Background

Early pregnancy loss is estimated to occur in 10% of all clinically recognized pregnancies,
with about 80% occurring in the first trimester.[1] The term "abortion" is commonly used to
mean all forms of early pregnancy loss; however, due to the polarizing social stigma assigned
to this term, the term "miscarriage" is used here to indicate all forms of spontaneous early
pregnancy loss or potential loss. One of the common complications of pregnancy is
spontaneous miscarriage, which occurs in an estimated 5-15% of pregnancies. Spontaneous
miscarriages are categorized as threatened, inevitable, incomplete, complete, or missed, and
can be further classified as sporadic or recurrent (>3 occurrences).

Pathophysiology
The pathophysiology of a spontaneous miscarriage may be suggested by its timing.
Chromosomal defects are commonly seen in spontaneous miscarriages, especially those that
occur during 4-8 weeks' gestation. Genetic etiologies are common in early first-trimester loss
but may be seen throughout gestation. Trisomy chromosomes are the most common
chromosomal anomaly. Insufficient or excessive hormonal levels usually result in
spontaneous miscarriage before 10 weeks' gestation. Infectious, immunologic, and
environmental factors are generally seen in first-trimester pregnancy loss. Anatomic factors
are usually associated with second-trimester loss. Factor XIII deficiency and a complete or
partial deficiency of fibrinogen are associated with recurrent spontaneous miscarriage.[2]

A prospective study by Jayasena et al indicated that in in asymptomatic pregnant women at 6

weeks gestation or more, low plasma levels of the hormone kisspeptin are associated with an
increased miscarriage risk.[3]

A spontaneous miscarriage is a process that can be divided into 4 stages, as follows:

threatened, inevitable, incomplete, and complete.

Threatened miscarriage

Vaginal bleeding, abdominal/pelvic pain of any degree, or both during early pregnancy
represents a threatened miscarriage. Approximately a fourth of all pregnant women have
some degree of vaginal bleeding during the first 2 trimesters. About half of these cases
progress to an actual miscarriage.[4] Bleeding and pain accompanying threatened miscarriage
is usually not very intense. Threatened miscarriage rarely presents with severe vaginal
bleeding. On vaginal examination, the internal cervical os is closed and no cervical motion
tenderness or tissue is found. Diffuse uterine tenderness, adnexal tenderness, or both may be
present. Threatened miscarriage is defined by the absence of passing/passed tissue and the
presence of a closed internal cervical os. These findings differentiate threatened miscarriage
from later stages of a miscarriage.

Inevitable miscarriage

Vaginal bleeding is accompanied by dilatation of the cervical canal. Bleeding is usually more
severe than with threatened miscarriage and is often associated with abdominal pain and
cramping.
Incomplete miscarriage

Vaginal bleeding may be intense and accompanied by abdominal pain. The cervical os may
be open with products of conception being passed, or the internal cervical os may be closed.
Ultrasonography is used to reveal whether some products of conception are still present in the
uterus.

Complete miscarriage

Patients may present with a history of bleeding, abdominal pain, and tissue passage. By the
time the miscarriage is complete, bleeding and pain usually have subsided. Ultrasonography
reveals a vacant uterus. Diagnosis may be confirmed by observation of the aborted fetus with
the complete placenta, although caution is recommended in making this diagnosis without
ultrasonography because it can be difficult to determine if the miscarriage is complete.

Etiology
Causes of first- and second-trimester miscarriage

Embryonic abnormalities

Embryonic abnormalities account for 80-90% of first-trimester miscarriages. Note the

following:

Chromosomal abnormalities are the most common cause of spontaneous miscarriage.

More than 90% of cytogenic and morphologic errors are eliminated through
spontaneous miscarriage.
Chromosomal abnormalities have been found in more than 75% of fetuses that
miscarry in the first trimester.
The rate of chromosomal abnormalities increases with age, with a steep increase in
women older than 35 years.
Trisomy chromosomes commonly are encountered, with trisomy 16 accounting for
approximately a third of chromosomal abnormalities in early pregnancy.

Maternal factors

Maternal factors account for the majority of second-trimester miscarriages, with advanced
age and a previous eary pregnancy loss as the most common risk factors.[1] Chronic maternal
health factors include the following:

Maternal insulin-dependent diabetes mellitus (IDDM): As many as 30% of

pregnancies in women with IDDM result in spontaneous miscarriage, predominantly
in patients with poor glucose control in the first trimester.
Severe hypertension
Renal disease
Systemic lupus erythematosus (SLE)
Hypothyroidism and hyperthyroidism

Acute maternal health factors include the following:

 Infections (eg, rubella, cytomegalovirus [CMV], and mycoplasmal, ureaplasmal,
listerial, toxoplasmal infections)
Trauma

Severe emotional shock may also cause first- and second-trimester miscarriages.

Other factors that may contribute to miscarriage

Exogenous factors include the following:

Alcohol
Tobacco
Cocaine and other illicit drugs

Anatomic factors include the following:

Congenital or acquired anatomic factors are reported to occur in 10-15% of women who have
recurrent spontaneous miscarriages.

Congenital anatomic lesions include mllerian duct anomalies (eg, septate uterus,
diethylstilbestrol [DES]-related anomalies). Mllerian duct lesions usually are found
in second-trimester pregnancy loss.
Anomalies of the uterine artery with compromised endometrial blood flow are
congenital.
Acquired lesions include intrauterine adhesions (ie, synechiae), leiomyoma, and
endometriosis.
Other diseases or abnormalities of the reproductive system that may result in
miscarriage include congenital or acquired uterine defects, fibroids, cervical
incompetence, abnormal placental development, or grand multiparity.

Endocrine factors include the following:

Endocrine factors potentially contribute to recurrent miscarriage in 10-20% of cases.

Luteal phase insufficiency (ie, abnormal corpus luteum function with insufficient
progesterone production) is implicated as the most common endocrine abnormality
contributing to spontaneous miscarriage.
Hypothyroidism, hypoprolactinemia, poor diabetic control, and polycystic ovarian
syndrome are contributive factors in pregnancy loss.

Infectious factors include the following:

Presumed infectious etiology may be found in 5% of cases.

Bacterial, viral, parasitic, fungal, and zoonotic infections are associated with recurrent
spontaneous miscarriage.

Immunologic factors include the following:

Immunologic factors may contribute in up to 60% of recurrent spontaneous

miscarriages.
 Both the developing embryo and the trophoblast may be considered immunologically
foreign to the maternal immune system.
Antiphospholipid antibody syndrome generally is responsible for more second-
trimester pregnancy losses than first-trimester losses.

Miscellaneous factors

Miscellaneous factors may account for up to 3% of recurrent spontaneous miscarriages. Other

contributing factors implicated in sporadic and recurrent spontaneous abortions include
environment, drugs, placental abnormalities, medical illnesses, and male-related causes.

Gestational exposure to nonaspirin NSAIDs may increase the risk for miscarriage. Nakhai-
Pour et al identified 4705 women who had spontaneous abortions by 20 weeks' gestation.
Each case was matched to 10 control subjects (n=47,050) who did not have a spontaneous
abortion. In the women who had a miscarriage, 352 (7.5%) were exposed to a nonaspirin
NSAID, whereas NSAID exposure was lower (1213 exposed [2.6%]) in women who did not
have a miscarriage.[5]

On the other hand, a study by Daniel et al suggested that for the most part, gestational
exposure to nonaspirin NSAIDs does not increase the risk for spontaneous miscarriage. In a
study cohort that included 65,457 women who conceived during the study period, a total of
6508 (9.9%) experienced spontaneous miscarriage. Exposure to NSAIDs was not found to be
an independent risk factor for miscarriage, with the exception of indomethacin, which, the
study indicated, is significantly associated with spontaneous abortion following first-trimester
exposure.[6]

Epidemiology
United States statistics

Many pregnancies are not viable. According to estimates, 50% of pregnancies terminate
spontaneously before the first missed menstrual period; these miscarriages usually are not
clinically recognized. Spontaneous miscarriage is typically defined as a clinically recognized
(ie, by blood test, urine test, or ultrasonography) pregnancy loss before 20 weeks' gestation.
Approximately 5-15% of diagnosed pregnancies result in spontaneous miscarriage.

International

Some European investigators quote the rate of spontaneous miscarriage to be as low as 2-5%.
Chinese researchers concluded that increased parental exposure to phenols is associated with
spontaneous abortion.[7]

Race- and age-related demographics

Surveillance data for pregnancy-related deaths demonstrate more deaths due to ectopic
pregnancy, spontaneous miscarriage, and induced abortion among African American women
than among white women. Eight percent of pregnancy-related deaths among black women
were due to ectopic pregnancies; 7% were due to miscarriages. Among white women, data
show that 4% of pregnancy-related deaths were due to ectopic pregnancies; 4% were due to
miscarriages.[8, 9]

Age and increased parity affect a woman's risk of miscarriage. In women younger than 20
years, miscarriage occurs in an estimated 12% of pregnancies. In women older than 20 years,
miscarriage occurs in an estimated 26% of pregnancies.

Age primarily affects the oocyte. When oocytes from young women are used to create
embryos for transfer to older recipients, implantation and pregnancy rates mimic those seen
in younger women. The number of miscarriages and chromosomal anomalies decreases,
suggesting that the uterus is not responsible for poor outcomes in women of advanced
reproductive age.

Prognosis
The prognosis for a successful pregnancy depends upon the etiology of previous spontaneous
miscarriages, the age of the patient, and the sonographic appearance of the gestation.

Correction of an endocrine abnormality in women with recurrent miscarriage has the best
prognosis for a successful pregnancy (>90%).

In women with an unknown etiology of prior pregnancy loss, the probability of achieving
successful pregnancies is 40-80%.

The live-birth rate after documentation of fetal cardiac activity at 5-6 weeks of gestation in
women with 2 or more unexplained spontaneous miscarriages is approximately 77%.

When the transvaginal pelvic sonogram shows an embryo of at least 8 weeks estimated
gestational age (EGA) and cardiac activity, the miscarriage rate for patients younger than 35
years is 3-5% and for those older than 35 years is 8%.

Unfavorable sonographic prognostic indicators are a fetal cardiac activity rate that is slower
than 90 beats per minute, an abnormally shaped or sized gestational sac, and a large
subchorionic hemorrhage.

The overall miscarriage rate for patients older than 35 years is 14% and for patients younger
than 35 years is 7%.

Mortality/Morbidity

Surveillance data suggest that spontaneous miscarriages and induced abortions accounted for
about 4% of pregnancy-related deaths in the United States.[8]

Complications

Potential complications of early pregnancy loss include septic miscarriage and hypovolemic
or septic shock.

Preexisting anemia may make patients more susceptible to hypovolemic shock.

Patients with HIV infection who are undergoing curettage may have a higher rate of
procedure-related complications but no increase in infectious morbidity.

Coagulation defects may be associated with a retained dead fetus.

Other possible complications include post miscarriage bleeding, retained products of

conception, and hematometra.

Patient Education
Advise patients to return to the ED upon occurrence of symptoms such as the following:

Profuse vaginal bleeding (more than 1 pad/hour)

Severe pelvic pain
Temperature above 38C (100.4F)

Patients may experience intermittent menstrual-like flow and cramps during the following
week. The next menstrual period usually occurs in 4-5 weeks.

Patients can resume regular activities when able to but should refrain from intercourse and
douching for approximately 2 weeks.

For patient education resources, see Pregnancy Center, as well as Bleeding During
Pregnancy, Miscarriage, Abortion, and Dilation and Curettage (D&C).

History
Patients with spontaneous miscarriage usually present to the ED with vaginal bleeding,
abdominal pain, or both. Note the following:

Vaginal bleeding may vary from slight spotting to a severe life-threatening

hemorrhage. The patient's history should include the number of pads or tampons used.
Hasan et al found that heavy bleeding in the first trimester, particularly when
associated with abdominal pain, is associated with higher risk of miscarriage.[10]
Presence of blood clots or tissue may be an important sign indicating progression of
spontaneous miscarriage.
Abdominal pain is usually located in the suprapubic area or in one or both lower
quadrants.
Pain may radiate to the lower back, buttocks, genitalia, and perineum.

The patient's history should also include the following:

Date of last menstrual period (LMP)

Estimated length of gestation
Sonogram results, if previously performed
Bleeding disorders
Previous miscarriage or elective abortions
Other symptoms, such as fever or chills, are more characteristic of a septic miscarriage or
abortion.

Consider any woman of childbearing age with vaginal bleeding pregnant until proven
otherwise.

Physical
Pelvic examination should focus on determining the source of bleeding, such as the
following:

Blood from cervical os

Intensity of bleeding
Presence of clots or tissue fragments
Cervical motion tenderness (presence increases suspicion for ectopic pregnancy)
Status of internal cervical os: open indicates inevitable or possibly incomplete
miscarriage; closed indicates threatened miscarriage.
Uterine size and tenderness, as well as adnexal tenderness or masses

Signs of threatened miscarriage include the following:

Vital signs should be within reference ranges unless infection is present or

hemorrhage has caused hypovolemia.
The abdomen usually is soft and nontender.
Pelvic examination reveals a closed internal cervical os. The bimanual examination is
unremarkable.

Signs of incomplete miscarriage include the following:

The cervix may appear dilated and effaced, or it may be closed.

Bimanual examination may reveal an enlarged and soft uterus.
On pelvic examination, products of conception may be partially present in the uterus,
may protrude from the external os, or may be present in the vagina. Bleeding and
cramping usually persist.

Signs of complete miscarriage: On pelvic examination, the cervix should be closed, and the
uterus should be contracted.

Signs of missed miscarriage include the following:

Vital signs usually are within reference ranges. Abdominal examination may or may
not reveal a palpable uterus. If palpable, the uterus usually is small for the presumed
gestational age.
Fetal heart tones are inaudible or unseen on sonogram.
The cervical os is closed upon pelvic examination. The uterus may feel soft and
enlarged.
Diagnostic ConsiderationsImportant
considerationsSpecial considerations
Perform pregnancy testing for every woman of childbearing age who presents with lower
abdominal pain, vaginal bleeding, or both. History alone is not sufficient to exclude
pregnancy. Pregnancy is possible even if the patient gives a history of a recent normal
menstrual period, lactation, or contraceptive use.

Rule out ectopic pregnancy. An ectopic pregnancy must be excluded in every pregnant
woman with abdominal pain, vaginal bleeding, or both during the first or second trimester.
Endometrial shedding, which clinically simulates miscarriage, may occur with an ectopic
pregnancy. This misdiagnosis is the greatest potential pitfall. An empty uterus on sonogram
may represent an ectopic pregnancy.

Prevent hemolytic disease of the newborn. Ascertain the blood type of every pregnant patient
with vaginal bleeding. If the patient is Rh-negative, administer RhoGAM to prevent
hemolytic disease of the newborn (see Medication).

Assess the intensity of hemorrhage. External bleeding may not accurately reflect total
hemorrhage. The patient, especially in the supine position, may collect large amounts of
blood in the vagina with minimal external bleeding. Similarly, a large quantity of retained
blood may be present in the uterine cavity and, in the case of ectopic pregnancy, in the
peritoneal cavity. Therefore, never rely on the external examination to assess the rate of
hemorrhage in patients with vaginal bleeding. Always perform a pelvic examination to look
for blood collection in the vagina, disproportionately tender uterus, and signs of peritoneal
irritation.

Identify retained products of conception. Ultrasonography for the diagnosis of retained

products can yield false-positive rates, with one report of an overall false-positive rate of
34%. Retained products may be more commonly found when an evacuation is performed
after 15 weeks' gestation.

Offer grief counseling to all patients after a miscarriage.

Referral to a specialist for determination of the cause of recurrent miscarriage may be

indicated.[11]

Differential Diagnoses
Abortion Complications
Appendicitis
Dysfunctional Uterine Bleeding in Emergency Medicine
Dysmenorrhea
Emergent Management of Ectopic Pregnancy
Emergent Treatment of Endometriosis
Molar pregnancy
Ovarian Cysts
Ovarian Torsion
 Pregnancy Trauma
Urinary Tract Infections in Pregnancy
Vaginitis

Laboratory Studies
Laboratory studies may include the following:

Qualitative urine pregnancy test, to confirm pregnancy

Complete blood count with differential
Blood type and Rh factor: Blood type must be documented for every pregnant patient
with vaginal bleeding. If Rh-negative, administer RhoGAM to prevent hemolytic
disease of the newborn in this pregnancy and subsequent pregnancies.
Hemoglobin and hematocrit: These studies establish baseline and detect hemorrhagic
anemia.
Factor XIII and fibrinogen, if indicated per history

Quantitative human chorionic gonadotropin-beta

The discriminatory level of beta-hCG is approximately 1500 mIU/mL above which there
should be sonographic evidence of early intrauterine pregnancy, if present. Beta-hCG level
rises at rate of doubling approximately every 48 hours for 85% of intrauterine pregnancies.
The remaining 15% may rise with a different slope or be plateaued.

A higher likelihood of ectopic pregnancy or subsequent miscarriage exists if hCG blood level
is lower than predicted by estimated gestational age (GA) based on the last menstrual period
(LMP).

The possibility of molar pregnancy exists if beta-hCG is very high and out of proportion to
predicted gestational age. This pregnancy occurs with or without evidence of early normal
trophoblast growth and function, as indicated by adequately rising beta-hCG levels.

Imaging Studies
Ultrasonography is used widely and is the imaging study of choice. Advantages of
ultrasonography include bedside use, availability, low cost, and noninvasiveness.
Disadvantages include operator dependency.

Ultrasonography aids identification of retained products of conception, fetal demise,

incomplete miscarriage, ectopic pregnancy, or empty uterus; therefore, it provides a clinically
relevant classification of early pregnancy loss. Following spontaneous first-trimester
complete miscarriage, endovaginal ultrasonography has been found to be 81% sensitive and
94% specific in detection of retained products of conception.[12] Ultrasonography is the most
accurate diagnostic modality in the confirmation of a viable pregnancy during the first
trimester.[12]

Transabdominal ultrasonography of the pelvis provides an overall view of the pelvic

structures. A full bladder is required as a sonographic window.
Endovaginal ultrasonography gives a detailed view of the endometrium of the uterus, ovaries,
adnexa, and cul-de-sac. An empty bladder is required for optimal imaging.

Indications for ultrasonography in the ED include abdominal or pelvic pain, vaginal bleeding,
persistently open cervical os, adnexal mass or fullness, cervical motion tenderness,
discrepancy between uterine size and last menstrual period (LMP), and discrepancy between
expected and measured beta-hCG levels.

Seymour et al sought to determine whether a physical examination was necessary in pregnant

patients presenting with pregnancy-related complaints and a viable pregnancy as shown on
bedside ultrasonography. Fifty patients were enrolled in the study; each patient received a
pelvic examination before ultrasonography. In all patients, findings on physical examination
were the same as those found by ultrasonography. Bedside ultrasonography provided all the
information needed to determine immediate management of these patients. Few findings on
pelvic examination are likely to alter this management.[13]

The findings of the study by Seymour et al also complement the findings of Close et al, who
found there was very little inter-examiner reliability of the bimanual pelvic examination for
identifying masses or uterine size,[14] which are principally the physical findings being
evaluated in the early pregnant patient in the ED setting. Taken together, these studies
highlight the impact that advances in technology has on the practice of medicine, but, at this
time, the findings are unlikely to change current practice.

A high-resolution vaginal ultrasound probe can detect pregnancy at 3-4 weeks' gestation and
fetal heart activity at 5 and a half weeks. The presence of fetal cardiac activity in women with
bleeding in early pregnancy has been noted to have a sensitivity of 97% and a specificity of
98% for fetal survival to the 20th week of pregnancy.[12]

Fetal studies are limited in the first trimester due to small fetal size. Ultrasonography usually
provides information in 3 major areas: location of pregnancy, pregnancy size, and absence or
presence of fetal cardiac activity.

An apparently empty uterus revealed by ultrasonography in a pregnant woman (ie, positive

beta-hCG findings, LMP within last 20 wk) suggests a very early pregnancy (ie, < 3 wk GA),
a completed miscarriage, or an ectopic pregnancy. (See Bedside Ultrasonography, First-
Trimester Pregnancy.)

Sonographic signs suggestive of a nonviable pregnancy include the following:

Irregular gestational sac (ie, gestational sac >25-mm mean sac diameter [MSD] on
transabdominal sonogram; >16-mm MSD on endovaginal sonogram without a
detectable embryo)
Nonliving embryo (embryo without a heartbeat)
Presence of abnormal hyperechoic material within the uterine cavity, as depicted in
the sonogram below
 This endovaginal
longitudinal view demonstrates fluid within the uterus (Ut). Echogenic debris also is
present within the endometrial cavity. This image shows a large pseudogestational sac
of an ectopic pregnancy.

The Society of Radiologists in Ultrasound indicate the following findings are diagnostic of
early pregnancy loss[1] :

A fetal crownrump length of 7 mm or greater and absent heartbeat

A mean sac diameter of 25 mm or greater without an embryo
Absence of an embryo with a heartbeat 2 weeks or longer after a scan that showed a
gestational sac without a yolk sac
Absence of an embryo with a heartbeat 11 days or longer after a scan that showed a
gestational sac with a yolk sac

Consider the sonographic diagnosis of early pregnancy failure in relationship to

developmental stage. Note the following:

Subclinical or preclinical loss: This occurs within the first 2 weeks after conception.
Sonographic evidence of pregnancy does not exist at this stage.
Loss at 5-6 weeks: Loss at this stage is based upon gestational sac characteristics.
Abnormal gestational sac size is the most reliable indicator of abnormal outcome.
Gestational sacs should be 5-mm mean sac diameter (MSD) by the fifth gestational
week. An abnormally large gestational sac, as determined by high-frequency
endovaginal sonography (HFEVS), is observed when the MSD is more than 8 mm
without a demonstrable yolk sac or is more than 16 mm without a demonstrable
embryo.
Loss at 7-8 weeks: Sonographic evidence is based upon demonstration of an abnormal
embryo or gestational sac.
Loss at 9-12 weeks: Sonographic diagnosis of embryonic demise is usually made on
demonstration of an abnormal fetus. Sonographic evidence of a fetus lacking cardiac
activity is the most specific indicator of embryonic demise. This is depicted in the
sonogram below.
 This endovaginal
ultrasonogram reveals an irregular gestational sac with an amorphic fetal pole. No
fetal cardiac activity was noted. This image represents a missed miscarriage or fetal
demise.

Caution is advised in the diagnosis of embryonic demise. Determination of whether the

viewed structure is the embryo is critical, as no other morphologically recognizable
structures, other than a heartbeat, exist at this stage of development. The embryo must be
scanned thoroughly for evidence of a heartbeat. Note the following:

Most recommendations call for 2 independent examiners to view the embryo, either
concurrent with the ED visit or at follow-up.
Most sonographers recommend repeating the scan within 3-7 days to determine if
normal development is occurring.
On follow-up, a falling beta-human chorionic gonadotropin (hCG) level, as well as
abnormal fetal development, confirms embryonic demise.

Sonography can identify presence of a subchorionic hematoma or hemorrhage (ie, bleeding

between the endometrium and the gestational sac) and may include the following features:

A subchorionic hemorrhage is the most commonly identified source of first-trimester

bleeding, appearing on sonography as a crescent-shaped hypoechoic area next to the
gestational sac.
Subchorionic hemorrhage encompasses a spectrum of sonographic findings.
Subchorionic fluid can be classified in relation to gestational sac size and length of
gestation. Subchorionic bleeding is present when pulsation of the subchorionic fluid is
noted.
Size of the subchorionic hemorrhage should be taken into consideration, as greater
size relates to an increased risk of spontaneous miscarriage. A large subchorionic
hematoma (ie, surrounding greater than 50% of the gestational sac) is a poor
prognostic indicator for the pregnancy outcome. A subchorionic hemorrhage is
depicted below.
 This endovaginal
ultrasonographic image demonstrates a subchorionic hemorrhage (SH) less than half
the gestational sac size.

Subchorionic bleeding can be demonstrated using color Doppler imaging.

Endovaginal ultrasonography should be applied whenever possible to limit image
distortion due to patient habitus or an overdistended bladder.

An incomplete miscarriage may demonstrate a variety of sonographic findings as follows:

The gestational sac may be misshaped or collapsed, or it may be intact, containing a

nonliving embryo. In addition, an irregular complex mass within the endometrial or
endocervical canal may be present. Sonogram of an incomplete miscarriage is shown
below.

This image shows an

endovaginal longitudinal view of a low-lying gestational sac (GS) within the uterus
(Ut), representing an incomplete miscarriage.
 Echogenic material or debris within the endometrial canal may represent retained
products of conception or clotted blood.
First-trimester molar pregnancies may simulate an incomplete miscarriage, with
echogenic material within the endometrial cavity that has no characteristic vesicles or
cysts.
Intrauterine fluid collections may represent pseudogestational sacs found in ectopic
pregnancies.
Studies suggest no statistically significant relationship between the initial presence of
a gestational sac or endometrial thickness and the success rate of expectant
management.

A complete miscarriage may demonstrate the following sonographic findings:

An empty uterus noted on endovaginal sonogram suggests a complete miscarriage;

however, sonographic diagnosis includes ectopic pregnancy and early intrauterine
pregnancy.
Careful scanning for adnexal masses and/or free fluid is advised.

No single ultrasonographic measurement of the different anatomical features in the first

trimester has demonstrated a high predictive value for determining early pregnancy outcome.
Relatively recent research suggests the finding of blood flow in the intervillous space in cases
of first-trimester miscarriage using color Doppler ultrasonography as useful in the prediction
of successful expectant management. Miscarriages with intervillous space blood flow were 4
times more likely to complete with expectant management.

Prehospital Care
Maintain routine universal precautions in view of potentially heavy vaginal bleeding.
Emergency medical services (EMS) personnel should be aware of the potential for
hemorrhagic shock and should treat any hemodynamic instability.

Obtain vital signs and establish an intravenous line in all pregnant patients who have
abdominal pain and vaginal bleeding. If the patient is hypotensive, an intravenous bolus of
normal saline (NS) is indicated for hemodynamic stabilization.

Administer oxygen.

Encourage the patient to bring any passed tissue to the hospital for evaluation.

Emergency Department Care

Management

Treat all patients with vaginal bleeding of any etiology as follows:

Determine hemodynamic stability and treat instability. If the patient is in hemorrhagic

shock, treatment includes the Trendelenburg position, oxygen, aggressive fluid
resuscitation (at least 2 large-bore IV lines with lactated Ringer [LR] solution or
normal saline, wide open), and hemotransfusion.
 Determine pregnancy status (qualitative and quantitative).
Make laboratory determination of hematocrit (Hct) level and Rh status.
Perform a pelvic examination to determine the rate of bleeding; presence of blood
clots or products of conception; and condition of cervical os, cervix, uterus, and
adnexa.
Perform pelvic ultrasonography to determine intrauterine and/or extrauterine contents
(fetal heart activity) and/or to clinically classify spontaneous miscarriage.

The American College of Obstetricians and Gynecologists (ACOG) recommends generally

limiting expectant management to gestations within the first trimester owing to potential
hemorrhage as well as a lack of safety studies of expectant management in the second
trimester.[1] An estimated 80% success rate in achieving complete expulsion when adequate
time is allowed (8 weeks). For women who wish to reduce the time to complete expulsion
but do not wish to undergo surgical evacuation, treatment with misoprostol may be
considered.[1]

Nadarajah et al found no statistically significant difference in the success rate between 360
women who underwent expectant or surgical management of early pregnancy loss, nor was
there any difference in the types of miscarriage.[15] With expectant management, 74% patients
had a complete spontaneous expulsion of products of conception. Of these patients, 106
(83%) miscarried within 7 days. However, the rates of unplanned admissions (18.1%) and
unplanned surgical evacuations (17.5%) in the expectant group,were significantly higher than
those in the surgical group (7.4% and 8% respectively).[15]

Diagnostic specific management

Inevitable miscarriage

The goal of treatment is evacuation of the uterus to prevent complications (eg, further
hemorrhage, infection).

Incomplete miscarriage

If tissue, blood clots, or products of conception are found in the cervical os, remove them
with ring forceps to facilitate uterine contractions and hemostasis. For the same reason, use
oxytocin in cases of severe bleeding (10-20 mcg/L of NS, wide open).

Administer RhoGAM to a gravid patient who is Rh-negative and is experiencing vaginal

bleeding.

Consider hemotransfusion in the case of severe bleeding, hemodynamic instability, or both.

Consider treatment with misoprostol to facilitate completion of the miscarriage.

Complete miscarriage

Treatment of a patient who has had a complete miscarriage varies depending on the degree of
certainty of the diagnosis. Diagnosing complete miscarriage in the ED can be difficult, unless
an intact gestational sac was expelled.
If pelvic examination produces fetal tissue (or material of similar appearance), send it to the
laboratory for identification of possible products of conception.

Missed miscarriage

Treatment may vary depending on gestational age as follows:

First trimester: Most patients pass the products of conception spontaneously.

Coagulation defects secondary to a dead fetus are rare. Expectant management, [16]
suction curettage, or misoprostol for medical management to facilitate passage of
products of conception may be performed. [17]
Second trimester: The uterus is emptied by dilatation and evacuation; alternatively,
the uterus is emptied by induction of labor.

Hospitalization

If vaginal bleeding cannot be controlled in the ED, transfer the patient to the operating room
(OR) for examination. Anesthetize the patient and perform uterine evacuation.

Transfer

Transfer patients with evidence of a coagulation disorder to a higher level of care.

Consultations
Consultation with an obstetrician/gynecologist is indicated in all patients with the diagnosis
of inevitable or incomplete miscarriage; patients with severe hemorrhage or patients who are
hemodynamically unstable require immediate consultation for assistance with definitive
treatment. Definitive treatment may be to evacuate the products of conception from the uterus
with curettage. Depending on hospital policy, curettage may be performed in the emergency
department with subsequent observation of patients for 4-6 hours after curettage, and then
discharge if no complications occur. Curettage is generally reserved for those patients who
are at risk for hemodynamic instability due to the briskness of bleeding or for those in whom
endometritis is a concern. However, most patients with inevitable or incomplete miscarriage
are candidates for medical management with misoprostol.[18, 19, 20, 21]

Long-Term Monitoring
Threatened miscarriage

Counsel all patients discharged from the ED (with any stage of miscarriage) regarding
possible complications. OB/GYN follow up in 1-2 days should be arranged.

Incomplete miscarriage

After the first dose of misoprostol is administered intravaginally, the patient may be
discharged to follow up with her OB/GYN in 24-48 hours.
If a curettage is performed in the ED, the patient should be observed for 4-6 hours. If stable,
the patient can be discharged.

Administer the standard dose of Rho(D) immune globulin (ie, 300 mcg) to women who are
Rh-negative to prevent Rh immunization (see Medication).

Send the products of conception for pathologic evaluation.

Missed miscarriage

Ultrasonographic findings, in association with presence or absence of significant clinical

bleeding, may aid in determination of medical versus expectant management as well as
urgent versus routine follow-up.

In the case of expectant management, advise the patient to return to the ED or to contact an
OB/GYN if severe cramping, bleeding, fever, and/or passage of tissue occur.

In the case of medical management with misoprostol, the first dose of 800 micrograms may
be administered intravaginally in the ED, with follow up to an OB/GYN in 24-48 hours.
Patients should be warned to return to the ED or contact their OB/GYN immediately for
severe cramping, bleeding, fever, and/or passage of tissue.

Medication Summary
The goals of pharmacotherapy are to prevent complications and to reduce morbidity.

Immune globulins
Class Summary

This agent suppresses immune response and antibody formation.

View full drug information

Rho(D) Immune Globulin (RhoGAM)

In nonsensitized Rho(D)-negative mothers who are exposed to Rho(D) prevents antibody

formation to Rh-positive red blood cells of the fetus caused by abortion, fetomaternal
hemorrhage, abdominal trauma, amniocentesis, full-term delivery, or transfusion accident.

Oxytocic Agent
Class Summary

This agent has vasopressive effects and prevents postpartum bleeding.

View full drug information

Oxytocin (Pitocin, Syntocinon)

Produces rhythmic uterine contractions and can control postpartum bleeding or hemorrhage.

Prostaglandin
Class Summary

These agents induce uterine contractions.

View full drug information

Misoprostol (Cytotec)

Not approved for use in pregnancy, yet is an invaluable medication widely used for cervical
preparation for miscarriage, labor induction, and as a medical abortifacient. Provides safe,
passive method of cervical dilatation and should be considered for facilitation of passage of
products of conception in the setting of inevitable or incomplete miscarriage, preabortion
ripening when prior uterine surgery (ie, LEEP, cesarean delivery) are known risk factors for
uterine perforation during surgical abortion. Can be administered orally or vaginally. Some
studies show premoistened tablets placed vaginally help absorption. Patients can be instructed
in self-administration to help time the dose in synchrony with their abortion procedure.

In a study by Singh of primigravid women (6-11 wk gestation), 93.3% achieved dilatation of

the cervix of 8 mm or greater after 3 h postintravaginal misoprostol 400 mcg, whereas only
16.7% of women achieved this after 2 h of 600 mcg. The 600-mcg group had slightly greater
adverse effects (eg, bleeding, abdominal pain, fever >38C).

Dosage intended for cervical ripening can induce abortion in some patients. Oral doses of
100-400 mcg can be combined with vaginal insertion of prostaglandins to enhance cervical
dilatation.

Early Pregnancy Loss in Emergency Medicine Medication

Author: Slava V Gaufberg, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD

http://emedicine.medscape.com/article/795085-medication#showall

Updated: Nov 08, 2015

Practice Essentials
Early pregnancy loss, or miscarriage, is the loss of a pregnancy before 20 weeks.

In the first trimester, embryonic causes of spontaneous abortion are the predominant etiology
and account for 80-90% of miscarriages (see the image below).

Second transvaginal sonogram

obtained 1 week after the initial study fails to demonstrate fetal development. This confirms
the diagnosis of an embryonic pregnancy.

Signs and symptoms

Patients with spontaneous complete abortion usually present with a history of vaginal
bleeding, abdominal pain, and passage of tissue. After the tissue passes, the vaginal bleeding
and abdominal pain subsides.

Other symptoms, such as fever or chills, are more characteristic of infection, such as in a
septic abortion. Septic abortions need to be treated immediately, otherwise they may be life-
threatening.

Patients who are pregnant and bleeding vaginally need immediate evaluation.

See Clinical Presentation for more detail.

Diagnosis

Examination in women with suspected early pregnancy loss includes the following:

Assessment of hemodynamic stability, including vital signs

Abdomen: In a complete abortion, the abdomen is benign, with normal bowel sounds,
no distention, no rebound, no hepatosplenomegaly, and mild suprapubic tenderness;
complete abortion is unlikely if rebound tenderness or a distended abdomen is
present instead, assume ectopic pregnancy (and promptly initiate appropriate
therapy)
Pelvis: In a complete abortion, some blood may be present on the perineum or vagina,
but there is limited active bleeding, no cervical motion tenderness, a closed cervical
 canal, smaller uterus than expected for dates, uterus and adnexa nontender to mildly
tender, no adnexal masses (unless a corpus luteum is still palpable)

The pelvic examination checklist includes assessment of the following:

Source of bleeding (cervical os)

Intensity of bleeding (active, heavy, clots)
Any presence or passage of tissue
Cervical motion tenderness (increases suspicion for ectopic pregnancy)
Cervical os closed for complete or threatened abortion (If it is open, consider
inevitable or incomplete abortion.)
Uterine size and tenderness
Adnexal masses (suspicious for ectopic pregnancy)

Testing

Laboratory studies used in the evaluation of early pregnancy loss include the following:

Complete blood count with differential

levels of beta-human chorionic gonadotropin
Blood type and screen (possible crossmatch)
Disseminated intravascular coagulopathy profile in women with significant bleeding
(platelet count, fibrinogen level, prothrombin time, activated partial prothrombin
time)

Urinalysis

Imaging studies

Perform pelvic ultrasonography using a vaginal probe to rule out an ectopic pregnancy,
retained products of conception, hematometra, or other etiologies.

Procedures

When the diagnosis is unclear, the following procedures may be performed:

Culdocentesis
Diagnostic dilation and curettage

See Workup for more detail.

Management

A complete abortion usually needs no further treatment, medically or surgically. With

missed, incomplete, or inevitable abortion present before 13 weeks' gestation, treatment may
include misoprostol as an alternative to surgery or performance of suction dilation and
curettage.

An ectopic pregnancy may be treated medically (methotrexate) or surgically (laparoscopy,

laparotomy), depending on the clinical situation.
Pharmacotherapy

For a complete abortion, no medication is likely to be needed. Usually, the uterus contracts
well after expelling the entire contents and the cervix is closed. The risk for infection is
minimal.

The following medications may be used in women with early pregnancy loss:

Immune globulins (eg, Rho (D) immune globulin)

Ergot alkaloid and derivatives (eg, methylergonovine)
Antimetabolite antineoplastic agents (eg, methotrexate)
Prostaglandins (eg, misoprostol)

Surgical option

Surgical intervention may include the following:

Complete abortion: None

Inevitable and incomplete abortions: Suction dilation and curettage
Septic abortion: Broad spectrum antibiotic therapy and suction dilation and curettage
Ectopic pregnancy: Treat medically for appropriate patients; the rest require surgery
such as linear salpingostomy or partial or complete salpingectomy via laparoscopy or
laparotomy
Unclear diagnosis: Diagnostic suction dilation and curettage with diagnostic
laparoscopy

See Treatment and Medication for more detail.

Background
An abortion is the spontaneous or induced loss of an early pregnancy. The period of
pregnancy prior to fetal viability outside of the uterus is considered early pregnancy. Most
consider early pregnancy to end at 20 weeks' gestation or when the fetus weighs 500 grams.
The term miscarriage is used often in the lay language and refers to spontaneous abortion.

Pathophysiology
A spontaneous abortion is a process that can be divided into 4 stagesthreatened, inevitable,
incomplete, and complete. The 4 stages of abortion form a continuum. Most studies do not
differentiate separately between the epidemiology and pathophysiology of each entity.

The combination of oxidative stress, a more hypoxic environment, and defective placentation
may lead to increased serum ischemia-modified albumin (IMA) concentrations, which in
turn, may play a role in the pathophysiology of early pregnancy loss.[1]

Threatened abortion
Threatened abortion consists of any vaginal bleeding during early pregnancy without cervical
dilatation or change in cervical consistency. Usually, no significant pain exists, although mild
cramps may occur. More severe cramps may lead to an inevitable abortion.

Threatened abortion is very common in the first trimester; about 25-30% of all pregnancies
have some bleeding during the pregnancy. Less than one half proceed to a complete abortion.
On examination, blood or brownish discharge may be present in the vagina. The cervix is not
tender, and the cervical os is closed. No fetal tissue or membranes have passed. The
ultrasound shows a continuing intrauterine pregnancy. If an ultrasound was not performed
previously, it is required at this time to rule out an ectopic pregnancy, which could present
similarly. If the uterine cavity is empty on ultrasound, obtaining a human chorionic
gonadotropin (hCG) level is necessary to determine if the discriminatory zone has been
passed.

The discriminatory zone is the level of hCG beyond which a normal, singleton, intrauterine
pregnancy is consistently visible by ultrasound. The discriminatory zone may vary depending
on a number of factors, including the hCG assay type and reference calibration standard used,
ultrasound equipment resolution, the skill and experience of the sonographer, and patient
factors (eg, obesity, leiomyomas, uterine axis, multiple gestations). Also, the discriminatory
zone will vary depending on whether the ultrasound is performed abdominally or vaginally.
Therefore, having a universal discriminatory zone is difficult, and it optimally should be
calculated at each site.

Some studies recommend that a gestational sac should be visualized by 5.5 weeks' gestation;
a gestational sac should be visualized with an hCG level of 1500-2400 mIU/mL for
transvaginal ultrasound or with an hCG level over 3000 mIU/mL for a transabdominal
ultrasound. If the hCG level is higher than the discriminatory zone and no gestational sac is
visualized in the uterus, then consider that an ectopic pregnancy may be present.[2] Multiple
gestations are an exception and can have higher hCG levels earlier in gestation because more
hCG is being made by the trophoblasts from the multiple implantations. Thus, the gestational
sac(s) may not be visible on ultrasound despite the hCG levels being higher than the
discriminatory zone. Even with multiple gestations, the gestational sacs should be visible at a
similar gestational age as singleton gestations or about 6 weeks' gestation if the dating is
good.

A clinician should be concerned about ectopic pregnancy but cannot make the diagnosis of
ectopic pregnancy just because the hCG level is higher than the discriminatory zone and the
uterus appears empty on ultrasound. Many of these pregnancies are abnormal intrauterine
pregnancies as opposed to ectopic. One needs to take into consideration the clinical history,
and estimated gestational age by LMP or date of conception, if known. A positive pregnancy
test result and an ultrasound that does not reveal the location is known as a pregnancy of
unknown location (PUL).[3] Occasionally, a normal intrauterine pregnancy does result.
Depending on the clinical scenario, a clinician may choose to observe this patient with serial
hCG levels and ultrasonography instead of intervening, or a clinician may need to intervene
depending on the situation.

Inevitable abortion

Inevitable abortion is an early pregnancy with vaginal bleeding and dilatation of the cervix.
Typically, the vaginal bleeding is worse than with a threatened abortion, and more cramping
is present. No tissue has passed yet. On ultrasound, the products of conception are located in
the lower uterine segment or the cervical canal.

Incomplete abortion

Incomplete abortion is a pregnancy that is associated with vaginal bleeding, dilatation of the
cervical canal, and passage of products of conception. Usually, the cramps are intense, and
the vaginal bleeding is heavy. Patients may describe passage of tissue, or the examiner may
observe evidence of tissue passage within the vagina. Ultrasound may show that some of the
products of conception are still present in the uterus.

Complete abortion

Complete abortion is a completed miscarriage. Typically, a history of vaginal bleeding,

abdominal pain, and passage of tissue exists. After the tissue passes, the patient notes that the
pain subsides and the vaginal bleeding significantly diminishes. The examination reveals
some blood in the vaginal vault; a closed cervical os; and no tenderness of the cervix, uterus,
adnexa, or abdomen. The ultrasound demonstrates an empty uterus.

Missed abortion

A fifth term that does not follow the continuum but is important to be aware of is missed
abortion. A missed abortion is a nonviable intrauterine pregnancy that has been retained
within the uterus without spontaneous abortion. Typically, no symptoms exist besides
amenorrhea, and the patient finds out that the pregnancy stopped developing earlier when a
fetal heartbeat is not observed or heard at the appropriate time. An ultrasound usually
confirms the diagnosis. No vaginal bleeding, abdominal pain, passage of tissue, or cervical
changes are present.

Etiology
In the first trimester, embryonic causes of spontaneous abortion are the predominant etiology
and account for 80-90% of miscarriages (see the image below).

Second transvaginal sonogram

obtained 1 week after the initial study fails to demonstrate fetal development. This confirms
the diagnosis of an embryonic pregnancy.
One study suggested that an inflammatory reaction occurs in normal pregnancy and may be
disrupted during miscarriage.[4]

Genetic abnormalities within the embryo (ie, chromosomal abnormalities) are the most
common cause of spontaneous abortion and account for 50-65% of all miscarriages. The most
common single chromosomal anomaly is 45,X karyotype, with an incidence of 14.6%.
Trisomies are the single largest group of chromosomal anomalies and account for
approximately one half of all anomalies associated with miscarriage. Trisomy 16 is the most
common trisomy found. Approximately 20% of genetic abnormalities are triploidies.

Teratogenic and mutagenic factors may also play a role in spontaneous abortion, but
quantification is difficult. Iatrogenic causes include Asherman syndrome.

Maternal causes of spontaneous miscarriage include the following:

Genetic: Maternal age is directly related to the aneuploidy risk (>30% in people aged
40 y). Couples with recurrent miscarriages have a 2-3% incidence of a parental
chromosomal anomaly (ie, balanced translocation).
Structural abnormalities of the reproductive tract include the following: Congenital
uterine defects (particularly uterine septum), fibroids, cervical incompetence

Acute maternal factors include the following:

Corpus luteum deficiency

Active infection (eg, rubella virus, cytomegalovirus, Listeria
infection, toxoplasmosis, malaria, brucellosis, human immunodeficiency virus (HIV),
dengue fever, influenza, as well as vaginal infection with bacterial vaginosis [5, 6] )

Chronic maternal health factors include the following:

Polycystic ovary syndrome

Poorly controlled diabetes mellitus (A successful pregnancy requires much tighter
control.)
Renal disease
Systemic lupus erythematosus (SLE)
Untreated thyroid disease: A meta-analysis evaluating the association between thyroid
autoantibodies and miscarriage and preterm birth in women with normal thyroid
function found a strong link between maternal thyroid autoantibodies and miscarriage
and preterm birth. [7] Evidence suggests that treatment with levothyroxine may
attenuate the risks.
Severe hypertension
Antiphospholipid syndrome

Exogenous factors include the following:

Tobacco
Alcohol
Cocaine
Caffeine (high doses)
Independent risk factors for a spontaneous miscarriage include the following[8, 9, 10] :

Advanced age
Extremes of age
Feeling stressed
Advanced paternal age

Symptoms of vaginal bleeding but not abdominal pain are associated with increased risk of
miscarriage. One paper suggests that miscarriage can occur in about 50% of patients who
present with threatened abortion.

Gestational exposure to nonaspirin NSAIDs may increase the risk for miscarriage. Nakhai-
Pour et al identified 4705 women who had spontaneous abortions by 20 weeks gestation.
Each case was matched to 10 control subjects (n=47,050) who did not have a spontaneous
abortion. In the women who had a miscarriage, 352 (7.5%) were exposed to a nonaspirin
NSAID, whereas NSAID exposure was lower (1213 exposed [2.6%]) in women who did not
have a miscarriage.[11]

A study by Hahn et al indicates that obesity increases the likelihood of spontaneous abortion,
with the risk being highest in the first two months of pregnancy. The study, of 5132 women,
found that compared with women of normal weight, women with a body mass index of 30 or
above had a hazard ratio (HR) for spontaneous abortion of 1.34 prior to eight weeks
gestation, after which it dropped to 1.23. The data also indicated that small stature (height <
166 cm) and a low waist-to-hip ratio are additional risk factors for spontaneous abortion.
However, neither waist circumference nor the location of typical weight gain was found to
significantly affect the risk.[12]

Select vaginal bacteria may also increase the risk of early pregnancy loss.{ A multicenter
study of 418 pregnant of whom 74 had a miscarriage showed that the greatest risk of
miscarriage among young women with high levels of was bacterial vaginosis-associated
bacteria 3 (BVAB3).[5]

Epidemiology
United States statistics

The overall miscarriage rate is reported as 15-20%, which means 15-20% of recognized
pregnancies result in miscarriage. The frequency of spontaneous miscarriage increases further
with maternal age. With the development of highly sensitive assays for hCG levels,
pregnancies can be detected prior to the expected next period. When these highly sensitive
hCG assays are used early, the magnitude of pregnancy loss significantly increases to about
60-70%. Late implantation by the conceptus beyond the usual 8-10 days after ovulation also
has an increased risk of miscarriage.

About 80% of miscarriages occur within the first trimester. The frequency of miscarriage
decreases with increasing gestational age. Recurrent early pregnancy loss, defined as 2-3
consecutive losses of clinical pregnancies, affects about 1% of all couples.

Risk factors
Independent risk factors for a spontaneous miscarriage include advanced age, extremes of
age, feeling stressed, and advanced paternal age.[8, 9, 10] Symptoms of vaginal bleeding but not
abdominal pain are associated with increased risk of miscarriage. One paper suggests that
miscarriage can occur in about 50% of patients who present with threatened abortion.

International statistics

No significant difference exists between international rates and the rates in the United States.

Race-, sex-, and age-related demographics

Early pregnancy loss may occur in any race without distinction.

Early pregnancy loss only affects females.

As women mature, the incidence of spontaneous miscarriages increases. Typically, the

distribution of miscarriage rates by age occurs as follows: younger than 35 years old, 15%
miscarriage rate; 35-39 years old, 20-25% miscarriage rate; 40-42 years old, about 35%
miscarriage rate; and older than 42 years old, about 50% miscarriage rate.

Women who conceive using donor eggs have miscarriage rates that are similar to the egg
donor's age and not the recipient's age. This information is well documented on the
CDC's Assisted Reproductive Technology Web site, and it indicates that miscarriages are
increased significantly due to aging oocytes rather than due to the aging uterus.

Prognosis
The prognosis for early pregnancy loss is excellent. After one complete abortion, no
increased risk exists for another one. Patients need reassurance. "Tender loving care" with
subsequent pregnancies is proven effective therapy in some studies.[13, 14, 15] This approach
includes early quantitative hCG levels and ultrasounds weekly, after the hCG threshold is
reached, with more frequent visits available if needed for reassurance.

Morbidity/mortality

A complete abortion is unlikely to cause any significant risk of mortality unless significant
blood loss or infection occurs. Morbidity would be increased if anemia or infection develops.
Patients who are pregnant may bleed quickly and significantly. Distinguishing the causes of
bleeding during pregnancy is important.

Incomplete and inevitable abortions are a cause for concern when significant bleeding or
infection occurs. If treatment is not performed in a timely manner, significant morbidity and
mortality may occur. Retained products of conception may occur after a spontaneous abortion
or after a suction D&C.

Patients with retained products usually return for medical care with symptoms of increased
bleeding, increased cramping, and/or infection. Caring for these patients quickly with
intravenous antibiotics is important, and, after the antibiotics are administered, then a suction
D&C is performed. These patients are at risk for developing Asherman syndrome, which
consists of adhesions within the uterine cavity. Patients who develop Asherman syndrome
may present with amenorrhea or decreased menstrual flow. Asherman syndrome may
compromise future fertility. When significant bleeding occurs, fluid management and
transfusions may be required while stabilizing the patient prior to a suction D&C.

A complication of D&C is perforation of the uterus, which may be handled by observation. If

the patient shows signs of uncontrolled bleeding, then proceeding to a laparoscopy or
laparotomy to control the bleeding may be necessary. The choice for laparoscopy or
laparotomy depends on the stability of the patient. Occasionally, the perforation is in the area
of the uterine vessels or other area where the bleeding is difficult to control and a
hysterectomy or uterine artery embolization may be necessary. When bleeding is severe, the
patient can easily go into hypovolemic shock or disseminated intravascular
coagulopathy (DIC). Both of these situations need prompt attention and treatment.

Surveillance data suggest that spontaneous miscarriages and induced abortions accounted for
about 4% of pregnancy-related deaths in the United States.[16]

Complications

In a long-term study of more than 1 million women, researchers found an association

between pregnancy loss and an increased risk of subsequently developing atherosclerosis,
particularly among women younger than 35 years.[17, 18] Women who had miscarriages had a
13% increased risk of subsequent myocardial infarction, a 16% increased risk of
cerebrovascular infarction, and a 20% increased risk of renovascular hypertension relative to
women who had not had miscarriages. The effect on adverse outcomes appeared to be
cumulative, with each additional miscarriage increasing the risk of myocardial infarction (by
9%), cerebral infarction (by 13%), and renovascular hypertension (by 19%).[17, 18]

Complete abortions may be complicated by infection or accumulation of clot in the uterine

cavity without expulsion due to uterine atony. Both of these complications are rare.

Occasionally, a decidual cast is passed and is mistaken for products of conception. In these
cases, an ectopic pregnancy is likely.

Patient Education
The patient needs to hear that one miscarriage does not put her at increased risk for another
miscarriage. Her next pregnancy is likely to last to term if she is young and has no other risk
factors.

Advise the patient to return to the emergency department if any of the following symptoms
occur:

Profuse vaginal bleeding

Severe pelvic pain
Temperature greater than 100F
Patients may experience intermittent menstrual-like flow and cramps during the following
week. The next menstrual period usually occurs in 4-5 weeks.

Patients may resume regular activities when able, but they should refrain from intercourse
and douching for approximately 2 weeks.

For patient education resources, see the Pregnancy Center, as well

as Miscarriage, Abortion, Ectopic Pregnancy, and Dilation and Curettage (D&C).