- Threatened Miscarriage Overview
- Threatened Miscarriage Causes
- Threatened Miscarriage Symptoms
- When to Seek Medical Care
- Threatened Miscarriage Diagnosis
- Threatened Miscarriage Treatment
- Threatened Miscarriage Self-Care at Home
- Threatened Miscarriage Medications
- Threatened Miscarriage Follow-up
- Threatened Miscarriage Prevention
- Threatened Miscarriage Prognosis
Threatened Miscarriage Overview
Any 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 one of every four 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 professional 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.
Threatened Miscarriage Causes
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 chromosomes cause an abnormal fetus and are found in more than half of miscarried fetuses. The risk of defective chromosomes 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 hormone production is an occasional cause of miscarriages.
- Acute infections, including German measles, CMV (cytomegalovirus), mycoplasma (atypical pneumonia) and other unusual germs can also cause miscarriage.
- Diseases and abnormalities of the internal female organs can also cause miscarriage. Some examples are an abnormal womb, fibroids, weakness in the mouth of the womb (cervix), abnormal growth of the placenta (also called the afterbirth), and being pregnant with multiples.
- Other factors, especially certain drugs, including excessive caffeine, alcohol, tobacco, and cocaine, may be the cause.
Threatened Miscarriage Symptoms
Symptoms of a spontaneous miscarriage include vaginal bleeding and abdominal pain.
Bleeding may be only slight spotting, or it can be heavy. The health care professional
will ask how heavy the bleeding is, and how many pads are being soaked through per hour. The health care professional 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 the lower back, buttocks, and genitals.
When to Seek Medical Care
A woman who is pregnant who experiences cramping or bleeding at any time should call her health care professional.
A pregnant woman who experiences these symptoms but does not have doctor should go to the 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 pregnancy (tubal pregnancy)
- Vomiting so severe she can't keep anything down
Threatened Miscarriage Diagnosis
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 examFor the pelvic exam, the patient will lie on her back with the knees bent and the feet in stirrups.
- The patient may have a speculum exam. A metal or plastic device is put in your vagina and then opened, spreading the walls of the vagina apart so the health care professional can look right at the mouth of your womb. If there is a lot of blood or clots, the health care professional may use a clamp or gauze to remove it. The patient should not feel any pain during this part of the exam, although she may be embarrassed and uncomfortable.
You may have bleeding from the vagina before, during, and even after a miscarriage. The health care professional
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 professional may put gloved fingers in the patient's vagina and feel the abdomen with the other hand. He or she can feel whether the mouth of the woman's uterus is open, how big the uterus may be, and whether there are any signs of infection or tubal pregnancy. The size of the uterus may be smaller than expected for the fetus if the patient has already miscarried.
Pregnancy tests can be either urine tests or blood tests. The health care professional or emergency department doctor, if the woman goes to the hospital with alarming symptoms, will act quickly to determine if she is 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 to 3 days to see if everything is developing normally.
- A complete blood count (CBC) may be ordered. If the patient has been bleeding a lot, she may be anemic (loss of too much blood) and need special care. If she has a fever, the white cell count may suggest she has an infection.
- If the patient does not know her blood type, this will also be checked. If she is Rh-negative, the patient will probably receive a special medicine called RhoGAM to protect the mother and her baby from a bad reaction.
- If the patient has symptoms of a urinary infection, a urine sample will be taken and examined.
If a woman is 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, the patient will likely be evaluated further for a pregnancy that is outside of the uterus. When the fertilized egg implants in the Fallopian tube, this is called a tubal or ectopic pregnancy.
- The technician may put some jelly on the abdomen for transabdominal ultrasound and press down with a probe to see the internal organs. The ultrasound technician may also use a vaginal probe inside the vagina to get a better look at the Fallopian tubes and ovaries. Neither of these studies should be painful.
Threatened Miscarriage Treatment
If a miscarriage is inevitable and the health care professional does not think the woman has 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 (curettage or D&C), 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.
Threatened Miscarriage 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 professional at once and follow the health care professional's instructions.
The dilation and curettage procedure (D&C) involves dilating the uterine cervix so that the lining tissue (endometrium) of the uterus can be removed by scraping or suction.
The D&C is a safe procedure that is done for a variety of reasons. It is minor surgery performed in a hospital or ambulatory surgery center or clinic. D&C is usually a diagnostic procedure.
Therapeutic dilation and curettage: A D&C is often planned as treatment when the source of the problem is already known. One situation is an incomplete miscarriage or even full-term delivery when, for some reason, the fetal or placental tissue inside of the uterus has not been completely expelled. If tissue is left behind, excess bleeding can result, perhaps even life-threatening bleeding.
Your health care professional will avoid D&C in the following situations, except when absolutely necessary:
- Pelvic infection: If you have an infection involving the reproductive organs, there is a chance the surgical instruments that will enter the vagina and cervix can carry the bacteria from your vagina or cervix into your uterus. There is also an increased risk of injury to infected tissue. For these reasons, the doctor may prefer to wait until after the infection is cleared up with antibiotics before performing the D&C.
- Blood clotting disorders: Doctors depend on the body's natural ability to clot to stop bleeding after curettage. Women with certain blood disorders are usually not given this surgery.
- Serious medical problems: Heart and lung disease, for example, can make general, and sometimes local, anesthesia more risky.
Threatened Miscarriage 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 one week.
Return to the emergency department in the following cases:
- Cramping worsens
- Bleeding worsens (requiring more than one pad per hour)
- Passage of tissue
- Anything else alarming
- Another blood test may be performed in 48 to 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.
Threatened Miscarriage 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.
Threatened Miscarriage Prognosis
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.
Medically reviewed by Steven Nelson, MD; Board Certified Obstetrics and Gynecology
REFERENCE: MedscapeReference.com. Early Pregnancy Loss.