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Pregnancy loss

Last updated: March 24, 2021

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Pregnancy loss can occur even in previously healthy pregnancies. If it occurs before 20 weeks' of gestation (∼ 10% of pregnancies), it is called early pregnancy loss, miscarriage, or spontaneous abortion. If it occurs after 20 weeks' gestation, it is called stillbirth or intrauterine fetal demise. The majority of spontaneous abortions are due to fetal aneuploidy. Other common causes of spontaneous abortion are maternal disease, trauma, and congenital anomalies. Stillbirth can be caused by maternal disease, placental disorders, umbilical cord complications, or fetal congenital anomalies. In many cases, the cause of spontaneous abortion or stillbirth is unknown. The management of pregnancy loss depends on the week of gestation and clinical presentation. Most commonly, it involves medication-induced evacuation of the pregnancy, surgical evacuation of the pregnancy, or expectant management. After a spontaneous abortion, the products of conception should undergo histopathological examination. Similarly, fetal autopsy should be performed after a stillbirth in order to determine the underlying cause and address any modifiable etiologies.

Spontaneous abortion

Stillbirth

Clinical features of pregnancy loss
Type Findings Cervical os Prognosis
Threatened abortion closed reversible
Inevitable abortion dilated irreversible
Missed abortion
  • No bleeding
  • No expulsion of the products of conception
  • No fetal activity
closed irreversible
Incomplete abortion dilated irreversible
Complete abortion closed irreversible
Stillbirth
  • Absence of fetal movements and cardiac activity
variable irreversible

References:[1]

Spontaneous abortion (< 20 weeks' gestation)

Stillbirth (> 20 weeks' gestation)

  • Ultrasound examination is the best diagnostic modality to confirm loss of fetal heart activity and fetal demise.
  • Fetal autopsy is recommended to ascertain the cause of death.

Spontaneous abortion (< 20 weeks' gestation)

Prevention

  • Minimize risk with treatment of maternal disease and adequate prenatal care.

Threatened abortion

Inevitable, incomplete, or missed abortions

The management of uncomplicated spontaneous abortions depends mostly on patient preference. Possibilities include:

Complete abortion

Stillbirth (>20 weeks' gestation)

  • Do not rush delivery unless maternal health is at risk (i.e., preeclampsia, infection).
  • Spontaneous labor usually begins within 2 weeks of intrauterine fetal death. However, labor may be induced with oxytocin if maternal disease develops (e.g., coagulation abnormalities) or if the patient prefers induction.
  • Vaginal delivery is safer than cesarean delivery, but many patients will prefer cesarean delivery.
  • Express empathy and acknowledge patient grief; provide privacy and emotional support.
  • Patients should be offered a fetal autopsy to determine the cause of death.

Medical abortion [3][4][5]

We list the most important complications. The selection is not exhaustive.

  1. Dutta DC, Konar H. Textbook of Obstetrics. Jaypee Brothers Medical Publishers ; 2015
  2. Dilation and Curettage. https://www.acog.org/Patients/FAQs/Dilation-and-Curettage. Updated: March 1, 2019. Accessed: June 27, 2019.
  3. Creinin MD. Medical abortion regimens: historical context and overview.. Am J Obstet Gynecol. 2000; 183 (2 Suppl): p.S3-9.
  4. Bryant AG, Regan E, Stuart G. An overview of medical abortion for clinical practice. Obstet Gynecol Surv. 2014; 69 (1): p.39-45. doi: 10.1097/ogx.0000000000000017 . | Open in Read by QxMD
  5. Medical Management of First-Trimester Abortion. https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Medical-Management-of-First-Trimester-Abortion. Updated: March 1, 2014. Accessed: April 9, 2018.