Miscarriage
A miscarriage is the natural death of an embryo or fetus in the womb, before it is old enough to live on its own, outside the mother.[1] The medical words for a miscarriage are spontaneous abortion. ("Spontaneous" means something that a person did not expect to happen).
| Miscarriage | |
|---|---|
| Other names | spontaneous abortion, early pregnancy loss |
 | |
| An ultrasound showing a gestational sac containing a yolk sac but no embryo | |
| Medical specialty | Obstetrics and Gynaecology, Neonatology, Pediatrics |
| Symptoms | Vaginal bleeding with or without pain[2] |
| Complications | Infection, bleeding,[3] sadness, anxiety, guilt[4] |
| Usual onset | Before 20 weeks of pregnancy[5] |
| Causes | Chromosomal abnormalities,[2][6] uterine abnormalities[7] |
| Risk factors | Being an older parent, previous miscarriage, exposure to tobacco smoke, obesity, diabetes, autoimmune diseases, drug or alcohol use[8][9][10] |
| Diagnostic method | Physical examination, human chorionic gonadotropin, ultrasound[11] |
| Differential diagnosis | Ectopic pregnancy, implantation bleeding.[2] |
| Prevention | Prenatal care[12] |
| Treatment | Expectant management, vacuum aspiration, emotional support[9][13] |
| Medication | misoprostol |
| Frequency | 10–50% of pregnancies[2][8] |
An "abortion" is when a pregnancy ends early, before birth.
Among women who know they are pregnant, about 15-20% have miscarriages. (This means that up to 1 in every 5 women who know they are pregnant miscarries.)[1] It is the most common complication (serious problem) that happens in early pregnancy in humans.[14][15]
Miscarriage vs. Stillbirth
[change | change source]In the United States, if a fetus dies after it is 20 weeks old, its death is no longer called a miscarriage. Its death is called a stillbirth, a fetal demise, or a fetal death. ("Demise" means "death.") Different countries have different ways of defining the difference between a miscarriage and a fetal death. For example:[16][17][18]
| In This Country: | Miscarriage Is: | Fetal Death Is: |
|---|---|---|
| Norway | Death of a fetus under 16 weeks old | Death of a fetus over 16 weeks old |
| Australia | Death of a fetus under 20 weeks old | Death of a fetus over 20 weeks old |
| United Kingdom | Death of a fetus under 24 weeks old | Death of a fetus over 24 weeks old |
| Italy | Death of a fetus under 26 weeks old | Death of a fetus over 26 weeks old |
| Spain | Death of a fetus under 26 weeks old | Death of a fetus over 26 weeks old |
Causes of miscarriage
[change | change source]Nobody knows all of the reasons why a woman may miscarry. However, some common causes include:
- Genetic problems, like aneuploidy[19]
- Problems with the mother's uterus or hormones
- An infection somewhere in the mother's reproductive system
- Tissue rejection (where the mother's body reacts to the fetus like it is something that does not belong in her body)
- Serious physical trauma (injury, like a bad car accident
- Very rarely, medical procedures that are used to diagnose problems with the fetus can cause miscarriage. This happens in only about 1% of cases (1 out of 100) when a woman has had chorionic villus sampling (CVS) or amniocentesis)[20][21]
The most common causes of miscarriage change depending on what trimester the mother is in. (Each trimester lasts about three months.)
First trimester (Weeks 1-12)
[change | change source]
Most miscarriages happen during the first trimester. Some studies say that two-thirds (two out of three) to three-quarters (three out of four) of all miscarriages happen during this trimester.[22][23] About 30% to 40% (3 to 4 in every 10) of all fertilized eggs miscarry, often before a woman knows she is pregnant.[24]
In more than half of embryos miscarried in the first 13 weeks of pregnancy, the embryo has chromosomes that are not normal.[25] These chromosomal problems may happen because of problems as the embryo grows and its cells make copies of themselves. It is also possible for chromosomal problems to happen because of a problem with a parent's genes. However, this is more likely to happen in women who have had other miscarriages, or if one of the parents has a child or other relatives with birth defects.[26] Genetic problems are more likely to happen with older parents; this may be why miscarriages are more common in older women.[27]
Another cause may be the mother not having enough progesterone. If a woman is diagnosed with low progesterone levels in the second half of her menstrual cycle (the luteal phase), she may be prescribed progesterone, to take during the first trimester of her pregnancy.[26] However, when a woman might already be miscarrying, there is no evidence that first-trimester progesterone pills decrease the risk of having a miscarriage.[28] Scientists have even questioned whether problems with the luteal phase really can cause miscarriages.[29]
Second trimester (Weeks 13-27)
[change | change source]Common causes of miscarriage during the second trimester are:[22]
- Uterine malformation (when the mother's uterus is not shaped normally)
- Growths in the mother's uterus (these are called fibroids)
- Problems with the mother's cervix
These problems can also cause premature birth (when a baby is born earlier than expected).[22] One study found that 19% of second-trimester miscarriages were caused by problems with the umbilical cord. The fetus gets blood and oxygen through the umbilical cord. Every part of the body needs blood and oxygen to survive. If the baby cannot get enough oxygen because of a problem with the cord, it can die.[30] Problems with the placenta may also cause second-trimester miscarriages.[30] Nutrients and blood pass through the placenta in order to get from the mother to the umbilical cord. The placenta also helps filter out some things that could hurt the fetus. If there is a problem with the placenta, the fetus could die because it did not get enough nutrients and oxygen, or because the placenta did not filter out harmful things.
Diagnosis
[change | change source]Miscarriage is usually diagnosed when a pregnant woman notices that she is having certain symptoms and goes to see a doctor. The most common symptom of a coming miscarriage is bleeding during early pregnancy. The woman may not have any pain.[31]
Usually, if a pregnant woman is bleeding or having pain, an ultrasound should be done. The ultrasound can show that the fetus's heart is not beating, which means that the fetus has miscarried. If this happens, special tests should be done to make sure the woman does not have an ectopic pregnancy, which can kill a woman.[32][33]
Not all light bleeding during early pregnancy means a woman is having a miscarriage. But any woman having light bleeding during pregnancy should see her doctor. If the bleeding is heavy, the woman is having a lot of pain, or she has a fever, she should go to an Emergency Room or call an ambulance to take her to the hospital.[32]
If a woman has bleeding during her pregnancy, she may be diagnosed with a "threatened miscarriage." In the past, if a doctor thought a pregnancy might miscarry in the future, they would suggest bed rest for the mother (lying in bed for most of the time). Today, most doctors and scientists think that bed rest does not help.[34]
Treatment
[change | change source]There are a few different types of miscarriage:[35]
- In a complete miscarriage, the fetus has totally left the mother's body. So has the placenta. There are no pieces of fetal or placental tissue left in the uterus.
- In a missed miscarriage, the fetus has miscarried but is still inside the mother's body. This often happens when the mother does not realize she had a miscarriage (which is common when the pregnancy is very early on).
- In an incomplete miscarriage, parts of the fetus or the placenta are still in the uterus.
The treatment is different for each kind of miscarriage.
Complete miscarriage
[change | change source]If a woman has a complete miscarriage, she usually does not need any medical treatment.[35]
Incomplete or missed miscarriage
[change | change source]If a woman has an incomplete miscarriage or a missed miscarriage, there are three different choices for treatment:
- Watchful Waiting means that a doctor will keep checking on the woman, but will not give any treatment unless a problem happens. With watchful waiting, most of these miscarriages will pass naturally in two to six weeks. This means that the tissue left in the woman will leave her body, through the vagina, without any treatment.
With no treatment (watchful waiting), most of these cases (65–80%) will pass naturally within two to six weeks.[36] This path avoids the side effects and complications possible from medications and surgery,[37] but increases the risk of mild bleeding, need for unplanned surgical treatment, and incomplete miscarriage.
- Medical Management means that medicine is given. Usually, a medicine called misoprostol is given. Misoprostol makes the uterus contract (get tighter) to push out whatever is inside. In about 95% of cases (95 out of 100), the fetal or placental tissue that is left in the uterus will leave the woman's body within a few days.[37]
- Surgery is the fastest way to complete a miscarriage. It also makes bleeding less heavy and makes it not last as long. Also, the woman will not have to go through the physical pain of the miscarriage.[36] Most often, one of two surgeries are used to complete the miscarriage:
- Vacuum aspiration, sometimes called dilation and evacuation (D&E). In a D&E, a tube attached to a pump sucks the tissue left in the uterus out through the cervix.
- Dilation and curettage (D&C). In a D&C, the cervix is widened, and the tissue left in the uterus is scraped and scooped out ("curettage"). Compared to giving medications, D&C has a higher risk of causing problems. For example, the cervix or uterus may be injured. Because of this, some women prefer not to have a D&C because they want to have children in the future and want to lower the chances of problems during future pregnancies. However, if a woman has had more than one miscarriage, D&C is the most convenient way to get tissue samples, which can be studied to see if a reason for the miscarriages can be found.
Which treatment should be used?
[change | change source]The choice of which treatment to use depends on many things, including what the mother wants. However, there are guidelines that doctors use to suggest what treatment to use.
Missed Miscarriage
The most important things that help doctors decide what to do are the age and size of the embryo, and the size of the gestational sac (the fluid around the embryo.[38]
- For embryos that were less than 7 weeks old, and the smallest gestational sacs, watchful waiting is the best choice, because the embryo will often leave the mother's body naturally.
- For embryos that were 7–9 weeks old with larger sizes and gestational sacs, medicine is suggested, but either watchful waiting or surgery might be used depending on the situation.
- For the embryos that were over 9 weeks old, with the largest gestational sacs, surgery is suggested because the mother is likely to have a lot of pain and bleeding when she miscarries.
Incomplete Miscarriages
- For an incomplete miscarriage, the size of the tissue left in the uterus is the most important thing that helps doctors decide what to do. Ultrasound is used to find out how large the tissue is.[38]
- If the tissue left is smaller than 15mm (millimeters): Watchful waiting is usually the best choice because it is likely that the tissue will leave the mother's body on its own.
- If the tissue is between 15 and 20mm: Medical or expectant management is suggested. Surgery is chosen only if there is a specific reason why the mother needs it.
- If the tissue is over 35 to 50mm, these things are suggested:
- Giving misoprostol to make the tissue left in the uterus leave the mother's body on its own more quickly.
- Having the mother stay in the hospital to be watched for a few hours or overnight. She should stay until most of the tissue left in her uterus has passed, and she has stopped bleeding.
- If misoprostol has not worked, surgery may be needed.
Risk factors
[change | change source]A risk factor for miscarriage is something that makes a woman more likely to miscarry. There are many risk factors for miscarriage. For example:[39]
- The age of the mother. Women older than age 35 have a higher risk of miscarriage than younger women. At age 35, a woman has about a 20 percent risk. At age 40, the risk is about 40 percent. And at age 45, it's about 80 percent.[39]
- Multiple pregnancies (pregnancies with more than one fetus, like twins and triplets). The more fetuses in the womb, the higher the risk.[40]
- If the mother has certain diseases, like:
- Diabetes, especially the mother needs insulin and her diabetes is still not controlled well.[41]
- Hypothyroidism, especially when the hypothyroidism is very bad.[42]
- Some infections, like HIV, rubella, malaria, and some sexually transmitted diseases like chlamydia, gonorrhea, and syphilis.[43]
- If the mother[44] or father[45] smokes tobacco (cigarettes).
- If the mother drinks alcohol while she is pregnant, especially if she drinks often, or drinks a lot at once.[39] The United Kingdom's National Health Service says that drinking alcohol becomes a risk factor if a mother drinks more than one glass of wine, more than one shot of whiskey, or more than two-thirds of a pint of beer a week. Most doctors say that no amount of alcohol during pregnancy is safe.[43]
- If the mother uses illegal drugs, like cocaine, while she is pregnant.[44]
- If the mother is injured, exposed to certain poisons, or is using an IUD when she gets pregnant.[46]
- Problems with the mother's uterus or cervix.[39]
- Some types of food poisoning.[43]
Related pages
[change | change source]- Congenital disabilities that can cause miscarriage
- Ultrasound (used to diagnose miscarriage)
- Dilation and curettage
- Dilation and evacuation
- Stillbirth
References
[change | change source]- ↑ 1.0 1.1 Susan Storck and A.D.A.M. Inc. "Miscarriage". American Accreditation HealthCare Commission.
- ↑ 2.0 2.1 2.2 2.3 Cite error: The named reference
John20122was used but no text was provided for refs named (see the help page). - ↑ "Spontaneous Abortion – Gynecology and Obstetrics". Merck Manuals Professional Edition. Archived from the original on December 4, 2020. Retrieved 5 May 2018.
- ↑ Cite error: The named reference
Pregnancy losswas used but no text was provided for refs named (see the help page). - ↑ Cite error: The named reference
NIH2013Defwas used but no text was provided for refs named (see the help page). - ↑ Cite error: The named reference
Vai2015was used but no text was provided for refs named (see the help page). - ↑ Chan YY, Jayaprakasan K, Tan A, Thornton JG, Coomarasamy A, Raine-Fenning NJ (October 2011). "Reproductive outcomes in women with congenital uterine anomalies: a systematic review". Ultrasound in Obstetrics & Gynecology. 38 (4): 371–382. doi:10.1002/uog.10056. PMID 21830244. S2CID 40113681.
- ↑ 8.0 8.1 Cite error: The named reference
NIH2013Epi2was used but no text was provided for refs named (see the help page). - ↑ 9.0 9.1 Cite error: The named reference
Ol2014was used but no text was provided for refs named (see the help page). - ↑ Cite error: The named reference
CarpSelmi2012was used but no text was provided for refs named (see the help page). - ↑ Cite error: The named reference
NIH2015Diagwas used but no text was provided for refs named (see the help page). - ↑ Cite error: The named reference
NIH2013Prewas used but no text was provided for refs named (see the help page). - ↑ Cite error: The named reference
NIH2013Txwas used but no text was provided for refs named (see the help page). - ↑ National Coordinating Centre for Women's and Children's Health (UK) (December 2012). "Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management in Early Pregnancy of Ectopic Pregnancy and Miscarriage". NICE Clinical Guidelines, No. 154. Royal College of Obstetricians and Gynaecologists. PMID 23638497. Retrieved 4 July 2013.
- ↑ "Abortion Guide".
- ↑ Mohangoo AD, Blondel B, Gissler M, Velebil P, Macfarlane A, Zeitlin J (2013). "International comparisons of fetal and neonatal mortality rates in high-income countries: should exclusion thresholds be based on birth weight or gestational age?". PLOS ONE. 8 (5): e64869. Bibcode:2013PLoSO...864869M. doi:10.1371/journal.pone.0064869. PMC 3658983. PMID 23700489.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ↑ Li, Z; Zeki, R; Hilder, L; Sullivan, EA (2012). "Australia's Mothers and Babies 2010". Perinatal statistics series no. 27. Cat. no. PER 57. Australian Institute of Health and Welfare National Perinatal Statistics Unit, Australian Government. Retrieved 4 July 2013.
- ↑ Royal College of Obstetricians and Gynaecologists UK (April 2001). "Further Issues Relating to Late Abortion, Fetal Viability and Registration of Births and Deaths". Royal College of Obstetricians and Gynaecologists UK. Archived from the original on 16 July 2014. Retrieved 4 July 2013.
- ↑ Terry Hassold; Heather Hall; Patricia Hunt, 'The origin of human aneuploidy: where we have been, where we are going', Human Molecular Genetics Volume 16, Review Issue 2 (22 August 2007), p. R203
- ↑ Tabor A, Alfirevic Z (2010). "Update on procedure-related risks for prenatal diagnosis techniques". Fetal Diagnosis and Therapy. 27 (1): 1–7. doi:10.1159/000271995. PMID 20051662. S2CID 25228648.
- ↑ Agarwal K, Alfirevic Z (August 2012). "Pregnancy loss after chorionic villus sampling and genetic amniocentesis in twin pregnancies: a systematic review". Ultrasound in Obstetrics & Gynecology : The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology. 40 (2): 128–34. doi:10.1002/uog.10152. PMID 22125091. S2CID 23379631.
- ↑ 22.0 22.1 22.2 Rosenthal, M. Sara (1999). "The Second Trimester". The Gynecological Sourcebook. WebMD. Retrieved December 18, 2006.
- ↑ Francis O (1959). "An analysis of 1150 cases of abortions from the Government R.S.R.M. Lying-in Hospital, Madras". Journal of Obstetrics and Gynaecology of India. 10 (1): 62–70. PMID 12336441.
- ↑ The Johns Hopkins Manual of Gynecology and Obstetrics (4 ed.). Lippincott Williams & Wilkins. 2012. pp. 438–439. ISBN 9781451148015.
- ↑ Kajii T, Ferrier A, Niikawa N, Takahara H, Ohama K, Avirachan S (1980). "Anatomic and chromosomal anomalies in 639 spontaneous abortuses". Human Genetics. 55 (1): 87–98. doi:10.1007/BF00329132. PMID 7450760. S2CID 2133855.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ↑ 26.0 26.1 "Miscarriage: Causes of Miscarriage". HealthCentral.com. Retrieved July 26, 2012.taken word-for-word from pp. 347–9 of: "What To Do When Miscarriage Strikes". The PDR Family Guide to Women's Health and Prescription Drugs. Montvale, NJ: Medical Economics. 1994. pp. 345–50. ISBN 1-56363-086-9.
- ↑ "Pregnancy Over Age 30". MUSC Children's Hospital. Archived from the original on November 13, 2006. Retrieved December 18, 2006.
- ↑ Wahabi HA, Fayed AA, Esmaeil SA, Al Zeidan RA (2007). Wahabi, Hayfaa A (ed.). "Progestogen for treating threatened miscarriage". Cochrane Database of Systematic Reviews (12): CD005943. doi:10.1002/14651858.CD005943.pub2. PMID 22161393.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ↑ Bukulmez O, Arici A (2004). "Luteal phase defect: Myth or reality". Obstetrics and Gynecology Clinics of North America. 31 (4): 727–44, ix. doi:10.1016/j.ogc.2004.08.007. PMID 15550332.
- ↑ 30.0 30.1 Peng HQ, Levitin-Smith M, Rochelson B, Kahn E (2006). "Umbilical Cord Stricture and Overcoiling Are Common Causes of Fetal Demise". Pediatric and Developmental Pathology. 9 (1): 14–9. doi:10.2350/05-05-0051.1. PMID 16808633. S2CID 20887175.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ↑ Gracia CR, Sammel MD, Chittams J, Hummel AC, Shaunik A, Barnhart KT (2005). "Risk Factors for Spontaneous Abortion in Early Symptomatic First-Trimester Pregnancies". Obstetrics & Gynecology. 106 (5, Part 1): 993–9. doi:10.1097/01.AOG.0000183604.09922.e0. PMID 16260517. S2CID 44600202.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ↑ 32.0 32.1 Yip SK, Sahota D, Cheung LP, Lam P, Haines CJ, Chung TK (2003). "Accuracy of Clinical Diagnostic Methods of Threatened Abortion". Gynecologic and Obstetric Investigation. 56 (1): 38–42. doi:10.1159/000072482. PMID 12876423. S2CID 24451895.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ↑ Condous G, Okaro E, Khalid A, Bourne T (2005). "Do we need to follow up complete miscarriages with serum human chorionic gonadotrophin levels?". BJOG. 112 (6): 827–9. doi:10.1111/j.1471-0528.2004.00542.x. PMID 15924545. S2CID 7546943.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ↑ Tien JC, Tan TY (2007). "Non-surgical interventions for threatened and recurrent miscarriages". Singapore Medical Journal. 48 (12): 1074–90, quiz 1090. PMID 18043834.
- ↑ 35.0 35.1 "Miscarriage: Signs, Symptoms, Treatment, and Prevention". American Pregnancy Association. August 2015. Retrieved December 13, 2015.
- ↑ 36.0 36.1 Kripke C (2006). "Expectant management vs. surgical treatment for miscarriage". American Family Physician. 74 (7): 1125–6. PMID 17039747.
- ↑ 37.0 37.1 Tang OS, Ho PC (2006). "The use of misoprostol for early pregnancy failure". Current Opinion in Obstetrics and Gynecology. 18 (6): 581–6. doi:10.1097/GCO.0b013e32800feedb. PMID 17099326. S2CID 23354454.
- ↑ 38.0 38.1 Clinical Practice Guideline: Miscarriage: Management Archived 2011-03-12 at the Wayback Machine from Royal Women's Hospital. Publication date: 7 October 2010.
- ↑ 39.0 39.1 39.2 39.3 "Miscarriage - Risk Factors". American Pregnancy Association. July 9, 2013. Retrieved December 13, 2015.
- ↑ "Complications in a Multiples Pregnancy". American Pregnancy Association. July 2015. Retrieved December 13, 2015.
- ↑ Mills JL, Simpson JL, Driscoll SG, Jovanovic-Peterson L, Van Allen M, Aarons JH, Metzger B, Bieber FR, Knopp RH, Holmes LB (1988). "Incidence of Spontaneous Abortion among Normal Women and Insulin-Dependent Diabetic Women Whose Pregnancies Were Identified within 21 Days of Conception". New England Journal of Medicine. 319 (25): 1617–23. doi:10.1056/NEJM198812223192501. PMID 3200277.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ↑ van den Boogaard E, Vissenberg R, Land JA, van Wely M, van der Post JA, Goddijn M, Bisschop PH (2011). "Significance of (sub)clinical thyroid dysfunction and thyroid autoimmunity before conception and in early pregnancy: A systematic review". Human Reproduction Update. 17 (5): 605–19. doi:10.1093/humupd/dmr024. PMID 21622978.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ↑ 43.0 43.1 43.2 "Miscarriages - Causes". NHS Choices. May 21, 2015. Retrieved December 13, 2015.
- ↑ 44.0 44.1 Ness RB, Grisso JA, Hirschinger N, Markovic N, Shaw LM, Day NL, Kline J (1999). "Cocaine and Tobacco Use and the Risk of Spontaneous Abortion". New England Journal of Medicine. 340 (5): 333–9. doi:10.1056/NEJM199902043400501. PMID 9929522.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ↑ Venners SA, Wang X, Chen C, Wang L, Chen D, Guang W, Huang A, Ryan L, O'Connor J, Lasley B, Overstreet J, Wilcox A, Xu X (2004). "Paternal Smoking and Pregnancy Loss: A Prospective Study Using a Biomarker of Pregnancy". American Journal of Epidemiology. 159 (10): 993–1001. doi:10.1093/aje/kwh128. PMID 15128612.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ↑ "Miscarriage: An Overview". Armenian Medical Network. 2005. Retrieved September 19, 2007.