Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Early Pregnancy Loss Clinical Presentation

  • Author: Elizabeth E Puscheck, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG  more...
 
Updated: Nov 14, 2015
 

History

Patients with spontaneous complete abortion usually present with a history of vaginal bleeding, abdominal pain, and passage of tissue. After the tissue passes, the vaginal bleeding and abdominal pain subsides.

Consider any reproductive-aged woman presenting with vaginal bleeding to be pregnant until proven otherwise.

Other symptoms, such as fever or chills, are more characteristic of infection, such as in a septic abortion. Septic abortions need to be treated immediately, otherwise they may be life threatening.

Vaginal bleeding is usually heavy

Quantification of the amount of bleeding is very important because life-threatening hemorrhage may occur. The patient may be able to quantify the number of pads or tampons used over a specified time and qualify the amount that each pad is soaked. This is just an estimate; yet, soaking a pad or more an hour suggests significant and worrisome amounts of bleeding that require prompt attention. These patients should be sent to the emergency department.

The presence of blood clots suggests heavy bleeding. The presence of blood clots also may be confused with passage of tissue.

Examining the passed material helps clarify whether the material is clot or tissue. If the material is tissue, then the type of abortion may be identified. If the tissue is evaluated and appears complete, then a complete abortion is confirmed.

Abdominal pain is associated with concurrent abortion and resolves with the completion of the abortion.

The pain usually is in the suprapubic area, but reports of pain in one or both lower quadrants are not uncommon. The pain may radiate to the lower back, buttocks, genitalia, and perineum.

If the pain is occurring only on one side, consider an ectopic pregnancy or a ruptured ovarian cyst as possible causes.

Next

Physical

Patients who are pregnant and bleeding vaginally need immediate evaluation.

Estimating the patient's hemodynamic stability is the first step, as follows:

  • Obtain orthostatic vital signs.
  • Initiate fluid resuscitation early in cases of orthostatic hypotension.
  • Abdominal and pelvic examinations are next.

The abdominal examination helps determine whether or not the state of an acute abdomen is present. Note the following:

  • In a complete abortion, the abdomen is benign, with no distension, no rebound, normal bowel sounds, no hepatosplenomegaly, and mild suprapubic tenderness.
  • Usually, the uterus is either not palpable abdominally or is just slightly above the pubic symphysis in a first-trimester pregnancy loss. The uterus can be enlarged due to other pathology (eg, leiomyomas).
  • If rebound tenderness or a distended abdomen is present, a complete abortion is unlikely. Assume instead that an ectopic pregnancy is present and if rebound tenderness is present, then provide the patient with aggressive fluid resuscitation with 2 IV lines, quantitative hCG, stat ultrasound (if stable enough) and an emergent laparoscopy or an emergent exploratory laparotomy.

In the case of a complete abortion, pelvic examination may show some blood on the perineum or vagina but there is limited active bleeding. Note the following:

  • Cervical motion tenderness does not exist.
  • The cervical canal is closed.
  • The uterus is smaller than expected for dates, and it is nontender to mildly tender.
  • The adnexa are nontender to mildly tender. Usually, no adnexal masses exist, unless a corpus luteum is still palpable.

In summary, the pelvic examination check list includes assessment of the following:

  • Source of bleeding (cervical os)
  • Intensity of bleeding (active, heavy, clots)
  • Any presence or passage of tissue
  • Cervical motion tenderness (increases suspicion for ectopic pregnancy)
  • Cervical os closed for complete or threatened abortion (If it is open, consider inevitable or incomplete abortion.)
  • Uterine size and tenderness
  • Adnexal masses (suspicious for ectopic pregnancy)
Previous
 
 
Contributor Information and Disclosures
Author

Elizabeth E Puscheck, MD Professor, Department of Obstetrics and Gynecology, Wayne State University School of Medicine; In Vitro Fertilization Director, Gynecologic Ultrasound Director, Clinical Endocrine Laboratory Consultant, Department of Obstetrics and Gynecology, University Women's Care

Elizabeth E Puscheck, MD is a member of the following medical societies: American Institute of Ultrasound in Medicine, International Society for Clinical Densitometry, Society for Assisted Reproductive Technology, Society of Reproductive Surgeons, Society for Reproductive Endocrinology and Infertility, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Endocrine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard S Legro, MD Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Pennsylvania State University College of Medicine; Consulting Staff, Milton S Hershey Medical Center

Richard S Legro, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Society of Reproductive Surgeons, American Society for Reproductive Medicine, Endocrine Society, Phi Beta Kappa

Disclosure: Received honoraria from Korea National Institute of Health and National Institute of Health (Bethesda, MD) for speaking and teaching; Received honoraria from Greater Toronto Area Reproductive Medicine Society (Toronto, ON, CA) for speaking and teaching; Received honoraria from American College of Obstetrics and Gynecologists (Washington, DC) for speaking and teaching; Received honoraria from National Institute of Child Health and Human Development Pediatric and Adolescent Gynecology Research Thi.

Chief Editor

Richard Scott Lucidi, MD, FACOG Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Suzanne R Trupin, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, International Society for Clinical Densitometry, AAGL, North American Menopause Society, American Medical Association, Association of Reproductive Health Professionals

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author Archana Pradhan, MD, MPH, to the development and writing of this article.

References
  1. Cengiz H, Dagdeviren H, Kanawati A, et al. Ischemia-modified albumin as an oxidative stress biomarker in early pregnancy loss. J Matern Fetal Neonatal Med. 2015 Sep 18. 1-4. [Medline].

  2. Barnhart KT, Katz I, Hummel A, Gracia CR. Presumed diagnosis of ectopic pregnancy. Obstet Gynecol. 2002 Sep. 100(3):505-10. [Medline].

  3. Condous G, Kirk E, Lu C, et al. There is no role for uterine curettage in the contemporary diagnostic workup of women with a pregnancy of unknown location. Hum Reprod. 2006 Oct. 21(10):2706-10. [Medline].

  4. Calleja-Agius J, Jauniaux E, Pizzey AR, Muttukrishna S. Investigation of systemic inflammatory response in first trimester pregnancy failure. Hum Reprod. 2011 Nov 29. [Medline].

  5. Nelson DB, Hanlon AL, Wu G, Liu C, Fredricks DN. First trimester levels of BV-associated bacteria and risk of miscarriage among women early in pregnancy. Matern Child Health J. 2015 Dec. 19 (12):2682-7. [Medline].

  6. Giakoumelou S, Wheelhouse N, Cuschieri K, Entrican G, Howie SE, Horne AW. The role of infection in miscarriage. Hum Reprod Update. 2015 Sep 19. [Medline].

  7. Thangaratinam S, Tan A, Knox E, et al. Association between thyroid autoantibodies and miscarriage and preterm birth: meta-analysis of evidence. BMJ. 2011 May 9. 342:d2616. [Medline]. [Full Text].

  8. Arck PC, Rucke M, Rose M, et al. Early risk factors for miscarriage: a prospective cohort study in pregnant women. Reprod Biomed Online. 2008 Jul. 17(1):101-13. [Medline].

  9. Maconochie N, Doyle P, Prior S, Simmons R. Risk factors for first trimester miscarriage--results from a UK-population-based case-control study. BJOG. 2007 Feb. 114(2):170-86. [Medline].

  10. Gracia CR, Sammel MD, Chittams J, Hummel AC, Shaunik A, Barnhart KT. Risk factors for spontaneous abortion in early symptomatic first-trimester pregnancies. Obstet Gynecol. 2005 Nov. 106(5 Pt 1):993-9. [Medline].

  11. Nakhai-Pour HR, Perrine B, Sheehy O, Berard A. Use of nonaspirin nonsteroidal anti-inflammatory drugs during pregnancy and the risk of spontaneous abortion. CMAJ. September 6, 2011. [Full Text].

  12. Hahn KA, Hatch EE, Rothman KJ, et al. Body Size and Risk of Spontaneous Abortion among Danish Pregnancy Planners. Paediatr Perinat Epidemiol. 2014 Sep. 28(5):412-23. [Medline].

  13. Clifford K, Rai R, Regan L. Future pregnancy outcome in unexplained recurrent first trimester miscarriage. Hum Reprod. 1997 Feb. 12(2):387-9. [Medline].

  14. Liddell HS, Pattison NS, Zanderigo A. Recurrent miscarriage--outcome after supportive care in early pregnancy. Aust N Z J Obstet Gynaecol. 1991 Nov. 31(4):320-2. [Medline].

  15. Stray-Pedersen B, Stray-Pedersen S. Etiologic factors and subsequent reproductive performance in 195 couples with a prior history of habitual abortion. Am J Obstet Gynecol. 1984 Jan 15. 148(2):140-6. [Medline].

  16. Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ. 2003 Feb 21. 52(2):1-8. [Medline].

  17. O’Riordan M. Pregnancy loss associated with a later risk of atherosclerosis. March 29, 2013. Available at http://www.medscape.com/viewarticle/781681.

  18. Ranthe MF, Andersen EA, Wohlfarht J, Bundgaard H, Melbye M, Boyd HA. Pregnancy Loss and Later Risk of Atherosclerotic Disease. Circulation. 2013 Mar 27. [Medline].

  19. Practice Committee of American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy. Fertil Steril. 2008 Nov. 90(5 Suppl):S206-12. [Medline].

  20. Lewis R. First Do No Harm: Guidelines Define a Nonviable Pregnancy. Medscape Medical News. Available at http://www.medscape.com/viewarticle/812346. Accessed: October 15, 2013.

  21. Doubilet PM, Benson CB, Bourne T, Blaivas M. Diagnostic Criteria for Nonviable Pregnancy Early in the First Trimester. N Engl J Med. 2013 Oct 10. 369(15):1443-1451. [Medline].

  22. Weeks A, Alia G, Blum J, et al. A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion. Obstet Gynecol. 2005 Sep. 106(3):540-7. [Medline].

  23. Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med. 2005 Aug 25. 353(8):761-9. [Medline].

  24. Lee SK, Kim JY, Han AR, et al. Intravenous immunoglobulin G improves pregnancy outcome in women with recurrent pregnancy losses with cellular immune abnormalities. Am J Reprod Immunol. 2015 Oct 29. [Medline].

  25. Luna RL, Nunes AK, Oliveira AG, et al. Sildenafil (Viagra) blocks inflammatory injury in LPS-induced mouse abortion: A potential prophylactic treatment against acute pregnancy loss?. Placenta. 2015 Oct. 36 (10):1122-9. [Medline].

  26. [Guideline] American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 94: Medical management of ectopic pregnancy. Obstet Gynecol. 2008 Jun. 111(6):1479-85. [Medline]. [Full Text].

  27. Wahabi HA, Fayed AA, Esmaeil SA, Al Zeidan RA. Progestogen for treating threatened miscarriage. Cochrane Database Syst Rev. 2011 Dec 7. 12:CD005943. [Medline].

  28. Boyle FM, Mutch AJ, Barber EA, Carroll C, Dean JH. Supporting parents following pregnancy loss: a cross-sectional study of telephone peer supporters. BMC Pregnancy Childbirth. 2015 Nov 9. 15:291. [Medline].

  29. [Guideline] ACOG practice bulletin. ACOG practice bulletin. Medical management of tubal pregnancy. Number 3, December 1998. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 1999 Apr. 65(1):97-103. [Medline].

  30. Chipchase J, James D. Randomised trial of expectant versus surgical management of spontaneous miscarriage. Br J Obstet Gynaecol. 1997 Jul. 104(7):840-1. [Medline].

  31. Chung TK, Cheung LP, Sahota DS, Haines CJ, Chang AM. Spontaneous abortion: short-term complications following either conservative or surgical management. Aust N Z J Obstet Gynaecol. 1998 Feb. 38(1):61-4. [Medline].

  32. Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure--current management concepts. Obstet Gynecol Surv. 2001 Feb. 56(2):105-13. [Medline].

  33. Geyman JP, Oliver LM, Sullivan SD. Expectant, medical, or surgical treatment of spontaneous abortion in first trimester of pregnancy? A pooled quantitative literature evaluation. J Am Board Fam Pract. 1999 Jan-Feb. 12(1):55-64. [Medline].

  34. Hurd WW, Whitfield RR, Randolph JF Jr, Kercher ML. Expectant management versus elective curettage for the treatment of spontaneous abortion. Fertil Steril. 1997 Oct. 68(4):601-6. [Medline].

  35. Jurkovic D, Ross JA, Nicolaides KH. Expectant management of missed miscarriage. Br J Obstet Gynaecol. 1998 Jun. 105(6):670-1. [Medline].

  36. Kalousek DK. Clinical significance of morphologic and genetic examination of spontaneously aborted embryos. Am J Reprod Immunol. 1998 Feb. 39(2):108-19. [Medline].

  37. Katz VL, Lentz G, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby Elsevier; 2007.

  38. Keith SC, London SN, Weitzman GA, O'Brien TJ, Miller MM. Serial transvaginal ultrasound scans and beta-human chorionic gonadotropin levels in early singleton and multiple pregnancies. Fertil Steril. 1993 May. 59(5):1007-10. [Medline].

  39. Nielsen S, Hahlin M. Expectant management of first-trimester spontaneous abortion. Lancet. 1995 Jan 14. 345(8942):84-6. [Medline].

  40. Scroggins KM, Smucker WD, Krishen AE. Spontaneous pregnancy loss: evaluation, management, and follow-up counseling. Prim Care. 2000 Mar. 27(1):153-67. [Medline].

  41. van Veen TR, Haeri S, Baker AM. Teen pregnancy: are pregnancies following an elective termination associated with increased risk for adverse perinatal outcomes?. J Pediatr Adolesc Gynecol. 2015 Dec. 28 (6):530-2. [Medline].

  42. Marko EK, Buery-Joyner SD, Sheridan MJ, Nieves K, Khoury AN, Dalrymple JL. Structured teaching of early pregnancy loss counseling. Obstet Gynecol. 2015 Oct. 126 suppl 4:1S-6S. [Medline].

 
Previous
Next
 
Second transvaginal sonogram obtained 1 week after the initial study fails to demonstrate fetal development. This confirms the diagnosis of an embryonic pregnancy.
1a Video courtesy; Armando Hernandez
1b Video courtesy; Armando Hernandez
1c Video courtesy; Armando Hernandez
1d Video courtesy; Armando Hernandez
1e Video courtesy; Armando Hernandez
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.