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Pregnancy loss

Last updated: July 9, 2021

Summarytoggle arrow icon

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.

Types of pregnancy loss [1]
Type Definition Findings Treatment
Threatened abortion
  • A process of miscarriage that has started but not yet progressed to a state from which recovery is impossible (potentially reversible) before 20 weeks' gestation
Inevitable abortion
Missed abortion
Incomplete abortion
  • Passage of some but not all POC before 20 weeks' gestation.
Complete abortion
  • The complete passage of all POC before 20 weeks' gestation.
  • No treatment required
Stillbirth
  • Absence of fetal movements and cardiac activity
  • Cervical os variable

Definition

Etiology

Clinical features

Clinical features of spontaneous pregnancy loss [1]
Type Vaginal bleeding Fetal activity Products of conception (POC) Cervical os Prognosis
Threatened abortion
  • Yes
  • Yes
  • Intrauterine
  • Closed
  • Reversible
Inevitable abortion
  • Yes
  • May be present
  • Visible/palpable POC
  • Dilated
  • Irreversible
Missed abortion
  • No
  • No
  • No expulsion of the POC
  • Closed
  • Irreversible
Incomplete abortion
  • Yes
  • No
  • Dilated
  • Irreversible
Complete abortion
  • Yes
  • No
  • Closed
  • Irreversible

Diagnostics

Treatment

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

Complications

Definition

Etiology

Clinical features

  • Absence of fetal movements and cardiac activity
  • Cervical os may be open or closed

Diagnostics

Treatment

  • 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.

Complications

Definition

  • Method for terminating pregnancy at an early stage [3][4][5]

Management

The choice of management depends on the gestational age and the patient's preference

Overview of elective abortion options [3][4]
Medical abortion Surgical abortion

First trimester

(≤ 12 weeks' gestation)

Second trimester

(between 13–24 weeks' gestation)

  • Dilation and evacuation

Complications

  1. Dutta DC, Konar H. Textbook of Obstetrics. Jaypee Brothers Medical Publishers ; 2015
  2. Dilation and Curettage. https://www.acog.org/Patients/FAQs/Dilation-and-Curettage. Updated: March 1, 2019. Accessed: June 27, 2019.
  3. Creinin MD. Medical abortion regimens: historical context and overview.. Am J Obstet Gynecol. 2000; 183 (2 Suppl): p.S3-9.
  4. 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
  5. 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.
  6. Practice Bulletin - Medication Abortion Up to 70 Days of Gestation. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation. Updated: October 1, 2020. Accessed: May 28, 2021.
  7. Medical management of abortion.
  8. ACOG, no authors listed. Second-trimester abortion. Obstetrics and Gynecology. 2013 . doi: 10.1097/01.AOG.0000431056.79334.cc. . | Open in Read by QxMD