Background

Pregnancy loss also medically known as miscarriage refers to the unplanned termination of embryo or fetal growth before the fetus attains the stage of viability and typically occurrs in the first 20 weeks of embryonic development. The pregnancy termination process can be incredibly distressing and emotionally draining for the couple involved which involves the termination of the future that had been planned for and the dreams and ambitions for a baby that was developing. 

There are different reasons of miscarriage which may have the problems related to genetic makeup of the embryo or fetus of a woman’s body like diabetes or blood diseases, problems with the shape of a woman’s uterus, infections, autoimmune disorders and lifestyle factors like smoking, alcohol consumption and a woman’s age as she gets older. While the precise reason for a loss of pregnancy is often complicated to be found out, it should be noted that most of them happen because there are genetic abnormalities. The first indications of miscarriage are the presence of blood in the vagina, pain in the abdomen, or the occurrence of tissue clots. 

Epidemiology

Incidence: Pregnancy lose in the first trimester is the highest and coincides with early pregnancy loss in around three million cases. It’s believed that nearly 80% of the congenital abnormalities happen before 13 weeks. 
 
Prevalence: To count the precise number of women that undergo losses of pregnancy is hard due to some cases occurring before pregnancy confirmation is obtained. While it is considered that a rate of 10% of confirmed pregnancies finishes in a miscarriage, some more cases are still uncertain. The wide range may depend on the child-bearing woman’s conditions such as maternal age, general health, and life-style. 

Geographic Variations: There is a geographic variation in the occurred and overall cases of pregnancy loss as well as the between the different regions and populations. Research has shown that maternal exposure to ambient particulate matter of DOC (PM 2.5) is linked to increased risk for pregnancy loss in the South Asian countries which have high documented PM 2.5 pollution. These differentiation geographical processes can be helpful by designing measures and interventions that are adaptable well. 

Anatomy

Pathophysiology

The pathology of pregnancy loss or miscarriage may be different depending on the reason it is caused as different factors may be involved. 

Normal pregnancy involves embryo place itself in the uterus wall and continuous growth. The placenta which gives oxygen, nutrition to the fetal development is formed and gets attached to the uterus wall. But still, in the process of pregnancy complications, genetic abnormalities are able to break this circle. Chromosomal anomalies, such as aneuploidy (an abnormal number of chromosomes), can mostly be an underlying cause of miscarriage. Such aberrations could arise either as an outcome of a deficiency in the division of chromosomes during fertilization or because of a genetic factor of the parental line. 

When an embryo or fetus has been diagnosed with a serious genetic issue, it may not develop properly or may not manage to survive. Naturally, the organism’s way of getting rid of an abnormal product is withdrawal. Women develop vaginal bleeding, abdominal pain, and tissues outside in these instances. 

Etiology

Genetic factors: Chromosomal abnormalities, including aneuploidy (Karyotypical anomalies) are the main reason for spontaneous abortion,having the chromosome number deviated from the norm. These malformations can be caused by the fundamental unit of life spontaneously or during the processes of fertilization and ordinal embryonic development. 

Anatomical factors: Impaired uterine architecture, for example uterine septum (the partition inside the uterus), the presence of uterine fibroids (the non – cancerous growths) and weakness of the cervix (the cervical incompetence), can add to the risk of miscarriage during the process of implantation or through difficulties to deliver the fetus until it is ripe. 

Maternal health conditions: Some maternal conditions like diabetes, hyperthyroidism, polycystic ovarian syndrome (PCOS) or autoimmune diseases could condition for pregnancy loss. This unbalance endocrine environment can interfere with the hormonal system that oversees ensuring a healthy pregnancy. 

Infections: Infections for which the root is bacterial, viral, or parasitic also pose a danger to the pregnancy and may end through miscarriage if not treated. Sample are those such as the bacterial vaginosis, urinary tract infections or sexually transmitted. 

Genetics

Prognostic Factors

Maternal age: It is beginning to be known that higher age of the woman (for instance, when she reaches 35 years of age and older) could increase the risk of loss of pregnancy. This early stage miscarriage is as a result attachment of abnormal chromosomes from the mother as she ages. 
Underlying medical conditions: Embryonic fatalities specifically ensue from some specific maternal health condition including diabetes, thyroid axis disorders, or any kind of allergies to autoimmune disorders. Control and care of diseases requires rigorous coordination and treatment to prevent more forthcoming damages. 
Uterine abnormalities: The abnormal structure in the uterus can poses significant problems, for example, double uterus, growth ulcer, or cervical incompetence, these all can interfere with the completion of pregnancy. For the difficulty to be mitigated or to ensure better prognosis, corrective procedures may be taken in the next possibly pregnancies. 
Genetic factors: Genetic disorders can result in the parents or a developing embryo. In this case, it is a matter of the ‘pregnancy outcome forecast’. Genetic specialist and testing could find particular genetic factors and subsequently allow to the identification and management of these factors for future pregnancies. 
Lifestyle factors: Easily modifiable lifestyle factors, including smoking, alcohol consumption, illegal drug use, or obesity, can lead to the rise of the possibility that an individual can suffer miscarriage or general pregnancy loss. Changing the habit could incline the transgenerational infertility to previous ones. 
Emotional support and mental health: The emotional health of women who have suffered through these miscarriages can affect the course of next pregnancy. Inhabiting a supportive emotional milieu, for example, the patient’s psychotherapy, as well as considering the problem of any psychiatric disorders is the key to a successful outcome. 

Clinical History

Age group: The clinical manifestation of pregnancy loss can be various between the age group of cases like so.
Adolescents: The teenagers who are undergoing miscarriages will present with products like uterine bleeding, pains of abdomen, and characteristics of menstrual like vaginal bleeding. In addition to this, a timing of the loss in pregnancy that has come to happen may bring emotional suffering because of the unexpected distress.
Reproductive-age adults: The age of reproductive potential that generally accounts for most pregnancies includes pregnancy loss related symptoms that include vaginal bleeding, lower stomach cramping or pain and the discharge of clots or tissue from the vagina. Besides anxiety, there is a shock-like feeling as well.
Perimenopausal or older adults: The pregnancy loss at this age has identical or similar apparent manifestation as in reproductive age. Nevertheless, one cannot ignore the possibility of the coexistence of the common underlying diseases such as hypertension or diabetes, which can also influence a particular treatment and care. 

Associated comorbidity or activity: Comorbidities or behavior related to the current pregnancy could be able to effect the physical signs of miscarriage.
Comorbidities: Some people may have conditions like diabetes, thyroid or autoimmune diseases which may change the way they go through a pregnancy that leads to miscarriage. The clinical presentations of (the mother’s) condition will be affected by whether the condition is present. If it is, then it will influence the effects the condition has on (the mother’s) pregnancy.

Physical Examination

General assessment: One of them will perform a basic medical examination, including a physical appearance assessment, measurement of the vital signs, and a check of the level of trouble or discomfort. In turn, this makes the benchmark of the woman’s demeanor and gives the doctor an insight into her overall welfare. 
Abdominal examination: An in-depth abdominal examination is performed to determine and specify if there are any tenderness, masses or findigs which are considered abnormal. The provider of healthcare can meetamet the purpose by palpating the abdomen which enables him/her possible size and position of the uterus. Besides, the pregnancy period starts with the feelings of being a little rounded and sensitive Uterus. When it comes to ultrasounds for women who had miscarriage in later stages or those experiencing incomplete miscarriage, the uterine size is usually smaller and less tender. 
Pelvic examination: Feelings associated to cervix, vagina, and pelvic organs may be held through the pelvic exam. The doctor would employ a speculum for visualization purpose to physically look at the cervix and signs of any bleeding, cervical dilation, tissue presence or clotting can be identified. For the evaluation of the cervical os (opening) its size, the dilation state can be assessed, which is an indication of miscarriage. 
Ultrasound examination: Though the ultrasound examination is not performed as a part of clinical examination a scanner may be recommended after the clinical diagnosis of miscarriage to confirm it. Through the sonogram, the doctor can clearly see the uterus, gestational sac and fetal structures, to consequently verify a viable pregnancy or signs of miscarriage. In determining which ultrasound technique – transabdominal or transvaginal, would be, gestational age would be taken to observation as well as the moment. 

Age group

Associated comorbidity

Comorbidities or engagement in certain activities can impact the clinical presentation of pregnancy loss. 

• Comorbidities: Individuals with pre-existing medical conditions, such as diabetes, thyroid disorders, or autoimmune diseases, may experience pregnancy loss differently. The clinical presentation may be influenced by the underlying condition and its effects on the pregnancy. 
• Activities: Engaging in physically demanding activities, such as heavy lifting or strenuous exercise, may exacerbate symptoms of pregnancy loss. In such cases, individuals may experience increased abdominal pain or bleeding during or after these activities. 

Associated activity

Acuity of presentation

Acute presentation: Some miscarriages occur premonanaously, associating them with severe symptoms that include bright vaginal bleeding, large abdominal pain and sudden passage of tissue. Acute presentations that need quick action may be a big deal for other emergencies while they are in the pain. 
Subacute or chronic presentation: In other instances, however, the clinical picture can usually come on quicker, where symptoms such as mild to moderate vaginal bleeding/ vigorous cramping or the passage of tissue in small portions would usually be observed. These forums might greatly shorten the duration of dissemination of information and help through a more targeted approach to management, even though medical examination and treatment are a must. 

Differential Diagnoses

Threatened miscarriage: This term applies to vaginal bleeding during the early pregnancy period before the cervix has dilated and expelled anal tissues. In a threatened miscarriage the pregnancy may still persist, and a cautious monitoring to also know the prognosis of the pregnancy can eliminate worries and bring the desired results. 
Ectopic pregnancy: An ectopic pregnancy is a case whereby the or the ovum of the woman is incompletely dislodged from its position in the fallopian tube. It may have the signs that are vaginal bleeding, usually one side of abdominal pain and the confirmed positive pregnancy test. Ectopic pregnancy represents a life-threatening condition while emergency intervention is a must. 
Molar pregnancy: It is a less common condition in which tissue from the placenta grows, abnormally. It may manifest itself a with a symptoms, such as bleeding vaginally, queasiness, and vomiting that is severe, an enlarged uterus and hCG levels that are above the average. Molar pregnancy, even if it is considered as a rare condition, should not be neglected, and treated immediately. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

• Offers empathetic treatment, treats bodily ailments, and promotes mental health. • Methods vary according on patient preferences, problems, and gestational age. • Close observation, supportive care, and the natural removal of pregnancy tissue are all part of early treatment. • If necessary, prescriptions for painkillers may be issued. D&C procedures may be necessary in cases of incomplete miscarriage or severe bleeding. • Future losses or issues may require more proactive management. • Pain control, emotional support, and surgical or medical intervention are possible intervention strategies. Support groups and mental health specialists can be referred to, along with therapy and other services, to provide essential emotional support. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-the-non-pharmacological-therapy-for-modifying-the-environment

Psychology 

Seek emotional support: Talk to your partner who are able to hear you, understand you, and give you emotional support. Note the possibility of attending support groups or consulting a counselor so that you work through the feelings caused by the loss. 

Communicate with your healthcare provider: Seek medical advice from your doctor to help you understand the cause of the miscarriage and to offer you the necessary medical intervention regarding the matter. 

Take care of your physical health: Besides activities such as soaking in a bath tub or just being in a calm state of meditation, self-care can also help us relax. Managing a balanced diet, regular physical activity as well as getting repair all have a positive effect on your health. 

Use of combination regimen mifepristone and misoprostol in pregnancy loss

Mifepristone: 
Anti-progestin drugs acting as receptor blockers that serve the functions of progesterone, which are necessary for pregnancy. Initiated to begin miscarriage or just for preparation with the uterus to eject pregnancy tissue. 
Misoprostol: 
Prostaglandin E1 that mimics synthetic pro-uterine gene expression to induce uterine contractions. The drug is normally used in conjunction with mifepristone or as a standalone to facilitate expulsion of a pregnancy tissue. 
Administration: Mifepristone is to be taken a night before the appointment and should be taken orally to soften the cervix and separate the pregnancy from the lining of the uterus. Misoprostol, taken within the 24 or 48 hrs of mifepristone administration. 
Monitoring and Follow-up: 
Constant medical oversight is essential to timely detect improvement and see it through. 

Use of Misoprostol only in managing pregnancy loss

A patient who expresses a preference for medication management, the case where mifepristone is not available, and seeks the use of a single misoprostol regimen is deemed an acceptable regimen. Nevertheless, providing the required guidance on the lowered logic of the regimen is a vital undertaking. There can be as high as 17 to 26 percent pregnancy late period as reported for pregnancies up to 12weeks of pregnancy treated with misoprostol only method at 8 and 30 days respectively. 
 
First trimester: 
The patients are indoctrinated with the information that the process is efficacious as about two-thirds of all persons under the treatment will undergo the complete emptying of the pregnancy within one treatment. Nevertheless, around 25% of patients profess the necessity for further uterine aspiration to guarantee full removal of the product. 
 
Although sometimes, after the first dose, the fetus is not completely pushed out, you can give the patient the pill within 12 to 24 hours. This extra dose is intended to intensify the effect and increase the likelihood of achieving the goal. Relate other sentences: Humanize the given sentence. 
 
Second trimester: 
It is confirmed that those studies prove that the meaning of misoprostol together can help achieve the purpose of pregnancy loss in the 2nd trimester of pregnancy. 

Use of surgical management (uterine aspiration) in pregnancy loss

Surgical management, specifically uterine aspiration, is a procedure commonly used in the management of pregnancy loss. It is also known as suction curettage or manual vacuum aspiration (MVA). Uterine aspiration involves the removal of fetal tissue and products of conception from the uterus through suction or manual techniques.  

Indications: Uterine aspiration is typically performed in cases of incomplete miscarriage, missed miscarriage, or inevitable miscarriage where the pregnancy has failed to progress or has ended, but the products of conception have not been completely expelled from the uterus. It is also utilized in cases of early pregnancy failure or for elective pregnancy termination. 

Procedure: Uterine aspiration is usually conducted as an outpatient procedure in a clinic or hospital setting. The woman is usually given a local anesthetic to numb the cervix, or in some cases, conscious sedation or general anesthesia may be used.

The cervix is dilated, and a thin tube (cannula) is inserted into the uterus. Suction or manual aspiration is then applied to remove the contents of the uterus, including the fetus and placental tissue. 

Advantages: Uterine aspiration offers several advantages in the management of pregnancy loss. It provides a relatively quick and effective method of removing retained products of conception, which helps prevent complications like infection or excessive bleeding.

It is a less invasive alternative to a surgical dilation and curettage (D&C) procedure and can often be performed earlier in pregnancy, minimizing the need for more extensive interventions. 

Use of surgical management (uterine aspiration) in pregnancy loss

Among the surgical methods, uterine aspiration is peculiar since it is often performed during a miscarriage. Not only is it known as suction curettage or manual (MVA) vacuum aspiration but is also sometimes called the Manual Vacuum Aspiration (MVA) method. Uterine evacuation is an operation that is done by evacuating the fetal tissue and products of conception from the uterine cavity through suction or manual methods. 
 
Indications: The ‘uterine aspiration’ procedure is performed in cases of incomplete miscarriage, missed miscarriage and inevitable miscarriage when the process of pregnancy loss is not fully completed, or the fetal material is left within the womb. It is likewise used in cases of unsuccessful pregnancies early on or as the intended means of terminating pregnancies. 
 
Procedure: Uterine aspiration may be carried out in the form of an out-patient procedure in a clinic or hospital’s location. The woman is normally given a local anesthetic that is designed to stop her from feeling any kind of pain in the cervix, unless in other cases she is given sedation or general anesthesia. It is then opened, and a relatively long and thin tube (cannula) is transferred into the uterus. The obstetrician uses the suction or manual methods to clear the uterus and remove the organism as well as the placental tissue. 

use-of-intervention-with-a-procedure-in-treating-pregnancy-loss

The intervention or procedure recommended may depend on factors such as the gestational age of the pregnancy and the specific circumstances surrounding the loss. Here are a few common procedures that may be performed in the case of a pregnancy loss: 

• Dilation and curettage (D&C): This procedure involves dilating the cervix, removing the contents of the uterus using suction or a curette. It is often performed for incomplete miscarriages or when there is a risk of infection or excessive bleeding. 
• Medication: In some cases, medication might be prescribed to help expel the contents of the uterus. This option is usually considered for early pregnancy losses. 
• Manual vacuum aspiration (MVA): Similar to a D&C, this procedure involves removing the contents of the uterus using a manual suction device. It is commonly used for early pregnancy losses. 
• Expectant management: In certain cases, your healthcare provider may recommend allowing the body to naturally expel the pregnancy tissues without any intervention. This approach may be considered for early miscarriages or when there are no immediate medical concerns. 
• The choice of procedure depends on factors such as your medical history, the gestational age of the pregnancy, and your preferences. 

use-of-phases-in-managing-pregnancy-loss

Pregnancy loss management process usually involves the following phases: first of all, assessment of pregnancy and after that – decision making and ongoing care. undefined 
 
Initial evaluation: Since pregnancy loss can be either suspected or proven, some evaluation is done for that purpose. 
 
Decision-making: Based upon the outcomes of the evaluation and your preference, you along with your healthcare provider will together decide upon the management of the pregnancy loss. The choices could be ranging from expectant management (the body will spontaneously start eliminating pregnancy tissues), medical assistance (using the medicines to help induce a miscarriage) or a surgical procedures (the D&C or MVA) to completely eliminate the pregnancy tissues. 
 
Emotional support and counseling: Emotional support needs to be highlighted at every stage of management. Counseling services might include referring you to support groups/mental health specialists who specifically cater to helping people, individuals and couples who are struggling to cope with pregnancy loss. The same resources might be designated to provide a space to express your emotions, get grief counseling and obtain assistance in coping with the emotional difficulties caused by the death. 
 
Ongoing care and follow-up: After going through the first phase, you will receive the ongoing follow-up care to ensure that your physical and mental well-being are in good shape. These could be arranging for some recovery procedures, mitigating any possible complications, and providing additional support as needed. 

Medication

Future Trends

Media Gallary

References

Miscarriage rates by week: Risks and statistics (medicalnewstoday.com)  

Eunice Kennedy Shriver National Institute of Child Health and Human Development – NICHD (nih.gov)  

Estimation of pregnancy losses attributable to exposure to ambient fine particles in south Asia: an epidemiological case-control study – The Lancet Planetary Health  

Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss – PubMed (nih.gov)