• What is a miscarriage?
• What causes a miscarriage, and what are the tests for the different causes?
• What does NOT cause miscarriage?
• What are the symptoms of a miscarriage?
• What will the doctor look for during an examination with suspected miscarriage?
• How is threatened abortion evaluated?
• What are common terms a woman might hear during evaluation for miscarriage?
• What treatment can a woman expect when she has had a miscarriage?
• When should a woman receive evaluation for underlying causes of pregnancy loss?
• Can something be done to prevent future miscarriages?
• Miscarriage At A Glance

What is a miscarriage?

A miscarriage (spontaneous abortion) is any pregnancy that is non-viable (wherein the fetus cannot survive or is born before the 20th week of pregnancy). Miscarriages can be divided according to when in pregnancy they occur. Miscarriage occurs in about 15-20% of all recognized pregnancies, and usually occurs before the 13th week of pregnancy. Of those miscarriages before the eighth week, 30% have no fetus associated with the sac or placenta. This condition is called blighted ovum and many women are surprised to learn that there was never an embryo inside the sac.

Some miscarriages occur before women recognize that they are pregnant. About 15% of fertilized eggs are lost before the egg even has a chance to implant (embed itself) in the wall of the uterus. A woman would not generally identify this type of miscarriage. Another 15% of conceptions are lost before 8 weeks gestation. Once fetal heart function is detected in a given pregnancy, the chance of miscarriage is less than 5%.

A woman who may be showing the signs of a possible miscarriage (such as vaginal bleeding) may hear the term "threatened abortion" used to describe her situation.

What causes a miscarriage, and what are the tests for the different causes?

The most common causes of miscarriage in the first third of pregnancy (1st trimester) are chromosomal abnormalities, collagen vascular disease (such as lupus), diabetes, luteal phase defect, infection, and congenital (present at birth) abnormalities of the uterus. Each of these causes will be described below.

Chromosomes are microscopic components of every cell in the body that carry all of the genetic material that determine hair color, eye color and our overall appearance and makeup. These chromosomes duplicate themselves and divide many times during the process of development and there are numerous points along the way where a problem can occur. Certain genetic abnormalities are known to be more prevalent in couples that experience repeated losses. These genetic traits can be screened for by blood tests prior to attempting to become pregnant. Half of the fetal tissue from 1st trimester miscarriages contain abnormal chromosomes. This number drops to 20% with 2nd trimester miscarriages. In other words, abnormal chromosomes are more common with 1st trimester than with 2nd trimester miscarriages. First trimester miscarriages are so very common that unless they occur more than once, they are not considered "abnormal" per se. They do not prompt further evaluation unless they occur more than once. In contrast, 2nd trimester miscarriages are more unusual, and therefore may trigger evaluation even after a 1st occurrence. It is therefore clear that causes of miscarriages seem to vary according to trimester.

Collagen vascular diseases are illnesses in which a person's own immune system attacks their own organs. These diseases can be potentially very serious, either during or between pregnancies. In these diseases, a woman makes antibodies to her own body's tissues. Examples of collagen vascular diseases are systemic lupus erythematosus, and antiphospholipid antibody syndrome .

Diabetes generally can be well-managed during pregnancy, if a woman and her doctor work closely together. However, if the diabetes is insufficiently controlled, not only is the risk of miscarriages higher, but the baby can have major birth defects . Other problems can also occur in relation to diabetes during pregnancy. Good control of blood sugars during pregnancy is very important.

Luteal phase defect is a condition that can cause miscarriages because of an inadequate amount of progesterone hormone production during the menstrual cycle. The lack of progesterone may possibly make the inner lining of the womb (endometrium) unable to "support" a gestation (pregnancy), because progesterone is felt to be important in maintaining gestation until 10 weeks. Luteal phase defect is not well-understood. This lack of understanding probably contributes greatly to the controversy about how to diagnose and treat it. Sometimes medication treatment is prescribed to try to correct this lack of adequate progesterone. The specifics of whether and how luteal phase defect contributes to spontaneous miscarriage need to be determined, and effectiveness of commonly-used treatments require further research.

Infection of the uterus by bacteria and viruses has been associated with miscarriages. However, it is interesting to note that the same infections found at the time of miscarriage can also be present in normal pregnancies carried to completion. In fact, some of these bacteria, such as mycoplasma, are considered to be "normal" vaginal bacteria by many experts. Therefore, the exact role infection plays in miscarriages is uncertain. Sometimes antibiotics are given, especially to women who have had repeated abortions, if vaginal culture testing (on sampling of vaginal secretions) reveals mycoplasma.

Abnormal design of the uterus can also cause miscarriages. In some women there can be a tissue bridge (uterine septum), that acts like a partial wall dividing the uterine cavity into sections. The septum usually has a very poor blood supply, and is not well suited for placental attachment and growth. Therefore, an embryo implanting on the septum would be at increased risk of miscarriage. Women who are suspected of having an abnormally-shaped uterus will often under hysterosalpingogram or laparoscopy with hysteroscopy. Surgical repair may allow future successful pregnancy. Other structural abnormalities can result from benign growths in the uterus called fibroids. Fibroid tumors are benign growths of muscle cells in the uterus. While most fibroid tumors do not cause miscarriages, (in fact, they are a rare cause of infertility), some can interfere with the embryo implantation and the embryo's blood supply, thereby causing miscarriage.

What does NOT cause miscarriage?

It must be emphasized that exercise, working, and intercourse do not increase the risk of pregnancy loss in routine (uncomplicated) pregnancies. However, in the unusual circumstance where a women is felt by her physician to be at higher risk of spontaneous abortion, she may be advised to stop work and intercourse. Women with past history of premature delivery and other specific obstetrical conditions might fall under this category.

What are the symptoms of a miscarriage?

Cramping and vaginal bleeding are the most common symptoms noticed with spontaneous abortion. The cramping and bleeding may be very mild, moderate, or severe. There is no particular pattern as to how long the symptoms will last.

What will the doctor look for during an examination with suspected miscarriage?

A woman's cervix might have some bloody discharge, but nothing else unusual will be characteristic of threatened abortion. Some women will have mild uterine tenderness during the manual examination of the uterus.

How is threatened abortion evaluated?

Again, a threatened abortion is when a woman may be showing the signs of a possible miscarriage (such as vaginal bleeding). In this situation, a doctor will order human chorionic gonadotropin levels or pelvic ultrasound to determine whether a pregnancy is still viable. During the evaluation, the woman may be advised to rest and avoid sexual intercourse (activity).

What are common terms a woman might hear during evaluation for miscarriage?

1. Miscarriage (spontaneous abortion) is termination of pregnancy before 20 weeks' gestation. Complete abortion describes spontaneous (not intentionally induced by medication or procedures) passage of all fetal and placental tissue prior to 20 weeks' gestation.
2. Incomplete abortion is when some, but not all, the fetal and placental tissue is expelled.
3. Products of conception refers to the combination of fetal and placental tissue.
4. Threatened abortion is when a miscarriage does not actually occur, but there is vaginal bleeding from the uterus. The cervix will not show signs of imminent passage of fetal and placental tissue.
5. Missed abortion describes when the fetus dies prior to 20 weeks' gestation, but the products of conception are not passed.

What treatment can a woman expect when she has had a miscarriage?

The central goal of the doctor in this situation will be to try to figure out whether the woman has passed all of the tissue from the fetus and placenta. If she has passed all the tissue, she may only require observation. On the other hand, a woman who has not passed all of the tissue (incomplete abortion) will usually need suction dilation and curettage. This procedure is done with local anesthesia, with or without antibiotics, depending on the doctor's usual practice style. Blood tests will help figure out whether, immune globulin (a medication) has to be prescribed.

When should a woman receive evaluation for underlying causes of pregnancy loss?

Currently, most practitioners will not initiate an extensive medical evaluation for a single pregnancy loss since the chance of having a normal pregnancy subsequent to even two consecutive miscarriages is 80-90%. For women with recurrent pregnancy loss, an evaluation will focus on the pattern and history of the prior miscarriages. Three consecutive miscarriages would suggest a woman should receive further evaluation.

Thus, the following tests are considered for women with 3 consecutive miscarriages. Blood testing can be done to identify chromosomal abnormalities in the couple that could be transmitted to the fetus. The couple can each appear completely normal but still carry chromosomal defects, which, when combined, can be lethal to the embryo. This type of testing is called karyotyping, and it is performed on both members of the couple. Hysterosalpingogram can identify uterus abnormalities. Antinuclear antibody, anticardiolipin antibody, and lupus anticoagulant are tested to look for autoimmune diseases that cause recurrent miscarriage. As described above, some of these illnesses will already by apparent to the woman and her doctor, but not all cases. Other antibody tests may be performed as well.

Can something be done to prevent future miscarriages?

The treatment of recurrent miscarriage depends on what is believed to be the underlying cause. This often is not as simple as it sounds. Careful evaluation may turn up several potential factors which alone or together may be responsible for the losses. If a chromosomal problem is found in one or both spouses, then counseling as to future risks is the only option. There is currently no method to correct genetic problems. If a structural problem is encountered with the uterus, surgical correction could be contemplated. It should be emphasized that just because a structural abnormality is found, it does not necessarily mean that it caused the miscarriage. Removal of a fibroid or uterine septum does not guarantee a future successful pregnancy, since the fibroid or uterine septum may not have been the cause of miscarriage in the first place. Adequate control of diabetes and thyroid disease is critical in trying to prevent recurrent pregnancy loss in women with those conditions. For women with antibody problems, certain medications have been found to be useful in achieving successful pregnancy outcomes. Blood thinners can, in some cases, prevent further pregnancy loss.

The use of progesterone to increase the blood levels of this hormone is commonly used for patients with recurrent pregnancy loss. This is especially true if it is found that the hormone concentration is low during the critical time of implantation. Some practitioners may even give this medication when the progesterone level has been tested and found to be normal. This is done because it has been shown that the progesterone level can fluctuate from month to month. As described above, although treatment with progesterone is common, research is still lacking on the truly proper approach to this "luteal phase defect".

In dealing with recurrent pregnancy loss, it is important to realize that even though apparently obvious problems can be corrected, a miscarriage can still occur. This is not to say that attempts should not be taken to correct identified abnormalities that have been historically associated with miscarriage. However, no treatment can be guaranteed. Even with repeated miscarriages, there is still a very good chance of achieving a successful pregnancy. Early pregnancy and pre-pregnancy counseling can help identify risk factors and allow the practitioner to provide any special care that may be needed.

Miscarriage At A Glance

• Spontaneous miscarriage is a pregnancy that is non-viable or when the fetus is born before the 20th week.
• Exercise, working, and intercourse do NOT increase risk of miscarriage for women without underlying specific medical conditions that place them at risk.
• Causes for miscarriage include genetic abnormalities, infection, medications, hormonal effects, structural abnormality of the uterus, and immune abnormalities.
• After an isolated miscarriage, the chance of having a normal term pregnancy in the future is near 90%.
• Treatment of recurrent miscarriage is directed toward the underlying cause.

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