Miscarriage

Disease Description (Causes and Symptoms)

Miscarriage (fetal death or termination of pregnancy before 20 weeks of gestation) occurs in approximately 20–30% of all pregnancies, and most cases (about 80% or more) occur in early pregnancy (within 12 weeks). The main causes include

• Fetal chromosomal abnormalities (the most common),
• Uterine structural abnormalities such as uterine malformations, fibroids, and adhesions,
• Cervical insufficiency (incompetent cervix),
• Maternal endocrine or chronic diseases (thyroid disease, diabetes, hypertension, systemic lupus erythematosus, etc.),
• Infections (e.g., rubella, toxoplasmosis, bacterial pelvic infections, etc.),
• Trauma, smoking, excessive alcohol consumption, malnutrition, and stress.

The main symptoms are abdominal pain (cramping lower abdominal pain) and vaginal bleeding (red or brown, with varying amounts), and symptoms suggesting decreased fetal movement or termination of pregnancy may occur. Diagnosis involves a medical history and pelvic examination, ultrasound (especially transvaginal ultrasound) to check the gestational sac and fetal heartbeat, and quantitative blood hCG testing.

Treatment Methods

• Expectant management (observation of the natural course): Observation for a certain period may be appropriate when the condition is stable, such as when bleeding is light and the fetus has a heartbeat.
• Medication: Mifepristone followed by misoprostol, or misoprostol alone, may be used to induce expulsion of the uterine contents (medical management of miscarriage). Administration and follow-up according to medical instructions are necessary.
• Surgical treatment: Suction curettage (vacuum aspiration) or dilation and curettage (D&C) — performed when retained placental tissue, heavy bleeding, or suspected infection is present.
• Antibiotic treatment if infection is suspected.
• Rh immunoglobulin (RhIg) is administered to mothers with Rh-negative blood types after miscarriage (to prevent sensitization after bleeding or surgery).
• Pain control (analgesics), and blood transfusion and emergency treatment if necessary.
• Psychosocial support and counseling: Counseling is recommended because psychological trauma or depression may occur after a miscarriage.

Precautions and complications:

• Risk of persistent bleeding, endometritis (infection), and sepsis due to retained products of conception in the uterus.
• Risk of infertility due to intrauterine adhesions (Asherman syndrome) after repeated curettage.
• Shock and the need for blood transfusion in cases of heavy bleeding.
• If signs of infection (fever, foul-smelling discharge, persistent abdominal pain) occur, visit a medical institution immediately.

Prognosis:

• The prognosis for a subsequent pregnancy after a single miscarriage is generally good. Recurrent miscarriages (two or more consecutive miscarriages or three or more miscarriages) require additional testing to identify the cause.

Lifestyle management:

• Get adequate rest and hydration, take prescribed medications, prevent infection and care for wounds, and seek psychological support (counseling with family or professionals).
• When preparing for a future pregnancy, optimize chronic conditions (diabetes, thyroid disease, etc.), stop smoking, limit alcohol consumption, and take folic acid.

Checklist Before an Outpatient Visit (Including Sample Questions)

Items and information to prepare

• List of medications and supplements currently being taken (including doses)
• First day of the last menstrual period (LMP) and estimated gestational age
• Time bleeding began, amount, and color (frequency of pad changes), and characteristics of abdominal pain (intensity and duration)
• Previous obstetric history: number of pregnancies (gravidity and parity), any previous miscarriages or miscarriage treatment, and uterine surgery (intrauterine surgery, hysteroscopic surgery, etc.)
• Allergies (especially medication allergies) and blood type (including Rh status if possible)
• Results of previous ultrasound or blood tests (if available)

Tests to receive at the outpatient visit

• Transvaginal ultrasound (to check the fetal heartbeat and gestational sac)
• Quantitative blood hCG and, if necessary, blood tests (anemia and infection markers)
• Pelvic examination

Sample questions (for patient preparation)

• When should I come back if the bleeding or pain gets worse?
• My blood type is Rh-negative. Do I need RhIg?
• Why do you recommend surgery instead of medication?

General Sample Questions to Ask the Doctor

• How certain is the diagnosis of this condition (based on the ultrasound findings and interpretation of hCG)?
• Among the treatment options (observation, medication, and surgery), which is recommended for my situation, and why?
• What are the side effects of the medications used? (For example, the side effects of misoprostol)
• How long is the recovery period after surgery, and when can I return to my daily activities?
• How high is the risk of recurrence, and what tests do you recommend for a future pregnancy?
• If necessary, can I be referred to psychological support or counseling resources?

Examples of Condition-Specific Questions

• I was told that my ultrasound showed a “blighted ovum (empty sac) / missed abortion.” Is it okay to wait for natural expulsion, or is treatment necessary?
• I am Rh-negative. When should Rh immunoglobulin be administered for this bleeding or procedure?