Threatened Miscarriage

Any vaginal bleeding other than spotting during early pregnancy is considered a threatened miscarriage. (A miscarriage may also be referred to as a spontaneous abortion.) Vaginal bleeding is common in early pregnancy. About 1 of every 4 pregnant women has some bleeding during the first few months. About half of these women stop bleeding and have a normal pregnancy.

The bleeding and pain associated with threatened miscarriage are usually mild. In the best case, the cervical os (mouth of the womb) is closed. (A health care provider can determine if the cervical os is open by performing a pelvic exam.) Typically, no tissue has been passed from the womb. The womb and fallopian tubes may be tender. 

When a miscarriage is inevitable, the cervical os is open (dilated). Bleeding is often heavier, and abdominal pain and cramping often occur.
 
If a miscarriage is incomplete, the cervical os is open, and the pregnancy is being expelled. Ultrasound reveals some material that remains in the womb. Bleeding is heavy and abdominal pain is almost always present.

With a complete miscarriage, bleeding and abdominal pain have occurred but have usually stopped. Products of conception have been passed. The early fetus has been passed and was not alive. Ultrasound reveals an empty womb.

Although the actual cause of the miscarriage is frequently unclear, the most common reasons include the following:

• An abnormal fetus is almost always the cause of miscarriages during the first 3 months of pregnancy (first trimester). Problems in the genes cause an abnormal fetus and are found in more than half of miscarried fetuses. The risk of defective genes increases with the woman's age.

• 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 excessive caffeine, alcohol, tobacco, and cocaine, may be the cause.

Symptoms of a spontaneous miscarriage include vaginal bleeding and abdominal pain.

• Bleeding may be only slight spotting, or it can be heavy. Your health care provider will ask how heavy the bleeding is and how many pads are being soaked through per hour. The health care provider will also ask about blood clots or tissue passed.
  
  
• Pain and cramping are in the lower abdomen. They may be on one side, both sides, or in the middle. The pain can go into your lower back, buttocks, and genitals.

A woman who is pregnant who experiences cramping or bleeding at any time should call her health care provider. A pregnant woman who experiences these symptoms but does not have a health care provider should go to her closest hospital's emergency department to be examined.

A pregnant woman should go to the hospital if she experiences the following symptoms:

• Heavy bleeding (soaking more than one pad per hour)
  
  
• Passing something that looks like tissue (Place this tissue in a container and take it with you to the hospital.)
  
  
• Severe cramping (like a menstrual period)
  
  
• Cramping or bleeding accompanied by fever
  
  
• Bleeding or abdominal pain in a woman who has had a previous ectopic (tubal) pregnancy
  
  
• Vomiting so severe she can't keep anything down

Medical history: The doctor or nurse in the emergency department will ask many questions, 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?



• Were you using any sort of birth control when you got pregnant this time?



• Have you had any prenatal care?



• Have you had an ultrasound yet to show that the pregnancy is in the right place?



• 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 there is a lot of blood or clots, the provider may use a clamp or gauze to remove it. You should not feel any pain during this part of the exam, although you may be embarrassed and uncomfortable.



• You may have bleeding 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 there are any signs of infection or tubal pregnancy. 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 it is an abnormal pregnancy. 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 are Rh-negative, you will probably receive a special medicine called RhoGAM to protect you and your baby from a bad reaction.



• 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.

• The technician may put some cold jelly on your abdomen for transabdominal ultrasound 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 a miscarriage is inevitable and the health care provider does not think you have a living pregnancy, an obstetrician will be consulted as well. The obstetrician may recommend the cervix be dilated and the contents of the womb be extracted (dilation and curettage), or the obstetrician may recommend that the woman be monitored as the body expels the pregnancy on its own.

The woman may be sent home with special instructions in the following circumstances:

• The cervical os is closed.
  
  
• Bleeding is not heavy.
  
  
• Lab study results are normal.
  
  
• Ultrasound reveals the pregnancy is not tubal.

|Self-Care at Home|

If a woman is not sure if she is pregnant, a home pregnancy test will confirm or exclude pregnancy in most cases. If a woman knows she is pregnant and experiences cramps or vaginal bleeding, she should call her health care provider at once and follow the health care provider's instructions.

|Medications|

Acetaminophen (Tylenol) can be safely taken during pregnancy to treat pain. Do not take aspirin, ibuprofen (Motrin or Advil), or naproxen (Aleve) during pregnancy.

|Surgery|

See Dilation and Curettage.

|Follow-up|

• Although rest will not prevent miscarriage, a woman may feel better if she avoids exerting herself.



• Do not douche or insert anything (including tampons) into the vagina.



• Do not have sex until symptoms have been completely gone for 1 week.



• Return to the emergency department in the following cases:
  
  
  • Cramping worsens
  
  
  
  • Bleeding worsens (requiring more than 1 pad per hour)
  
  
  
  • Passage of tissue
  
  
  
  • Fever
  
  
  
  • Anything else alarming


• Another blood test may be performed in 48-72 hours to check the hCG level. The rise or fall of this level is helpful in predicting if the pregnancy has ended. If the level is falling, the pregnancy may have ended.



• A follow-up ultrasound may be performed.

|Prevention|

While there is no way to predict or prevent miscarriage in most cases, certain steps can be taken to improve the chance of a pregnancy continuing to term.

• Get prenatal care and follow the advice of your health care provider.
  
  
• Avoid alcohol, nicotine, and street drugs, especially cocaine.
  
  
• Avoid or reduce caffeine intake.
  
  
• Control high blood pressure and diabetes.
  
  
• Get treatment for infections.

|Outlook|

More than half of women who bleed during the first 12 weeks of pregnancy stop bleeding and have a healthy pregnancy. For the other half of these women, cramping and bleeding worsen and they eventually miscarry.

A woman may not know whether she is going to miscarry when she leaves 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): Joseph R Lex, Jr, MD, Assistant Professor, Department of Emergency Medicine, Temple University Hospital.

Editors: Bryan D Cowan, MD, Director, Division of Reproductive Endocrinology, Professor, Department of Obstetrics and Gynecology, University of Mississippi College of Medicine; Mary L Windle, Pharm D, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, .com, Inc; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.