2d:I[856015,["/_next/static/immutable/chunks/1xzisbplk9czp.js","/_next/static/immutable/chunks/3j2i1faptc_-9.js","/_next/static/immutable/chunks/0fma7nlq6immz.js","/_next/static/immutable/chunks/08tq8rmv423j5.js","/_next/static/immutable/chunks/1chr5wkk3j58k.js","/_next/static/immutable/chunks/37kmmh_zm4dov.js","/_next/static/immutable/chunks/311zvdjfxff-f.js","/_next/static/immutable/chunks/1a_hqhrsle_n_.js"],"default"] 2e:T5f71,

Summary Table

Feature	Detail
Risk Factors	Chromosomal anomalies (most common cause), advanced maternal age, uterine/cervical anomalies, chronic illness, severe nutritional deficiency, infections, immunologic disorders, alcohol/smoking, physical/psychological trauma
Etiology	Spontaneous: fetal anomaly, chromosomal defect, implantation failure, hormonal insufficiency. Induced: medical or procedural termination before viability
Patient Presentation	Vaginal bleeding in the first or early second trimester (before 20 weeks or fetal weight <500 g), with or without cramping lower abdominal pain
Classic Physical Exam	Cervical os status (open vs. closed), uterine size relative to gestational age, presence or absence of tissue at the os, uterine tenderness, foul-smelling discharge (if septic)
Key Diagnostic Results	Positive pregnancy test (beta-hCG), ultrasound showing gestational sac/fetal viability or absence thereof, hemoglobin if anemia is suspected, blood type and Rh status
Management	Varies by type: conservative observation (threatened), uterine evacuation with misoprostol or manual vacuum aspiration (MVA) (inevitable, incomplete, missed), antibiotics + evacuation (septic), no evacuation needed (complete)
Keywords	Vaginal bleeding in early pregnancy, cervical os open/closed, products of conception, incomplete evacuation, misoprostol, MVA, sharp curettage (obsolete)

1. Pathophysiology

The fundamental process in all forms of abortion is the premature termination of pregnancy before the fetus reaches viability, defined as before 20 weeks of gestation or fetal weight below 500 grams.

In spontaneous abortion, the most frequent underlying mechanism is a lethal chromosomal abnormality (particularly trisomies, monosomy X, and polyploidy) that prevents normal embryonic development. The defective conceptus fails to progress, triggering an inflammatory and hemorrhagic cascade in the decidua. This leads to separation of the gestational sac from the uterine wall, which manifests clinically as vaginal bleeding and uterine cramping. Prostaglandins released at the site of decidual disruption stimulate myometrial contractions, producing pain and eventually expelling the products of conception.

The cervical os is the single most important physical finding that differentiates one type from another. In threatened abortion, the cervix remains closed because the process is still reversible and the gestational sac has not yet detached fully. Once the cervix dilates, the process becomes irreversible (inevitable abortion). If only part of the tissue is expelled, retained products act as a foreign body that prevents the uterus from contracting effectively, leading to continued bleeding (incomplete abortion). Conversely, if all products pass spontaneously, the uterus contracts down, the cervix closes, and bleeding diminishes (complete abortion).

In missed abortion, the embryo/fetus dies but the body fails to mount a sufficient expulsion response. The uterus neither grows nor contracts to expel, and the cervix stays closed. Over time, pregnancy symptoms regress and previously positive pregnancy tests may become negative.

Septic abortion develops when bacteria, most commonly polymicrobial flora from the lower genital tract, ascend into the uterine cavity through an open cervix or following instrumentation performed without proper aseptic technique. The infection can remain localized to the decidua (infectious abortion) or spread to the myometrium, parametrium, peritoneum, and eventually the bloodstream (septic abortion with sepsis). This is why septic abortion is associated with high-grade fever, tachycardia, foul-smelling vaginal discharge, and uterine tenderness.

2. Classification and Clinical Manifestation

Type	Vaginal Bleeding	Abdominal Pain	Uterine Size	Cervical Os	Hallmark Finding
Threatened (Iminens)	Scant	Mild or absent	Appropriate for gestational age	Closed	No tissue expelled; fetus is viable
Inevitable (Insipiens)	Moderate to heavy	Moderate to severe	Appropriate for gestational age	Open	No tissue expelled yet, but cervix is dilating progressively
Incomplete (Inkomplit)	Moderate to heavy	Moderate to severe	Equal or smaller than expected	Open	Partial expulsion of products of conception; tissue may be palpable at or protruding from the os
Complete (Komplit)	Scant/minimal	Minimal or absent	Smaller than expected	Open or closed	All products expelled; uterus is well-contracted and small
Missed Abortion	None	None	Smaller than expected	Closed	Fetal death without expulsion; regression of pregnancy symptoms; previously positive pregnancy test may turn negative
Septic	Variable	Variable	Variable	Open or closed	Fever, tachycardia, foul-smelling vaginal discharge, tender/boggy uterus, leukocytosis; may progress to peritonitis and septic shock
Habitual (Recurrent)	Variable	Variable	Variable	Variable	Three or more consecutive spontaneous abortions before 28 weeks

3. Diagnostic Workup

Test	Purpose	When to Order
Pregnancy test (beta-hCG)	Confirm pregnancy	All cases where pregnancy is not yet confirmed
Pelvic/bimanual examination	Assess cervical os status, uterine size and tenderness, tissue at os	All cases; this is the best initial assessment
Ultrasound	Confirm intrauterine pregnancy, evaluate fetal viability, estimate gestational age, rule out ectopic pregnancy	When available; not a mandatory prerequisite for diagnosis per PNPK
Hemoglobin	Detect anemia from blood loss	If significant bleeding is suspected
Blood type and Rh	Determine Rh status for anti-D immunoglobulin consideration	All cases
Complete blood count	Evaluate leukocytosis (septic abortion)	If infection is suspected
Tissue examination	Confirm products of conception (villi, decidua, membranes); rule out molar pregnancy (hydropic villi)	After any evacuation procedure

The best initial test in any woman presenting with first-trimester vaginal bleeding is a thorough history and bimanual pelvic examination. The status of the cervical os is what immediately classifies the type of abortion. A closed cervix with a viable fetus on ultrasound points to threatened abortion; an open cervix with tissue at the os points to inevitable or incomplete abortion.

Ultrasound is the most useful adjunct to confirm the diagnosis and, importantly, to rule out ectopic pregnancy before initiating any medical treatment. The PNPK emphasizes that ultrasound is helpful but not an absolute requirement for establishing the diagnosis. Gestational age can be estimated by uterine size on bimanual exam when ultrasound is unavailable.

After evacuation, tissue inspection should be performed. The operator looks for villi, decidua, and membranes in a clear container with water and backlighting. Absence of villi raises concern for ectopic pregnancy or incomplete evacuation. Grape-like hydropic villi suggest molar pregnancy.

4. Management and Treatment

Overview Table (Aligned with PNPK Kemenkes 2020)

Type	Management	Key Details
Threatened	Conservative/expectant	Bed rest, referral to Ob-Gyn; no evacuation
Inevitable	Evacuate: medical (misoprostol) or operative (MVA/D&E)	Same protocol as incomplete abortion
Incomplete	Evacuate: medical (misoprostol) or operative (MVA/D&E)	See misoprostol dosing table below
Missed Abortion	Evacuate: medical (misoprostol +/- mifepristone) or operative (MVA/D&E)	Higher misoprostol doses; mifepristone can be added if available
Complete	No evacuation needed	Counseling, iron supplementation, nutritional advice, contraception
Septic	Antibiotics first, then evacuation (MVA) once first antibiotic dose is given	Regimen depends on severity of infection

Misoprostol Dosing for Evacuation

Case	Uterus <13 Weeks	Uterus 13 Weeks or More
Incomplete / Inevitable	Misoprostol 600 mcg oral as a single dose, OR 400 mcg sublingual as a single dose, OR 400 mcg per vaginam (if no active vaginal bleeding)	Misoprostol 400 mcg every 3 hours until expulsion; given buccal, sublingual, or per vaginam (if no active vaginal bleeding)
Missed Abortion	Misoprostol 600 mcg sublingual OR 800 mcg per vaginam (if no active vaginal bleeding) every 3 hours until expulsion (usually 1-3 doses)	Misoprostol 400 mcg sublingual or per vaginam every 4-6 hours until expulsion. If available, mifepristone 200 mg oral can be given 1-2 days before misoprostol

Operative Management

For uterine size below 13 weeks, the procedure of choice is manual vacuum aspiration (MVA). For uterine size 13 weeks or more, the procedure is dilation and evacuation (D&E), which is essentially MVA preceded by cervical preparation and must be performed by a trained Ob-Gyn specialist at a referral facility.

Sharp curettage (D&C) is obsolete. The PNPK explicitly states that sharp curettage is no longer recommended by WHO or FIGO due to higher complication rates, including a 1.2% risk of Asherman syndrome, which is not observed with MVA or misoprostol.

Cervical Preparation Before Operative Evacuation

For uterine size <13 weeks, cervical priming is not mandatory but can reduce procedural difficulty. If used: misoprostol 400 mcg per vaginam 3-4 hours before the procedure, OR sublingual 2-3 hours before. For uterine size 13 weeks or more, cervical preparation is recommended for all patients with the same misoprostol regimen; laminaria is an alternative especially beyond 20 weeks.

Pain Management

For medical management, NSAIDs are the first-line analgesic (ibuprofen, ketoprofen, mefenamic acid, diclofenac, or ketorolac), given before or when cramping begins. Paracetamol is a second-line option only when NSAIDs cannot be given. For uterine size beyond 12 weeks, epidural anesthesia should also be considered.

For operative management (MVA/D&E), a paracervical block using lidocaine (typically 20 mL of 1% lidocaine) plus NSAIDs is recommended for all patients. General anesthesia is not routinely recommended because it increases morbidity and mortality risk in post-abortion care.

Prophylactic Antibiotics

Antibiotics are recommended before operative procedures (MVA or D&E) only: doxycycline 200 mg oral, OR azithromycin 500 mg oral, OR metronidazole 500 mg oral, given as a single dose before the procedure. Routine prophylactic antibiotics are not recommended for medical management with misoprostol.

Septic Abortion: Antibiotic Regimens

Severity	Regimen	Duration
Mild/Moderate Endometritis	Ceftriaxone 250 mg IM single dose + Doxycycline 100 mg oral twice daily for 14 days, with or without Metronidazole 500 mg oral twice daily for 14 days	14 days total
Severe Endometritis	Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours + Doxycycline 100 mg oral or IV every 12 hours; switch to oral after 24-48 hours of clinical improvement	14 days total
Sepsis	Ampicillin 2 g IV/IM then 1 g every 6 hours + Gentamicin 5 mg/kg IV every 24 hours + Metronidazole 500 mg IV every 8 hours; switch to oral after 48 hours afebrile	7 days after switching to oral

In septic abortion, the first dose of antibiotics is given immediately, and uterine evacuation with MVA should follow as soon as possible. The PNPK emphasizes that in suspected unsafe induced abortion, tetanus prophylaxis (0.5 mL tetanus toxoid IM + 1500 units tetanus antitoxin IM) should be administered if immunization history is unknown.

Post-Procedure

Contraception can begin immediately after operative evacuation. Hormonal contraceptives, IUD insertion (except in septic cases), and barrier methods are all options. After medical management, hormonal methods can start once expulsion is confirmed. Fertility returns in approximately 8 days after a completed abortion. A follow-up visit at 7-14 days is offered but not mandatory.

5. Differential Diagnosis and Distractors

Differential	Why It Looks Similar	Key Discriminator
Ectopic pregnancy	First-trimester vaginal bleeding + abdominal pain, positive pregnancy test	No intrauterine gestational sac on ultrasound; adnexal mass or tenderness; beta-hCG plateau or slow rise. Misoprostol is ineffective for ectopic pregnancy.
Gestational trophoblastic disease (molar pregnancy)	Vaginal bleeding in early pregnancy, enlarged uterus	Uterus is larger than expected for gestational age (not smaller); "snowstorm" appearance on ultrasound; markedly elevated beta-hCG; grape-like hydropic villi on tissue exam
Implantation bleeding	Light vaginal bleeding in early pregnancy	Very scant, brief, red bleeding around the time of expected menses; no pain; self-resolving; often before a positive pregnancy test
Cervical pathology (polyp, ectropion, cervical cancer)	Vaginal bleeding during pregnancy	Bleeding is from the cervix, not the uterine cavity; speculum exam reveals the lesion; os is closed; ultrasound shows normal intrauterine pregnancy
Threatened vs. inevitable abortion	Both present with first-trimester bleeding	The pivotal distinction is cervical os status: closed = threatened, open = inevitable. This is the single highest-yield discriminator on the exam.
Incomplete vs. complete abortion	Both follow passage of tissue	In incomplete, the uterus remains larger than expected, cervix is still open, and bleeding continues. In complete, the uterus has involuted, os is closed/closing, and bleeding is minimal.

6. Traps and High-Yield Pearls

The most common way students lose points on this topic is by confusing the types of abortion based on cervical os status. The exam will give you a vignette with vaginal bleeding in early pregnancy and expects you to classify it based on two key variables: whether the cervix is open or closed, and whether products of conception have been partially or fully expelled. A closed cervix with a viable fetus is threatened; a closed cervix with a dead fetus and no expulsion is missed abortion. An open cervix with tissue still inside is inevitable or incomplete. Memorize the cervical os as the branching point for your entire diagnostic algorithm.

A second trap involves management selection. Students who answer "D&C" for evacuation of retained products are choosing an obsolete method. The current standard per WHO and FIGO guidelines (and the PNPK 2020) is misoprostol or MVA, not sharp curettage. If you see sharp curettage or D&C as an answer choice alongside MVA, it is almost always the distractor.

Third, never forget to rule out ectopic pregnancy before giving misoprostol. Misoprostol has no therapeutic effect on ectopic pregnancy, and a delay in recognizing an ectopic can be fatal. If the vignette includes no intrauterine pregnancy on ultrasound with a positive beta-hCG, the next best step is to investigate for ectopic, not to administer misoprostol.

Finally, for missed abortion at 13 weeks or more, recognize that the PNPK includes the option to give mifepristone 200 mg oral 1-2 days before misoprostol when available. This combination improves expulsion rates and is a testable detail that distinguishes missed abortion management from incomplete/inevitable abortion management, where mifepristone is not part of the standard protocol.

1e:["$","$L2d",null,{"article":{"id":"87a2f353-25f7-4d6f-a773-03d1173e660a","title":"Abortus","content":"$2e","category":"Reproduksi","created_at":"2026-05-15T15:36:07.860723+00:00","status":"published","subcategory":null},"questionCount":3,"sections":[{"id":"section-pathophysiology","num":"01","title":"Pathophysiology"},{"id":"section-classification-and-clinical-manifestation","num":"02","title":"Classification and Clinical Manifestation"},{"id":"section-diagnostic-workup","num":"03","title":"Diagnostic Workup"},{"id":"section-management-and-treatment","num":"04","title":"Management and Treatment"},{"id":"section-differential-diagnosis-and-distractors","num":"05","title":"Differential Diagnosis and Distractors"},{"id":"section-traps-and-high-yield-pearls","num":"06","title":"Traps and High-Yield Pearls"}],"hasSummaryTable":true}]