Pregnancy loss

Last updated: July 5, 2023

Summarytoggle arrow icon

Pregnancy loss can occur even in previously healthy pregnancies. If it occurs before 20 weeks' gestation (∼ 10% of pregnancies), it is called 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 and may involve 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 offered after a stillbirth in order to determine the underlying cause and address any modifiable etiologies.

See also “Counseling on pregnancy loss” and “Induced abortion.”

Overviewtoggle arrow icon

Types of pregnancy loss [1]
Type [2][3] Definition Findings Treatment
Threatened abortion
  • An abortion process starting before 20 weeks' gestation that has not progressed to a state from which recovery is impossible (potentially reversible)
Inevitable abortion
Missed abortion
Incomplete abortion
  • Passage of some but not all POC before 20 weeks' gestation
Complete abortion
  • The complete passage of all POC before 20 weeks' gestation
  • No treatment required
  • Absence of fetal movements and cardiac activity
  • Cervical os variable

Spontaneous abortiontoggle arrow icon

Definition [1][2]

Etiology [1]

Clinical features [3][4]

Diagnostics [2][3][5]

General principles

Features of spontaneous pregnancy loss [3]
Type Vaginal bleeding Fetal cardiac activity Products of conception (POC) Cervical os
Threatened abortion
  • Yes
  • Yes
  • Intrauterine
  • Closed
Inevitable abortion
  • Yes
  • May be present
  • Visible/palpable POC
  • Dilated
Missed abortion
  • No
  • No
  • No expulsion of the POC
  • Closed
Incomplete abortion
  • Yes
  • No
  • Dilated
Complete abortion
  • Yes
  • No
  • Closed

Diagnostic confirmation of fetal death prior to treatment is essential to avoid compromising a viable pregnancy.

Consider the diagnosis of septic abortion in patients with clinical features of pregnancy loss and fever. [6]

Clinical evaluation

In stable patients after a resolved episode of mild to moderate vaginal bleeding, pregnancy viability may be assessed by ultrasound without a bimanual or speculum examination. [4]


Perform a pelvic ultrasound on pregnant patients who present to the emergency department with abdominal pain or vaginal bleeding, regardless of β-hCG levels. [9]

Laboratory studies

  • Serial serum β-hCG: Downtrending levels suggest a failed pregnancy. [10][11][12]
  • Additional studies

β-hCG levels above the discriminatory zone threshold without visualization of an intrauterine pregnancy on ultrasound should raise concern for spontaneous abortion or ectopic pregnancy. [13]

Management [2][3][4]


Consult OB/GYN for emergency surgical evacuation for miscarriage complicated by heavy bleeding, hemodynamic instability, or septic abortion.

Threatened abortion

Inevitable abortion, incomplete abortion, or missed abortion

Management of uncomplicated spontaneous abortions depends mostly on patient preference.

Instruct patients managed expectantly or with medical evacuation to seek medical attention without delay for heavy bleeding, fever, or any other concerning symptom.


See also “Complications of induced abortion.”


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

Acute management checklisttoggle arrow icon

Stillbirthtoggle arrow icon

Definition [15]

Etiology [15][16]

Clinical features [17]

  • Absence of fetal movements and cardiac activity
  • Delivery of a fetus with no signs of life

Diagnostics [15]

Management [15][17]


Referencestoggle arrow icon

  1. Beckmann CRB. Obstetrics and Gynecology. Lippincott Williams & Wilkins ; 2010
  2. Prager S, Dalton VK, Allen RH. ACOG Practice Bulletin No. 200: Early Pregnancy Loss. Obstet Gynecol. 2018; 132 (5): p.e197-e207.doi: 10.1097/aog.0000000000002899 . | Open in Read by QxMD
  3. Prine LW, MacNaughton H. Office management of early pregnancy loss. Am Fam Physician. 2011; 84 (1): p.75-82.
  4. Jurkovic D, Overton C, Bender-Atik R. Diagnosis and management of first trimester miscarriage. BMJ. 2013; 346 (jun19 2): p.f3676-f3676.doi: 10.1136/bmj.f3676 . | Open in Read by QxMD
  5. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  6. Eschenbach DA. Treating Spontaneous and Induced Septic Abortions. Obstet Gynecol. 2015; 125 (5): p.1042-1048.doi: 10.1097/aog.0000000000000795 . | Open in Read by QxMD
  7. Zolotor AJ, Carlough MC. Update on prenatal care. Am Fam Physician. 2014; 89 (3): p.199-208.
  8. Brown DL, Packard A, Maturen KE, et al. ACR Appropriateness Criteria First Trimester Vaginal Bleeding. JACR. 2018; 15 (5): p.S69-S77.doi: 10.1016/j.jacr.2018.03.018 . | Open in Read by QxMD
  9. Hahn SA, Promes SB, Brown MD, et al. Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy. Ann Emerg Med. 2017; 69 (2): p.241-250.e20.doi: 10.1016/j.annemergmed.2016.11.002 . | Open in Read by QxMD
  10. Barnhart K, Franasiak J, and the Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 191: Tubal Ectopic Pregnancy. Obstet Gynecol. 2018; 131 (2): p.e65-e77.doi: 10.1097/AOG.0000000000002464 . | Open in Read by QxMD
  11. Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. Am Fam Physician. 2020; 101 (10): p.599-606.
  12. Van Mello NM, Mol F, Opmeer BC, et al. Diagnostic value of serum hCG on the outcome of pregnancy of unknown location: a systematic review and meta-analysis. Hum Reprod Update. 2012; 18 (6): p.603-617.doi: 10.1093/humupd/dms035 . | Open in Read by QxMD
  13. Hendriks E, MacNaughton H, MacKenzie MC. First Trimester Bleeding: Evaluation and Management. Am Fam Physician. 2019; 99 (3): p.166-174.
  14. Committee on Practice Bulletins—Obstetrics. Practice Bulletin No. 181: Prevention of Rh D Alloimmunization 2017. Obstet Gynecol. 2017; 130 (2): p.e57-e70.doi: 10.1097/aog.0000000000002232 . | Open in Read by QxMD
  15. American College of Obstetricians and Gynecologists. Management of Stillbirth: Obstetric Care Consensus No, 10. Obstet Gynecol. 2020; 135 (3): p.e110-e132.doi: 10.1097/AOG.0000000000003719 . | Open in Read by QxMD
  16. Reddy UM, Goldenberg R, Silver R, et al. Stillbirth Classification—Developing an International Consensus for Research. Obstet Gynecol. 2009; 114 (4): p.901-914.doi: 10.1097/aog.0b013e3181b8f6e4 . | Open in Read by QxMD
  17. Tsakiridis I, Giouleka S, Mamopoulos A, Athanasiadis A, Dagklis T. Investigation and management of stillbirth: a descriptive review of major guidelines. J Perinat Med. 2022; 50 (6): p.796-813.doi: 10.1515/jpm-2021-0403 . | Open in Read by QxMD
  18. Hennegan JM, Henderson J, Redshaw M. Contact with the baby following stillbirth and parental mental health and well-being: a systematic review. BMJ Open. 2015; 5 (11): p.e008616.doi: 10.1136/bmjopen-2015-008616 . | Open in Read by QxMD

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