Abortion, Spontaneous (Miscarriage)

Basics
Description
Spontaneous abortion (SAb) (miscarriage) is the failure
or loss of a pregnancy before 14 weeks gestational age
(WGA).
Related terms
o Anembryonic gestation: gestational sac on ultrasound
(US) without visible embryo after 6 WGA
o Complete abortion: entire contents of uterus expelled
o Ectopic pregnancy: pregnancy outside the uterus
o Embryonic or fetal demise: Cervix closed, embryo or
fetus present in the uterus without cardiac activity.
o Incomplete abortion: abortion with retained products
of conception, generally placental tissue
o Induced or therapeutic abortion: evacuation of uterine
contents or products of conception medically or
surgically
o Inevitable abortion: cervical dilatation or rupture of
membranes in the presence of vaginal bleeding
o Recurrent abortion: 3 consecutive pregnancy losses
at <15 WGA
o Threatened abortion: vaginal bleeding in the 1st
trimester of pregnancy
o Septic abortion: a spontaneous or therapeutic
abortion complicated by pelvic infection; common
complication of illegally performed induced abortions
Synonym(s): miscarriage; early pregnancy loss

o Missed abortion and blighted ovum are used less

frequently in favor of terms representing the
sonographic diagnosis.

Epidemiology
Predominant age: increases with advancing age, especially >35 years; at age 40 years, the loss
rate is twice that of age 20 years.
Incidence

Threatened abortion (1st-trimester bleeding) occurs in

2025% of clinical pregnancies.
Between 10 and 15% of all clinically recognized
pregnancies end in SAb, with 80% of these occurring
within 12 weeks after last menstrual period (LMP) (1).
When both clinical and biochemical (-hCG detected)
pregnancies are considered, about 30% of pregnancies
end in SAb.
One in four women will have a SAb during her lifetime
(1).

Etiology and Pathophysiology

Chromosomal anomalies (5065% of cases)

Congenital anomalies
Trauma
Maternal factors: uterine abnormalities, infection
(toxoplasma, other viruses, rubella, cytomegalovirus,
herpesvirus), maternal endocrine disorders,
hypercoagulable state

Genetics
5065% of 1st-trimester SAbs have significant chromosomal anomalies, with 50% of these being autosomal trisomies
and the remainder being triploidy, tetraploidy, or 45X monosomies.

Risk Factors
Most cases of SAb occur in patients without identifiable risk factors; however, risk
factors include the following:

Chromosomal abnormalities
Advancing maternal age
Uterine abnormalities
Maternal chronic disease (antiphospholipid antibodies,
uncontrolled diabetes mellitus, polycystic ovarian
syndrome, obesity, hypertension, thyroid disease, renal
disease)
Other possible contributing factors include smoking,
alcohol, cocaine use, infection, and luteal phase defect.

General Prevention

 Insufficient evidence supports the use of aspirin and/or

other anticoagulants, bed rest, hCG, immunotherapy,
progestogens, uterine muscle relaxants, or vitamins for
general prevention of SAb, before or after threatened
abortion is diagnosed.
By the time hemorrhage begins, 1/2 of pregnancies
complicated by threatened abortion already have no
fetal cardiac activity.
Recurrent abortion: Women with a history of 3 prior
SAbs may benefit from progestogens (OR 0.39, 95% CI
0.210.72) (2)[A].
Antiphospholipid syndrome: The combination of
unfractionated heparin and aspirin reduces risk of SAb in
women with antiphospholipid antibodies and a history of
recurrent abortion (RR 46%, 95% CI 0.290.71) (3)[A].

Diagnosis
History
The possibility of pregnancy should be considered in a
reproductive-age woman who presents with
nonmenstrual vaginal bleeding.
Vaginal bleeding
o Characteristics (amount, color, consistency,
associated symptoms), onset (abrupt or gradual),
duration, intensity/quantity, and
exacerbating/precipitating factors
o Document LMP if known: allows calculation of
estimated gestational age
Abdominal pain/uterine cramping, as well as associated
nausea/vomiting/syncope
Rupture of membranes
Passage of products of conception
Prenatal course: toxic or infectious exposures, family or
personal history of genetic abnormalities, past history of
ectopic pregnancy or SAb, endocrine disease,
autoimmune disorder, bleeding/clotting disorder

Physical Exam
Orthostatic vital signs to estimate hemodynamic stability
Abdominal exam for tenderness, guarding, rebound,
bowel sounds (peritoneal signs more likely with ectopic
pregnancy)

 Speculum exam for visual assessment of cervical

dilation, blood, and products of conception (confirms
diagnosis of SAb)
Bimanual exam to assess for uterine sizedates
discrepancy and adnexal tenderness or mass

Differential Diagnosis
Ectopic pregnancy: potentially life-threatening; must be
considered in any woman of childbearing age with
abdominal pain and vaginal bleeding
Physiologic bleeding in normal pregnancy (implantation
bleeding)
Subchorionic bleeding
Cervical polyps, neoplasia, and/or inflammatory
conditions
Hydatidiform mole pregnancy
hCG-secreting ovarian tumor

Diagnostic Tests and Interpretation

Initial Tests (lab, imaging)

Quantitative hCG
o Particularly useful if intrauterine pregnancy (IUP) has
not been documented by US
o Serial quantitative serum hCG measurements can
assess viability of the pregnancy. Serum hCG should
rise at least 53% every 48 hours through 7 weeks
after LMP. An inappropriate rise, plateau, or decrease
of hCG suggests abnormal IUP or possible ectopic
pregnancy.
CBC with differential
Rh type
Cultures: gonorrhea/chlamydia
US exam to evaluate fetal viability and to rule out ectopic
pregnancy (4)[A]
o hCG >2,000 mIU/mL necessary to detect IUP via
transvaginal US (TVUS), >5,500 mIU/mL for abdominal
US
o TVUS criteria for nonviable intrauterine gestation: 7mm fetal pole without cardiac activity or 25-mm
gestational sac without a fetal pole, IUP with no
growth over 1 week, or previously seen IUP no longer
visible

o Structures and timing: with TVUS, gestational sac of

23 mm generally seen around 5 WGA; yolk sac by 5.5
WGA; fetal pole with cardiac activity by 6 WGA
Follow-Up Tests & Special Considerations

In the case of vaginal bleeding with no documented IUP

and hCG <2,000 mIU/mL, follow serum hCG levels
weekly to zero.
If levels plateau, consider ectopic pregnancy or retained
products of conception. If levels are very high, consider
gestational trophoblastic disease.
If initial hCG level does not permit documentation of IUP
by TVUS, follow serum hCG in 48 hours to document
appropriate rise.
Repeat US once hCG is at a level commensurate with
visualization on US (see above).
Provide patient with ectopic precautions in interim:
worsening abdominal pain, dizziness/syncope,
nausea/vomiting.
In a pregnancy of unknown location with hCG rise <53%
in 48 hours, offer methotrexate for treatment of
presumed ectopic pregnancy.
Diagnostic Procedures/Surgery

Fetal heart tones can be auscultated with Doppler starting

between 10 and 12 WGA in a viable pregnancy.
In threatened abortion, fetal cardiac activity at 711 WGA
is 9096% predictive of continued pregnancy.

Treatment
General Measures
Discuss contraception plan at the time of diagnosis of
SAb, as ovulation can occur prior to resumption of
normal menses.
Watchful waiting is 90% effective for incomplete
abortion, although it may take several weeks for the
process to be complete (1)[A].

Medication (Drugs)
Long-term conception rate and pregnancy outcomes are
similar for women who undergo expectant management,
medical treatment, or surgical evacuation.

 Postinfection rates are lower with medical versus surgical

management.
First Line

Misoprostol: most common agent for inducing passage of

tissue in missed or incomplete abortion
o Off-label use; has not been submitted to the FDA for
consideration for use in treatment of early pregnancy
failure. Recognized by the World Health Organization
as a life-saving medication for this indication
o Efficacy: complete expulsion of products of
conception in 71% by day 3, 84% by day 8
o Efficacy depends on route of administration,
gestational age of pregnancy, and dose.
o Recommended dose is 800 g vaginally; alternate
regimens include the World Health Organization
(WHO) regimen of 600 g sublingually q3h for up to 3
doses; multidose regimens and oral dosing (including
buccal and sublingual) may result in increased side
effects.
Common adverse effects include abdominal
pain/cramping, nausea, and diarrhea. Pain increases at
higher doses but is manageable with oral analgesia.
There is no increase in nausea/diarrhea with a higher
dose.
Recommended for stable patients who decline surgery
but do not want to wait for spontaneous passage of
products of conception
Second Line

Rh-negative patients should be given Rh immunoglobulin

(RhoGAM) 50 g IM following a SAb.
Women with evidence of anemia should receive iron
supplementation.

Issues For Referral

Patients should be monitored for up to 1 year for the development of pathologic grief. There is
insufficient evidence to support counseling to prevent development of anxiety or depression
related to grief following SAb.

Surgery/Other Procedures
Uterine aspiration (suction dilation and curettage [D&C]
or manual vacuum aspiration [MVA]) is the conventional
treatment.
Indications: septic abortion, heavy bleeding,
hypotension, patient choice

 Risks (all rare): anesthesia (usually local), uterine

perforation, intrauterine adhesions, cervical trauma,
infection that may lead to infertility or increased risk of
ectopic pregnancy
When compared with expectant management, surgical
intervention leads to fewer days of vaginal bleeding, with
a lower risk of incomplete abortion and heavy bleeding
but a higher risk of infection (5)[A].
Vacuum aspiration (manual or electric) is considered
preferable to sharp curettage, as aspiration is less
painful, takes less time, involves less blood loss, and
does not require general anesthesia. The WHO supports
use of suction curettage over rigid metal curettage.
Although data from induced abortions suggest that
antibiotic prophylaxis with doxycycline 100 mg BID
reduces the already rare risk of postprocedure infection,
data are insufficient to support use of antibiotics after
aspiration for SAb (6)[A].

Complementary and Alternative Medicine

A systematic review of Chinese herbal medicine alone and in conjunction with Western medicine
showed benefit over Western medicine alone in achieving continued viability at 28 weeks
(number needed to treat [NNT] = 4.8 pregnancies with combined therapy). However, the
available studies did not meet international standards for reporting quality (7)[C].

In-Patient Considerations
Admission Criteria
If the patient has orthostatic vital signs, initiate resuscitation with IV fluids and/or blood products,
if needed.
IV Fluids
Hemodynamically unstable patients may require IV fluids and/or blood products to maintain BP.

Ongoing Care
Follow-Up Recommendations
All patients should be offered follow-up in 26 weeks to monitor for resolution of bleeding, return
of menses, and symptoms related to grief, as well as to review the contraception plan.

Patient Monitoring

If SAb occurs in setting of previously documented IUP

and abortion is completed with resumption of normal
menses, it is not necessary to check or follow serum hCG
to 0.

 If pregnancy is not immediately desired, offer effective

contraception. Immediate insertion of an intrauterine
device is both acceptable and safe.
If pregnancy is desired, provide preconception
counseling. There is no evidence that it is necessary to
wait a certain number of cycles before attempting
conception again.

Diet
NPO if patient is to undergo D&C under general anesthesia

Patient Education
Pelvic rest for 1 week after D&C or MVA
Advise patients to call with excessive bleeding (soaking
two pads per hour for 2 hours), fever, pelvic pain, or
malaise, which could indicate retained products of
conception or endometritis.
A patient fact sheet on miscarriage is available through
the American Academy of Family Physicians
at http://www.aafp.org/afp/2011/0701/p85.html.

Prognosis
Prognosis is excellent once bleeding is controlled.
Recurrent abortion: Prognosis depends on etiology. Up to
70% rate of success with subsequent pregnancy

Complications
D&C or MVA: uterine perforation, bleeding, adhesions,
cervical trauma, and infection that may lead to infertility
or increased risk of ectopic pregnancy. Bleeding and
adhesions more common with D&C than with MVA; all
complications rare.
Retained products of conception