Miscarriage

Understanding Miscarriage -- the Basics from WebMD

What Is a Miscarriage?
A miscarriage, or spontaneous abortion, is a pregnancy that ends by itself within the first 20 weeks. "Stillbirth" refers to the loss of a pregnancy with fetal death when it occurs after the first 20 weeks. Experts estimate that about half of all fertilized eggs die and are miscarried, usually even before the woman knows she is pregnant. Most miscarriages occur between the 7th and 12th weeks of pregnancy.

A miscarriage is a common experience. About 10% to 20% of pregnancies that a mother knows about -- because she has missed her period, her pregnancy has been confirmed by a health care provider, or both -- end in miscarriage. In most cases, miscarriage may be considered a "natural-selection" process because it marks the ending of a pregnancy that would not have developed into a healthy baby. Only placental tissue, not a fetus, had formed.

The term "abortion" is commonly used to refer to the deliberate ending of a pregnancy. But, medically speaking, it refers to both the intentional and unintentional ending of a pregnancy, up until the time a fetus could be expected to survive outside the womb. Health care providers commonly use the medical term "spontaneous abortion" to refer to miscarriage.

What Causes a Miscarriage?
Most miscarriages occur when the unborn baby has fatal genetic problems. Usually, these problems are unrelated to the mother.

Other possible causes of miscarriage include:

Infection
Medical conditions in the mother, such as diabetes or thyroid disease
Hormonal factors
Immune responses
Physical problems in the mother
The risk for miscarriage is higher in women:

Over age 35
With certain diseases such as diabetes or thyroid problems
With a history of three or more previous miscarriage
Incompetent Cervix

A miscarriage sometimes occurs because there is a weakness of the cervix, called an incompetent cervix, which cannot hold the pregnancy. A miscarriage from an incompetent cervix usually occurs after the 14th to 16th week of pregnancy.

There are usually few symptoms prior to a miscarriage. A woman may feel sudden pressure, her "water" may break, and tissue from the fetus and placenta may be expelled without too much pain. An incompetent cervix can usually be treated with a "circling" stitch in the cervix in the next pregnancy, usually around 12 weeks. The stitch holds the cervix closed until it is pulled out around the time of delivery.

Stages and Types of Miscarriage
There are several stages and types of miscarriage. They include:

Threatened abortion. Early symptoms of a miscarriage occur, such as vaginal bleeding, but usually without other symptoms.
Inevitable abortion. The membranes have broken or the cervix has dilated too much.
Incomplete abortion. Some of the pregnancy tissue has been expelled, while other tissue remains in the uterus.
Complete spontaneous abortion. All of the pregnancy tissue is expelled from the uterus.
Missed abortion. The fetus has not developed or has died, but no bleeding or other symptoms are observed, and pregnancy tissue has not been expelled from the uterus.
Septic (infected) abortion. A serious infection has developed in the fetal material before, during, or after a miscarriage.

Abnormal Bleeding

Dysfunctional Uterine Bleeding - Topic Overview
Is this topic for you?
This topic is for women who want to learn about or have been diagnosed with dysfunctional uterine bleeding (DUB). It is related to changes in hormone levels. If you don't know what kind of bleeding you have, see the topic Abnormal Vaginal Bleeding.

What is dysfunctional uterine bleeding?
Dysfunctional uterine bleeding is irregular bleeding from the uterus. For example, you may get your period more often than every 21 days or farther apart than 35 days. Your period may last longer than 7 days. It is not serious, but it can be annoying and disrupt your life.

In most cases, this problem is related to changes in hormone levels. It is not caused by other medical conditions, such as miscarriage, fibroids, cancer, or blood clotting problems. Your doctor will rule out these and other causes of vaginal bleeding to confirm that you have dysfunctional uterine bleeding.

What causes dysfunctional uterine bleeding?
Dysfunctional uterine bleeding is usually caused by changes in hormone levels. In some cases the cause of the bleeding isn't known.

Normally one of your ovaries releases an egg during your menstrual cycle. This is called ovulation. Dysfunctional uterine bleeding is often triggered when women don't ovulate. This causes changes in hormone levels and in some cases can lead to unexpected vaginal bleeding.

Women can also get this condition even though they ovulate, although this is less common. Experts don't fully understand this type of vaginal bleeding. It may be caused by changes in certain body chemicals.

What are the symptoms?
You may have dysfunctional uterine bleeding if you have one or more of the following symptoms:

You get your period more often than every 21 days or farther apart than 35 days. A normal adult menstrual cycle is 21 to 35 days long. A normal teen cycle is 21 to 45 days.
Your period lasts longer than 7 days (normally 4 to 6 days).
Your bleeding is heavier than normal. If you are passing blood clots and soaking through your usual pads or tampons each hour for 2 or more hours, your bleeding is considered severe and you should call your doctor.
Talk to your doctor if you have had irregular vaginal bleeding for three or more menstrual cycles or if your symptoms are affecting your daily life.

How is dysfunctional uterine bleeding diagnosed?
Your doctor must first rule out all other causes of vaginal bleeding before diagnosing dysfunctional uterine bleeding. These causes include miscarriage and problems with pregnancy. Vaginal bleeding may also be caused by common conditions, such as uterine fibroids.

Your doctor will ask how often, how long, and how much you have been bleeding. You may also have a pelvic exam, urine test, blood tests, and possibly an ultrasound. These tests will help your doctor check for other causes of your symptoms. He or she may also take a tiny sample (biopsy) of tissue from your uterus for testing.

You have dysfunctional uterine bleeding if, after testing, your doctor finds no other diseases or conditions that are causing your symptoms.

How is it treated?
There are many things you can do to treat dysfunctional uterine bleeding. Some are meant to return the menstrual cycle to normal. Others are used to reduce bleeding or to stop monthly periods. Each treatment works for some women but not others. Treatments include:

Hormones, such as a progestin pill or daily birth control pill (progestin and estrogen). These hormones help control the menstrual cycle and reduce bleeding and cramping.
A short course of high-dose estrogen. Estrogen is a hormone that is often used to stop dangerously heavy bleeding.
Use of the levonorgestrel IUD, which releases a progesterone-like hormone into the uterus. This reduces bleeding while preventing pregnancy.
Rarely used medicines that stop estrogen production and menstruation, such as gonadotropin-releasing hormones. These drugs can cause severe side effects but are used in special cases.
Surgery, such as endometrial ablation or hysterectomy, when other treatments do not work.
If you also have menstrual pain or heavy bleeding, you can take regular doses of a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen.

In some cases, doctors use watchful waiting, or a wait-and-see approach. It may be okay for a teen or for a woman nearing menopause. Some teens have times of irregular vaginal bleeding. This usually gets better over time as hormone levels even out. Women in menopause can expect their periods to stop. They may choose to wait and see if this happens before they try other treatments.

AAGL New Hysterectomy Recommendations

AAGL Recommends Vaginal or Laparoscopic Approach for Hysterectomies
Laurie Barclay, MD
Authors and Disclosures
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November 16, 2010 — The American Academy of Gynecologic Laparoscopists (AAGL) recommends minimally invasive surgical approaches such as vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH) for benign uterine disease, according to a position statement published online November 7 in the Journal of Minimally Invasive Gynecology.

"When procedures are required to treat gynecologic disorders, the AAGL is committed to the principles of informed patient choice and provision of minimally invasive options," said Franklin D. Loffer, MD, executive vice president/medical director of the AAGL, in a news release. "When hysterectomy is necessary, the demonstrated safety, efficacy, and cost-effectiveness of VH and LH mandate that they be the procedures of choice. When hysterectomy is performed without a laparotomy, early institutional discharge is feasible and safe, in many cases within the first 24 hours."

In the United States, approximately 600,000 hysterectomies are performed every year for benign disorders of the pelvis, and more than two thirds are performed via an abdominal approach. In some countries, however, as few as 24% of hysterectomies are performed abdominally.

To lower morbidity risk and speed recovery, the AAGL recommends a vaginal or laparoscopic approach to hysterectomy for benign disease. Surgical risks are low for these minimally invasive procedures, which can often be done as an outpatient procedure or with a short hospital stay.

In contrast, the relatively large abdominal incision needed for abdominal hysterectomy (AH) may result in more complications, particularly associated with abdominal wound infections, leading to longer hospitalization and disability before normal activities can be resumed.

Obesity and a previous cesarean delivery were once thought to be contraindications to LH. However, the safety and efficacy of LH are similar in obese and nonobese patients, although operative times are longer in obese patients. Compared with other techniques, LH may be associated with an increased risk for cystotomy, but overall risk is low. The AAGL recommends that previous cesarean delivery should no longer be considered a contraindication to either VH or LH.

Even when the uterus is large, a number of surgeons can feasibly and safely perform VH. LH appears to be a safe alternative preserving most of the advantages of VH vs AH, and it can be performed when uterine size or other coexisting disease or surgical considerations preclude performance of VH.

Direct costs of either VH or LH are less than those of AH, but institutional costs of LH may be higher vs VH depending on what instrumentation is used. Compared with AH, LH appears to reduce indirect costs of hysterectomy by 50%, based on high-quality evidence from several randomized controlled trials.

In several oncologic studies, LH vs AH has been shown to lower morbidity risk without compromising clinical efficacy in women with cervical or endometrial carcinoma.

"Given the advantages that VH and LH offer to women, their families, their employers, and the health care system in general, it seems desirable to optimize their application in women requiring hysterectomy because of benign uterine conditions," the authors of the position statement write. "Abdominal hysterectomy should be reserved for the minority of women for whom a laparoscopic or vaginal approach is not appropriate. These situations are not common."

Women in whom LH is not appropriate may include the following:

Those with cardiopulmonary disease or other medical conditions in which the risks are unacceptable, either for general anesthesia or for increased intraperitoneal pressure associated with laparoscopy.
Those in whom morcellation, or cutting the tumor into pieces before removal, is known or likely to be required and uterine malignancy is either known or suspected.
Situations in which LH and VH are not appropriate may include the following:

Although hysterectomy is indicated, there is no access to the surgeons or facilities needed for VH or LH, and referral is not feasible.
Surgeons expert in either VH or LH techniques consider the vaginal or laparoscopic approach to be unsafe or unreasonable because of uterine disease or adhesions significantly distorting the anatomy.
"It is the position of the AAGL that most hysterectomies for benign disease should be performed either vaginally or laparoscopically and that continued efforts should be taken to facilitate these approaches," the authors of the position statement write. "Surgeons without the requisite training and skills required for the safe performance of VH or LH should enlist the aid of colleagues who do or should refer patients requiring hysterectomy to such individuals for their surgical care."

J Minim Invasive Gynecol. Published online November 7, 2010.