Early Pregnancy Loss in Emergency Medicine Clinical Presentation

  • Author: Slava V Gaufberg, MD; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Sep 7, 2011
 

History

  • Patients with spontaneous miscarriage usually present to the ED with vaginal bleeding, abdominal pain, or both.
    • Vaginal bleeding may vary from slight spotting to a severe life-threatening hemorrhage. The patient's history should include the number of pads or tampons used. Hasan et al found that heavy bleeding in the first trimester, particularly when associated with abdominal pain, is associated with higher risk of miscarriage.[5]
    • Presence of blood clots or tissue may be an important sign indicating progression of spontaneous miscarriage.
    • Abdominal pain is usually located in the suprapubic area or in one or both lower quadrants.
    • Pain may radiate to the lower back, buttocks, genitalia, and perineum.
  • The patient's history should also include the following:
    • Date of last menstrual period (LMP)
    • Estimated length of gestation
    • Sonogram results, if previously performed
    • Bleeding disorders
    • Previous miscarriage or elective abortions
  • Other symptoms, such as fever or chills, are more characteristic of a septic miscarriage or abortion.
  • Consider any woman of childbearing age with vaginal bleeding pregnant until proven otherwise.
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Physical

  • Pelvic examination should focus on determining the source of bleeding.
    • Blood from cervical os
    • Intensity of bleeding
    • Presence of clots or tissue fragments
    • Cervical motion tenderness (presence increases suspicion for ectopic pregnancy)
    • Status of internal cervical os: open indicates inevitable or possibly incomplete miscarriage; closed indicates threatened miscarriage.
    • Uterine size and tenderness, as well as adnexal tenderness or masses
  • Signs of threatened miscarriage:
    • Vital signs should be within reference ranges unless infection is present or hemorrhage has caused hypovolemia.
    • The abdomen usually is soft and nontender.
    • Pelvic examination reveals a closed internal cervical os. The bimanual examination is unremarkable.
  • Signs of incomplete miscarriage:
    • The cervix may appear dilated and effaced, or it may be closed.
    • Bimanual examination may reveal an enlarged and soft uterus.
    • On pelvic examination, products of conception may be partially present in the uterus, may protrude from the external os, or may be present in the vagina. Bleeding and cramping usually persist.
  • Complete miscarriage: On pelvic examination, the cervix should be closed, and the uterus should be contracted.
  • Missed miscarriage:
    • Vital signs usually are within reference ranges. Abdominal examination may or may not reveal a palpable uterus. If palpable, the uterus usually is small for the presumed gestational age.
    • Fetal heart tones are inaudible or unseen on sonogram.
    • The cervical os is closed upon pelvic examination. The uterus may feel soft and enlarged.
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Causes

Causes of first- and second-trimester miscarriage

  • Embryonic abnormalities account for 80-90% of first-trimester miscarriages.
    • Chromosomal abnormalities are the most common cause of spontaneous miscarriage. More than 90% of cytogenic and morphologic errors are eliminated through spontaneous miscarriage.
    • Chromosomal abnormalities have been found in more than 75% of fetuses that miscarry in the first trimester.
    • The rate of chromosomal abnormalities increases with age, with a steep increase in women older than 35 years.
    • Trisomy chromosomes commonly are encountered, with trisomy 16 accounting for approximately a third of chromosomal abnormalities in early pregnancy.
  • Maternal factors account for the majority of second-trimester miscarriages.
    • Chronic maternal health factors:
      • Maternal insulin-dependent diabetes mellitus (IDDM): As many as 30% of pregnancies in women with IDDM result in spontaneous miscarriage, predominantly in patients with poor glucose control in the first trimester.
      • Severe hypertension
      • Renal disease
      • Systemic lupus erythematosus (SLE)
      • Hypothyroidism and hyperthyroidism
    • Acute maternal health factors:
      • Infections (eg, rubella, cytomegalovirus [CMV], and mycoplasmal, ureaplasmal, listerial, toxoplasmal infections)
      • Trauma
    • Severe emotional shock

Other factors that may contribute to miscarriage

  • Exogenous factors:
    • Alcohol
    • Tobacco
    • Cocaine and other illicit drugs
  • Anatomic factors: Congenital or acquired anatomic factors are reported to occur in 10-15% of women who have recurrent spontaneous miscarriages.
    • Congenital anatomic lesions include müllerian duct anomalies (eg, septate uterus, diethylstilbestrol [DES]-related anomalies). Müllerian duct lesions usually are found in second-trimester pregnancy loss.
    • Anomalies of the uterine artery with compromised endometrial blood flow are congenital.
    • Acquired lesions include intrauterine adhesions (ie, synechiae), leiomyoma, and endometriosis.
    • Other diseases or abnormalities of the reproductive system that may result in miscarriage include congenital or acquired uterine defects, fibroids, cervical incompetence, abnormal placental development, or grand multiparity.
  • Endocrine factors:
    • Endocrine factors potentially contribute to recurrent miscarriage in 10-20% of cases.
    • Luteal phase insufficiency (ie, abnormal corpus luteum function with insufficient progesterone production) is implicated as the most common endocrine abnormality contributing to spontaneous miscarriage.
    • Hypothyroidism, hypoprolactinemia, poor diabetic control, and polycystic ovarian syndrome are contributive factors in pregnancy loss.
  • Infectious factors:
    • Presumed infectious etiology may be found in 5% of cases.
    • Bacterial, viral, parasitic, fungal, and zoonotic infections are associated with recurrent spontaneous miscarriage.
  • Immunologic factors:
    • Immunologic factors may contribute in up to 60% of recurrent spontaneous miscarriages.
    • Both the developing embryo and the trophoblast may be considered immunologically foreign to the maternal immune system.
    • Antiphospholipid antibody syndrome generally is responsible for more second-trimester pregnancy losses than first-trimester losses.
  • Miscellaneous factors:
    • Miscellaneous factors may account for up to 3% of recurrent spontaneous miscarriages.
    • Other contributing factors implicated in sporadic and recurrent spontaneous abortions include environment, drugs, placental abnormalities, medical illnesses, and male-related causes.
    • Gestational exposure to nonaspirin NSAIDs may increase the risk for miscarriage. Nakhai-Pour et al identified 4705 women who had spontaneous abortions by 20 weeks’ gestation. Each case was matched to 10 control subjects (n=47,050) who did not have a spontaneous abortion. In the women who had a miscarriage, 352 (7.5%) were exposed to a nonaspirin NSAID, whereas NSAID exposure was lower (1213 exposed [2.6%]) in women who did not have a miscarriage.[6]
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Contributor Information and Disclosures
Author

Slava V Gaufberg, MD  Assistant Professor of Medicine, Harvard Medical School; Director of Transitional Residency Training Program, Cambridge Health Alliance

Slava V Gaufberg, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Roy Alson, MD, PhD, FACEP, FAAEM  Associate Professor, Department of Emergency Medicine, Wake Forest University School of Medicine; Medical Director, Forsyth County EMS; Deputy Medical Advisor, North Carolina Office of EMS; Associate Medical Director, North Carolina Baptist AirCare

Roy Alson, MD, PhD, FACEP, FAAEM is a member of the following medical societies: Air Medical Physician Association, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, North Carolina Medical Society, Society for Academic Emergency Medicine, and World Association for Disaster and Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Zwanger, MD, MBA  Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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This image shows an endovaginal longitudinal view of a low-lying gestational sac (GS) within the uterus (Ut), representing an incomplete miscarriage.
This endovaginal longitudinal view demonstrates fluid within the uterus (Ut). Echogenic debris also is present within the endometrial cavity. This image shows a large pseudogestational sac of an ectopic pregnancy.
This endovaginal ultrasonographic image demonstrates a subchorionic hemorrhage (SH) less than half the gestational sac size.
This flowchart details a diagnostic algorithm based on sonographic findings in early pregnancy, using high-frequency endovaginal sonography (HFEVS) of more than 5 megahertz (MHz). The flowchart incorporates clinical presentation (spotting vs clinical bleeding) with sonographic findings to aid in making clinical decisions. The algorithm continues in Media file 5.
This flowchart outlines a diagnostic algorithm based on the initial endovaginal sonographic finding of an intrauterine embryo. The chart incorporates fetal cardiac activity, crown-rump length (CRL), presence of subchorionic hemorrhage (SCH), and uterine or adnexal masses with clinical presentation (spotting vs bleeding) to aid in making clinical decisions.
This endovaginal ultrasonogram reveals an irregular gestational sac with an amorphic fetal pole. No fetal cardiac activity was noted. This image represents a missed miscarriage or fetal demise.
 
 
 
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