With pain and opening of the cervix a woman is about to have an "inevitable abortion," which indicates that she has an absolute probability of miscarrying.

If some of the tissue remains in the uterus after a passing products of conception, this is called an "incomplete abortion." If the tissue in the uterus gets infected, it is a "septic abortion." In some cases, the fetus dies but the uterus does not expel the pregnancy; this is called a "missed abortion." A "blighted ovum" pregnancy is a form of a miscarriage in which the fetus either did not form or died early, and the pregnancy consists only of trophoblastic tissue.

A specific form of a miscarriage is the ectopic pregnancy.

Forms and types

Threatened abortion (O20.0)

Management of these patients involves an examination to assess for cervical dilatation, an ultrasound to assess fetal viability, and bedrest for the woman, though there is no scientifically-proven benefit for the latter. When a threatened abortion occurs, no hormones or medications have been shown to influence whether this will resolve or progresses to a full abortion.

Inevitable abortion

• There is an obvious rupture of membranes
• An open cervix
• There is tissue in the cervix
• There is an absence of fetal heart at a ßHCG level consistent with fetal heart activity

When any of these symptoms are detected, management involves conservative observation, monitoring for heavy bleeding and sepsis, and a dilatation and curettage (D&C).

Incomplete abortion (O03.0-O06.4)

Empty sac

Missed abortion (O02.1)

Septic abortion

Habitual abortion (N96)

Habitual abortion (recurrent pregnancy loss or recurrent miscarriage) is the occurrence of 3 consecutive miscarriages. The majority (85%) of women who have had two miscarriages will conceive and carry normally afterwards, so statistically the occurrence of three abortions at 0.34% is regarded as "habitual".

There are various medical conditions associated with this problem (e.g. Antiphospholipid syndrome), some of which may be corrected with medication.

Pathology

Timing

Some women are prone to miscarry; the term "habitual abortion" is more and more replaced by "recurrent pregnancy loss" (RPL) or recurrent miscarriage and describes the condition where three consecutive pregnancies have terminated before 20 weeks gestation.

Causes

First trimester losses are most commonly caused by one time non-repeating genetic problems. This can be the result of an abnormal sperm, and abnormal ovum or an abnormal combination of the egg and sperm. The resulting baby does not develop properly and in some cases, the development of the embryo stops before it can be seen, a "blighted ovum". It is important to keep in mind that these are non-repeating genetic defects. Therefore, women who have had one miscarriage do not have a higher risk of having a second miscarriage.

Other possible but much less common causes include physical trauma, exposure to certain chemicals, infection, and immune factors. A number of studies have examined lifestyle factors. Thus obesity, high caffeine intake (> 300 mg/day), alcohol consumption, and use of NSAIDs have all been linked to higher miscarriage rates in general. Also women undergoing fertility therapy tend to have higher miscarriage rates.

In the US, smoking label warnings must be displayed to inform women that smoking can lead to "low birth weights."

Pregnancy losses in the second trimester may be due to fetal abnormalities, uterine malformation, cervical problems, infection, trauma, immune factors, and medical disease.

Management

• Threatened miscarriages with little blood loss or pain may be managed by seeing one's doctor the next working day to arrange an ultrasound scan to verify that the pregnancy is continuing (i.e., that a fetal heartbeat can be seen).
  • However, if the bleeding is heavy or accompanied by considerable pain, then emergency medical attention should be sought.
• If a miscarriage is complete and bleeding is contained and limited, only expectant management may be necessary.Excessive or prolonged bleeding needs medical attention.
• In cases of an incomplete abortion, empty sac, or missed abortion there are usually several treatment options:
  • A dilation and curettage is commonly used and generally the fasted way to remove tissue from the uterus. Tissue examination, including cytogenetic studies, are helpful to determine the cause of the pregnancy loss (but no routine investigations are undertaken for non-habitual early miscarriages in the UK).
  • Medical management of these situations is becoming more common using primarily a prostaglandin, misoprostol to expel the pregnancy.
  • Watchful waiting remains an option inpatients with a documented intrauterine nonviable pregnancy that is not infected. However, medical supervision is necessary as with prolonged waiting the risk of a clotting disorder increases.
• A miscarriage accompanied by a fever needs emergency medical attention.
• Severe lower abdominal pain may indicate an ectopic pregnancy and needs emergency medical attention.

Psychological aspects

For the women who do go through a process of grief, it is often as if the baby had been born but died. How short a time the child in her womb has lived may not matter for the feeling of loss. From the moment a woman becomes aware that she is pregnant she can start to bond with her unborn child. When the child turns out not to be viable, dreams, fantasies and plans for the future are disturbed roughly.

Besides the feeling of loss, a lack of understanding by others is often important. People who have not experienced a miscarriage themselves may find it hard to empathise with what has occurred and how upsetting it may be. This may lead to unrealistic expectations of the woman's recovery. The pregnancy and miscarriage are hardly mentioned anymore in conversation, often too because the subject is too painful. This can make the woman feel isolated.

Interaction with pregnant women and newborn children is often also painful for a woman who has miscarried. Sometimes this makes the interaction with friends, acquaintances and family very difficult. Immediately after a miscarriage some women do not leave home at all for fear of meeting acquaintances or pregnant women.

Some things a woman can do to deal with a miscarriage better are:

• naming the child
• keeping photos
• arranging a funeral for the child
• reading books on the subject
• talking about it
• finding others who have gone through a miscarriage
• finding professional help: although it is a natural grieving process, it may take a long time. In such cases, a psychologist or grief counselor may be of help.

Notes