Spontaneous Abortion (Miscarriage)- Causes, Symptoms, Treatment, and Complications

Overview:

Spontaneous abortion (miscarriage) refers to the natural termination of pregnancy at less than twenty weeks of gestation; in the absence of any elective medical or surgical measures. The term “miscarriage” is preferred over “abortion” as the latter is associated with elective termination of pregnancy. However, any early pregnancy loss that occurs naturally can also be called spontaneous abortion, occurring primarily in the first trimester.

What Are the Causes of Spontaneous Abortion?

Common factors responsible for spontaneous abortion (miscarriage) are:

• Genetic abnormalities in the developing embryo (chromosomal anomaly).

• The maternal age is more than 35.

• History of spontaneous abortion.

• Smoking cigarettes.

• Drugs such as cocaine, alcohol, or caffeine.

• Rapid conception after the last delivery.

• Chronic diseases include diabetes, hypertension, thyroid, celiac disease, and autoimmune conditions like Antiphospholipid syndrome (APS).

• Infections include malaria, cervicitis, vaginitis, HIV (Human immunodeficiency virus), and syphilis.

• Exposure to harmful substances: arsenic and lead.

• Uterine Abnormalities such as congenital anomalies (malformations of the uterus that develop during embryonic life), leiomyoma (also known as a fibroid, is a benign smooth muscle tumor), or intrauterine adhesions (bands of fibrous tissue formed in the endometrial cavity in response to a uterine procedure).

• Sudden trauma.

• Incompetent cervix.

What Are the Symptoms of Spontaneous Abortion?

1. Early Symptoms:

• Pelvic pain and cramps.

• Vaginal bleeding (sometimes mistaken for heavy late periods) or spotting.

• Expulsion of some tissues.

2. Late Symptoms:

• Membrane rupture: resulting in a massive gush of fluid.

• Hemorrhage leading to hypovolemic shock.

• Dilated cervix (inevitable abortion).

After the spontaneous abortion, if products of conception remain in the uterus, vaginal bleeding may occur, leading to infection, fever, pain, and sometimes sepsis (called septic abortion).

How Is Spontaneous Abortion Diagnosed and Evaluated?

The most commonly used tests are:

• Urine pregnancy test.

• Serum beta-hCG (human chorionic gonadotropin) test.

• Transvaginal ultrasound.

Depending on the patient history and physical examination, various tests are performed to diagnose the correct type and reason for spontaneous abortion.

1. Missed Abortion (silent miscarriage) is a type of miscarriage in which the fetus does not form or die, but the placenta and embryonic tissues are present in the uterus. Such cases show a low quantitative beta-hCG level for gestational age and do not double within 48 hours to 72 hours.

Ultrasonography shows:

• Disappeared previously detected embryonic cardiac activity.

• The uterus does not progressively enlarge.

• Absence of a fetal pole.

2. Threatened Abortion- vaginal bleeding before 20 weeks gestational age, a positive pregnancy test (blood or urine), closed cervical os, no remnant products of conception, and no evidence of fetal death. Diagnosis will be based on viable intrauterine pregnancy on ultrasound and closed cervical os clinically.

3. Inevitable Abortion- cramping, vaginal bleeding, an open cervical os on the physical examination but no passage for conception products. Ultrasound might show viable or nonviable pregnancy.

4. Incomplete Abortion- vaginal bleeding, dilatation of the cervical canal, and passage of some products of conception. Ultrasound will show retained products of a nonviable pregnancy.

5. Complete Abortion- all the products (tissue) of conception leave the body, thereby showing no intrauterine conception products on ultrasound. It is diagnosed in cases of resolving cramps and bleeding with open or closed cervical os.

6. Septic Abortion- abortion that is complicated by uterine infection, including endometritis. Signs and symptoms: cramping and bleeding, purulent cervical or vaginal discharge, fever, and an open or closed cervical os. Pelvic ultrasound may reveal retained conception products, exudative fluid, an extra-uterine extension of the infection, or uterine perforation.

7. Recurrent Spontaneous Abortion: consecutive pregnancy loss more than three times.

Besides beta-hCG and ultrasound, some other tests are:

• Hemoglobin and hematocrit level- to rule out acute blood loss anemia.

• Determine the mother’s blood group and Rh type in case blood transfusion or administration of Rh (D)-immune globulin is needed.

• Screening for gonorrhea and chlamydia (especially for cases of septic abortions).

• May need other tests to rule out ectopic pregnancy.

What Is the Treatment of Spontaneous Abortion?

Management of spontaneous abortions can be either expectant, medical, or surgical, depending on their types and causes.

• Surgical Evacuation of the Uterus (Dilatation and Curettage)- most traditional approach.

• Completed Spontaneous Abortion- rarely requires medical or surgical intervention.

• Incomplete Spontaneous Abortion- expectant management (up to two weeks) followed by medical therapy.

• Missed Spontaneous Abortion- expectant management and medical therapy with intravaginal Misoprostol.

After a spontaneous abortion, women are at increased risk of depression and anxiety; parents may feel grief and guilt. Therefore, patient counseling is needed for emotional support and for coping with the situation.

What Are the Complications of Spontaneous Abortion?

Complications of spontaneous abortion can be:

1. Early Complications- blood loss and infections; if left untreated, it may lead to DIC (disseminated intravascular coagulation) or even mortality. The following steps are taken to manage the situation:

• Removal of the retained products of conception.

• Broad-spectrum antibiotics.

• Blood transfusion.

• Hematologic treatment (tranexamic acid).

• Prophylactic antibiotics (to reduce postabortion infection).

• Complications related to surgical intervention: cervical lacerations, uterine perforation, hematometra, and anesthesia-related complications.

2. Late Complications- Symptoms: pain and bleeding with difficulties in conceiving due to retained products of conception and uterine adhesions (Asherman syndrome).

• Administration of anti-D for the prevention of rhesus isoimmunization in the early diagnosis.

• Counseling and assistance for post-miscarriage depression.

• If three or more spontaneous miscarriages occur, the expecting parents should consult a fertility specialist.

What Happens After a Spontaneous Miscarriage and How to Cope?

Recovering from a spontaneous miscarriage, both physically and emotionally, takes time and patience.

Typical body changes that occur after a pregnancy loss:

• Uterine contractions.

• Abdominal cramps.

• Vaginal bleeding (like a light to a heavy period).

• Passing small blood clots.

• Abstaining sex and tampons for at least two weeks is advised.

• It may take a few weeks for the body to recover, as pregnancy hormones can be present in the blood for two months after the miscarriage.

• Most women get their periods again after 4 to 6 weeks. After having at least one normal menstrual cycle, the patient can again plan for pregnancy.

It may take longer to recover emotionally from a miscarriage: grief, guilt, and anxiety. But, eventually, recovery begins with proper counseling and emotional management.

Conclusion:

Spontaneous abortion (miscarriage) is a mishap that can occur to anyone, but this is not the end of the road. There is a greater need for increased awareness, as the experience of miscarriage has a considerable impact on expecting parents. Women who experience miscarriage worry that it might reoccur. But, it can be a one-off incident and is not necessarily a sign of future miscarriage risk. Research has shown that about 85 % of women can bear a healthy pregnancy even after a miscarriage.