Pregnancy Loss

Pregnancy loss refers to the loss of an unborn fetus at any time during pregnancy.  Approximately 50% of all pregnancies end in a loss.  The majority of losses occur in the first trimester and for many women, the loss may have happened so early that they were not even aware that they were pregnant. The incidence of pregnancy loss significantly decreases after the first trimester. Pregnancy losses typically fall into one of the following categories:

• Early miscarriage – when a pregnancy is lost in the first 12 weeks (first trimester) of pregnancy.  This is the most common type of miscarriage.
• Late miscarriage – when a pregnancy is lost after 12 weeks (first trimester) but before 24 weeks.  About 1–2% of pregnancies end in a late miscarriage. This may be related to genetic abnormalities, infection, or sometimes the cervix being weak and opening too early (cervical insufficiency).
• Stillbirth – the loss of a pregnancy after 24 weeks.  Occurs in approximately 0.5% of births
• Recurrent miscarriage –when a miscarriage happens 3 or more times in a row.  Affects 1% of couples.

There are several different types of early pregnancy loss which occur during the first trimester. These include:

• Chemical pregnancy:  A very early miscarriage which can occur before you even learn that you are pregnant. A pregnancy test is positive but the loss occurs quickly following implantation and is never visible on ultrasound. Most likely the result of chromosomal abnormalities in the fertilized egg. There are typically no symptoms. Most women simply being to bleed around the time of their next period which may arrive a few days late or be slightly heavier. Requires no treatment. 
• Blighted ovum:  Also known as an anembryonic pregnancy, this condition occurs when a fertilized egg attaches to the uterine wall but an embryo does not develop. You may feel symptoms of pregnancy but when your physician performs an ultrasound, there is an empty gestational sac. You may miscarry the pregnancy or your physician may need to give you medication or perform a dilation and curettage (D&C) procedure to remove the pregnancy from the uterus. 
• Missed miscarriage:  Also known as a missed abortion, this occurs when a fetus implants but fails to develop. The body does not expel the pregnancy tissue and a physician identifies a fetus without a heartbeat on ultrasound. You may continue to feel signs of pregnancy as the placenta still releases hormones. Some women notice that the signs of pregnancy fade. Most women have no symptoms of a miscarriage. Your physician may need to give you medication or perform a dilation and curettage (D&C) procedure to remove the pregnancy from the uterus. 
• Inevitable miscarriage:  Refers to vaginal bleeding and cramping with dilation of the cervix during early pregnancy. The opening of the cervix is a sign that the body is in the process of miscarrying the pregnancy. Symptoms include bleeding and cramping. Typically no intervention is required. 
• Incomplete miscarriage:  Occurs when some, but not all, of the pregnancy tissue is passed. Some tissue remains inside and can cause bleeding or infection. Symptoms include heavy vaginal bleeding, cramping, and passage of some tissue. Typically requires medication or a dilation and curettage (D&C) procedure to remove the rest of the pregnancy tissue and stop the bleeding.
• Complete miscarriage:  Refers to a miscarriage in which all of the pregnancy tissue is expelled from the uterus.  Symptoms include heavy vaginal bleeding and cramping which subsides quickly after passage of tissue. Requires no treatment. 
• Ectopic pregnancy:  Refers to a condition in which the pregnancy implants outside of the uterus, usually in one of the fallopian tubes. If left untreated, it can cause rupture of the fallopian tube, significant internal bleeding, and death. Given the serious threat of internal bleeding, it is essential to treat an ectopic pregnancy as soon as possible.  This occurs 1% of all pregnancies and is the number one cause of maternal death in the first trimester. Typically has no symptoms but if rupture occurs, heavy bleeding, severe pain, and fainting can occur. An ectopic pregnancy can be treated with medication to help the body stop and dissolve the pregnancy, or with surgery to remove the pregnancy.  Unfortunately, once a pregnancy has implanted outside of the uterus, the pregnancy cannot be moved into the uterus.
• Molar pregnancy:  Also known as a hydatidiform mole, this is a rare complication of pregnancy caused when an egg and sperm join incorrectly and a tumor forms instead of a healthy placenta. There are two different types of molar pregnancies -- complete and partial.  In a complete molar pregnancy, the placenta tissue is abnormal and swollen and forms cysts. There is no formation of fetal tissue. In a partial molar pregnancy, there may be normal placental tissue along with abnormal placental tissue and there may also be formation of a fetus. This fetus is not able to survive and is usually lost early in the pregnancy. Both types of molar pregnancies can have serious complications – including a rare form of cancer – and requires early treatment. Occurs 1 in 1000 pregnancies. Symptoms may include bleeding in pregnancy, severe nausea/vomiting, rapid uterine growth, high blood pressure, ovarian cysts, pelvic pain, overactive thyroid (hyperthyroidism). Treatment typically involves surgery (including possible hysterectomy) and sometimes chemotherapy. Close monitoring for 6-12 months will be required and no attempts to get pregnant should occur during this time. 

Pregnancy loss which occurs in the first trimester is most often caused by genetic abnormalities which happens when the egg and sperm met to create an embryo. When the body recognizes that the genetic makeup of the fetus is abnormal and incompatible with life, a miscarriage occurs. Pregnancy loss can also occur in the second and third trimester.  Some causes of these later losses include intrauterine infection, premature opening of the cervix, uncontrolled diabetes or high blood pressure, exposure to toxic substances or chemicals, and injury/trauma to name a few.   

In the first trimester, pregnancy loss can be managed expectantly, medically, or surgically.  Expectant management refers to waiting for the pregnancy to pass on its own. Most pregnancies will pass on their own within 2 weeks after loss occurs.  Medical management refers to the use of medications to induce uterine contractions to allow for the pregnancy to pass.  Surgical management refers to a dilation & curettage (D&C) procedure where pregnancy tissue is removed from the uterus; this procedure can be performed in the office or in the operating room.  When pregnancy loss occurs in the second trimester, typically a dilation and evacuation (D&E) procedure or induction of labor is recommended. In the third trimester, pregnancy loss involves admission to the hospital for an induction of labor.  

While some interventions can be taken to minimize the risk of miscarriage (controlling diabetes, taking prenatal vitamins, avoiding alcohol/tobacco/drugs, limiting caffeine) most first trimester pregnancy losses are not preventable.  In fact, they are a sign that your body is doing the right thing but recognizing an abnormal pregnancy and stopping it before it gets too far along.  Certain losses in the second trimester, such as those related to cervical insufficiency, may be prevented with a cerclage (a stitch placed in the cervix to add strength and prevent it from opening too soon).  In rare occasions (1%), recurrent pregnancy loss, defined as having 3 or more miscarriages in a row, occurs.  Sometimes testing can be performed in an attempt to identify a cause of recurrent pregnancy loss and if a cause is found, there may be options to minimize this risk in the future. However, for many women, a cause for pregnancy loss is not able to be identified.

The term “rainbow baby” has become so common because pregnancy loss is so common.  And the good news is while 50% of pregnancies end in loss, having a loss does not increase your risk for another.  Most women go on to have successful pregnancies after an early pregnancy loss.  At Alliance Obstetrics & Gynecology Group, we emphasize the importance of maintaining good health before and during pregnancy. 

he loss of a baby at any time during pregnancy can be devastating.  You may experience sadness, anxiety, and shock, but you do not have to go through this alone.  If you are experiencing feelings of overwhelming grief, it is important to discuss this with your provider.  We can assist you in finding resources and support groups that can help after pregnancy loss.

If you’re experiencing a pregnancy loss or have in the past, set up a consultation with us at Alliance Obstetrics & Gynecology and The Center for Pediatric & Adolescent Gynecology.