Understanding Early Pregnancy Loss
Introduction
Early pregnancy loss (aka. miscarriage) happens in about 1 in 5 pregnancies, with nearly 80% of miscarriages occurring in the first trimester. This particular type of loss will usually occur up until the 13th week of pregnancy. About half of all early pregnancy losses are due to chromosomal abnormalities in the developing embryo.Symptoms of Miscarriage
Signs and symptoms of early pregnancy loss include:
Bleeding (with or without tissue) - because it can occur in 25% of pregnancies, it’s not always associated with a loss
Cramping
Abdominal or pelvic pain - about 85% of pregnant people experience abdominal pain in the first 7 weeks of pregnancy
The risk of pregnancy loss is 5x greater when pregnant people experience both bleeding and cramping, compared to just cramping alone.
Because an ectopic pregnancy is an emergent condition (and people need to be seen ASAP), symptoms of an ectopic pregnancy need to be ruled out as well, they include:
Worsening abdominal pain
Dizziness
Bleeding
Shoulder-tip pain
Risk Factors
As mentioned earlier, some losses are due to chromosomal abnormalities in the developing embryo. That said, there are some risk factors associated with early pregnancy loss. They include:
Maternal age older than 35
History of early pregnancy loss
Infections like Chlamydia trachomatis
Older paternal age
BMI extremes - underweight and obese
Smoking
Alcohol consumption
Physical trauma
Psychological stress
Exposure to toxins like air pollution and pesticide exposure
Types of Miscarriage
Early pregnancy loss can be divided into a few categories, based on symptoms, physical exam, and ultrasound findings. They are:
Threatened Miscarriage
Symptoms: Bleeding or cramping
Physical exam: Cervix is closed, with no tissue in the vaginal canal
Ultrasound: May show cardiac activity of the fetus (indicating a viable pregnancy)
Incomplete Miscarriage
Symptoms: Bleeding or cramping
Physical exam: Cervix is either open or closed, with tissue or blood clots found in the vaginal canal
Ultrasound: No cardiac activity of the fetus
Inevitable
Symptoms: Bleeding or cramping
Physical exam: Cervix is open with tissue or blood clots found in the vaginal canal
Ultrasound: May show cardiac activity of the fetus (indicating a viable pregnancy)
Complete Miscarriage
Symptoms: Bleeding or cramping
Physical exam: Cervix is closed, and all tissue has passed. It’s usually followed by continuous bleeding or spotting
Ultrasound: No cardiac activity of the fetus
Missed miscarriage
Symptoms: No symptoms
Physical exam: Cervix is closed, with no tissue in the vaginal canal
Ultrasound: No cardiac activity of the fetus.
Usually a missed miscarriage is seen at routine screening in the first trimester. For instance, at the dating ultrasound (between 6-8 weeks) or at their Nuchal Translucency Scan (between 11-14 weeks). During these scans, the pregnant person may be told that no cardiac activity is seen, and that the fetus has not grown.
Testing
When early pregnancy loss is suspected, a gamut of testing is done. This includes: a complete blood count, blood typing, Rh factor, and β-hCG levels.
β-hCG
β-hCG is commonly known as the pregnancy hormone, as it quickly increases during pregnancy. It can be detected via blood test 11 days after conception, or by urine 12-14 after conception.
A single β-hCG test cannot diagnose the if a pregnancy is viable or where the pregnancy is. A baseline β-hCG is needed to determine if β-hCG is increasing or decreasing.
Transvaginal Ultrasound
A transvaginal ultrasound will assess for cardiac activity of the fetus, as well as how it’s growing (known as the crown-rump length, CRL). Cardiac activity may not be seen until the CRL is 7mm. When there is no cardiac activity in an embryo with a CRL of 7mm or greater, then a diagnosis of early pregnancy loss is considered.
Management of Early Pregnancy Loss
Expectant
Expectant management, the watch and wait approach, is considered safe for people experiencing early pregnancy loss who are stable, do not have any active pelvic infections, no severe anemia or bleeding disorders, and no active uterine hemorrhage.
Within 1 week of the miscarriage, about half of all people with early pregnancy loss will spontaneously pass all pregnancy tissue. This is especially common if people are already experiencing bleeding and cramping.
Obviously if this does not happen, then another management pathway may begin.
Medical
Medical management, using pharmaceuticals, brings about completed miscarriages earlier than expectant management. The pharmaceuticals induce uterine contractions and block progesterone. Heavy bleeding and cramping can be expected with these medications, and may begin a few hours after starting. A person may also see fetal tissue (if the loss is over 9 weeks) during this process - which, understandably, can be very difficult. Light bleeding may continue for another 9-16 days.
In the instance of excessive bleeding (filling more than 2 pads per hour, for 2 hours), fainting or passing out, and severe abdominal pain - a person should return to the emergency department right away.
There are contraindications to using some of these medications, so be sure to speak to your care provider to ensure that this is an appropriate treatment method.
Surgical
Surgical management requires the fewest visits with a health care provider. It may involve the aspiration of products of conception, or a procedure called a dilation and curettage (D&C).
This type of management is standard for molar pregnancies, an intrauterine device that cannot be removed, or any signs of infection.
Future Pregnancy
Understandable, early pregnancy loss can have serious emotional and psychological effects on a person. It may bring about feelings of grief, guilt, depression, and anxiety. It’s a traumatic experience not matter how many weeks a person is, and it’s possible reoccurrence may be at the forefront of someone’s mind in subsequent pregnancies.
When someone is emotionally and physically ready to conceive again, they can start trying after their first period following their miscarriage.
Early Pregnancy Assessment Centres
Depending on where you are located, Early Pregnancy Assessment Centres provide patient-centred care for complications. In Toronto, many of the major hospitals have Early Pregnancy Assessment clinics that can be accessed by a REFERRAL from that particular hospital’s emergency department or your family doctor/walk-in clinic. They accept patients experiencing pregnancy complications like: vaginal bleeding, abdominal pain, cramping, ectopic pregnancy, threatened or actual pregnancy loss.
Up to 13 weeks gestation:
Up to 20 weeks gestation:
Early Pregnancy Assessment Clinic at North York General Hospital
Early Pregnancy Clinic at Michael Garron Hospital (South Riverdale Community Health Centre): This clinic is run by midwives from the Midwife and Toronto Community Health Program.
More information needed:
Early Pregnancy Management Clinic at St. Michael's Hospital: Unsure if a referral is needed. Very little information was provided on their website.
Sunnybrook Hospital: I’m unable to determine if an Early Pregnancy Clinic exists at this hospital. I’d imagine that it would because this is the home of the Pregnancy and Infant Loss Network. In any case, they do have a Subsequent Pregnancy Program for people with a subsequent pregnancy after a previous late-pregnancy loss or death of their baby during pregnancy (greater than 15 weeks), or people who have had a baby die shortly after birth (neonatal death).
Additional Support
More support and information can be found at: