Pregnancy Loss

Pregnancy loss encompasses the unfortunate event of fetal demise and is defined differently across various regions. The World Health Organization (WHO) identifies miscarriage as the expulsion of an unborn baby weighing 500g or less, corresponding to a gestation period of up to 20 weeks. The terms miscarriage and abortion are often used interchangeably, though miscarriage is the more widely recognized term.

Miscarriage refers to the spontaneous or induced termination of pregnancy. It is categorized as early miscarriage or first-trimester loss when occurring before 13 weeks of gestation, while second or mid-trimester loss refers to the period between 13 and 26 weeks. Pregnancy loss beyond this stage is known as stillbirth.

Statistics

Miscarriage is a relatively common occurrence, affecting approximately 10% of confirmed pregnancies. Studies estimate that up to 26% of all pregnancies end in miscarriage. Around 80% of pregnancy losses occur within the first trimester, while 1 to 5% of pregnancies experience miscarriage in the second trimester. Shockingly, the World Health Organization records nearly 2 million stillbirths annually.

Classification

There are two main types of pregnancy loss:

• Spontaneous Miscarriage

  This refers to the natural loss of pregnancy before reaching 20 weeks of gestation. It is commonly known as a miscarriage, as opposed to an induced miscarriage, which is colloquially referred to as an abortion. Various types of spontaneous miscarriage include:

1. Threatened Miscarriage: Typically occurring early in pregnancy, this type is characterized by vaginal spotting and closed cervical os. It may be accompanied by mild abdominal cramps, indicating that the miscarriage has not yet taken place.
2. Inevitable Miscarriage: This occurs in early pregnancy and involves more substantial vaginal bleeding (worse than threatened miscarriage). The cervix is open, accompanied by increased abdominal pain. Although no tissue has been expelled, the fetus and other uterine contents can be observed in the cervical canal through ultrasound.
3. Incomplete Miscarriage: In this type, a miscarriage has occurred, resulting in vaginal bleeding and an open cervix. Intense abdominal pain is experienced, but not all uterine contents have been expelled.
4. Complete Miscarriage: This type signifies the complete expulsion of all uterine contents. It is typically preceded by a history of vaginal bleeding and abdominal pain. Following the passage of tissue, pain and bleeding subside significantly. Complete miscarriage can occur spontaneously or be medically induced following an incomplete miscarriage.
5. Missed Miscarriage: This type is characterized by the absence of symptoms and the absence of tissue expulsion. It involves the retention of an empty gestational sac in the uterus.
6. Recurrent Miscarriage: Defined by the spontaneous loss of two or more pregnancies, recurrent miscarriage affects approximately 1% of women. The risk of experiencing a second miscarriage is 2%, which rises to about 28% after two consecutive miscarriages.
7. Septic Miscarriage: This rare complication of miscarriage is associated with evidence of infection in cases of incomplete miscarriage. Symptoms include fever, chills, heavy bleeding, severe abdominal pain, low blood pressure, reduced urinary output, and difficulty breathing.

• Induced Miscarriage

  This refers to the medical or surgical termination of pregnancy before the fetus reaches viability. The legality of induced miscarriage varies by country, and it can be categorized as criminal or illegal in some cases. However, there are specific therapeutic indications for induced miscarriage.

Unfortunately, miscarriage remains a sensitive topic, often carrying social taboos and stigmatization for many women worldwide, hindering them from receiving the appropriate care. It can take a few weeks or months or more for the body to recover physically and emotionally.

References

• Puscheck, E.E. (2021) Early pregnancy loss, Practice Essentials, Background, Pathophysiology. Available at: https://reference.medscape.com/article/266317-overview (Accessed: 21 May 2023).
• Why we need to talk about losing a baby (no date) World Health Organization. Available at: https://www.who.int/news-room/spotlight/why-we-need-to-talk-about-losing-a-baby (Accessed: 21 May 2023).
• Petrozza, J.C. (2022) Recurrent early pregnancy loss, Practice Essentials, Overview, Incidence. Available at: https://emedicine.medscape.com/article/260495-overview (Accessed: 21 May 2023).
• Kumar, G. and Kumar, B. (no date) Miscarriage (chapter 2) – early pregnancy issues for the MRCOG and beyond, Cambridge Core. Available at: https://www.cambridge.org/core/books/abs/early-pregnancy-issues-for-the-mrcog-and-beyond/miscarriage/35BD587901CCB0A05D987C108AEA0B3B (Accessed: 21 May 2023).

Frequently Asked Questions About Pregnancy Loss

• What can cause loss during pregnancy?
  Genetic causes like aneuploidy, trisomies. Maternal infections like malaria, urinary tract infections. Maternal diseases like anaemia, sickle cell disease, hypertension, diabetes mellitus. Uterine abnormalities like cervical incompetence and congenital abnormalities. Toxic factors like alcohol, smoking, radiation. Immunologic factors like ABO incompatibility, rhesus incompatibility.
• Is pregnancy loss painful?
  Not all miscarriages are painful. It can range from no pain to mild cramping in threatened miscarriages to severe abdominal pain in incomplete/complete abortion.
• What is the most common type of pregnancy loss?
  Spontaneous abortion is the commonest type of pregnancy loss. It is estimated that as many as 26% of all pregnancies end in miscarriage and up to 10% of confirmed pregnancies.
• What are the main causes of pregnancy loss?
  50-60% of fetuses expelled spontaneously contain genetic abnormalities.
• What type of infection causes pregnancy loss?
  Common infections like malaria, urinary tract infections and TORCHS (Toxoplasmosis, Rubella, Cytomegalovirus, Herpes, Syphilis) can cause pregnancy loss.
• Can pregnancy loss be prevented?
  Depending on the cause, it can be prevented. Healthy lifestyle practices like abstaining from smoking alcoholism as well as management of maternal diseases can prevent pregnancy loss.