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Spontaneous Abortion

(Miscarriage)

By

Antonette T. Dulay

, MD, Main Line Health System

Last full review/revision Oct 2020
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Spontaneous abortion is noninduced embryonic or fetal death or passage of products of conception before 20 weeks gestation. Threatened abortion is vaginal bleeding without cervical dilation occurring during this time frame and indicating that spontaneous abortion may occur in a woman with a confirmed viable intrauterine pregnancy. Diagnosis is by clinical criteria and ultrasonography. Treatment is usually expectant observation for threatened abortion and, if spontaneous abortion has occurred or appears unavoidable, observation or uterine evacuation.

Spontaneous abortion, by definition, is death of the fetus; it may increase the risk of spontaneous abortion in subsequent pregnancies.

Fetal death and early delivery are classified as follows:

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About 20 to 30% of women with confirmed pregnancies bleed during the first 20 weeks of pregnancy; half of these women spontaneously abort. Thus, incidence of spontaneous abortion is up to about 20% in confirmed pregnancies. Incidence in all pregnancies is probably higher because some very early abortions are mistaken for a late menstrual period.

Etiology of Spontaneous Abortion

Isolated spontaneous abortions may result from certain viruses—most notably cytomegalovirus, herpesvirus, parvovirus, and rubella virus—or from disorders that can cause sporadic abortions or recurrent pregnancy loss Recurrent Pregnancy Loss Spontaneous abortion is noninduced embryonic or fetal death or passage of products of conception before 20 weeks gestation. Threatened abortion is vaginal bleeding without cervical dilation... read more (eg, chromosomal or mendelian abnormalities, luteal phase defects). Other causes include immunologic abnormalities, major trauma, and uterine abnormalities (eg, fibroids, adhesions). Most often, the cause is unknown.

Risk factors for spontaneous abortion include

Subclinical thyroid disorders, a retroverted uterus, and minor trauma have not been shown to cause spontaneous abortions.

Symptoms and Signs of Spontaneous Abortion

Symptoms of spontaneous abortion include crampy pelvic pain, bleeding, and eventually expulsion of tissue. Late spontaneous abortion may begin with a gush of fluid when the membranes rupture. Hemorrhage is rarely massive. A dilated cervix indicates that abortion is inevitable.

If products of conception remain in the uterus after spontaneous abortion, vaginal bleeding may occur, sometimes after a delay of hours to days. Infection may also develop, causing fever, pain, and sometimes sepsis (called septic abortion Septic Abortion Septic abortion is serious uterine infection during or shortly before or after an abortion. Septic abortions usually result from induced abortions done by untrained practitioners using nonsterile... read more ).

Diagnosis of Spontaneous Abortion

  • Clinical criteria

  • Usually ultrasonography and quantitative beta subunit of human chorionic gonadotropin (beta-hCG)

Ultrasonography and quantitative measurement of serum beta-hCG are usually also done to exclude ectopic pregnancy and to determine whether products of conception remain in the uterus (suggesting that abortion is incomplete rather than complete). However, results may be inconclusive, particularly during early pregnancy.

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Missed abortion is suspected if the uterus does not progressively enlarge or if quantitative beta-hCG is low for gestational age or does not double within 48 to 72 hours. Missed abortion is confirmed if ultrasonography shows any of the following:

  • Disappearance of previously detected embryonic cardiac activity

  • Absence of such activity when the fetal crown-rump length is > 7 mm

  • Absence of a fetal pole (determined by transvaginal ultrasonography) when the mean sac diameter (average of diameters measured in 3 orthogonal planes) is > 25 mm

Treatment of Spontaneous Abortion

  • Observation for threatened abortion

  • Uterine evacuation for inevitable, incomplete, or missed abortions

  • Emotional support

For threatened abortion, treatment is observation. No evidence suggests that bed rest decreases risk of subsequent completed abortion.

For inevitable, incomplete, or missed abortions, treatment is uterine evacuation or waiting for spontaneous passage of the products of conception. Evacuation usually involves suction curettage Instrumental evacuation In the US, abortion of a previable fetus is legal, although state-specific restrictions (eg, mandatory waiting periods, gestational age restrictions) exist. In the US, about half of pregnancies... read more at < 12 weeks, dilation and evacuation Instrumental evacuation In the US, abortion of a previable fetus is legal, although state-specific restrictions (eg, mandatory waiting periods, gestational age restrictions) exist. In the US, about half of pregnancies... read more at 12 to 23 weeks, or medical induction Induced Abortion In the US, abortion of a previable fetus is legal, although state-specific restrictions (eg, mandatory waiting periods, gestational age restrictions) exist. In the US, about half of pregnancies... read more at > 16 to 23 weeks (eg, with misoprostol). The later the uterus is evacuated, the greater the likelihood of placental bleeding, uterine perforation by long bones of the fetus, and difficulty dilating the cervix. These complications are reduced by preoperative use of osmotic cervical dilators (eg, laminaria), misoprostol, or mifepristone (RU 486).

If complete abortion is suspected, uterine evacuation need not be done routinely. Uterine evacuation can be done if bleeding occurs and/or if other signs indicate that products of conception may be retained.

After an induced or spontaneous abortion, parents may feel grief and guilt. They should be given emotional support and, in most cases of spontaneous abortions, reassured that their actions were not the cause. Formal counseling is rarely indicated but should be made available.

Key Points

  • Spontaneous abortion probably occurs in about 10 to 15% of pregnancies.

  • The cause of an isolated spontaneous abortion is usually unknown.

  • A dilated cervix means that abortion is inevitable.

  • Confirm spontaneous abortion and determine its type based on clinical criteria, ultrasonography, and quantitative beta-hCG.

  • Uterine evacuation is eventually necessary for inevitable, incomplete, or missed abortions.

  • Often, uterine evacuation is not needed for threatened and complete abortions.

  • After spontaneous abortion, provide emotional support to the parents.

Recurrent Pregnancy Loss

Recurrent pregnancy loss is 2 to 3 consecutive spontaneous abortions. Determining the cause may require extensive evaluation of both parents. Some causes can be treated.

Etiology of Recurrent Pregnancy Loss

Causes of recurrent pregnancy loss may be maternal, fetal, or placental.

Common maternal causes include

  • Uterine or cervical abnormalities (eg, polyps, myomas, adhesions, cervical insufficiency)

  • Maternal (or paternal) chromosomal abnormalities (eg, balanced translocations)

  • Overt and poorly controlled chronic disorders (eg, hypothyroidism, hyperthyroidism, diabetes mellitus, hypertension)

  • Chronic renal disorders

Placental causes include preexisting chronic disorders that are poorly controlled (eg, systemic lupus erythematosus [SLE], chronic hypertension).

Fetal causes are usually

  • Chromosomal or genetic abnormalities

  • Anatomic malformations

Chromosomal abnormalities Overview of Chromosomal Anomalies Chromosomal anomalies cause various disorders. Anomalies that affect autosomes (the 22 paired chromosomes that are alike in males and females) are more common than those that affect sex chromosomes... read more may cause 50% of recurrent pregnancy losses; losses due to chromosomal abnormalities are more common during early pregnancy. Aneuploidy is involved in up to 80% of all spontaneous abortions occurring at < 10 weeks gestation but in < 15% of those occurring at ≥ 20 weeks.

Whether a history of recurrent pregnancy loss increases risk of fetal growth restriction and premature delivery in subsequent pregnancies depends on the cause of the losses.

Diagnosis of Recurrent Pregnancy Loss

  • Clinical evaluation

  • Tests to identify the cause

The diagnosis of recurrent pregnancy loss is clinical.

Evaluation for recurrent pregnancy loss should include the following to help determine the cause:

Cause cannot be determined in up to 50% of women. Screening for hereditary thrombotic disorders is no longer routinely recommended unless supervised by a maternal-fetal medicine specialist.

Treatment of Recurrent Pregnancy Loss

  • Treatment of the cause if possible

Some causes of recurrent pregnancy loss can be treated. If the cause cannot be identified, the chance of a live birth in the next pregnancy is 35 to 85%.

Key Points

  • Causes of recurrent pregnancy loss may be maternal, fetal, or placental.

  • Chromosomal abnormalities (particularly aneuploidy) may cause 50% of recurrent pregnancy losses.

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