Miscarriage

Any vaginal bleeding, other than spotting, during early pregnancy is considered a threatened miscarriage. Vaginal bleeding is very common in early pregnancy. About 1 out of every 4 pregnant women has some bleeding during the first few months. About half of these women stop bleeding and complete a normal pregnancy.

• Threatened miscarriage - Vaginal bleeding during early pregnancy. The bleeding and pain with threatened miscarriage are usually mild and the cervical os (the mouth of the womb) is closed. Your health care provider will be able to determine if the cervical os is open upon performing a pelvic exam. Typically, no tissue is passed from the womb. The womb and fallopian tubes may be tender.
  
  
• Inevitable miscarriage - Vaginal bleeding along with opening of the cervical os. In this situation, vaginal bleeding is present, and the mouth of the womb is open (dilated). Bleeding is usually more severe, and abdominal pain and cramping often occur.
  
  
• Incomplete miscarriage - Expulsion of some, but not all, of the products of conception before the twentieth week of pregnancy. With incomplete miscarriage, the bleeding is heavier, and abdominal pain is almost always present. The mouth of the womb is open, and the pregnancy is being expelled. Ultrasound would show some material still remaining in the womb.
  
  
• Complete miscarriage - Expulsion of all products of conception before the twentieth week of pregnancy. Complete miscarriage is just as it sounds. Bleeding, abdominal pain, and the passing of tissue have all occurred, but the bleeding and pain have usually stopped. If you can see the fetus, you have miscarried. Ultrasound shows an empty womb. 

A miscarriage occurs when a pregnancy ends without obvious cause before the twentieth week. This time is measured from the first day of your last menstrual period. Miscarriage is a common complication of pregnancy. It can occur in 10-15% of pregnancies. This ending of pregnancy is called a spontaneous abortion. In the medical field, the term abortion is often used to describe a miscarriage.

Miscarriage is caused by the separation of the fetus and placenta from the uterine wall. Although the actual cause of the miscarriage is frequently unclear, the most common reasons include the following:

• An abnormal fetus causes almost all miscarriages during the first 3 months of pregnancy (first trimester). Problems in the genes are responsible for an abnormal fetus and are found in more than half of miscarried fetuses. The risk of defective genes increases with the woman's age, especially over if she is older than 35 years.

• Miscarriage during the fourth through sixth months of pregnancy (second trimester) is usually related to an abnormality in the mother rather than in the fetus.
  
  
  • Chronic illnesses, including diabetes, severe high blood pressure, kidney disease, lupus, and underactive or overactive thyroid gland, are frequent causes of a miscarriage. Prenatal care is important because it screens for some of these diseases.
    
    
  • Inadequate ovarian hormone production is one of the most common causes of a miscarriage.
    
    
  • Acute infections, including German measles, CMV (cytomegalovirus), mycoplasma ("walking" pneumonia) and other unusual germs, and severe emotional shock, can also cause miscarriage.
    
    
  • Diseases and abnormalities of the internal female organs can also cause miscarriage. Some examples are an abnormal womb, fibroids, poor muscle tone in the mouth of the womb, abnormal growth of the placenta (also called the afterbirth), and carrying too many babies for your system.
    
    
  • Other factors, especially certain drugs, including caffeine, alcohol, tobacco, and cocaine, may be the cause.
    
    
  
  

If you are having a spontaneous miscarriage, you will probably have vaginal bleeding, abdominal pain, and cramping.

• Bleeding may be only slight spotting, or it can be quite severe. Your health care provider will ask about how much you have bled—usually the number of pads you've soaked through. You will also be asked about blood clots or whether you saw any tissue.

• Pain and cramping occur in the lower abdomen. They may occur on only one side, both sides, or in the middle. The pain can also go into your lower back, buttocks, and genitals.
  
  
• You may no longer have signs of pregnancy such as nausea or breast swelling/tenderness if you have experienced a miscarriage.

Call your health care provider if you know or suspect you are pregnant and you are experiencing any of the following:

• Vaginal bleeding

• Abdominal pain or cramping, or low back pain

• Weakness or dizziness

• Urinary symptoms such as burning, frequency, or pain with urination

Go immediately to the hospital's emergency department if any of the following are true:

• You know or suspect you are pregnant and have heavy vaginal bleeding (soaking more than one pad every hour) or pain in the back or the abdomen.
  
  
• You are passing something that looks like tissue (place what you have passed into a jar or container and take it with you to the hospital).
  
  
• You have a history of ectopic (tubal) pregnancy.
  
  
• You are extremely dizzy or pass out.
  
  
• You have a known pregnancy accompanied with passage of clots or other material.
  
  
• You have a fever of greater than 100.4°F.
  
  
• You are vomiting; nothing stays down.

Medical history: You will be asked questions about your pregnancy, such as the following:

• How far along is your pregnancy?
• When was your last normal period?
• How many times have you been pregnant?
• How many living children do you have?
• How many miscarriages have you had?
• Have you ever had an ectopic (tubal) pregnancy?
• How many abortions have you had?
• Were you using any sort of birth control when you got pregnant this time?
• Is this a planned pregnancy?
• Do you plan to keep this pregnancy?
• Have you had any prenatal care?
• Have you had any problems urinating?
• Have you had an ultrasound yet to show that the pregnancy is in the right place?
• Do you know your blood type?
• What medical problems do you have?
• What medications do you take every day?
• What herbs or other products do you take every day?

Physical exam: For the pelvic exam, you will lie on your back with your knees bent and your feet in stirrups.

• You may have a speculum exam. A metal or plastic device is put in your vagina and then opened, spreading the walls of your vagina apart so the health care provider can look right at the mouth of your womb. If a lot of blood or clots are present, the provider may use a clamp or gauze to remove them. You should not feel any pain during this part of the exam, although you may be embarrassed and uncomfortable.
  
  
• You may bleed from the vagina before, during, and even after a miscarriage. The health care provider will assess the opening of the entrance to the womb (called the os) and, depending on the findings, will be able to tell you more accurately which of the stages of miscarriage you might be experiencing. 

• The health care provider may put gloved fingers in your vagina and feel your abdomen with the other hand. He or she can feel whether the mouth of your uterus is open, how big your uterus may be, and whether any signs of infection or tubal pregnancy exist. The size of your uterus may be smaller than expected for the fetus if you have already miscarried.

Lab tests: Pregnancy tests can be either urine tests or blood tests. Your health care provider or emergency department doctor, if you go to the hospital with alarming symptoms, will act quickly to determine if you are pregnant.

• A urine pregnancy test along with blood samples will be sent to the laboratory to check for blood loss or anemia, blood type, and the level of the pregnancy hormone. This hormone is called human chorionic gonadotropin or hCG.
  
  
  • A number too low may suggest that the pregnancy is abnormal. No single number is "normal." A very low number (under 1,000) suggests an abnormal pregnancy, although it could just be an early pregnancy.
    
    
  • A very high number (over 100,000) strongly suggests a normal living pregnancy. Most other numbers by themselves do not help a lot but can be compared to another test done in 2-3 days to see if everything is developing normally.
  
  
• A complete blood count may be drawn. If you have been bleeding a lot, you may be anemic (loss of too much blood) and need special care. If you have a fever, your white cell count may suggest you have an infection.
  
  
• If you do not know your blood type, this will also be checked.
  
  
• If you have symptoms of a urinary infection, a urine sample will be taken and examined.

Ultrasound: If you are pregnant, an ultrasound may be performed to look for evidence of a pregnancy within the uterus. If the radiologist, gynecologist, or emergency department doctor cannot find evidence of a pregnancy within the uterus, you will likely be evaluated further for a pregnancy that is outside your uterus. When the fertilized egg implants in the fallopian tube, this is called a tubal or ectopic pregnancy.

• Your bladder has to be full for this test, so you will have to drink a lot of water, or the technician will give you fluid in your vein and ask you not to go to the bathroom until after the test is done.
  
  
• The technician will put some cold jelly on your abdomen and press down with a probe to see your internal organs. The ultrasound technician may also use a vaginal probe inside your vagina to get a better look at your tubes and ovaries. Neither of these studies should be painful.

If your health care provider feels that you are having a spontaneous abortion or miscarriage, little can be done in the way of prevention. If you are actively miscarrying and your health care provider does not think you have a living pregnancy, you will also be seen by an obstetrician (specialist in women’s reproductive health), who may recommend ending the pregnancy. A procedure called dilation and curettage (D&C) can be performed or further observation takes place to let nature take its course.

• If you have a urinary tract infection, antibiotics that are safe to take in pregnancy will be prescribed.

• In certain situations, you and your baby may have incompatible blood types. If your blood sample shows that you are Rh factor negative (a certain blood type), you will be given medication (RhoGAM) to prevent a possible blood type interaction with the baby (which could occur if the baby were Rh positive).

• You will be counseled and given materials or instruction concerning the possibility of spontaneous abortion. If the mouth of your uterus is closed, if you are not bleeding heavily, your lab work is normal, and an ultrasound shows you do not have an ectopic pregnancy, you may rest at home with the following instructions:

• Get plenty of rest.

• Avoid douching and sexual intercourse.

• Watch for the passage of any white or gray material from your vagina. This may represent what are known as the products of conception.

• Return to the emergency department if bleeding or pain worsens, or if you develop fever, weakness, or dizziness.

• Go to your doctor to be reexamined in about 48 hours.

|Self-Care at Home|

If you are not sure if you are pregnant, a home pregnancy test will confirm or exclude pregnancy in most cases.

• If the test is negative, discuss the bleeding and cramping with your health care provider.

• If the test is positive and you have bleeding or cramping, call your provider. 

• Rest and avoid sexual intercourse.

• You may also safely take acetaminophen (Tylenol) at any time during pregnancy. Do NOT take aspirin, ibuprofen (Motrin or Advil), or naproxen (Aleve) if you are pregnant.

|Surgery|

See Miscarriage Treatment.

|Follow-up|

Your health care provider will monitor you until the pregnancy resumes or if the miscarriage becomes complete.

• Avoid exerting yourself. You may feel better if you rest, although resting will not prevent the miscarriage from happening.
  
  
• Do not douche or insert anything in your vagina, including tampons.
  
  
• Do not have sex until the symptoms have completely gone away for 1 week.
  
  
• Return to the emergency department if the following symptoms develop:
  
  
  • Worse cramping
    
    
  • Worse bleeding (more than 1 pad per hour)
    
    
  • Passage of tissue
    
    
  • Fever
    
    
  • Anything else that concerns you 
  
  
• With another blood test, your quantitative beta-HCG level may be checked in 48-72 hours. The rise or fall of this level is helpful in predicting the viability or failure of the pregnancy. If the level is falling, then the pregnancy may have ended.
  
  
• A follow-up ultrasound may be done at some point.  

|Prevention|

There is no way to predict or prevent a miscarriage. Certain steps can be taken, however, to give your pregnancy every chance to continue to term.  

• Get prenatal care and follow the advice of your health care provider (family doctor, obstetrician, midwife).

• Avoid alcohol, nicotine, and street drugs, especially cocaine, during pregnancy.

• Avoid or cut down on caffeine.
  
  
• Control high blood pressure and diabetes.
  
  
• Identify and treat any bacterial and certain viral infections.

|Outlook|

More than half of women who bleed during the first 12 weeks of pregnancy stop bleeding and end up having a normal baby. The others get more cramping and bleeding and eventually miscarry. Although emotionally unsettling, most women physically handle spontaneous abortions well. You may not know whether you are going to miscarry when you leave the emergency department.

|Web Links|

American College of Surgeons, About d&c for miscarriage

MedlinePlus, Miscarriage

The Miscarriage Association

spontaneous abortion, threatened abortion, TAB, inevitable abortion, incomplete abortion, missed abortion, abortion, threatened miscarriage, vaginal bleeding, vaginal bleeding during early pregnancy, bleeding in pregnancy, bleeding during pregnancy, pregnancy and bleeding, signs of miscarriage, miscarriage symptoms, pregnancy loss, D&C, home pregnancy test, cramps, abdominal pain 

Author: Vicken P Sepilian, MD, Clinical Fellow, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Texas Medical Branch.

Coauthor(s): Chester D Shermer, MD, Assistant Program Director, Assistant Professor, Department of Emergency Medicine, University of Mississippi School of Medicine; Verena Valley, MD, Director of Ultrasound, Associate Professor, Department of Emergency Medicine, University of Mississippi School of Medicine.

Editors: Richard Harrigan, MD, Associate Professor, Department of Emergency Medicine, Temple University Hospital, Temple University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.