See Early pregnancy loss

Spontaneous pregnancy loss before the 20th week of gestation.

Nearly one in three pregnancies end spontaneously in the first trimester, affecting 1 million patients in the US annually.

The most common etiology of early pregnancy loss is fetal chromosomal abnormalities, which accounts for more than 2/3 of pregnancy losses between six and 10 weeks gestation.

Is defined as the loss of a pregnancy before viability.

Defined as an involuntary, spontaneous loss of a pregnancy before 20 completed weeks.

One of the most common complications of pregnancy.

The majority of spontaneous miscarriages occur in the first trimester.

About 6% of miscarriages have trisomy 16.

The prevalence of women who have experienced at least one missed miscarriage in their lifespan is 10.8% and the pool risk for miscarriage is approximately 15% of all pregnancies.

After miscarriage 60% of individuals who desire future pregnancy achieve it within two years.

Spontaneous abortion has been reported in as many as a fifth of pregnancies in some populations in low- and medium-income countries.

An  estimated 23 million miscarriages occur every year, leading to 44 pregnancy losses every minute worldwide.

An abnormal fetus is almost always the cause of miscarriages during the first trimester.

The natural history of miscarriage is spontaneous towards the complete expulsion of the products of conception.

When explosion is incomplete, the retained products of conception, may require medical or surgical evacuation.

Chromosomal abnormalities in the fetus are found in more than half of miscarried fetuses, and the risk of such changes increases with the woman’s age.

Less than 3% occur in the second trimester.

Chronic illnesses, are frequent causes of a miscarriage.

The etiology can be divided into embryonic and/or maternal factors, although it is more likely to be multifactorial.

Recurrent miscarriages affects 1-3% of women of reproductive age.

Recurrent miscarriage is defined as the loss of three or more pregnancies.

Miscarriages are associated with high morbidity and mortality, mainly due to infections or hemorrhage.

Prevalence of recurrent miscarriages can be up to 5% for women with 2 pregnancy losses.

Majority of women with recurrence miscarriages, especially those with early pregnancy losses the causative factors can include: chromosomal abnormalities of the fetus, uterine anatomic abnormalities, endocrine disorders, infections, and a hypercoaguable state.

The cause of recurrent miscarriage is identified in fewer than half of the couples.

Miscarriages are associated with high morbidity and mortality, mainly due to infections or hemorrhage.

Miscarriages are noted to be higher among women who are positive for HIV infection than among those who are HIV negative.

The antiphospholipid syndrome, and pregnancy complications are defined by the presence of antiphospholipid, anti-lupus coagulant, anti-cardiolipin, and/or anti-beta-2- glycoprotein I antibodies, and the presence of thrombotic pregnancy complications or in the venous or arterial systems.

Hereditary thrombophilia, such as factor V Leiden mutation or prothrombin mutation are associated with thrombotic pregnancy complications.

About two-thirds of products of conception reveal chromosomal abnormalities.

Rate at age 20 is about 10% and increases to 90% for women of 45 years of age or older.

High rates contribute significantly to decreased fertility in older women.

May result from thrombosis and from the adverse effects of coagulation cascade on the trophoblast.

Most frequent complication of pregnancy.

Also ref2242ed to as spontaneous abortion.

Nearly 60% of pregnancies end before the woman recognizes she is pregnant.

Approximately 15% of pregnancies will result in a miscarriage.

80% of cases occur before 12 weeks of pregnancy.

There is a strong association between the presence of thyroid peroxidase antibodies and miscarriage.

In 10% of pregnancies miscarriage is clinically recognized, and another 20% of pregnancies is manifested by a transient elevation of hCG before a near menses ( Wilcox AJ et al).

Risk after 16 weeks is less than 1%.

Symptoms include vaginal pain and bleeding.

Additional symptoms include back pain, passing of tissue from the vagina and slower than expected growth of the uterus.

Decrease in pregnancy symptoms may indicate that a miscarriage has occurred.

Diagnosis requires that a pregnancy occurred and then that it has failed.

There is an increased incidence of miscarriage in flight attendants, perhaps related to circadian rhythm disruption and radiation (Heidecker B).

Blood and urine HCG levels confirm the diagnosis of pregnancy and serial tests can demonstrate that a pregnancy is failing or has failed.

Ultrasound can image the uterus and the confirm the diagnosis: if there is an empty gestational sac without an embryo, the embryo has reached a certain size but no heart beat can be identified, a previous heart beat is subsequently absent and there is no growth of the pregnancy for more than 1 week.

The majority of miscarriages that occur before 10 weeks gestation are related to chromosomal abnormalities from noninherited, new nondisjunctionalevents (Si2242a S et al).

The rate of miscarriage increased with maternal age less than 18 years or greater than 35 years of age.

Increased risk of miscarriages after the age of 35 is due to increased rates of aneuploidy in older oocytes.

Risk of miscarriage increases with history of previous miscarriages and with increasing parity (Nybo Andersen AM et al).

Risk factors include: advancing maternal age, prior pregnancy loss, teratogenic exposures, maternal endocrine or autoimmune conditions, such as diabetes, hyperyhyroidism, and systemic lupus erythematosus.

Approximately 1% of women trying to conceive have recurrent miscarriage.

Recurrent miscarriage defined as 3 previous miscarriages.

If recurrent miscarriages defined as 2 previous miscarriages, 5% of women trying to conceive will have such events.

In recurrent miscarriages no cause can be identified in half of the cases.

Associated with antiphospholipid syndrome, acquired thrombophilia, factor V Leiden, and Prothrombin mutation G20210A.

Early pregnancy loss may be diagnosed by the presence of symptoms, such as vaginal bleeding, and ann  open cervical os with decreasing beta human chorionic gonadotropin level.

Ultrasound has allowed it an increasing number of patients to be diagnosed with early pregnancy loss prior to the onset of symptoms based on radiologic criteria.

For recurrent miscarriages no effective treatment has been identified.

Heparin and aspirin in recurrent miscarriage and antiphospholipid syndrome may improve pregnancy outcome, but trials have been inconsistent.

Aspirin and low molecular weight heparin commonly used in in women with unexplained recurrent miscarriage.

A randomized placebo controlled trial, the Anticoagulants for Living Fetuses (ALIFE) combined aspirin with low molecular weight heparin or aspirin alone, as compared with placebo to improve live-birth rate among women with unexplained recurrent miscarriage: neither aspirin alone or combined with low molecular weight heparin improved the live-birth rate as compared with placebo.

Patients without hemorrhage or signs of infection have  three management options after diagnosis of early pregnancy loss: expectant management, medication management, surgical management.

Of patients with early pregnancy loss, 25 to 50% will pass pregnancy tissue on their own within one week without any intervention and more than 80% with bleeding will expel the pregnancy tissue within two weeks.

Expectant management without signs of infection or hemorrhage is safe.

Pain management typically includes over-the-counter analgesics, nonsteroidal anti-inflammatory agents, and acetaminophen, as well as heat packs or lower back massage.

Medical management includes misoprostol only or misoprostol -mifepristone regimens.

Medical management allows to expedite care compared with expectant management.

Medication management is not ideal for patients with significant bleeding or patients with significant anemia, or patients on anticoagulation,.

Progesterone therapy given in the first trimester in patients with a history of unexplained recurrent miscarriages does not result in significant higher rate of live births (Coomarasamy A et al).

Surgery is frequently used to manage incomplete miscarriage in low-medium income countries.

Incomplete, spontaneous abortions are treated by expectant, medical, or surgical management.

The surgery may be performed immediately or after unsuccessful expectant medical treatment.

Surgical methods are ranked above expected and medical treatment in terms of efficacy.

Vacuum aspiration is the standard for surgical treatment.

vacuum aspiration has risks of scarring of the uterine cavity, which can compromise, postoperative fertility, with an estimated 30% risk of intrauterine adhesions.

Hysteroscopy is performed by insertion of a hysteroscope through the cervical canal into the endometrial cavity.

The hysteroscopy can remove retained products of conception, under direct visualization, and may reduce risk to the uterine cavity and improve future fertility.

Retrospective studies suggest that compared with vacuum aspiration hysteroscopy is associated with a 13% risk of post operative intrauterine adhesions and better subsequent fertility with the shorten meantime of conception, with up to 70% of treated individuals becoming pregnant again within two years of the initial intervention.

In a randomized clinical trial of 574 patients with incomplete, spontaneous abortion, hysteroscopy was not associated with higher. subsequent rates of pregnancy of at least 22 weeks gestation than  was vacuum aspiration during a two-year follow up (Huchon C).

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