Miscarriage (Abortion): Drug Therapy

Therapeutic target

Prevention of abortion in abortus imminens or promotion of expulsion of the fruit.

Therapy recommendations

  • Therapy recommendations depending on the diagnosis:
    • Abortes imminens (threatened abortion): magnesium, progesterone/dehyrosterone (progestins).
    • Missed abortion (restrained abortion): abortion induction (initiation of abortion) using Gemeprost (prostaglandin E1 analogue).
    • Late abortion 15 – 24 SSW post menstruationem: abortion induction in two steps: Cervical ripening (cervical ripening), labor induction (uterine smooth muscle/uterine muscle stimulation) to abortion.
    • Febrile abortion/septic abortion): Antibiosis, heparin, volume substitution.
    • Abortus habitualis (habitual abortion; recurrent spontaneous abortion, RSA; repeated spontaneous abortion (WSA)).
      • Treatment of chronic endometritis (inflammation of the uterus) for the purpose of abortion prophylaxis using antibiotics.
      • Treatment of hyperthyroidism (hyperthyroidism) [upper limit for TSH in infertility: 2.5 mU/l]If TSH findings are unremarkable, additional fT3 and fT4 and thyroid autoantibodies should be determined.
      • Treatment of thrombophilia (tendency to thrombosis) with heparin if there is evidence of antiphospholipid syndrome (APS; antiphospholipid antibody syndrome; incidence of APS in WSA: 2-15%).
      • In the presence of antiphospholipid syndrome (APS; antiphospholipid antibody syndrome; APLS) and “non-criteria” APLS, therapy should be given with low-dose acetylsalicylic acid (ASA) and low-molecular-weight heparin (NMH):
        • From the positive pregnancy test, ASA is given until 34 + 0 weeks gestation (SSW); NMH until at least 6 weeks post partum; treatment of “non-criteria” APS should be identical
      • Women with habitual preterm abortions and hereditary factor XII deficiency: acetylsalicylic acid (ASA) monotherapy (40 mg/day).
      • Women with idiopathic WSA: therapy with synthetic progestins in the first trimester (third trimester) for abortion prophylaxis.
  • See also under “Further therapy“.

Further notes

  • There is no established drug therapy or prophylaxis for abortus imminens or incipiens. The agents mentioned above are occasionally used.Preventing preterm birth by intravaginal application of progesterone has not helped to achieve a live birth in women who have already had one or more miscarriages.
  • Prevention of alloimmunization (formation of antibodies to foreign antigens (alloantigens): Rh-D immunoglobulin administration in Rh(rhesus factor)-negative women with miscarriages – especially in the late first trimester (third trimester) and during surgical procedures.

Amniotic death in early pregnancy

  • 200 mg mifepristone (progesterone receptor antagonist) + vaginal application of 800 µg misoprostol (prostaglandin E1 analogue) →.
    • Mifepristone administration increased the proportion of women who experienced complete expulsion after a single misoprostol treatment from 67.1% to 83.8%.
    • The proportion of women who required manual vacuum aspiration (MVA) was decreased from 23.5% to 8.8%.
  • Pretreatment with mifepristone significantly improved the success rate of treatment of restrained miscarriage (“missed abortion”) with misoprostol: treatment with mifepristone plus misoprostol was more effective than misoprostol alone in treating miscarriage.

Note: 7 to 21 days after drug use, sonographic follow-up and HCG checks, if necessary, should be performed; the same applies to unscheduled heavier bleeding. Febrile abortion / septic abortion.

Therapy

  • Antibiotics i.v., broad spectrum including anaerobes (e.g., cephazolin + metronidazole).
  • Heparin
  • Volume substitution
  • Early abortion < 14 SSW, curettage 4-6 h after antibiotic administration.
  • Late abortion > 14 SSW, curettage after abortion induction.

Anti-D prophylaxis in Rh-negative patients.

Abortus habitualis (habitual abortion; recurrent spontaneous abortion, RSA; repeated spontaneous abortion (WSA))

  • Definition: ≥ 3. Spontaneous abortions (initially of unclear etiology) before 20 weeks’ gestation (SSW).
  • No confirmed effects have been demonstrated for: Glucocorticoids, intravenous immunoglobulins, lipiodine infusions, lowering NK cell activity as well as proinflammatory cytokine formation, allogeneic lymphocyte transfer (“lymphocyte immunization”), G-CSF(“granulocyte-colony stimulating factor”) administration.
  • Therapy of autoimmune thyroiditis (autoimmune disease leading to chronic inflammation of the thyroid gland) and subclinical hypothyroidism (hypothyroidism).
  • Treatment of thrombophilia with heparin in the presence of evidence of antiphospholipid syndrome (APS; antiphospholipid antibody syndrome).
  • In the presence of an antiphospholipid syndrome (APS, APLS) and a “non-criteria” APLS should be treated with low-dose acetylsalicylic acid (ASA) and low-molecular-weight heparin.
  • Women with habitual preterm abortion and hereditary factor XII deficiency: acetylsalicylic acid (ASA) monotherapy (40 mg/day).

Supplements (dietary supplements; vital substances)

Suitable dietary supplements should contain the following vital substances, among others:

Legend:

* Prevention
* * Risk group
* * * Deficiency symptoms

Note: The listed vital substances are not a substitute for drug therapy. Dietary supplements are intended to supplement the general diet in a given life situation.