Miscarriage means loss of an embryo or fetus before the 20th week of pregnancy
. Most miscarriages occur during the first 14 weeks of pregnancy. The medical term for miscarriage is spontaneous abortion.
Miscarriages are very common. Approximately 20% of pregnancies (one in five) end in miscarriage. The most common cause is a genetic abnormality of the fetus. Not all women realize that they are miscarrying and others may not seek medical care when it occurs.
A miscarriage is often a traumatic event for both partners, and can cause feelings similar to the loss of a child or other member of the family. Fortunately, 90% of women who have had one miscarriage subsequently have a normal pregnancy and healthy baby; 60% are able to have a healthy baby after two miscarriages. Even a woman who has had three miscarriages in a row still has more than a 50% chance of having a successful pregnancy the fourth time.
Causes and symptoms
There are many reasons why a woman's pregnancy ends in miscarriage. Often the cause is not clear. However, more than half the miscarriages that occur in the first eight weeks of pregnancy involve serious chromosomal abnormalities or birth defects
that would make it impossible for the baby to survive. These are different from inherited genetic diseases. They probably occur during development of the specific egg or sperm, and therefore are not likely to occur again.
In about 17% of cases, miscarriage is caused by an abnormal hormonal imbalance that interferes with the ability of the uterus to support the growing embryo. This is known as luteal phase defect. In another 10% of cases, there is a problem with the structure of the uterus or cervix. This can especially occur in women whose mothers used diethylstilbestrol (DES) when pregnant with them.
The risk of miscarriage is increased by:
- Smoking (up to a 50% increased risk)
- Exposure to toxins (such as arsenic, lead, formaldehyde, benzene, and ethylene oxide)
- Multiple pregnancy
- Poorly-controlled diabetes.
The most common symptom of miscarriage is bleeding from the vagina, which may be light or heavy. However, bleeding during early pregnancy is common and is not always serious. Many women have slight vaginal bleeding after the egg implants in the uterus (about 7-10 days after conception), which can be mistaken for a threatened miscarriage. A few women bleed at the time of their monthly periods through the pregnancy. However, any bleeding in the first three months of pregnancy (first trimester) is considered a threat of miscarriage.
Women should not ignore vaginal bleeding during early pregnancy. In addition to signaling a threatened miscarriage, it could also indicate a potentially life-threatening condition known as ectopic pregnancy
. In an ectopic pregnancy, the fetus implants at a site other than the inside of the uterus. Most often this occurs in the fallopian tube.
Cramping is another common sign of a possible miscarriage. The cramping occurs because the uterus attempts to push out the pregnancy tissue. If a pregnant woman experiences both bleeding and cramping the possibility of miscarriage is more likely than if only one of these symptoms is present.
If a woman experiences any sign of impending miscarriage, she should be examined by a practitioner. The doctor or nurse will perform a pelvic exam
to check if the cervix is closed as it should be. If the cervix is open, miscarriage is inevitable and nothing can preserve the pregnancy. Symptoms of an inevitable miscarriage may include dull relentless or sharp intermittent pain
in the lower abdomen or back. Bleeding may be heavy. Clotted material and tissue (the placenta and embryo) may pass from the vagina.
A situation in which only some of the products in the uterus have been expelled is called an incomplete miscarriage. Pain and bleeding may continue and become severe. An incomplete miscarriage requires medical attention.
A "missed abortion" occurs when the fetus has died but neither the fetus nor placenta is expelled. There may not be any bleeding or pain, but the symptoms of pregnancy will disappear. The physician may suspect a missed abortion if the uterus does not continue to grow. The physician will diagnose a missed abortion with an ultrasound examination.
A woman should contact her doctor if she experiences any of the following:
- Any bleeding during pregnancy.
- Pain or cramps during pregnancy.
- Passing of tissue.
- Fever and chills during or after miscarriage.
If a woman experiences any sign of impending miscarriage she should see a doctor or nurse for a pelvic examination to check if the cervix is closed, as it should be. If the cervix is open, miscarriage is inevitable.
An ultrasound examination can confirm a missed abortion if the uterus has shrunk and the patient has had continual spotting with no other symptoms.
For women who experience bleeding and cramping, bed rest is often ordered until symptoms disappear. Women should not have sex until the outcome of the threatened miscarriage is determined. If bleeding and cramping are severe, women should drink fluids only.
Although it may be psychologically difficult, if a woman has a miscarriage at home she should try to collect any material she passes in a clean container for analysis in a laboratory. This may help determine why the miscarriage occurred.
An incomplete miscarriage or missed abortion may require the removal of the fetus and placenta by a D&C (dilatation and curettage
). In this procedure the contents of the uterus are scraped out. It is performed in the doctor's office or hospital.
After miscarriage, a doctor may prescribe rest or antibiotics
for infection. There will be some bleeding from the vagina for several days to two weeks after miscarriage. To give the cervix time to close and avoid possible infection, women should not use tampons or have sex for at least two weeks. Couples should wait for one to three normal menstrual cycles before trying to get pregnant again.
A miscarriage that is properly treated is not life-threatening, and usually does not affect a woman's ability to deliver a healthy baby in the future.
Feelings of grief and loss after a miscarriage are common. In fact, some women who experience a miscarriage suffer from major depression during the six months after the loss. This is especially true for women who don't have any children or who have had depression in the past. The emotional crisis can be similar to that of a woman whose baby has died after birth.
The majority of miscarriages cannot be prevented because they are caused by severe genetic problems determined at conception. Some doctors advise women who have a threatened miscarriage to rest in bed for a day and avoid sex for a few weeks after the bleeding stops. Other experts believe that a healthy woman (especially early in the pregnancy) should continue normal activities instead of protecting a pregnancy that may end in miscarriage later on, causing even more profound distress.
If miscarriage was caused by a hormonal imbalance (luteal phase defect), this can be treated with a hormone called progesterone to help prevent subsequent miscarriages. If structural problems have led to repeated miscarriage, there are some possible procedures to treat these problems. Other possible ways to prevent miscarriage are to treat genital infections, eat a well-balanced diet, and refrain from smoking and using recreational drugs.
American College of Obstetricians and Gynecologists. 409 12th Street, S.W., P.O. Box 96920.
Hygeia Foundation, Inc. P.O. Box 3943 New Haven, CT 06525. (203) 387-3589. http://www.hygeia.org.
— This is a synthetic estrogen drug that is used to treat a number of hormonal conditions. However, it causes problems in developing fetuses and should not be taken during pregnancy. From about 1938 to 1971, DES was given to pregnant women because it was thought to prevent miscarriage. Children of women who took the drug during pregnancy are at risk for certain health problems.
Dilation and curettage (D&C)
— A procedure in which the neck of the womb (cervix) is expanded and the lining of the uterus is scraped to remove pregnancy tissue or abnormal tissue.
— An unborn child in the first eight weeks after conception. After the eighth week until birth, the baby is called a fetus.
termination of pregnancy before the fetus is viable. In the medical sense, this term and the term miscarriage
both refer to the termination of pregnancy before the fetus is capable of survival outside the uterus. The term abortion
is more commonly used as a synonym for induced abortion,
the deliberate interruption of pregnancy, as opposed to miscarriage, which connotes a spontaneous or natural loss of the fetus. Because of this distinction made by the average layperson, care should be exercised in the use of the word abortion when speaking of a spontaneous loss of the fetus.
The technique chosen to terminate pregnancy depends on the stage of pregnancy and the policies of the institution and patient needs. It is rare for a fetus to survive if it weighs less than 500 g, or if the pregnancy is terminated before 20 weeks of gestation. These factors are, however, difficult to determine with a high degree of accuracy while the fetus is still in utero;
survival of the fetus delivered near the end of the second trimester often depends to a great extent on the availability of personnel and equipment capable of supporting life until the infant develops sufficiently.
Viability of the fetus outside the uterus is frequently used as the determining factor in deciding the legality and morality of induced abortion. Whether this is a valid criterion is essentially based on whether one believes that the fetus is human from the moment of conception or that it achieves humanity at some point during physical development. Those who oppose abortion on moral grounds believe that the fetus is human or potentially human and that destruction of the fetal body is tantamount to murder. Many others have equally strong beliefs that abortion is a woman's right.
The liberalization of abortion laws has resulted in a dramatic increase in the number of abortions performed in physicians' offices, clinics, and hospitals. While this has diminished the occurrence of septic abortions performed at the hands of unscrupulous abortionists and has improved the possibility of safe and uneventful physical recovery from an induced abortion, the issue remains controversial and charged with emotion. The health care provider who strongly objects to abortion is legally and morally free to choose not to participate in the procedure and is advised to avoid situations involving responsibility for the care of patients who have chosen abortion as a means of ending an unwanted pregnancy. Women who have made a decision to have an abortion need a safe, non-judgmental environment to recover physically and emotionally from the procedure.
The patient should know that other alternatives are available and that an abortion after 20 weeks is inadvisable for medical and other reasons. Preabortion counseling in the psychological, religious, and legal aspects of abortion should be readily available, with immediate referral to the proper resources. Although delay in carrying out the procedure may increase the risk of complications, no patient should be encouraged to go through with an abortion until she has had time and sufficient counseling to reach a rational decision. During postabortion counseling there should be a discussion of various methods of contraception
. The client will need information on the advantages and disadvantages of each method, her responsibilities in preventing future unwanted pregnancies, and available help in initiating and following through on a program of effective contraception. She should be informed that women who have had two or more abortions run a greatly increased risk of miscarriage or spontaneous abortion in the first six months of subsequent pregnancies.
Patient Care. The type of care required and the complications to be avoided in abortion will depend on the stage of pregnancy at the time of termination and whether the abortion is spontaneous, is induced under sterile conditions, or is performed by an unskilled abortionist or the patient herself. Many women who choose to have an abortion are anxious and confused about the physical and psychological outcomes of the procedure. Therefore both pre- and postabortion counseling are recommended.
In cases of spontaneous or habitual abortion, patient care is directed toward emotional support of the patient and acceptance of her feelings of bitterness, grief, guilt, relief, and other emotions associated with the loss of the fetus. The patient should be able to express her feelings in an open, nonjudgmental, and nonthreatening environment.
complete abortion complete expulsion of all the products of conception.
criminal abortion termination of pregnancy by illegal interference, usually undertaken when legal induced abortion is unavailable. The most frequent complications are severe hemorrhage and sepsis, and for those who delay seeking medical attention the mortality rate is high.
early abortion abortion within the first 12 weeks of pregnancy.
elective abortion induced abortion done at the request of the mother for other than therapeutic reasons.
habitual abortion spontaneous abortion
in three or more consecutive pregnancies before the 20th week of gestation.
incomplete abortion abortion in which parts of the products of conception are retained in the uterus.
induced abortion abortion brought on intentionally by medication or instrumentation.
inevitable abortion a condition in which vaginal bleeding has been profuse, membranes usually show gross rupturing, the cervix has become dilated, and abortion is almost certain.
infected abortion abortion associated with infection of the genital tract from retained material, with a febrile reaction.
missed abortion retention of dead products of conception in utero for more than 8 weeks.
septic abortion abortion associated with serious infection of the products of conception and endometrial lining of the uterus, leading to generalized infection; it is usually caused by pathogenic organisms of the bowel or vagina.
spontaneous abortion termination of pregnancy before the fetus is sufficiently developed to survive; called miscarriage by laypersons. In the United States this definition is confined to the termination of pregnancy before 20 weeks' gestation (based upon the date of the first day of the last normal menses). Chromosomal abnormalities cause at least half of spontaneous abortions.
therapeutic abortion abortion induced legally by a qualified physician to safeguard the health of the mother.
threatened abortion a condition in which vaginal bleeding is less than in inevitable abortion, the cervix is not dilated, and abortion may or may not occur; this is the presumed diagnosis when any bloody vaginal discharge or vaginal bleeding occurs in the first half of pregnancy.