Early pregnancy loss is non-induced embryonic or fetal death or passage of products of conception before 20 weeks gestation. Early pregnancy loss is also termed as spontaneous abortion or miscarriage. The World Health Organization (WHO) defines it as expulsion or extraction of an embryo or fetus weighing 500 g or less.
Spontaneous abortion in the first trimester is common, affecting at least 15–20% of the clinically recognized pregnancies. Approximately 80% of all cases of pregnancy loss occur within the first three months of pregnancy (first trimester).
According to March of Dimes, nearly 50% of all pregnancies end in spontaneous abortion most often before a woman misses a menstrual period or even knows she is pregnant.
The different stages of spontaneous abortion may include:
Septic abortion is defined as abortion complicated by infection. Sepsis may result from infection if organisms rise from the lower genital tract following either spontaneous or unsafe abortion. Sepsis is more likely to occur if there are retained products of conception and evacuation has been delayed.
Recurrent spontaneous abortion (RSA) is defined as three or more consecutive pregnancy losses before 20– 22 weeks of gestation. The causes of RSA can be often related to factors associated with implantation, genetics, autoimmunity, endocrine abnormalities, infection, and anatomic uterine defects.
Missed abortion: In missed abortion there is pregnancy loss after the development of embryo or fetus; but it is retained within the uterine cavity. There may be brownish vaginal discharge or spotting.
Anembryonic gestation is pregnancy in which a gestational sac develops without development of any embryonic structures; previously referred to as an “empty sac” or “blighted ovum.
Induced abortion is defined as a process by which pregnancy is terminated before fetal viability.
Unsafe abortion is defined as a procedure performed either by persons lacking necessary skills or in an environment lacking minimal medical standards, or both.
Signs and symptoms of spontaneous abortion may be:
In most of the cases of early pregnancy loss, cause of spontaneous abortion is not known; approximately 50% of all cases of early pregnancy loss are due to fetal chromosomal abnormalities.
Other causes include:
Risk factors for spontaneous abortion-
A thorough evaluation is needed to make a definitive diagnosis as common symptoms of early pregnancy loss, such as vaginal bleeding and pain in lower abdomen, also are common in normal pregnancy, ectopic pregnancy and molar pregnancy.
Diagnosis includes a detailed medical history and physical examination combined with ultrasonography and human chorionic gonadotropin (β-hCG) testing are helpful in making confirm diagnosis.
Ultrasonography is used to verify the presence of intrauterine pregnancy; to rule out ectopic pregnancy and to know the status of pregnancy. Sometimes repetitive sonography is required to make a definitive diagnosis; whether the embryo is still growing in the uterus or to determine whether products of conception are remained in the uterus or expelled completely.
Hemoglobin estimation: It is done to evaluate anemia.
Urine pregnancy test: It is used to confirm pregnancy state.
Serum human chorionic gonadotropin (β-hCG) testing: Serial quantitative blood tests are used to determine the viability of a pregnancy.
Blood group and Rh typing are done, if these are not already known. Rh typing is used to plan for administration of anti- Rh D immunoglobulin in Rh-negative woman.
Management depends on the stage of spontaneous abortion.
Threatened abortion: No medications such as hormones (e.g. estrogens or progestins) or tocolytic agents are helpful as they will not prevent abortion.
Inevitable and incomplete abortion: During and after the miscarriage the aim is to prevent the haemorrhage and infection. Management options for early pregnancy loss include expectant management, medical treatment, or surgical evacuation.
Expectant management: After discussing all treatment options (expectant, medical, and surgical management) with the woman to allow her to make an informed choice; many women first prefer to take a “wait and see” approach in hopes that spontaneous abortion will be complete. This is called expectant management. It is generally limited to pregnancies within the first trimester and if woman is haemodynamically stable. Proper counseling is given to the woman who is waiting for spontaneous passage of the products of conception.
It should be avoided in woman with:
Medical management- For patients who prefer to avoid surgical evacuation, medical management of early pregnancy loss can be advised with the proper counseling about bleeding, pain and that surgery may be needed if medical management does not achieve complete expulsion. Follow-up of the cases includes confirmation of complete expulsion by ultrasound examination, or serial serum β-hCG measurement used in settings where ultrasonography is unavailable.
Surgical management- For inevitable, incomplete, or missed abortions, treatment is uterine evacuation. Evacuation usually involves suction curettage in less than 12 weeks pregnancy and dilatation and evacuation at 12 to 23 weeks of pregnancy. Many women prefer surgical evacuation to expectant or medical treatment because it provides more immediate completion of the process with less follow-up.
A complete abortion usually needs no further treatment, medically or surgically.
After an induced or spontaneous abortion, parents may feel grief and guilt. They should be given emotional support and, in the case of spontaneous abortions, reassured that their actions were not the cause.
Some women may want to become pregnant soon after having an abortion. They should be encouraged to delay the next pregnancy until they have completely recovered.
Abortion care should always include comprehensive contraceptive counselling with initiation of the method of choice as soon as desired after the abortion.
Rh-immunoglobulin: Women who are Rh negative and unsensitized should receive 50 micrograms of Rh (D)- immunoglobulin immediately after surgical management of early pregnancy loss or within 72 hours of the diagnosis of early pregnancy loss with planned medical management or expectant management in the first trimester. It is reasonable to use the more readily available 300-microgram dose if the 50-microgram dose is unavailable. References-
As in most of the cases of early pregnancy loss, cause is not clear; however, there are ways to lower the risk of miscarriage. A healthy lifestyle before and during pregnancy may help to prevent early pregnancy loss include: