Abortion on the rise: treatment and emergency measures

The term "abortion in progress" typically refers to an early pregnancy loss in which the process of detachment of the fertilized egg has already begun or there is clinical evidence of bloody discharge with signs of incomplete tissue expulsion. In clinical practice, several terms are used: threatened miscarriage, incomplete abortion, incomplete pregnancy, and miscarriage with signs of the beginning of expulsion. These categories determine the subsequent management. [1]

The key goals of treatment are to preserve the woman's life and health, stop bleeding if hemodynamic instability is threatened, completely evacuate the uterine cavity if indicated, and prevent infection. The choice between watchful waiting, drug therapy, and surgical treatment depends on the patient's condition, the presence of significant bleeding, signs of infection, and preferences. [2]

Current guidelines recognize three equally valid options for a stable patient: observation, medical treatment, and surgical evacuation. The choice is made in consultation with the patient, taking into account evidence of efficacy, safety, and the desired outcome. For emergency conditions (massive bleeding, shock, sepsis), immediate surgical care is the priority. [3]

Proper documentation of diagnosis and care management is important: objective ultrasound data, hemoglobin, vital signs and an agreed plan for monitoring or treatment can reduce the risk of unnecessary interventions and improve patient satisfaction. [4]

Initial assessment - what you must do upon admission

Upon admission, the patient's condition should be assessed immediately: blood pressure and pulse rate should be measured, blood loss should be assessed based on the number of pads, and the patient's hemodynamic status should be assessed. If profuse bleeding is suspected, it is important to quickly determine the need for urgent hemostatic intervention. [5]

A transvaginal ultrasound is performed simultaneously to determine the location and extent of uterine filling, identify any remaining tissue, and rule out an ectopic pregnancy. A complete blood count and blood type with Rh factor are also taken. These data determine further management and the need for transfusion. [6]

An assessment for signs of infection is mandatory: body temperature, leukocytosis, the nature of discharge, and pain. If sepsis is suspected, a decision on urgent uterine evacuation and initiation of antibacterial therapy is made immediately. If the patient's condition is stable, a plan for further examination and a discussion of treatment options is established. [7]

Finally, it is important to clarify the gestational age, the patient's wishes regarding further attempts at pregnancy, and any contraindications to drug therapy. Informed consent is mandatory: the risks and benefits of each option are discussed. [8]

Table 1. A set of primary examinations for "abortion in progress"

Study	For what
Blood pressure and pulse	Hemodynamic assessment. [9]
Transvaginal ultrasound	Localization, tissue remnants, signs of incomplete miscarriage. [10]
Complete blood count	Hemoglobin, blood loss assessment. [11]
Blood type and Rh	Decision about transfusion and anti-D in Rh-negative women. [12]
Temperature, leukocytes, clinical picture	Exclusion or confirmation of infection. [13]

Treatment options: expectant management - when to wait

If bleeding is minimal and there are no signs of infection or hemodynamic instability, a watchful waiting approach is acceptable. This allows natural tissue clearance to complete spontaneously within 2 weeks in many patients. The patient should receive clear instructions regarding signs of deterioration and a follow-up plan. [14]

The advantages of expectant management include the absence of invasive procedures and the risk of surgical complications; disadvantages include prolonged blood loss, the need for frequent monitoring, and the likelihood of subsequent need for medical or surgical treatment. The decision is made jointly with the patient. [15]

When choosing a watchful waiting approach, a follow-up ultrasound is scheduled in 7-14 days, or earlier if bleeding or pain occurs. If there is no progression or if the condition worsens, a transition to active treatment is recommended. The patient is instructed on the "red flags" (severe bleeding, fever, pain) and given the clinic's contact information. [16]

Waiting is especially appropriate if the patient has contraindications to medications, or is categorically against surgery and is ready for dynamic observation; it is also important to ensure a safe system of rapid access to the hospital in case of complications. [17]

Table 2. Pros and cons of a wait-and-see approach

Pros	Cons
No invasive interventions	Long period with bleeding.[18]
No anesthesia or surgical risk	Risk of incomplete removal and subsequent surgery. [19]

Drug treatment - regimens, effectiveness and features

Drug therapy involves a combination of progesterone receptor blockers and prostaglandin drugs, or prostaglandin alone. Current data and guidelines support the effectiveness of regimens pre-treated with misoprostol or preceded by mifepristone, which increases the rate of complete tissue clearance. [20]

The most commonly used regimens are 200 mg mifepristone orally followed by 800 mcg misoprostol vaginally, sublingually, or buccally 24–48 hours later; if mifepristone is unavailable, 800 mcg misoprostol is given as a single dose, repeated at 400 mcg every 3 hours for up to two to three doses, according to FIGO and WHO recommendations. Efficacy depends on the gestational age and the initial diagnosis. [21]

Side effects of misoprostol include pain, fever, and nausea. With medical therapy, the patient should receive analgesics and have access to a hospital if significant bleeding occurs. If significant tissue remains after medical therapy or bleeding continues, surgical evacuation is indicated. [22]

Mifepristone plus misoprostol demonstrates a higher rate of complete elimination compared to misoprostol alone; therefore, if available and without contraindications, the combination is preferred. Local protocols and drug availability are taken into account when choosing a regimen. [23]

Table 3. Practical drug therapy regimens (guidelines)

Situation	Mode	Comment
Mifepristone is available	200 mg orally, then 24-48 hours later misoprostol 800 mcg vaginally or sublingually	Highly effective in early miscarriage. [24]
Mifepristone is not available.	Misoprostol 800 mcg once, then 400 mcg every 3 hours up to 2 doses	According to WHO and RCOG recommendations. [25]
After 14 weeks	Doses and intervals are adjusted; an experienced center is needed	Increased risk of complications at later stages. [26]

Surgical treatment - vacuum aspiration and indications

Surgical treatment remains a rapid and definitive method in cases of severe bleeding, suspected sepsis, significant tissue remnants, or at the patient's request. In the first trimester, preference is given to instrumental vacuum aspiration under local or general anesthesia; this reduces the risk of complications compared to separate curettage. [27]

The procedure is most often performed both inpatient and outpatient, depending on the patient's condition. Antibiotic prophylaxis is recommended in accordance with local protocols; a single dose of doxycycline or another recommended medication before the procedure reduces the risk of infectious complications. [28]

The advantages of surgery include rapid cessation of bleeding and complete evacuation of the uterine cavity; the risks include anatomical damage, perforation, adhesions, and infection. Operator experience and the use of soft instruments reduce complications. Postoperatively, bleeding and temperature are monitored, and contraceptive and recovery recommendations are provided if necessary. [29]

In emergency situations, with massive blood loss, advanced care may be required: transfusions, uterine suturing, and, in extremely severe cases, emergency laparotomy. Therefore, it is important to have an algorithm for quickly transitioning from conservative treatment to surgical intervention in a hospital setting. [30]

Table 4. Indications for immediate surgical evacuation

Indication	Why
Hepodynamically unstable blood loss	Urgent evacuation and hemostatic measures. [31]
Clinical presentation or suspicion of sepsis	Removal of the source of infection and antibacterial therapy. [32]
Significant tissue remnants after drug therapy	Risk of ongoing bleeding and infection.[33]
The patient prefers a quick final procedure	Individual choice. [34]

Rh prophylaxis, antibiotics and supportive measures

Women with a negative Rh factor were previously recommended to receive anti-D immunoglobulin after an abortion or miscarriage. Current recommendations vary: many guidelines recommend anti-D after procedures after 10 weeks of pregnancy and consider indications earlier in pregnancy according to local guidelines. The decision is individualized based on timing and local recommendations. [35]

Antibiotic prophylaxis during surgical treatment is recommended as a single dose to reduce the risk of postoperative infection. If signs of infection are present, empirical antibacterial therapy is initiated, and surgical evacuation is performed if necessary. During drug treatment, antibiotics are not routinely prescribed, only in cases of clinical infection. [36]

Supportive measures include hemoglobin monitoring and, if necessary, blood transfusions, analgesia, and accompanying psychological support. A plan for further contraception and the timing of conception attempts are discussed: it is usually recommended to postpone a new pregnancy until complete recovery is confirmed and according to situational indications. [37]

Particular attention is paid to informed consent, documentation and psychosocial support: pregnancy loss is a traumatic event, and the patient needs to be provided with contacts for a psychologist and resources for support. [38]

Follow-up care and planning for future pregnancies

Post-treatment follow-up includes a clinical examination, repeat ultrasound as indicated, and hemoglobin measurement. If there was tissue remnant or infection, follow-up is scheduled. If recovery is normal, planning for a subsequent pregnancy is discussed. [39]

In cases of repeated losses, a more in-depth examination is recommended: genetic, anatomical, and hormonal testing using standard algorithms, as well as a consultation with a reproductive specialist for an individualized strategy. The infectious origin is clarified when indicated. [40]

Contraceptive recommendations depend on the chosen treatment method and preferences: hormonal contraception can be started after full recovery according to clinical criteria; intrauterine systems are inserted taking into account the risk of infection and the condition of the uterine cavity. [41]

It is important to document discussions of risks and plans, provide written instructions on signs of complications, and provide emergency contact information. This reduces anxiety and makes it easier to access help if needed. [42]

Table 5. Follow-up observation - tentative plan

Post-treatment period	Action
1 week	Monitoring the condition, assessing bleeding, and testing if necessary
2-6 weeks	Ultrasound if residual material is suspected, hemoglobin monitoring
6-12 weeks	Discussion of pregnancy planning; in case of repeated losses, a more in-depth examination

Conclusion

1. In the case of an “abortion in progress,” hemodynamics are first assessed, a transvaginal ultrasound is performed, and basic tests are taken; in the case of shock or sepsis, immediate surgical care is required. [43]
2. In a stable patient, three options are available: expectant management, medical therapy, and surgical evacuation; the choice is individual and depends on the clinic, the gestational age, and the patient's preferences. [44]
3. The combination of mifepristone and misoprostol is more effective than misoprostol alone; regimens and doses should be adjusted according to FIGO, WHO and local protocols. [45]
4. Women with Rh-negative status should consider anti-D prophylaxis according to local guidelines; antibiotic prophylaxis is indicated in case of surgical treatment. [46]
5. Contact information, clear instructions on 'red flags', documented informed consent and access to psychosocial support are part of quality pregnancy loss care.[47]