Miscarriage or spontaneous abortion is the spontaneous end of a pregnancy at a

stage where the embryo or fetus is incapable of surviving, generally defined in humans at
prior to 24 weeks of gestation. Miscarriage is the most common complication of early
pregnancy.

Classification
The fetal or placental defect or the maternal condition results in the disruption of blood
flow, containing oxygen and nutrients, to the developing fetus. The fetus is
compromised and subsequently expelled from the uterus

The clinical presentation of a threatened abortion describes any bleeding seen during
pregnancy prior to viability, that has yet to be assessed further. At investigation it may be
found that the fetus remains viable and the pregnancy continues without further
problems. It has been suggested that bed rest improves the chances of the pregnancy
continuing when a small subchorionic hematoma has been found on ultrasound scan.

Chorionic hematoma (also chorionic hemorrhage) is the pooling of blood (hematoma)

between the chorion, a membrane surrounding the embryo, and the uterine wall.With an
incidence of 3.1% of all pregnancies, it is the most common sonographic abnormality and
the most common cause of first trimester bleeding. Chorionic hematomas can be caused
by the separation of the chorion from the endometrium (inner membrane of the uterus).

Alternatively the following terms are used to describe pregnancies that do not continue:

• An empty sac is a condition where the gestational sac develops normally, while
the embryonic part of the pregnancy is either absent or stops growing very early.
Other terms for this condition are blighted ovum and anembryonic pregnancy.
• An inevitable abortion describes where the cervix has already dilated open,but the
fetus has yet to be expelled. This usually will progress to a complete abortion. The
fetal heart beat may have been shown to have stopped, but this is not part of the
criteria.
• A complete abortion is when all products of conception have been expelled.
Products of conception may include the trophoblast, chorionic villi, gestational
sac, yolk sac, and fetal pole (embryo); or later in pregnancy the fetus, umbilical
cord, placenta, amniotic fluid, and amniotic membrane.
• An incomplete abortion occurs when tissue has been passed, but some remains in
utero.
• A missed abortion is when the embryo or fetus has died, but a miscarriage has not
yet occurred. It is also referred to as delayed or missed miscarriage.

The following two terms consider wider complications or implications of a miscarriage:

• A septic abortion occurs when the tissue from a missed or incomplete abortion
becomes infected. The infection of the womb carries risk of spreading infection
(septicaemia) and is a grave risk to the life of the woman.
 • Recurrent pregnancy loss (RPL) or recurrent miscarriage (medically termed
habitual abortion) is the occurrence of three consecutive miscarriages. If the
proportion of pregnancies ending in miscarriage is 15% then the probability of
two consecutive miscarriages is 2.25% and the probability of three consecutive
miscarriages is 0.34%. The occurrence of recurrent pregnancy loss is 1%.A large
majority (85%) of women who have had two miscarriages will conceive and carry
normally afterwards.

The physical symptoms of a miscarriage vary according to the length of pregnancy:

• At up to six weeks only small blood clots may be present, possibly accompanied
by mild cramping or period pain.
• At 6 to 13 weeks a clot will form around the embryo or fetus, and the placenta,
with many clots up to 5 cm in size being expelled prior to a completed
miscarriage. The process may take a few hours or be on and off for a few days.
Symptoms vary widely and can include vomiting and loose bowels, possibly due
to physical discomfort.
• At over 13 weeks the fetus may be easily passed from the womb, however the
placenta is more likely to be fully or partially retained in the uterus, resulting in an
incomplete abortion. The physical signs of bleeding, cramping and pain can be
similar to an early miscarriage, but sometimes more severe and labour-like.

Signs and symptoms

The most common symptom of a miscarriage is bleeding;bleeding during pregnancy may
be referred to as a threatened abortion. Of women who seek clinical treatment for
bleeding during pregnancy, about half will go on to have a miscarriage.Symptoms other
than bleeding are not statistically related to miscarriage.

Miscarriage may also be detected during an ultrasound exam, or through serial human
chorionic gonadotropin (HCG) testing. Women pregnant from ART methods, and women
with a history of miscarriage, may be monitored closely and so detect a miscarriage
sooner than women without such monitoring.

Several medical options exist for managing documented nonviable pregnancies that have
not been expelled naturally.

Psychological

Although a woman physically recovers from a miscarriage quickly, psychological

recovery for parents in general can take a long time. People differ greatly in this regard:
some are able to move on after a few months, but others take more than a year. Still
others may feel relief or other less negative emotions. A questionnaire (GHQ-12 General
Health Questionnaire) study following women having miscarried showed that half (55%)
of the miscarrying women presented with significant psychological distress immediately,
25% at 3 months; 18% at 6 months, and 11% at 1 year after miscarriage.

A cemetery for miscarried children

For those who do go through a process of grief, it is often as if a baby had been born but
died. How short a time the fetus lived in the womb may not matter for the feeling of loss.
From the moment pregnancy is discovered, the parents can start to bond with the embryo
or fetus. When the pregnancy turns out not to be viable, dreams, fantasies and plans for
the future are disturbed roughly.

Besides the feeling of loss, a lack of understanding by others is often important. People
who have not experienced a miscarriage themselves may find it hard to empathize with
what has occurred and how upsetting it may be. This may lead to unrealistic expectations
of the parents' recovery. The pregnancy and miscarriage are hardly mentioned any more
in conversation, often because the subject is too painful. This can make the woman feel
particularly isolated. Inappropriate or insensitive responses from the medical profession
can add to the distress and trauma experienced, so in some cases attempts have been
made to draw up a standard code of practice.

Interaction with pregnant women and newborn children is often also painful for parents
who have experienced miscarriage. Sometimes this makes interaction with friends,
acquaintances and family very difficult.

CAUSES :

Miscarriages can occur for many reasons, not all of which can be identified. Some of
these causes include genetic, uterine or hormonal abnormalities, reproductive tract
infections, and tissue rejection.

First trimester
A complete spontaneous abortion at about six weeks from conception, i.e. eight weeks
from the last menstrual period (LMP)

Most clinically apparent miscarriages (two thirds to three-quarters in various studies)

occur during the first trimester.

Chromosomal abnormalities are found in more than half of embryos miscarried in the
first 13 weeks. A pregnancy with a genetic problem has a 95% probability of ending in
miscarriage. Most chromosomal problems happen by chance, have nothing to do with the
parents, and are unlikely to recur. Chromosomal problems due to a parent's genes is,
however, a possibility. This is more likely to have been the cause in the case of repeated
miscarriages, or if one of the parents has a child or other relatives with birth defects.
Genetic problems are more likely to occur with older parents; this may account for the
higher miscarriage rates observed in older women.

Another cause of early miscarriage may be progesterone deficiency. Women diagnosed

with low progesterone levels in the second half of their menstrual cycle (luteal phase)
may be prescribed progesterone supplements, to be taken for the first trimester of
pregnancy. However, no study has shown that general first-trimester progesterone
supplements reduce the risk of miscarriage, and even the identification of problems with
the luteal phase as contributing to miscarriage has been questioned.

Second trimester

Up to 15% of pregnancy losses in the second trimester may be due to uterine

malformation, growths in the uterus (fibroids), or cervical problems. These conditions
may also contribute to premature birth.

One study found that 19% of second trimester losses were caused by problems with the
umbilical cord. Problems with the placenta may also account for a significant number of
later-term miscarriages.

General risk factors

Pregnancies involving more than one fetus are at increased risk of miscarriage.
Uncontrolled diabetes greatly increases the risk of miscarriage. Women with controlled
diabetes are not at higher risk of miscarriage. Because diabetes may develop during
pregnancy (gestational diabetes), an important part of prenatal care is to monitor for signs
of the disease.

Polycystic ovary syndrome is a risk factor for miscarriage, with 30-50% of pregnancies in
women with PCOS being miscarried in the first trimester. Two studies have shown
treatment with the drug metformin to significantly lower the rate of miscarriage in
women with PCOS (the metformin-treated groups experienced approximately one-third
the miscarriage rates of the control groups).However, a 2006 review of metformin
treatment in pregnancy found insufficient evidence of safety and did not recommend
routine treatment with the drug.

High blood pressure during pregnancy, known as preeclampsia, is sometimes caused by

an inappropriate immune reaction to the developing fetus, and is associated with the risk
of miscarriage. Similarly, women with a history of recurrent miscarriages are at risk of
developing preeclampsia.

Severe cases of hypothyroidism increase the risk of miscarriage. The effect of milder
cases of hypothyroidism on miscarriage rates has not been established. The presence of
certain immune conditions such as autoimmune diseases is associated with a greatly
increased risk of miscarriage.

Certain illnesses (such as rubella, chlamydia and others) increase the risk of miscarriage.[

Tobacco (cigarette) smokers have an increased risk of miscarriage.An increase in

miscarriage is also associated with the father being a cigarette smoker.The husband study
observed a 4% increased risk for husbands who smoke fewer than 20 cigarettes/day, and
an 81% increased risk for husbands who smoke 20 or more cigarettes/day.

Cocaine use increases miscarriage rates.Physical trauma, exposure to environmental

toxins, and use of an IUD during the time of conception have also been linked to
increased risk of miscarriage.

Antidepressants specially paroxetine and venlafaxine can lead to spontaneous abortion.

The age of the mother is a major risk factor. Miscarriage rates grow at an ever-increasing
rate after age 30.

Suspected risk factors

Several factors have been correlated with higher miscarriage rates, but whether they
cause miscarriages is debated. No causal mechanism may be known, the studies showing
a correlation may have been retrospective (beginning the study after the miscarriages
occurred, which can introduce bias) rather than prospective (beginning the study before
the women became pregnant), or both.
Nausea and vomiting of pregnancy (NVP, or morning sickness) are associated with a
decreased risk of miscarriage. Several mechanisms have been proposed for this
relationship, but none are widely agreed on. Because NVP may alter a woman's food
intake and other activities during pregnancy, it may be a confounding factor when
investigating possible causes of miscarriage.

One such factor is exercise. A study of over 92,000 pregnant women found that most
types of exercise (with the exception of swimming) correlated with a higher risk of
miscarriage prior to 18 weeks. Increasing time spent on exercise was associated with a
greater risk of miscarriage: an approximately 10% increased risk was seen with up to 1.5
hours per week of exercise, and a 200% increased risk was seen with over 7 hours per
week of exercise. High-impact exercise was especially associated with the increased risk.
No relationship was found between exercise and miscarriage rates after the 18th week of
pregnancy. The majority of miscarriages had already occurred at the time women were
recruited for the study, and no information on nausea during pregnancy or exercise habits
prior to pregnancy was collected.

Caffeine consumption has also been correlated to miscarriage rates, at least at higher
levels of intake. A 2007 study of over 1,000 pregnant women found that women who
reported consuming 200 mg or more of caffeine per day experienced a 25% miscarriage
rate, compared to 13% among women who reported no caffeine consumption. 200 mg of
caffeine is present in 10 oz (300 mL) of coffee or 25 oz (740 mL) of tea. This study
controlled for pregnancy-associated nausea and vomiting (NVP or morning sickness): the
increased miscarriage rate for heavy caffeine users was seen regardless of how NVP
affected the women. About half of the miscarriages had already occurred at the time
women were recruited for the study.A second 2007 study of approximately 2,400
pregnant women found that caffeine intake up to 200 mg per day was not associated with
increased miscarriage rates (the study did not include women who drank more than
200 mg per day past early pregnancy).A prospective cohort study in 2009 showed no
increased risk.

Diagnosis
A miscarriage can be confirmed via ultrasound and by the examination of the passed
tissue. When looking for gross or microscopic pathologic symptoms of miscarriage, one
looks for the products of conception. Microscopically, these include villi, trophoblast,
fetal parts, and background gestational changes in the endometrium. Genetic tests may
also be performed to look for abnormal chromosome arrangements.

Management
Blood loss during early pregnancy is the most common symptom of both miscarriage and
of ectopic pregnancy. Pain does not strongly correlate with miscarriage, but is a common
symptom of ectopic pregnancy.In the case of concerning blood loss, pain, or both,
transvaginal ultrasound is performed. If a viable intrauterine pregnancy is not found with
ultrasound, serial βHCG tests should be performed to rule out ectopic pregnancy, which
is a life-threatening situation.

If the bleeding is light, making an appointment to see one's doctor is recommended. If

bleeding is heavy, there is considerable pain, or there is a fever, then emergency medical
attention is recommended to be sought.

No treatment is necessary for a diagnosis of complete abortion (as long as ectopic

pregnancy is ruled out). In cases of an incomplete abortion, empty sac, or missed abortion
there are three treatment options:

• With no treatment (watchful waiting), most of these cases (65–80%) will pass
naturally within two to six weeks.This path avoids the side effects and
complications possible from medications and surgery.
• Medical management usually consists of using misoprostol (a prostaglandin,
brand name Cytotec) to encourage completion of the miscarriage. About 95% of
cases treated with misoprostol will complete within a few days.
• Surgical treatment (most commonly vacuum aspiration, sometimes referred to as
a D&C or D&E) is the fastest way to complete the miscarriage. It also shortens
the duration and heaviness of bleeding, and is the best treatment for physical pain
associated with the miscarriage.In cases of repeated miscarriage or later-term
pregnancy loss, D&C is also the best way to obtain tissue samples for pathology
examination. D&C, however, has a higher risk of complications, including risk of
injury to the cervix and uterus, perforation of the uterus, and potential scarring of
the intrauterine lining. This is an important consideration for women who would
like to have children in the future and want to minimize the risk of damaging their
uterus.

Epidemiology
Determining the prevalence of miscarriage is difficult. Many miscarriages happen very
early in the pregnancy, before a woman may know she is pregnant. Treatment of women
with miscarriage at home means medical statistics on miscarriage miss many cases.
Prospective studies using very sensitive early pregnancy tests have found that 25% of
pregnancies are miscarried by the sixth week LMP (since the woman's Last Menstrual
Period).Clinical miscarriages (those occurring after the sixth week LMP) occur in 8% of
pregnancies.

The risk of miscarriage decreases sharply after the 10th week LMP, i.e. when the fetal
stage begins.The loss rate between 8.5 weeks LMP and birth is about two percent; loss is
“virtually complete by the end of the embryonic period."

The prevalence of miscarriage increases considerably with age of the parents. One study
found that pregnancies from men younger than 25 years are 40% less likely to end in
miscarriage than pregnancies from men 25–29 years. The same study found that
pregnancies from men older than 40 years are 60% more likely to end in miscarriage than
the 25–29-year age group.Another study found that the increased risk of miscarriage in
pregnancies from older men is mainly seen in the first trimester.Yet another study found
an increased risk in women, by the age of 45, on the order of 800% (compared to the 20–
24 age group in that study), 75% of pregnancies ended in miscarriage
 INDEPENDENT: • Changes in blood
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volume (spontaneous nursing compare with used for rough intervention the patient was
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pa, 12 linggo na blood loss. that ends improved fluid pressure when • Symptomatology may stable vital signs, good skin
ang spontaneously balance as possible. be useful in gauging turgor, and prompt capillary
ipinagbubuntis before the evidenced by • Note patient’s severity or length of refill
ko” (I am twelve fetus can stable vital signs, individual bleeding episode.
Assessment
weeks pregnant, Diagnosis
survive. The Scientific
good skin turgor, Planning
physiological
Intervention
Worsening of
Rationale Evaluation
have had cramping World Health Explanation
and prompt response to symptoms may
and bleeding since
Organization capillary refill. bleeding such as reflect continued
last night) as
defines this changes in bleeding or
verbalize by the
unsurvivable mentation, inadequate fluid
patient
state as an weakness, replacement.
embryo or restlessness, and
fetus weighing pallor. • Reflects circulating
OBJECTIVE:
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capillary refill
corresponds • Measure central replacement.
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ness (gestational (CVP), if available. • Provides guidelines
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less. • Activity increases
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taken as occurs in • Monitor intake and pressure and can
follows about 15-20% output (I&O), and predispose to further
of all correlate with bleeding.
T: 36.9 ˚C recognized weight changes.
P: 90 pregnancies, • Maintain bed rest.
R: 19 and usually
BP: 110/ 70
Schedule activities • Fluid replacement
occurs before to provide with isotonic
the 13th week undisturbed rest solutions depends on
of pregnancy. periods. the degree and
The actual DEPENDENT: duration of bleeding.
percentage of • Administer fluids as • Promotes hepatic
miscarriages indicated. synthesis of
is estimated to
coagulation factors to
be as high as
support clotting.
50% of all
Aids in establishing blood
pregnancies,
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since many
• Administer vitamin monitoring the
miscarriages
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occur without
the woman