open), and hemotransfusion.

Determine pregnancy status (qualitative and quantitative).

Make laboratory determination of hematocrit (Hct) level and Rh status.

Perform a pelvic examination to determine the rate of bleeding; presence of blood clots or
products of conception; and condition of cervical os, cervix, uterus, and adnexa.

Perform pelvic ultrasonography to determine intrauterine and/or extrauterine contents

(fetal heart activity) and/or to clinically classify spontaneous miscarriage.

The American College of Obstetricians and Gynecologists (ACOG) recommends generally

limiting expectant management to gestations within the first trimester owing to potential
hemorrhage as well as a lack of safety studies of expectant management in the second trimester.
[1]
An estimated 80% success rate in achieving complete expulsion when adequate time is allowed
(8 weeks). For women who wish to reduce the time to complete expulsion but do not wish to
undergo surgical evacuation, treatment with misoprostol may be considered. [1]
Nadarajah et al found no statistically significant difference in the success rate between 360
women who underwent expectant or surgical management of early pregnancy loss, nor was there
any difference in the types of miscarriage. [15] With expectant management, 74% patients had a

complete spontaneous expulsion of products of conception. Of these patients, 106 (83%)

miscarried within 7 days. However, the rates of unplanned admissions (18.1%) and unplanned
surgical evacuations (17.5%) in the expectant group,were significantly higher than those in the
surgical group (7.4% and 8% respectively). [15]
Diagnostic specific management
Inevitable miscarriage
The goal of treatment is evacuation of the uterus to prevent complications (eg, further
hemorrhage, infection).
Incomplete miscarriage
If tissue, blood clots, or products of conception are found in the cervical os, remove them with
ring forceps to facilitate uterine contractions and hemostasis. For the same reason, use oxytocin
in cases of severe bleeding (10-20 mcg/L of NS, wide open).
Administer RhoGAM to a gravid patient who is Rh-negative and is experiencing vaginal
bleeding.
Consider hemotransfusion in the case of severe bleeding, hemodynamic instability, or both.
Consider treatment with misoprostol to facilitate completion of the miscarriage.
Complete miscarriage
Treatment of a patient who has had a complete miscarriage varies depending on the degree of
certainty of the diagnosis. Diagnosing complete miscarriage in the ED can be difficult, unless an
intact gestational sac was expelled.
If pelvic examination produces fetal tissue (or material of similar appearance), send it to the
laboratory for identification of possible products of conception.
Missed miscarriage
Treatment may vary depending on gestational age as follows:

First trimester: Most patients pass the products of conception spontaneously. Coagulation
defects secondary to a dead fetus are rare. Expectant management, [16] suction curettage,
or misoprostol for medical management to facilitate passage of products of conception
may be performed. [17]

Second trimester: The uterus is emptied by dilatation and evacuation; alternatively, the
uterus is emptied by induction of labor.

Hospitalization
If vaginal bleeding cannot be controlled in the ED, transfer the patient to the operating room
(OR) for examination. Anesthetize the patient and perform uterine evacuation.
Emergency
Department
Perawatan
Pengelolaan
Memperlakukan semua pasien dengan perdarahan vagina etiologi apapun sebagai berikut:
Menentukan stabilitas hemodinamik dan mengobati ketidakstabilan. Jika pasien shock
hemoragik, pengobatan termasuk posisi Trendelenburg, oksigen, agresif resusitasi cairan
(setidaknya 2 besar-menanggung garis IV dengan Ringer laktat [LR] solusi atau saline normal,
terbuka
lebar),
dan
hemotransfusion.

Menentukan
status
kehamilan
(kualitatif
dan
kuantitatif).
Membuat penentuan laboratorium hematokrit (Ht) tingkat dan status Rh.
Lakukan pemeriksaan panggul untuk menentukan tingkat perdarahan; Kehadiran bekuan darah
atau produk dari konsepsi; dan kondisi os serviks, leher rahim, rahim, dan adneksa.
Lakukan ultrasonografi panggul untuk menentukan intrauterin dan / atau isi extrauterine
(aktivitas jantung janin) dan / atau klinis mengklasifikasikan keguguran spontan.
American College of Obstetricians dan Gynecologists (ACOG) merekomendasikan umumnya
membatasi manajemen hamil untuk kehamilan dalam trimester pertama karena potensi
perdarahan serta kurangnya studi keselamatan manajemen hamil pada trimester kedua. [1]
Diperkirakan tingkat keberhasilan 80% dalam mencapai pengusiran lengkap bila waktu yang
cukup diperbolehkan (8 minggu). Bagi wanita yang ingin mengurangi waktu untuk
menyelesaikan pengusiran tapi tidak ingin menjalani evakuasi bedah, pengobatan dengan
misoprostol
dapat
dipertimbangkan.
[1]
Nadarajah et al menemukan tidak ada perbedaan yang signifikan dalam tingkat keberhasilan
antara 360 wanita yang menjalani manajemen hamil atau bedah kerugian awal kehamilan, juga
tidak ada perbedaan dalam jenis keguguran. [15] Dengan manajemen hamil, 74% pasien
memiliki pengusiran spontan lengkap hasil konsepsi. Dari pasien ini, 106 (83%) mengalami
keguguran dalam waktu 7 hari. Namun, tingkat penerimaan yang tidak direncanakan (18,1%)
dan evakuasi bedah yang tidak direncanakan (17,5%) pada kelompok hamil, secara signifikan
lebih tinggi dibandingkan pada kelompok bedah (7,4% dan 8% masing-masing). [15]
manajemen
tertentu
diagnostik
keguguran
Inevitable
Tujuan pengobatan adalah evakuasi rahim untuk mencegah komplikasi (misalnya, perdarahan
lanjut,
infeksi).
keguguran
tidak
lengkap
Jika gumpalan jaringan, darah, atau produk dari konsepsi ditemukan di os serviks,
menghapusnya dengan forsep cincin untuk memfasilitasi kontraksi rahim dan hemostasis. Untuk
alasan yang sama, menggunakan oksitosin dalam kasus-kasus yang parah pendarahan (10-20
mcg
/
L
dari
NS,
terbuka
lebar).
Mengelola RhoGAM kepada pasien gravid yang Rh-negatif dan mengalami pendarahan vagina.
Pertimbangkan hemotransfusion dalam kasus pendarahan parah, ketidakstabilan hemodinamik,
atau
keduanya.
Pertimbangkan pengobatan dengan misoprostol untuk memfasilitasi penyelesaian keguguran.
keguguran
lengkap

Pengobatan pasien yang telah mengalami keguguran lengkap bervariasi tergantung pada derajat
kepastian diagnosis. Mendiagnosis keguguran lengkap dalam ED bisa sulit, kecuali sebuah
kantung
kehamilan
utuh
diusir.
Jika pemeriksaan panggul menghasilkan jaringan janin (atau bahan dari penampilan serupa),
mengirimkannya ke laboratorium untuk identifikasi produk kemungkinan pembuahan.
terjawab
keguguran
Pengobatan dapat bervariasi tergantung pada usia kehamilan sebagai berikut:
trimester pertama: Kebanyakan pasien lulus hasil konsepsi secara spontan. cacat koagulasi
sekunder untuk janin mati jarang terjadi. manajemen hamil, [16] kuret hisap, atau misoprostol
untuk manajemen medis untuk memfasilitasi berjalannya hasil konsepsi dapat dilakukan. [17]
Trimester kedua: Rahim dikosongkan oleh dilatasi dan evakuasi; alternatif, rahim dikosongkan
oleh
induksi
persalinan.
rawat
inap
Jika perdarahan vagina tidak dapat dikontrol di ED, mentransfer pasien ke ruang operasi (OR)
untuk pemeriksaan. Membius pasien dan melakukan evakuasi uterus.
Transfer
Transfer patients with evidence of a coagulation disorder to a higher level of care.
Consultations
Consultation with an obstetrician/gynecologist is indicated in all patients with the diagnosis of
inevitable or incomplete miscarriage; patients with severe hemorrhage or patients who are
hemodynamically unstable require immediate consultation for assistance with definitive
treatment. Definitive treatment may be to evacuate the products of conception from the uterus
with curettage. Depending on hospital policy, curettage may be performed in the emergency
department with subsequent observation of patients for 4-6 hours after curettage, and then
discharge if no complications occur. Curettage is generally reserved for those patients who are at
risk for hemodynamic instability due to the briskness of bleeding or for those in whom
endometritis is a concern. However, most patients with inevitable or incomplete miscarriage are
candidates for medical management with misoprostol. [18, 19, 20, 21]
Long-Term Monitoring
Threatened miscarriage
Counsel all patients discharged from the ED (with any stage of miscarriage) regarding possible
complications. OB/GYN follow up in 1-2 days should be arranged.
Incomplete miscarriage
After the first dose of misoprostol is administered intravaginally, the patient may be discharged
to follow up with her OB/GYN in 24-48 hours.

If a curettage is performed in the ED, the patient should be observed for 4-6 hours. If stable, the
patient can be discharged.
Administer the standard dose of Rho(D) immune globulin (ie, 300 mcg) to women who are Rhnegative to prevent Rh immunization (see Medication).
Send the products of conception for pathologic evaluation.
Missed miscarriage
Ultrasonographic findings, in association with presence or absence of significant clinical
bleeding, may aid in determination of medical versus expectant management as well as urgent
versus routine follow-up.
In the case of expectant management, advise the patient to return to the ED or to contact an
OB/GYN if severe cramping, bleeding, fever, and/or passage of tissue occur.
In the case of medical management with misoprostol, the first dose of 800 micrograms may be
administered intravaginally in the ED, with follow up to an OB/GYN in 24-48 hours. Patients
should be warned to return to the ED or contact their OB/GYN immediately for severe cramping,
bleeding, fever, and/or passage of tissue.
Medication Summary
The goals of pharmacotherapy are to prevent complications and to reduce morbidity.
Immune globulins
Class Summary
This agent suppresses immune response and antibody formation.
Rho(D) Immune Globulin (RhoGAM)

View full drug information

In nonsensitized Rho(D)-negative mothers who are exposed to Rho(D) prevents antibody

formation to Rh-positive red blood cells of the fetus caused by abortion, fetomaternal
hemorrhage, abdominal trauma, amniocentesis, full-term delivery, or transfusion accident.
Oxytocic Agent
Class Summary
This agent has vasopressive effects and prevents postpartum bleeding.

Oxytocin (Pitocin, Syntocinon)

View full drug information

Produces rhythmic uterine contractions and can control postpartum bleeding or hemorrhage.
Prostaglandin
Class Summary
These agents induce uterine contractions.
Misoprostol (Cytotec)

View full drug information

Not approved for use in pregnancy, yet is an invaluable medication widely used for cervical
preparation for miscarriage, labor induction, and as a medical abortifacient. Provides safe,
passive method of cervical dilatation and should be considered for facilitation of passage of
products of conception in the setting of inevitable or incomplete miscarriage, preabortion
ripening when prior uterine surgery (ie, LEEP, cesarean delivery) are known risk factors for
uterine perforation during surgical abortion. Can be administered orally or vaginally. Some
studies show premoistened tablets placed vaginally help absorption. Patients can be instructed in
self-administration to help time the dose in synchrony with their abortion procedure.
In a study by Singh of primigravid women (6-11 wk gestation), 93.3% achieved dilatation of the
cervix of 8 mm or greater after 3 h postintravaginal misoprostol 400 mcg, whereas only 16.7% of
women achieved this after 2 h of 600 mcg. The 600-mcg group had slightly greater adverse
effects (eg, bleeding, abdominal pain, fever >38C).
Dosage intended for cervical ripening can induce abortion in some patients. Oral doses of 100400 mcg can be combined with vaginal insertion of prostaglandins to enhance cervical dilatation.
Transfer
Mentransfer pasien dengan bukti gangguan koagulasi ke tingkat perawatan yang lebih tinggi.
konsultasi
Konsultasi dengan dokter kandungan / ginekolog diindikasikan pada semua pasien dengan
diagnosis keguguran tidak bisa dihindari atau tidak lengkap; pasien dengan perdarahan berat atau
pasien yang hemodinamik tidak stabil memerlukan konsultasi langsung untuk bantuan
pengobatan definitif. pengobatan definitif mungkin untuk mengevakuasi hasil konsepsi dari
uterus dengan kuretase. Tergantung pada kebijakan rumah sakit, kuretase dapat dilakukan di
departemen darurat dengan pengamatan berikutnya pasien selama 4-6 jam setelah kuretase, dan
kemudian melepaskan bila tidak terjadi komplikasi. Kuretase umumnya dicadangkan untuk
pasien-pasien yang berisiko untuk ketidakstabilan hemodinamik karena kesibukan perdarahan
atau bagi mereka di antaranya endometritis adalah kekhawatiran. Namun, kebanyakan pasien
dengan keguguran tidak bisa dihindari atau tidak lengkap adalah kandidat untuk manajemen

medis
dengan
misoprostol.
[18,
19,
20,
21]
Pemantauan
Jangka
Panjang
terancam
keguguran
Counsel semua pasien dipulangkan dari ED (dengan setiap tahap keguguran) mengenai
kemungkinan komplikasi. OB / GYN menindaklanjuti dalam 1-2 hari harus diatur.
keguguran
tidak
lengkap
Setelah dosis pertama misoprostol diberikan dalam vagina, pasien dapat dipulangkan untuk
menindaklanjuti
dengan
OB
nya
/
GYN
dalam
24-48
jam.
Jika kuretase sebuah dilakukan di ED, pasien harus diamati selama 4-6 jam. Jika stabil, pasien
dapat
dipulangkan.
Mengelola dosis standar Rho (D) immune globulin (yaitu, 300 mcg) untuk wanita yang Rhnegatif
untuk
mencegah
Rh
imunisasi
(lihat
Obat).
Kirim
hasil
konsepsi
untuk
evaluasi
patologis.
terjawab
keguguran
Temuan ultrasonografi, berkaitan dengan ada tidaknya perdarahan klinis yang signifikan, dapat
membantu dalam penentuan manajemen medis terhadap hamil serta mendesak dibandingkan
rutin
tindak
lanjut.
Dalam kasus manajemen hamil, menyarankan pasien untuk kembali ke ED atau untuk
menghubungi OB / GYN jika kram parah, pendarahan, demam, dan / atau bagian dari jaringan
terjadi.
Dalam kasus manajemen medis dengan misoprostol, dosis pertama 800 mikrogram dapat
diberikan dalam vagina dalam ED, dengan menindaklanjuti ke OB / GYN di 24-48 jam. Pasien
harus diperingatkan untuk kembali ke ED atau hubungi OB mereka / GYN segera untuk kram
parah,
pendarahan,
demam,
dan
/
atau
bagian
dari
jaringan.
obat
Ringkasan
Tujuan dari farmakoterapi adalah untuk mencegah komplikasi dan mengurangi morbiditas.
globulin
imun
kelas
Ringkasan
Agen
ini
menekan
respon
kekebalan
tubuh
dan
pembentukan
antibodi.
Rho
(D)
Immune
Globulin
(RhoGAM)

View
informasi
obat
penuh
Dalam nonsensitized Rho (D) ibu -negatif yang terkena Rho (D) mencegah pembentukan
antibodi untuk sel darah merah Rh-positif janin yang disebabkan oleh aborsi, perdarahan
fetomaternal, trauma abdomen, amniosentesis, pengiriman jangka penuh, atau kecelakaan
transfusi
.
oxytocic
Agen
kelas
Ringkasan
Agen ini memiliki efek vasopressive dan mencegah perdarahan postpartum.
Oksitosin
(Pitocin,
Syntocinon)

View
informasi
obat
penuh
Menghasilkan kontraksi rahim berirama dan dapat mengontrol perdarahan postpartum atau
perdarahan.
prostaglandin
kelas
Ringkasan
Agen
ini
menyebabkan
kontraksi
rahim.
Misoprostol
(Cytotec)


View
informasi
obat
penuh
Tidak disetujui untuk digunakan dalam kehamilan, namun adalah obat yang sangat berharga
banyak digunakan untuk persiapan serviks untuk keguguran, induksi persalinan, dan sebagai
aborsi medis. Menyediakan, metode pasif aman dari dilatasi serviks dan harus dipertimbangkan
untuk fasilitasi dari bagian dari hasil konsepsi dalam pengaturan keguguran tidak bisa dihindari
atau tidak lengkap, preabortion pematangan faktor risiko ketika operasi rahim sebelumnya (yaitu,
LEEP, sesar) yang dikenal perforasi uterus selama aborsi bedah. Dapat diberikan secara oral atau
vagina. Beberapa studi menunjukkan tablet premoistened ditempatkan vagina membantu
penyerapan. Pasien dapat diinstruksikan dalam diri administrasi untuk membantu waktu dosis
selaras
dengan
prosedur
aborsi
mereka.
Dalam sebuah studi oleh Singh dari wanita primigravida (6-11 minggu kehamilan), 93,3%
mencapai dilatasi serviks dari 8 mm atau lebih besar setelah 3 jam postintravaginal misoprostol
400 mcg, sedangkan hanya 16,7% wanita mencapai ini setelah 2 jam dari 600 mcg . Kelompok
600-mcg memiliki efek samping yang sedikit lebih besar (misalnya, perdarahan, sakit perut,
demam>
38C).
Dosis ditujukan untuk pematangan serviks dapat menginduksi aborsi pada beberapa pasien. dosis
oral 100-400 mcg dapat dikombinasikan dengan penyisipan vagina prostaglandin untuk
meningkatkan dilatasi serviks.

1. Committee on Practice BulletinsGynecology. The American College of Obstetricians

and Gynecologists Practice Bulletin no. 150. Early pregnancy loss. Obstet Gynecol. 2015
May. 125 (5):1258-67. [Medline].
2. Inbal A, Muszbek L. Coagulation factor deficiencies and pregnancy loss. Semin Thromb
Hemost. 2003 Apr. 29(2):171-4. [Medline].
3. Jayasena C, Abbara A, Izzi-Engbeaya C, et al. Reduced levels of plasma kisspeptin
during the antenatal booking visit are associated with increased risk of miscarriage. J
Clin Endocrinol Metab. 2014 Aug 15. jc20141953. [Medline].
4. Dighe M, Cuevas C, Moshiri M, Dubinsky T, Dogra VS. Sonography in first trimester
bleeding. J Clin Ultrasound. 2008 Jul-Aug. 36(6):352-66. [Medline].
5. Nakhai-Pour HR, Broy P, Sheehy O, et al. Use of nonaspirin nonsteroidal antiinflammatory drugs during pregnancy and the risk of spontaneous abortion. CMAJ. 2011
Oct 18. 183(15):1713-20. [Medline].
6. Daniel S, Koren G, Lunenfeld E, et al. Fetal exposure to nonsteroidal anti-inflammatory
drugs and spontaneous abortions. CMAJ. 2014 Mar 18. 186(5):E177-82. [Medline]. [Full
Text].

7. Chen X, Chen M, Xu B, et al. Parental phenols exposure and spontaneous abortion in

Chinese population residing in the middle and lower reaches of the Yangtze River.
Chemosphere. 2013 Sep. 93(2):217-22. [Medline].
8. Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance-United States, 1991--1999. MMWR Surveill Summ. 2003 Feb 21. 52(2):1-8. [Medline].
[Full Text].
9. Koonin LM, MacKay AP, Berg CJ, Atrash HK, Smith JC. Pregnancy-related mortality
surveillance--United States, 1987-1990. MMWR CDC Surveill Summ. 1997 Aug 8.
46(4):17-36. [Medline].
10. Hasan R, Baird DD, Herring AH, Olshan AF, Jonsson Funk ML, Hartmann KE.
Association between first-trimester vaginal bleeding and miscarriage. Obstet Gynecol.
2009 Oct. 114(4):860-7. [Medline]. [Full Text].
11. [Guideline] Laurino MY, Bennett RL, Saraiya DS, Baumeister L, Doyle DL, Leppig K, et
al. Genetic evaluation and counseling of couples with recurrent miscarriage:
recommendations of the National Society of Genetic Counselors. J Genet Couns. 2005
Jun. 14(3):165-81. [Medline].
12. Tayal VS, Cohen H, Norton HJ. Outcome of patients with an indeterminate emergency
department first-trimester pelvic ultrasound to rule out ectopic pregnancy. Acad Emerg
Med. 2004 Sep. 11(9):912-7. [Medline].
13. Seymour A, Abebe H, Pavlik D, Sacchetti A. Pelvic examination is unnecessary in
pregnant patients with a normal bedside ultrasound. Am J Emerg Med. 2010 Feb.
28(2):213-6. [Medline].
14. Close RJ, Sachs CJ, Dyne PL. Reliability of bimanual pelvic examinations performed in
emergency departments. West J Med. 2001 Oct. 175(4):240-4; discussion 244-5.
[Medline].
15. Nadarajah R, Quek YS, Kuppannan K, Woon SY, Jeganathan R. A randomised controlled
trial of expectant management versus surgical evacuation of early pregnancy loss. Eur J
Obstet Gynecol Reprod Biol. 2014 Jul. 178:35-41. [Medline].
16. Pauleta JR, Clode N, Graca LM. Expectant management of incomplete abortion in the
first trimester. Int J Gynaecol Obstet. 2009 Jul. 106(1):35-8. [Medline].
17. Patua B, Dasgupta M, Bhattacharyya SK, Bhattacharya S, Hasan SH, Saha S. An
approach to evaluate the efficacy of vaginal misoprostol administered for a rapid

management of first trimester spontaneous onset incomplete abortion, in comparison to

surgical curettage. Arch Gynecol Obstet. 2013 May 26. [Medline].
18. Bagratee JS, Khullar V, Regan L, Moodley J, Kagoro H. A randomized controlled trial
comparing medical and expectant management of first trimester miscarriage. Hum
Reprod. 2004 Feb. 19(2):266-71. [Medline].
19. Sotiriadis A, Makrydimas G, Papatheodorou S, Ioannidis JP. Expectant, medical, or
surgical management of first-trimester miscarriage: a meta-analysis. Obstet Gynecol.
2005 May. 105(5 Pt 1):1104-13. [Medline].
20. Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of
miscarriage: expectant, medical, or surgical? Results of randomised controlled trial
(miscarriage treatment (MIST) trial). BMJ. 2006 May 27. 332(7552):1235-40. [Medline].
21. Dempsey A, Davis A. Medical management of early pregnancy failure: how to treat and
what to expect. Semin Reprod Med. 2008 Sep. 26(5):401-10. [Medline].

Threatened Miscarriage Overview

Any bleeding other than spotting during early pregnancy is considered a threatened miscarriage.
(A miscarriage may also be referred to as a spontaneous abortion.) Vaginal bleeding is common
in early pregnancy. About one of every four pregnant women has some bleeding during the first
few months. About half of these women stop bleeding and have a normal pregnancy.
The bleeding and pain associated with threatened miscarriage are usually mild. In the best case,
the cervical os (mouth of the womb) is closed. (A health care professional can determine if the
cervical os is open by performing a pelvic exam.) Typically, no tissue has been passed from the
womb. The womb and Fallopian tubes may be tender.
When a miscarriage is inevitable, the cervical os is open (dilated). Bleeding is often heavier, and
abdominal pain and cramping often occur.

If a miscarriage is incomplete, the cervical os is open, and the pregnancy is being expelled.
Ultrasound reveals some material that remains in the womb. Bleeding is heavy and abdominal
pain is almost always present.
With a complete miscarriage, bleeding and abdominal pain have occurred but have usually
stopped. Products of conception have been passed. The early fetus has been passed and was not
alive. Ultrasound reveals an empty womb.
Threatened Miscarriage Causes

Although the actual cause of the miscarriage is frequently unclear, the most common reasons
include the following:
An abnormal fetus is almost always the cause of miscarriages during the first 3 months of
pregnancy (first trimester). Problems in the chromosomes cause an abnormal fetus and are found
in more than half of miscarried fetuses. The risk of defective chromosomes increases with the
woman's age.
Miscarriage during the fourth through sixth months of pregnancy (second trimester) is
usually related to an abnormality in the mother rather than in the fetus.

Chronic illnesses, including diabetes, severe high blood pressure, kidney disease, lupus,
and underactive or overactive thyroid gland, are frequent causes of a miscarriage.
Prenatal care is important because it screens for some of these diseases.

Inadequate hormone production is an occasional cause of miscarriages.

Acute infections, including German measles, CMV (cytomegalovirus), mycoplasma

(atypical pneumonia) and other unusual germs can also cause miscarriage.

Diseases and abnormalities of the internal female organs can also cause miscarriage.
Some examples are an abnormal womb, fibroids, weakness in the mouth of the womb
(cervix), abnormal growth of the placenta (also called the afterbirth), and being pregnant
with multiples.

Other factors, especially certain drugs, including excessive caffeine, alcohol, tobacco, and
cocaine, may be the cause

Threatened Miscarriage Symptoms

Symptoms of a spontaneous miscarriage include vaginal bleeding and abdominal pain.

Bleeding may be only slight spotting, or it can be heavy. The health care professional
will ask how heavy the bleeding is, and how many pads are being soaked through per
hour. The health care professional will also ask about blood clots or tissue passed.

Pain and cramping are in the lower abdomen. They may be on one side, both sides, or in
the middle. The pain can go into the lower back, buttocks, and genitals.

When to Seek Medical Care

A woman who is pregnant who experiences cramping or bleeding at any time should call her
health care professional.
A pregnant woman who experiences these symptoms but does not have doctor should go to the
closest hospital's emergency department to be examined.
A pregnant woman should go to the hospital if she experiences the following symptoms:

Heavy bleeding (soaking more than one pad per hour)

Passing something that looks like tissue (Place this tissue in a container and take it with
you to the hospital.)

Severe cramping (like a menstrual period)

Cramping or bleeding accompanied by fever

Bleeding or abdominal pain in a woman who has had a previous ectopic pregnancy (tubal
pregnancy)

Vomiting so severe she can't keep anything down

Medical history

The doctor or nurse in the emergency department will ask many questions, such as the following:

How far along is your pregnancy?

When was your last normal period?

How many times have you been pregnant?

How many living children do you have?

How many miscarriages have you had?

Have you ever had an ectopic (tubal) pregnancy?

Were you using any sort of birth control when you got pregnant this time?

Have you had any prenatal care?

Have you had an ultrasound yet to show that the pregnancy is in the right
place?

What medical problems do you have?

What medications do you take every day?

What herbs or other products do you take every day?

Physical exam
For the pelvic exam, the patient will lie on her back with the knees bent and the feet
in stirrups.

The patient may have a speculum exam. A metal or plastic device is put in
your vagina and then opened, spreading the walls of the vagina apart so the
health care professional can look right at the mouth of your womb. If there is
a lot of blood or clots, the health care professional may use a clamp or gauze
to remove it. The patient should not feel any pain during this part of the
exam, although she may be embarrassed and uncomfortable.

You may have bleeding from the vagina before, during, and even after a
miscarriage. The health care professional
will assess the opening of the entrance to the womb (called the os) and,
depending on the findings, will be able to tell you more accurately which of
the stages of miscarriage you might be experiencing.

The health care professional may put gloved fingers in the patient's vagina
and feel the abdomen with the other hand. He or she can feel whether the
mouth of the woman's uterus is open, how big the uterus may be, and
whether there are any signs of infection or tubal pregnancy. The size of the
uterus may be smaller than expected for the fetus if the patient has already
miscarried.

Lab tests

Pregnancy tests can be either urine tests or blood tests. The health care professional or
emergency department doctor, if the woman goes to the hospital with alarming symptoms, will
act quickly to determine if she is pregnant.

A urine pregnancy test along with blood samples will be sent to the
laboratory to check for blood loss or anemia, blood type, and the level of the
pregnancy hormone. This hormone is called human chorionic gonadotropin or
hCG.
o

A number too low may suggest that it is an abnormal pregnancy. No

single number is "normal." A very low number (under 1,000) suggests
an abnormal pregnancy, although it could just be an early pregnancy.

A very high number (over 100,000) strongly suggests a normal living

pregnancy. Most other numbers by themselves do not help a lot but
can be compared to another test done in 2 to 3 days to see if
everything is developing normally.

A complete blood count (CBC) may be ordered. If the patient has been
bleeding a lot, she may be anemic (loss of too much blood) and need special
care. If she has a fever, the white cell count may suggest she has an
infection.

If the patient does not know her blood type, this will also be checked. If she is
Rh-negative, the patient will probably receive a special medicine called
RhoGAM to protect the mother and her baby from a bad reaction.

If the patient has symptoms of a urinary infection, a urine sample will be

taken and examined.

Ultrasound

If a woman is pregnant, an ultrasound may be performed to look for evidence of a pregnancy

within the uterus. If the radiologist, gynecologist, or emergency department doctor cannot find
evidence of a pregnancy within the uterus, the patient will likely be evaluated further for a
pregnancy that is outside of the uterus. When the fertilized egg implants in the Fallopian tube,
this is called a tubal or ectopic pregnancy.

The technician may put some jelly on the abdomen for transabdominal
ultrasound and press down with a probe to see the internal organs. The
ultrasound technician may also use a vaginal probe inside the vagina to get a
better look at the Fallopian tubes and ovaries. Neither of these studies should
be painful.

Threatened Miscarriage Treatment

If a miscarriage is inevitable and the health care professional does not think the woman has a
living pregnancy, an obstetrician will be consulted as well. The obstetrician may recommend the
cervix be dilated and the contents of the womb be extracted (curettage or D&C), or the
obstetrician may recommend that the woman be monitored as the body expels the pregnancy on
its own.
The woman may be sent home with special instructions in the following circumstances:

The cervical os is closed.

Bleeding is not heavy.

Lab study results are normal.

Ultrasound reveals the pregnancy is not tubal