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Pregnancy loss

Last updated: February 18, 2021

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Pregnancy loss can occur even in previously healthy pregnancies. If it occurs before 20 weeks' of gestation (∼ 10% of pregnancies), it is called early pregnancy loss, miscarriage, or spontaneous abortion. If it occurs after 20 weeks' gestation, it is called stillbirth or intrauterine fetal demise. The majority of spontaneous abortions are due to fetal aneuploidy. Other common causes of spontaneous abortion are maternal disease, trauma, and congenital anomalies. Stillbirth can be caused by maternal disease, placental disorders, umbilical cord complications, or fetal congenital anomalies. In many cases, the cause of spontaneous abortion or stillbirth is unknown. The management of pregnancy loss depends on the week of gestation and clinical presentation. Most commonly, it involves medication-induced evacuation of the pregnancy, surgical evacuation of the pregnancy, or expectant management. After a spontaneous abortion, the products of conception should undergo histopathological examination. Similarly, fetal autopsy should be performed after a stillbirth in order to determine the underlying cause and address any modifiable etiologies.

References:[1]

Spontaneous abortion

Stillbirth

References:[1][2][3]

Type Findings Cervical os Prognosis
Threatened abortion closed reversible
Inevitable abortion dilated irreversible
Missed abortion
  • No bleeding
  • No expulsion of the products of conception
  • No fetal activity
closed irreversible
Incomplete abortion dilated irreversible
Complete abortion closed irreversible
Stillbirth
  • Absence of fetal movements and cardiac activity
variable irreversible

References:[1][4]

Spontaneous abortion (< 20 weeks' gestation)

Stillbirth (> 20 weeks' gestation)

  • Ultrasound examination is the best diagnostic modality to confirm loss of fetal heart activity and fetal demise.
  • Fetal autopsy is recommended to ascertain the cause of death.

References:[1][3]

Spontaneous abortion (< 20 weeks' gestation)

Prevention

  • Minimize risk with treatment of maternal disease and adequate prenatal care.

Threatened abortion

Inevitable, incomplete, or missed abortions

The management of uncomplicated spontaneous abortions depends mostly on patient preference. Possibilities include:

Complete abortion

Stillbirth (>20 weeks' gestation)

  • Do not rush delivery unless maternal health is at risk (i.e., preeclampsia, infection).
  • Spontaneous labor usually begins within 2 weeks of intrauterine fetal death. However, labor may be induced with oxytocin if maternal disease develops (e.g., coagulation abnormalities) or if the patient prefers induction.
  • Vaginal delivery is safer than cesarean delivery, but many patients will prefer cesarean delivery.
  • Express empathy and acknowledge patient grief; provide privacy and emotional support.
  • Patients should be offered a fetal autopsy to determine the cause of death.

References:[6][7][8][9]

Medical abortion

References:[7][10][11][12]

References:[7]

We list the most important complications. The selection is not exhaustive.

  1. Tulandi T, Al-Fozan HM, Levine D, Barbieri RL, Eckler K. Spontaneous Abortion: Risk Factors, Etiology, Clinical Manifestations, and Diagnostic Evaluation. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/spontaneous-abortion-risk-factors-etiology-clinical-manifestations-and-diagnostic-evaluation.Last updated: January 19, 2017. Accessed: August 30, 2017.
  2. Jenkins B, McInnis M, Lewis C. Step-Up to USMLE Step 2 CK. Lippincott Williams & Wilkins ; 2015
  3. Fretts RC, Lockwood CJ, Barss VA. Fetal Death and Stillbirth: Incidence, Etiology, and Prevention. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/fetal-death-and-stillbirth-incidence-etiology-and-prevention.Last updated: April 24, 2017. Accessed: August 30, 2017.
  4. Dutta DC, Konar H. Textbook of Obstetrics. Jaypee Brothers Medical Publishers ; 2015
  5. Dilation and Curettage. https://www.acog.org/Patients/FAQs/Dilation-and-Curettage. Updated: March 1, 2019. Accessed: June 27, 2019.
  6. Moise KJ. Prevention of Rhesus (D) Alloimmunization in Pregnancy. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/prevention-of-rhesus-d-alloimmunization-in-pregnancy.Last updated: August 28, 2016. Accessed: May 11, 2017.
  7. Tulandi T, Al-Fozan HM, Barbieri RL, Eckler K. Spontaneous Abortion: Management. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/spontaneous-abortion-management.Last updated: August 7, 2017. Accessed: August 30, 2017.
  8. Salem L, Singer K, Lo BM. Rh Incompatibility. Rh Incompatibility. New York, NY: WebMD. http://emedicine.medscape.com/article/797150. Updated: March 15, 2017. Accessed: August 30, 2017.
  9. Grunebaum A, Chervenak FA, Lockwood CJ, Barss VA. Fetal Death and Stillbirth: Maternal Care. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/fetal-death-and-stillbirth-maternal-care.Last updated: January 12, 2017. Accessed: August 30, 2017.
  10. Creinin MD. Medical abortion regimens: historical context and overview.. Am J Obstet Gynecol. 2000; 183 (2 Suppl): p.S3-9.
  11. Bryant AG, Regan E, Stuart G. An overview of medical abortion for clinical practice. Obstet Gynecol Surv. 2014; 69 (1): p.39-45. doi: 10.1097/ogx.0000000000000017 . | Open in Read by QxMD
  12. Medical Management of First-Trimester Abortion. https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Medical-Management-of-First-Trimester-Abortion. Updated: March 1, 2014. Accessed: April 9, 2018.