eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Early Pregnancy Loss

Author: Elizabeth E Puscheck, MD, Professor, Department of Obstetrics and Gynecology, Wayne State University School of Medicine; In Vitro Fertilization Director, Gynecologic Ultrasound Director, Clinical Endocrine Laboratory Consultant, Department of Obstetrics and Gynecology, University Women's Care
Contributor Information and Disclosures

Updated: Feb 17, 2010

Introduction

Background

An abortion is the spontaneous or induced loss of an early pregnancy. The period of pregnancy prior to fetal viability outside of the uterus is considered early pregnancy. Most consider early pregnancy to end at 20 weeks' gestation or when the fetus weighs 500 grams. The term miscarriage is used often in the lay language and refers to spontaneous abortion.

Pathophysiology

A spontaneous abortion is a process that can be divided into 4 stages—threatened, inevitable, incomplete, and complete. The 4 stages of abortion form a continuum. Most studies do not differentiate separately between the epidemiology and pathophysiology of each entity.

Threatened abortion

Threatened abortion consists of any vaginal bleeding during early pregnancy without cervical dilatation or change in cervical consistency. Usually, no significant pain exists, although mild cramps may occur. More severe cramps may lead to an inevitable abortion.

Threatened abortion is very common in the first trimester; about 25-30% of all pregnancies have some bleeding during the pregnancy. Less than one half proceed to a complete abortion. On examination, blood or brownish discharge may be present in the vagina. The cervix is not tender, and the cervical os is closed. No fetal tissue or membranes have passed. The ultrasound shows a continuing intrauterine pregnancy. If an ultrasound was not performed previously, it is required at this time to rule out an ectopic pregnancy, which could present similarly. If the uterine cavity is empty on ultrasound, obtaining a human chorionic gonadotropin (hCG) level is necessary to determine if the discriminatory zone has been passed.

The discriminatory zone is the level of hCG beyond which an intrauterine pregnancy is consistently visible by ultrasound. The discriminatory zone may vary depending on a number of factors, including the hCG assay type and reference calibration standard used, ultrasound equipment resolution, the skill and experience of the sonographer, and patient factors (eg, obesity, leiomyomas, uterine axis, multiple gestations). Also, the discriminatory zone will vary depending on whether the ultrasound is performed abdominally or vaginally. Therefore, having a universal discriminatory zone is difficult, and it optimally should be calculated at each site.

Some studies recommend that a gestational sac should be visualized by 5.5 weeks' gestation; a gestational sac should be visualized with an hCG level of 1500-2400 mIU/mL for transvaginal ultrasound or with an hCG level over 3000 mIU/mL for a transabdominal ultrasound. If the hCG level is higher than the discriminatory zone and no gestational sac is visualized in the uterus, then consider that an ectopic pregnancy may be present.¹ Multiple gestations are an exception and can have higher hCG levels earlier in gestation because more hCG is being made by the trophoblasts from the multiple implantations. Thus, the gestational sac(s) may not be visible on ultrasound despite the hCG levels being higher than the discriminatory zone. Even with multiple gestations, the gestational sacs should be visible at a similar gestational age as singleton gestations or about 6 weeks' gestation if the dating is good.

A clinician should be concerned about ectopic pregnancy but cannot make the diagnosis of ectopic pregnancy just because the hCG level is higher than the discriminatory zone and the uterus appears empty on ultrasound. Many of these pregnancies are abnormal intrauterine pregnancies as opposed to ectopic. One needs to take into consideration the clinical history, and estimated gestational age by LMP or date of conception, if known. A positive pregnancy test result and an ultrasound that does not reveal the location is known as a pregnancy of unknown location (PUL).² Occasionally, a normal intrauterine pregnancy does result. Depending on the clinical scenario, a clinician may choose to observe this patient with serial hCG levels and ultrasonography instead of intervening, or a clinician may need to intervene depending on the situation.

Inevitable abortion

Inevitable abortion is an early pregnancy with vaginal bleeding and dilatation of the cervix. Typically, the vaginal bleeding is worse than with a threatened abortion, and more cramping is present. No tissue has passed yet. On ultrasound, the products of conception are located in the lower uterine segment or the cervical canal.

Incomplete abortion

Incomplete abortion is a pregnancy that is associated with vaginal bleeding, dilatation of the cervical canal, and passage of products of conception. Usually, the cramps are intense, and the vaginal bleeding is heavy. Patients may describe passage of tissue, or the examiner may observe evidence of tissue passage within the vagina. Ultrasound may show that some of the products of conception are still present in the uterus.

Complete abortion

Complete abortion is a completed miscarriage. Typically, a history of vaginal bleeding, abdominal pain, and passage of tissue exists. After the tissue passes, the patient notes that the pain subsides and the vaginal bleeding significantly diminishes. The examination reveals some blood in the vaginal vault; a closed cervical os; and no tenderness of the cervix, uterus, adnexa, or abdomen. The ultrasound demonstrates an empty uterus.

Missed abortion

A fifth term that does not follow the continuum but is important to be aware of is missed abortion. A missed abortion is a nonviable intrauterine pregnancy that has been retained within the uterus without spontaneous abortion. Typically, no symptoms exist besides amenorrhea, and the patient finds out that the pregnancy stopped developing earlier when a fetal heartbeat is not observed or heard at the appropriate time. An ultrasound usually confirms the diagnosis. No vaginal bleeding, abdominal pain, passage of tissue, or cervical changes are present.

Frequency

United States

The overall miscarriage rate is reported as 15-20%, which means 15-20% of recognized pregnancies result in miscarriage. The frequency of spontaneous miscarriage increases further with maternal age. With the development of highly sensitive assays for hCG levels, pregnancies can be detected prior to the expected next period. When these highly sensitive hCG assays are used early, the magnitude of pregnancy loss significantly increases to about 60-70%. Late implantation by the conceptus beyond the usual 8-10 days after ovulation also has an increased risk of miscarriage.

About 80% of miscarriages occur within the first trimester. The frequency of miscarriage decreases with increasing gestational age. Recurrent miscarriage, defined as 2-3 pregnancy losses, affects about 1% of all couples.

Risk factors

Independent risk factors for a spontaneous miscarriage include advanced age, extremes of age, feeling stressed, and advanced paternal age.^3,4,5 Symptoms of vaginal bleeding but not abdominal pain are associated with increased risk of miscarriage. One paper suggests that miscarriage can occur in about 50% of patients who present with threatened abortion.

International

No significant difference exists between international rates and the rates in the United States.

Mortality/Morbidity

A complete abortion is unlikely to cause any significant risk of mortality unless significant blood loss or infection occurs. Morbidity would be increased if anemia or infection develops. Patients who are pregnant may bleed quickly and significantly. Distinguishing the causes of bleeding during pregnancy is important.

Incomplete and inevitable abortions are a cause for concern when significant bleeding or infection occurs. If treatment is not performed in a timely manner, significant morbidity and mortality may occur. Retained products of conception may occur after a spontaneous abortion or after a suction D&C.

Patients with retained products usually return for medical care with symptoms of increased bleeding, increased cramping, and/or infection. Caring for these patients quickly with intravenous antibiotics is important, and, after the antibiotics are administered, then a suction D&C is performed. These patients are at risk for developing Asherman syndrome, which consists of adhesions within the uterine cavity. Patients who develop Asherman syndrome may present with amenorrhea or decreased menstrual flow. Asherman syndrome may compromise future fertility. When significant bleeding occurs, fluid management and transfusions may be required while stabilizing the patient prior to a suction D&C.

A complication of D&C is perforation of the uterus, which may be handled by observation. If the patient shows signs of uncontrolled bleeding on ultrasound, then proceeding to a laparoscopy or laparotomy with cauterization of the bleeding area may be necessary. The choice for laparoscopy or laparotomy depends on the stability of the patient. Occasionally, the perforation is in the area of the uterine vessels or other area where the bleeding is difficult to control and a hysterectomy or uterine artery embolization may be necessary. When bleeding is out of control, the patient can easily go into hypovolemic shock or disseminated intravascular coagulopathy (DIC). Both of these situations need prompt attention and treatment.

Surveillance data suggest that spontaneous miscarriages and induced abortions accounted for about 4% of pregnancy-related deaths in the United States.⁶

Race

Early pregnancy loss may occur in any race without distinction.

Sex

Early pregnancy loss only affects females.

Age

As women mature, the incidence of spontaneous miscarriages increases.

Typically, the distribution of miscarriage rates by age occurs as follows: younger than 35 years old, 15% miscarriage rate; 35-39 years old, 20-25% miscarriage rate; 40-42 years old, about 35% miscarriage rate; and older than 42 years old, about 50% miscarriage rate.

Women who conceive using donor eggs have miscarriage rates that are similar to the egg donor's age and not the recipient's age. This information is well documented on the CDC's Assisted Reproductive Technology Web site, and it indicates that miscarriages are increased significantly due to aging oocytes (oocytes from older women) and pregnancy rates drop dramatically due to the female's age. Pregnancy rates do not drop when young donor oocytes are used, and miscarriage rates remain low when donor oocytes are used. The uterus, which can easily be manipulated with hormonal therapy, does not appear to be affected by age when looking at miscarriage rates.

Clinical

History

Patients with spontaneous complete abortion usually present with a history of vaginal bleeding, abdominal pain, and passage of tissue. After the tissue passes, the vaginal bleeding and abdominal pain subsides.

• Vaginal bleeding is usually heavy.
  • Quantification of the amount of bleeding is very important because life-threatening hemorrhage may occur. The patient may be able to quantify the number of pads or tampons used over a specified time and qualify the amount that each pad is soaked. This is just an estimate; yet, soaking a pad or more an hour suggests significant and worrisome amounts of bleeding that require prompt attention. These patients should be sent to the emergency department.
  • The presence of blood clots suggests heavy bleeding. The presence of blood clots also may be confused with passage of tissue.
  • Examining the passed material helps clarify whether the material is clot or tissue. If the material is tissue, then the type of abortion may be identified. If the tissue is evaluated and appears complete, then a complete abortion is confirmed.
• Abdominal pain is associated with concurrent abortion and resolves with the completion of the abortion.
  • The pain usually is in the suprapubic area, but reports of pain in one or both lower quadrants are not uncommon.
  • The pain may radiate to the lower back, buttocks, genitalia, and perineum.
  • If the pain is occurring only on one side, consider an ectopic pregnancy or a ruptured ovarian cyst as possible causes.
• Consider any reproductive-aged woman presenting with vaginal bleeding to be pregnant until proven otherwise.
• Other symptoms, such as fever or chills, are more characteristic of infection, such as in a septic abortion. Septic abortions need to be treated immediately, otherwise they may be life threatening.

Physical

Patients who are pregnant and bleeding vaginally need immediate evaluation.

• Estimating the patient's hemodynamic stability is the first step.
  • Obtain orthostatic vital signs.
  • Initiate fluid resuscitation early in cases of orthostatic hypotension.
  • Abdominal and pelvic examinations are next.
• The abdominal examination helps determine whether or not the state of an acute abdomen is present.
  • In a complete abortion, the abdomen is benign, with no distension, no rebound, normal bowel sounds, no hepatosplenomegaly, and mild suprapubic tenderness.
  • Usually, the uterus is either not palpable abdominally or is just slightly above the pubic symphysis in a first-trimester pregnancy loss. The uterus can be enlarged due to other pathology (eg, leiomyomas).
  • If rebound tenderness or a distended abdomen is present, a complete abortion is unlikely. Assume instead that an ectopic pregnancy is present and if rebound tenderness is present, then provide the patient with aggressive fluid resuscitation with 2 IV lines, quantitative hCG, stat ultrasound (if stable enough) and an emergent laparoscopy or an emergent exploratory laparotomy.
• In the case of a complete abortion, pelvic examination may show some blood on the perineum or vagina but limited active bleeding.
  • Cervical motion tenderness does not exist.
  • The cervical canal is closed.
  • The uterus is smaller than expected for dates, and it is nontender to mildly tender.
  • The adnexa are nontender to mildly tender. Usually, no adnexal masses exist, unless a corpus luteum is still palpable.
  • In summary, the pelvic examination check list includes assessment of the following:
    • Source of bleeding (cervical os)
    • Intensity of bleeding (active, heavy, clots)
    • Any presence or passage of tissue
    • Cervical motion tenderness (increases suspicion for ectopic pregnancy)
    • Cervical os closed for complete or threatened abortion (If it is open, consider inevitable or incomplete abortion.)
    • Uterine size and tenderness
    • Adnexal masses (suspicious for ectopic pregnancy)

Causes

• In the first trimester, embryonic causes of spontaneous abortion are the predominant etiology and account for 80-90% of miscarriages (See following image.)
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    Second transvaginal sonogram obtained 1 week after the initial study fails to demonstrate fetal development. This confirms the diagnosis of an embryonic pregnancy.

    [ CLOSE WINDOW ]

    

    Second transvaginal sonogram obtained 1 week after the initial study fails to demonstrate fetal development. This confirms the diagnosis of an embryonic pregnancy.

• Genetic abnormalities within the embryo (ie, chromosomal abnormalities) are the most common cause of spontaneous abortion and account for 50-65% of all miscarriages.
  • The most common single chromosomal anomaly is 45,X karyotype, with an incidence of 14.6%.
  • Trisomies are the single largest group of chromosomal anomalies and account for approximately one half of all anomalies associated with miscarriage. Trisomy 16 is the most common trisomy found.
  • Approximately 20% of genetic abnormalities are triploidies.
• Teratogenic and mutagenic factors may play a role, but quantification is difficult.
• Maternal causes of spontaneous miscarriage include the following:
  • Genetic: Maternal age is directly related to the aneuploidy risk (>30% in people aged 40 y). Couples with recurrent miscarriages have a 2-3% incidence of a parental chromosomal anomaly (ie, balanced translocation).
  • Structural abnormalities of the reproductive tract include the following:
    • Congenital uterine defects (particularly uterine septum)
    • Fibroids
    • Cervical incompetence
• Iatrogenic causes (ie, Asherman syndrome)
• Acute maternal factors include the following:
  • Corpus luteum deficiency
  • Active infection (eg, rubella virus, cytomegalovirus, Listeria infection, toxoplasmosis)
• Chronic maternal health factors include the following:
  • Polycystic ovary syndrome
  • Poorly controlled diabetes mellitus (A successful pregnancy requires much tighter control.)
  • Renal disease
  • Systemic lupus erythematosus (SLE)
  • Untreated thyroid disease
  • Severe hypertension
  • Antiphospholipid syndrome
• Exogenous factors include the following:
  • Tobacco
  • Alcohol
  • Cocaine
  • Caffeine (high doses)
• Independent risk factors for a spontaneous miscarriage include the following:^3,4,5
  • Advanced age
  • Extremes of age
  • Feeling stressed
  • Advanced paternal age
• Symptoms of vaginal bleeding but not abdominal pain are associated with increased risk of miscarriage. One paper suggests that miscarriage can occur in about 50% of patients who present with threatened abortion.

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