Miscarriage

A miscarriage (also termed spontaneous abortion) is any early pregnancy that spontaneously ends before the fetus can survive. Any vaginal bleeding, other than spotting, during early pregnancy is considered a threatened miscarriage. Vaginal bleeding is very common in early pregnancy. About one out of every four pregnant women has some bleeding during the first few months. About half of these women stop bleeding and complete a normal pregnancy.

• Threatened miscarriage - Vaginal bleeding during early pregnancy. The bleeding and pain with threatened miscarriage are usually mild and the cervical os (the mouth of the womb) is closed. A health care professional will be able to determine if the cervical os is open upon performing a pelvic exam. Typically, no tissue is passed from the womb. The womb and Fallopian tubes may be tender.
• Inevitable miscarriage - Vaginal bleeding along with opening of the cervical os. In this situation, vaginal bleeding is present, and the mouth of the womb is open (dilated). Bleeding is usually more severe, and abdominal pain and cramping often occur.
• Incomplete miscarriage - Expulsion of some, but not all, of the products of conception before the 20th week of pregnancy. With incomplete miscarriage, the bleeding is heavier, and abdominal pain is almost always present. The mouth of the womb is open, and the pregnancy is being expelled. Ultrasound would show some material still remaining in the womb.
• Complete miscarriage - Expulsion of all products of conception from the womb including fetus and placental tissues. Complete miscarriage is just as it sounds. Bleeding, abdominal pain, and the passing of tissue have all occurred, but the bleeding and pain have usually stopped. If the fetus can be seen outside of the body, you have miscarried. Ultrasound shows an empty womb.

A miscarriage occurs when a pregnancy ends without obvious cause before the fetus is capable of survival, typically corresponding to the 20th week. This time is measured from the first day of the woman's last menstrual period. Miscarriage is a common complication of pregnancy. It can occur in up to 20% of all recognized pregnancies. This ending of pregnancy is called a spontaneous abortion. In the medical field, the term spontaneous abortion is often used to describe a miscarriage.

Miscarriage is caused by the separation of the fetus and placenta from the uterine wall. Although the actual cause of the miscarriage is frequently unclear, the most common reasons include the following:

• An abnormal fetus causes almost all miscarriages during the first three months of pregnancy (first trimester). Problems in the genes are responsible for an abnormal fetus and are found in more than half of miscarried fetuses. The risk of defective genes increases with the woman's age, especially if she is older than 35 years.
• Miscarriage during the fourth through sixth months of pregnancy (second trimester) is usually related to an abnormality in the mother rather than in the fetus.
  • Chronic illnesses, including diabetes, severe high blood pressure, kidney disease, lupus, and underactive or overactive thyroid gland, are frequent causes of a miscarriage. Prenatal care is important because it screens for some of these diseases.
  • Acute infections, including German measles, CMV (cytomegalovirus), mycoplasma ("walking" pneumonia) and other unusual germs can also cause miscarriage.
  • Diseases and abnormalities of the internal female organs can also cause miscarriage. Some examples are an abnormal womb, fibroids, poor muscle tone in the mouth of the womb, abnormal growth of the placenta (also called the afterbirth), and being pregnant with multiples.
  • Other factors, especially certain drugs, including alcohol, tobacco, and cocaine, may be related to miscarriage.

If a women is having a spontaneous miscarriage, she will probably have vaginal bleeding, abdominal pain, and cramping.

• Bleeding may be only slight spotting, or it can be quite severe. A health care professional will ask about how much the woman has bled-usually the number of pads you've soaked through. She will also be asked about blood clots or whether she saw any tissue.
• Pain and cramping occur in the lower abdomen. They may occur on only one side, both sides, or in the middle. The pain can also go into the lower back, buttocks, and genitals.
• The woman may no longer have signs of pregnancy such as nausea or breast swelling/tenderness if she has experienced a miscarriage.

Call a health care professional if you know or suspect you are pregnant and you are experiencing any of the following:

• Vaginal bleeding
• Abdominal pain or cramping, or low back pain
• Weakness or dizziness
• Uncontrollable or severe nausea or vomiting
• Urinary symptoms such as burning, frequency, or pain with urination

Go immediately to the hospital's emergency department if you experience any of the following:

• You know or suspect you are pregnant and have heavy vaginal bleeding (soaking more than one pad every hour) or pain in the back or the abdomen.
• You are passing something that looks like tissue (place what you have passed into a jar or container and take it with you to the hospital).
• You have a history of ectopic (tubal) pregnancy.
• You are extremely dizzy or pass out.
• You have a known pregnancy accompanied with passage of clots or other material.
• You have a fever of greater than 100.4 F (38 C).
• You are vomiting and cannot keep food or liquids down.

Medical history: You will be asked questions about your pregnancy, such as the following:

• How far along is your pregnancy?
• When was your last normal period?
• How many times have you been pregnant?
• How many living children do you have?
• How many miscarriages have you had?
• Have you ever had an ectopic (tubal) pregnancy?
• How many abortions have you had?
• Were you using any sort of birth control when you got pregnant this time?
• Is this a planned pregnancy?
• Do you plan to keep this pregnancy?
• Have you had any prenatal care?
• Have you had any problems urinating?
• Have you had an ultrasound yet to show that the pregnancy is in the right place?
• Do you know your blood type?
• What medical problems do you have?
• What medications do you take every day?
• What herbs or other products do you take every day?

Physical exam: For the pelvic exam, the patient will lie on her back with the knees bent and the feet in stirrups.

• The patient may have a speculum exam. A metal or plastic device is put in your vagina and then opened, spreading the walls of the vagina apart so the health care professional can look right at the mouth of your womb. If a lot of blood or clots are present, the health care professional may use a clamp or gauze to remove them. The patient should not feel any pain during this part of the exam, although she may be embarrassed and uncomfortable.
• The patient may bleed from the vagina before, during, and even after a miscarriage. The health care professional will assess the opening of the entrance to the womb (called the os) and, depending on the findings, will be able to tell the patient more accurately which of the types of miscarriage you might be experiencing.
• The health care professional may put gloved fingers in the vagina and feel the abdomen with the other hand. He or she can feel whether the mouth of the uterus is open, how big the uterus may be, and whether any signs of infection or tubal pregnancy exist. The size of the uterus may be smaller than expected for the fetus if the patient has already miscarried.

Lab tests: Pregnancy tests can be either urine tests or blood tests. A health care professional or emergency department doctor, if you go to the hospital with alarming symptoms, will act quickly to determine if you are pregnant.

• A urine pregnancy test along with blood samples will be sent to the laboratory to check for blood loss or anemia, blood type, and the level of the pregnancy hormone. This hormone is called human chorionic gonadotropin or hCG.
  • A number too low may suggest that the pregnancy is abnormal. No single number is "normal." A very low number (under 1,000) suggests an abnormal pregnancy, although it could just reflect an early stage of pregnancy.
  • A very high number (over 100,000) strongly suggests a normal living pregnancy. Most other hCG numbers by themselves do not help a lot but can be compared to another test done in two to three days to see if everything is developing normally.
• A complete blood count (CBC) may be ordered. If the patient has been bleeding a lot, she may be anemic (loss of too much blood) and need special care. If the patient has a fever, the white cell count may suggest she has an infection.
• If the patient does not know your blood type, this will also be checked.
• If the patient has symptoms of a urinary infection, a urine sample will be taken and examined.

Ultrasound: If a woman is pregnant, an ultrasound may be performed to look for evidence of a pregnancy within the uterus. If the radiologist, gynecologist, or emergency department doctor cannot find evidence of a pregnancy within the uterus, the patient will likely be evaluated further for a pregnancy that is outside the uterus. When the fertilized egg implants outside of the uterus, this is called an ectopic pregnancy. A tubal pregnancy refers to a type of ectopic where the pregnancy develops within the Fallopian tube.

• Your bladder has to be full for this test, so the patient will have to drink a lot of water, or the technician will give the woman fluid in a vein and ask her not to go to the bathroom until after the test is completed.
• The technician will put some cold jelly on the abdomen and press down with a probe to see the internal organs. The ultrasound technician may also use a vaginal probe inside the vagina to get a better look at the Fallopian tubes and ovaries. Neither of these studies should be painful.

If the health care professional feels that the patient is having a spontaneous abortion or miscarriage, little can be done in the way of prevention. If the patient is actively miscarrying and the health care professional does not think the patient has a living pregnancy, she will also be seen by an obstetrician (specialist in women's reproductive health) who may recommend ending the pregnancy. A procedure called dilation and curettage (D&C) can be performed or further observation may take place to let nature take its course.

• If the patient has a urinary tract infection, antibiotics that are safe to take in pregnancy will be prescribed.
• In certain situations, the woman and her baby may have incompatible blood types. If your blood sample shows that you are Rh factor negative (a certain blood type), you will be given medication (RhoGAM) to prevent a possible blood type interaction with the baby (which could occur if the baby were Rh positive).
• The patient will be counseled and given materials or instruction concerning the possibility of spontaneous abortion. If the mouth of the uterus is closed, if she is not bleeding heavily, the lab work is normal, and an ultrasound shows the woman does not have an ectopic pregnancy, she may rest at home with the following instructions:
  • Get plenty of rest.
  • Avoid douching and sexual intercourse.
  • Watch for the passage of any white or gray material from the vagina. This may represent what are known as the products of conception.
  • Return to the emergency department if bleeding or pain worsens, or if you develop fever, weakness, or dizziness.
  • Go to the doctor to be reexamined in about 48 hours.

If a woman is not sure she is pregnant, a home pregnancy test will confirm or exclude pregnancy in most cases.

• If the test is negative, discuss the bleeding and cramping with a health care professional.
• If the test is positive and you have bleeding or cramping, call a health care professional.
• Rest and avoid sexual intercourse.
• You may also safely take acetaminophen (Tylenol) at any time during pregnancy. Do not take aspirin, ibuprofen (Motrin or Advil), or naproxen (Aleve) if you are pregnant.

See Miscarriage Treatment.

The patient's health care professional will monitor you until the pregnancy resumes or if the miscarriage becomes complete.

• Avoid exerting yourself. You may feel better if you rest, although resting will not prevent the miscarriage from occurring.
• Do not douche or insert anything in the vagina, including tampons.
• Do not have sex until the symptoms have completely resolved for one week.
• Return to the emergency department if the following symptoms develop:
  • Worse cramping
  • Worse bleeding (more than one pad per hour)
  • Passage of tissue
  • Fever
  • Anything else that concerns you
• With another blood test, the patient's quantitative beta-HCG level may be checked in 48 to 72 hours. The rise or fall of this level is helpful in predicting the viability or failure of the pregnancy. If the level is falling, then the pregnancy may have ended.
• A follow-up ultrasound may be done at some point.

There is no way to predict or prevent a miscarriage. Certain steps can be taken, however, to give a pregnancy every chance to continue to term.

• Get prenatal care and follow the advice of the health care professional (family doctor, obstetrician, midwife).
• Avoid alcohol, nicotine, and street drugs, especially cocaine, during pregnancy.
• Avoid or cut down on caffeine.
• Control high blood pressure and diabetes.
• Identify and treat any bacterial and certain viral infections.

More than half of women who bleed during the first 12 weeks of pregnancy stop bleeding and end up having a normal pregnancy. The others get more cramping and bleeding and eventually miscarry. Although emotionally unsettling, most women physically handle spontaneous abortions well. A woman may not know whether she are going to miscarry when she leaves the emergency department.