Miscarriage

Some recommend not using the term "abortion" in discussions with those experiencing a miscarriage to decrease distress. In Britain, the term "miscarriage" has replaced any use of the term "spontaneous abortion" for pregnancy loss and in response to complaints of insensitivity towards women who had suffered such loss. An additional benefit of this change is reducing confusion among medical laymen, who may not realize that the term "spontaneous abortion" refers to a naturally occurring medical phenomenon and not the intentional termination of pregnancy. The medical terminology applied to experiences during early pregnancy has changed over time. Before the 1980s, health professionals used the phrase spontaneous abortion for a miscarriage and induced abortion for a termination of the pregnancy. By the 1940s, the popular assumption that an abortion was an intentional and immoral or criminal action was sufficiently ingrained that pregnancy books had to explain that abortion was the then-popular technical jargon for miscarriages. In the 1960s, the use of the word miscarriage in Britain (instead of spontaneous abortion) occurred after changes in legislation. In the late 1980s and 1990s, doctors became more conscious of their language about early pregnancy loss. Some medical authors advocated a change to the use of miscarriage instead of spontaneous abortion because they argued this would be more respectful and help ease a distressing experience. The change was being recommended in Britain in the late 1990s. A foetus that died before birth after this gestational age may be referred to as a stillbirth. ==Signs and symptoms==

Signs of a miscarriage include vaginal spotting, abdominal pain, cramping, fluid, blood clots, and tissue passing from the vagina. Bleeding can be a symptom of miscarriage, but many women also have bleeding in early pregnancy and do not miscarry. Bleeding during the first half of pregnancy may be referred to as a threatened miscarriage. Of those who seek treatment for bleeding during pregnancy, about half will miscarry. Miscarriage may be detected during an ultrasound exam or through serial human chorionic gonadotropin (HCG) testing. ==Risk factors==

Miscarriage may occur for many reasons, not all of which can be identified. Risk factors are those things that increase the likelihood of having a miscarriage but do not necessarily cause a miscarriage. Up to 70 conditions, infections, medical procedures, lifestyle factors, occupational exposures, Some of these risks include endocrine, genetic, uterine, or hormonal abnormalities, reproductive tract infections, and tissue rejection caused by an autoimmune disorder. Trimesters First trimester Most clinically apparent miscarriages (two-thirds to three-quarters in various studies) occur during the first trimester. About 30% to 40% of all fertilised eggs miscarry, often before the pregnancy is known. Successful implantation of the zygote into the uterus is most likely eight to ten days after fertilization. If the zygote has not been implanted by day ten, implantation becomes increasingly unlikely in subsequent days. A chemical pregnancy is a pregnancy that was detected by testing but ends in miscarriage before or around the time of the next expected period. Chromosomal abnormalities are found in more than half of embryos miscarried in the first 13 weeks. Half of embryonic miscarriages (25% of all miscarriages) have an aneuploidy (abnormal number of chromosomes). Common chromosome abnormalities found in miscarriages include an autosomal trisomy (22–32%), monosomy X (5–20%), triploidy (6–8%), tetraploidy (2–4%), or other structural chromosomal abnormalities (2%). Luteal phase progesterone deficiency may or may not be a contributing factor to miscarriage. Second and third trimesters Second-trimester losses may be due to maternal factors such as uterine malformation, growths in the uterus (fibroids), or cervical problems. Obesity, eating disorders, and caffeine Not only is obesity associated with miscarriage, but it can also result in sub-fertility and other adverse pregnancy outcomes. Recurrent miscarriage is also related to obesity. Women with bulimia nervosa and anorexia nervosa may have a greater risk for miscarriage. Nutrient deficiencies have not been found to impact miscarriage rates, but hyperemesis gravidarum sometimes precedes a miscarriage. Caffeine consumption also has been correlated to miscarriage rates, at least at higher levels of intake. Chinese traditional medicine has not been found to prevent miscarriage. Food poisoning Ingesting food that has been contaminated with listeriosis, toxoplasmosis, and salmonella is associated with an increased risk of miscarriage. The risk of miscarriage is not likely decreased by discontinuing SSRIs before pregnancy. Some available data suggest that there is a small increased risk of miscarriage for women taking any antidepressant, though this risk becomes less statistically significant when excluding studies of poor quality. Medicines that increase the risk of miscarriage include: • retinoids • nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen • misoprostol • methotrexate Immunisations Immunisations have not been found to cause miscarriage. Live vaccinations, like the MMR vaccine, can theoretically cause damage to the fetus as the live virus can cross the placenta and potentially increase the risk for miscarriage. Therefore, the Center for Disease Control (CDC) recommends against pregnant women receiving live vaccinations. However, there is no clear evidence that has shown live vaccinations increase the risk of miscarriage or fetal abnormalities. Treatments for cancer Ionising radiation levels given to a woman during cancer treatment cause miscarriage. Exposure can also impact fertility. The use of chemotherapeutic drugs to treat childhood cancer increases the risk of future miscarriage. Pre-existing diseases Several pre-existing diseases in pregnancy can potentially increase the risk of miscarriage, including diabetes, endometriosis, polycystic ovary syndrome (PCOS), hypothyroidism, certain infectious diseases, and autoimmune diseases. Women with endometriosis report a 76% to 298% increase in miscarriages versus their non-afflicted peers, the range affected by the severity of their disease. PCOS may increase the risk of miscarriage. but the quality of these studies has been questioned. Metformin treatment in pregnancy is not safe. In 2007, the Royal College of Obstetricians and Gynaecologists also recommended against the use of the drug to prevent miscarriage. Mycoplasma genitalium infection is associated with an increased risk of preterm birth and miscarriage. Autoimmune disease may cause abnormalities in embryos, which in turn may lead to miscarriage. As an example, coeliac disease increases the risk of miscarriage by an odds ratio of approximately 1.4. Having lupus also increases the risk of miscarriage. Immunohistochemical studies on decidual basalis and chorionic villi found that the imbalance of the immunological environment could be associated with recurrent pregnancy loss. Anatomical defects and trauma Fifteen per cent of women who have experienced three or more recurring miscarriages have some anatomical defect that prevents the pregnancy from being carried to term. The structure of the uterus affects the ability to carry a child to term. Anatomical differences are common and can be congenital. In some women, cervical incompetence or cervical insufficiency occurs with the inability of the cervix to stay closed during the entire pregnancy. NVP may represent a defence mechanism which discourages the mother's ingestion of foods that are harmful to the fetus; according to this model, a lower frequency of miscarriage would be an expected consequence of the different food choices made by women experiencing NVP. Chemicals and occupational exposure Chemical and occupational exposures may have some effect on pregnancy outcomes. A cause-and-effect relationship can rarely be established. Those chemicals that are implicated in increasing the risk for miscarriage are DDT, lead, formaldehyde, arsenic, benzene and ethylene oxide. Video display terminals and ultrasound have not been found to affect the rates of miscarriage. In dental offices where nitrous oxide is used with the absence of anaesthetic gas scavenging equipment, there is a greater risk of miscarriage. For women who work with cytotoxic antineoplastic chemotherapeutic agents, there is a small increased risk of miscarriage. No increased risk for cosmetologists has been found. Other Alcohol increases the risk of miscarriage. Subclinical infections of the lining of the womb, commonly known as chronic endometritis, are also associated with poor pregnancy outcomes, compared to women with treated chronic endometritis or no chronic endometritis. ==Diagnosis==

In the case of blood loss, pain, or both, transvaginal ultrasound is performed. If a viable intrauterine pregnancy is not found with ultrasound, blood tests (serial βHCG tests) can be performed to rule out ectopic pregnancy, which is a life-threatening situation. If hypotension, tachycardia, and anaemia are discovered, the exclusion of an ectopic pregnancy is important. Ultrasound criteria A review article in The New England Journal of Medicine based on a consensus meeting of the Society of Radiologists in Ultrasound in America (SRU) has suggested that miscarriage should be diagnosed only if any of the following criteria are met upon ultrasonography visualisation: Classification A threatened miscarriage is any bleeding during the first half of pregnancy. but the foetus has yet to be expelled. This usually will progress to a complete miscarriage. The foetus may or may not have cardiac activity. after an episode of heavy bleeding in an intrauterine pregnancy that had been confirmed by previous ultrasonography. There is some widening between the uterine walls, but no sign of any gestational sac, thus, in this case, being diagnostic of a complete miscarriage. A complete miscarriage is when all products of conception have been expelled; these may include the trophoblast, chorionic villi, gestational sac, yolk sac, and fetal pole (embryo); or later in the pregnancy the foetus, umbilical cord, placenta, amniotic fluid, and amniotic membrane. The presence of a pregnancy test that is still positive, as well as an empty uterus upon transvaginal ultrasonography, does, however, fulfil the definition of pregnancy of unknown location. Therefore, there may be a need for follow-up pregnancy tests to ensure that there is no remaining pregnancy, including ectopic pregnancy. , with some products of conception in the cervix (to the left in the image) and remnants of a gestational sac by the fundus (to the right in the image), indicating an incomplete miscarriage An incomplete miscarriage occurs when some products of conception have been passed, but some remain inside the uterus. However, an increased distance between the uterine walls on transvaginal ultrasonography may also simply be an increased endometrial thickness and/or a polyp. The use of a Doppler ultrasound may be better in confirming the presence of significant retained products of conception in the uterine cavity. In cases of uncertainty, ectopic pregnancy must be excluded using techniques like serial beta-hCG measurements. A septic miscarriage occurs when the tissue from a missed or incomplete miscarriage becomes infected, which carries the risk of spreading infection (sepsis) and can be fatal. A large majority (85%) of those who have had two miscarriages will conceive and carry normally afterward. ==Prevention==

Prevention of a miscarriage can sometimes be accomplished by decreasing risk factors. Progesterone has been shown to prevent miscarriage in women with 1) vaginal bleeding early in their current pregnancy and 2) a previous history of miscarriage. Non-modifiable risk factors Preventing a miscarriage in subsequent pregnancies may be enhanced with assessments of: • Immune status • Genetic abnormalities Modifiable risk factors Maintaining a healthy weight and good prenatal care can reduce the risk of miscarriage. Some risk factors can be minimized by avoiding the following: • Smoking • Cocaine use • Alcohol • Poor nutrition • Occupational exposure to agents that can cause miscarriage • Medications associated with miscarriage • Substance use ==Management==

Women who miscarry early in their pregnancy usually do not require any subsequent medical treatment, but they can benefit from support and counseling. Most early miscarriages will be completed on their own; in other cases, medication treatment or aspiration of the products of conception can be used to remove the remaining tissue. While bed rest has been advocated to prevent miscarriage, this is not of benefit. Those who are experiencing or who have experienced a miscarriage benefit from the use of careful medical language. Significant distress can often be managed by the ability of the clinician to clearly explain terms without suggesting that the woman or couple is somehow to blame. Evidence to support Rho(D) immune globulin after a spontaneous miscarriage is unclear. In the UK, Rho(D) immune globulin is recommended in Rh-negative women after 12 weeks gestational age and before 12 weeks gestational age in those who need surgery or medication to complete the miscarriage. Methods No treatment is necessary for a diagnosis of complete miscarriage (so long as ectopic pregnancy is ruled out). In cases of an incomplete miscarriage, empty sac, or missed abortion, there are three treatment options: watchful waiting, medical management, and surgical treatment. With no treatment (watchful waiting), most miscarriages (65–80%) will pass naturally within two to six weeks. This treatment avoids the possible side effects and complications of medications and surgery, but increases the risk of mild bleeding, the need for unplanned surgical treatment, and incomplete miscarriage. Medical treatment usually consists of using misoprostol (a prostaglandin) alone or in combination with mifepristone pre-treatment. These medications help the uterus to contract and expel the remaining tissue out of the body. This works within a few days in 95% of cases. Studies looking at the methods of anaesthesia for surgical management of incomplete miscarriage have not shown that any adaptation from normal practice is beneficial. Induced miscarriage An induced abortion may be performed by a qualified healthcare provider for women who cannot continue the pregnancy. Self-induced abortion performed by a woman or non-medical personnel can be dangerous and is still a cause of maternal mortality in some countries. In some locales, it is illegal or carries heavy social stigma. Sex Some organisations recommend delaying sex after a miscarriage until the bleeding has stopped to decrease the risk of infection. Others recommend delaying attempts at pregnancy until one period has occurred to make it easier to determine the dates of a subsequent pregnancy. Support Organisations exist that provide information and counselling to help those who have had a miscarriage. The husband of the mother gets seven days' fully paid leave up to the 4th pregnancy. • India – six weeks' leave • New Zealand – three days' bereavement leave for both parents • Mauritius – two weeks' leave • Indonesia – six weeks' leave • Northern Ireland – two weeks' paid leave for both parents, no matter at what stage the miscarriage occurs. ==Outcomes==

Psychological and emotional effects Every woman's personal experience of miscarriage is different, and women who have more than one miscarriage may react differently to each event. In Western cultures since the 1980s, It can affect the whole family. Many of those experiencing a miscarriage go through a grieving process. "Prenatal attachment" often exists that can be seen as parental sensitivity, love and preoccupation directed towards the unborn child. Serious emotional impact is usually experienced immediately after the miscarriage. In some, the realisation of the loss can take weeks. Providing family support to those experiencing the loss can be challenging because some find comfort in talking about the miscarriage, while others may find the event painful to discuss. The father can have the same sense of loss. Expressing feelings of grief and loss can sometimes be harder for men. Some women can begin planning their next pregnancy after a few weeks of having a miscarriage. For others, planning another pregnancy can be difficult. Some facilities acknowledge the loss. Parents can name and hold their infant. They may be given mementos such as photos and footprints. Some conduct a funeral or memorial service. They may express the loss by planting a tree. Some health organizations recommend that sexual activity be delayed after a miscarriage. The menstrual cycle should resume after about three to four months. Women reported that they were dissatisfied with the care they received from physicians and nurses. Subsequent pregnancies Some parents want to try to have a baby very soon after the miscarriage. The decision to try to become pregnant again can be difficult. Reasons exist that may prompt parents to consider another pregnancy. For older mothers, there may be some sense of urgency. Other parents are optimistic that future pregnancies are likely to be successful. Many are hesitant and want to know about the risk of having another or more miscarriages. Some clinicians recommend that the women have one menstrual cycle before attempting another pregnancy. This is because the date of conception may be hard to determine. Also, the first menstrual cycle after a miscarriage can be much longer or shorter than expected. Parents may be advised to wait even longer if they have experienced a late miscarriage or molar pregnancy, or are undergoing tests. Some parents wait for six months based on recommendations from their healthcare provider. The risks of having another miscarriage vary according to the cause. The risk of having another miscarriage after a molar pregnancy is very low. The risk of another miscarriage is highest after the third miscarriage. Pre-conception care is available in some locales. ==Epidemiology==

Around 15% of known pregnancies end in miscarriage, totaling around 23 million miscarriages per year worldwide. Miscarriage rates among all fertilized zygotes are around 30% to 50%. Additionally, those with bleeding in early pregnancy may seek medical care more often than those not experiencing bleeding. Although some studies attempt to account for this by recruiting women who are planning pregnancies and testing for very early pregnancy, they still are not representative of the wider population. In 2010, 50,000 inpatient admissions for miscarriage occurred in the UK. ==Society and culture==

Society's reactions to miscarriage have changed over time. In places where induced abortion is illegal or carries a social stigma, suspicion may surround miscarriage, complicating an already sensitive issue. Developments in ultrasound technology (in the early 1980s) allowed them to identify earlier miscarriages. although this does not apply to miscarriages. According to French statutes, an infant born before the age of viability, determined to be 28 weeks, is not registered as a 'child'. If birth occurs after this, the infant is granted a certificate that allows the parents to have a symbolic record of that child. This certificate can include a registered and given name to allow a funeral and acknowledgement of the event. ==Other animals ==

Spontaneous abortion is known from multiple species of non-hominid placental mammal and other vertebrates with convergent embryonic development, such as elasmobranch fishes. There are a variety of known risk factors; for example, in sheep, miscarriage may be caused by crowding through doors or being chased by dogs. In cows, spontaneous abortion may be caused by contagious diseases, such as brucellosis or Campylobacter, but often can be controlled by vaccination. In many species of sharks and rays, stress-induced miscarriage occurs frequently on capture. Other diseases and risks are also known to make animals susceptible to miscarriage. Spontaneous abortion occurs in pregnant prairie voles when their mate is removed and they are exposed to a new male, an example of the Bruce effect, although this effect is seen less in wild populations than in the laboratory. Female mice who had spontaneous abortions showed a sharp rise in the amount of time spent with unfamiliar males preceding the abortion than those who did not. == See also ==