HISTORY. Obtain a complete obstetric history. Determine the date of the last menstrual period to calculate the fetus's gestational age. Vaginal bleeding is usually the first symptom that signals the onset of a spontaneous abortion. Question the patient as to the onset and amount of bleeding. Inquire further about a small gush of fluid, which indicates a rupture of membranes, although at this early point in gestation, there is only a small amount of amniotic fluid expelled. Ask the patient to describe the duration, location, and intensity of her pain. Pain varies from a mild cramping to severe abdominal pain, depending on the type of abortion; pain can also occur as a backache or pelvic pressure. Although it is a sensitive topic, ask the patient about the passage of fetal tissue. If possible, the patient should bring the tissue passed at home into the hospital because sometimes laboratory pathological analysis can reveal the cause of the abortion. With a missed abortion, early signs of pregnancy cease; thus, inquire about nausea, vomiting, breast tenderness, urinary frequency, and leukorrhea (white or yellow mucous discharge from the vagina).

PHYSICAL EXAM. Temperature is elevated above 100.4°F if a maternal infection is present. In addition, pallor, cool and clammy skin, and changes in the level of consciousness are symptoms of shock. Examine the patient's peripad for blood loss, and determine if any tissue has been expelled. Sometimes tissue can be observed at the introitus, but do not perform a vaginal examination if that situation occurs.

PSYCHOSOCIAL. Assess the patient's emotional status, as well as that of the baby's father and other family members. Often this hospital admission is the first one for the patient, and it may cause anxiety and fear. The father may withhold expressing his grief, feeling he needs to "be strong" for the mother.

Diagnostic Highlights

General Comments: Most of the time, diagnosis of SAB is made based on patient symptoms and the documentation of a positive pregnancy test.

Test	Normal Result	Abnormality with Condition	Explanation
Human chorionic gonadotropin (hCG)	Negative < 5 mIU/mL	> 5 mIU/mL, increases as the gestation progresses	hCG normally is not present in nonpregnant women
Ultrasound (transvaginal, transabdominal)	Positive fetal heartbeat; growth within normal limits	Heartbeat absent; gestational sac appears shriveled, or shrinking	Used to diagnose a missed abortion
Red blood cells; hemoglobin; hematocrit	4.2–5.4 mL/mm3; 12–16 g/dL; 37%–47%	These three values will decrease several hours after significant blood loss has occurred	With active bleeding, red blood cells are lost

Other Tests: Blood type and crossmatch, white blood cells; habitual aborters should also undergo additional testing to rule out causes other than an incompetent cervix (thyroid-stimulating hormone, mid–luteal phase serum progesterone measurement, hysterosalpingogram, and screening for lupus anticoagulant).

IU = International units.