Spontaneous Abortion (Miscarriage) - Symptoms

Symptoms of a threatened abortion

A threatened abortion is characterized by nagging pain in the lower abdomen and lower back, sometimes accompanied by scant vaginal bleeding. Uterine tone is increased, the cervix is not shortened, the internal os is closed, and the uterine body is normal for the gestational age. A fetal heartbeat is detected during an ultrasound.

Symptoms of an incipient abortion

When an abortion has begun, vaginal pain and bloody discharge are more severe, and the cervical canal is slightly open. The following obstetric complications must be diagnosed: chorionic (placental) abruption and its size, placenta previa or low-lying chorionic (placental) sac, bleeding from the second uterine horn due to uterine malformations, and the loss of one fertilized egg in a multiple pregnancy.

Symptoms of abortion in progress

During an abortion, regular cramping contractions of the myometrium are observed, the uterus is smaller than the estimated gestational age, and in later stages of pregnancy, amniotic fluid leakage may occur. The internal and external os are open, and the fetal sac is present in the cervical canal or vagina. Bloody discharge can vary in intensity, but is often profuse.

Symptoms of incomplete abortion

Incomplete abortion is a condition associated with the retention of elements of the fertilized egg within the uterine cavity. The lack of complete uterine contraction and uterine closure leads to ongoing bleeding, which in some cases can lead to significant blood loss and hypovolemic shock. It most often occurs after 12 weeks of pregnancy when the miscarriage begins with the rupture of membranes. A bimanual examination reveals the uterus to be smaller than the estimated gestational age, with profuse cervical bleeding. Ultrasound reveals remnants of the fertilized egg in the uterine cavity, and in the second trimester, remnants of placental tissue.

Symptoms of an infected abortion

Infected abortion is a condition characterized by fever, chills, malaise, lower abdominal pain, and bloody, sometimes purulent, vaginal discharge. Physical examination reveals tachycardia, tachypnea, and abdominal wall muscle spasms. Bimanual examination reveals a tender, soft uterus and a dilated cervix. The inflammatory process is most often caused by Staphylococcus aureus, Streptococcus, Gram-negative bacteria, and Gram-positive cocci. If untreated, the infection may progress to salpingitis, localized or diffuse peritonitis, and septicemia.

A non-viable pregnancy (antenatal death of the fetus) is the death of an embryo or fetus before 20 weeks of pregnancy in the absence of expulsion of elements of the fertilized egg from the uterine cavity.

In the first trimester, a miscarriage is typically accompanied by pain and bloody discharge. In the second trimester, the initial symptoms of an abortion are cramping pain in the lower abdomen, with bleeding occurring after delivery of the fetus. An exception is the termination of pregnancy due to placenta previa, in which case bleeding, usually profuse, becomes the leading symptom.

A threatened miscarriage is characterized by mild pain in the lower abdomen. A miscarriage that has begun is accompanied by increasing pain and possible light spotting. An abortion in progress is characterized by a sharp increase in cramping pain and heavy bleeding. An incomplete abortion typically involves a decrease in pain while bleeding continues to varying degrees. A complete abortion results in a subsidence of pain and a cessation of bleeding.

The specific symptoms of a spontaneous miscarriage may be determined by the underlying etiologic factor. Thus, an abortion caused by cervical insufficiency occurs in the second trimester of pregnancy, beginning with the rupture of membranes and ending with the rapid birth of the fetus amidst mild, painless contractions. Genetic factors can lead to miscarriage in early pregnancy. Abortions associated with androgen deficiency in early pregnancy begin with spotting, followed by pain, and often lead to a missed abortion. In later pregnancy, intrauterine fetal death is possible. The death of the fertilized egg, followed by its expulsion from the uterus, can occur in the presence of chronic or acute infections; bleeding is rarely profuse.

To clarify the diagnosis, it is necessary to conduct an examination of the cervix and vagina using a speculum (if neoplasms of the cervix are suspected, a colposcopy and biopsy are performed), a careful bimanual examination, and determination of the level of human chorionic gonadotropin.

In developing pregnancy management tactics for bleeding in the first trimester of pregnancy, ultrasound plays a decisive role.

Unfavorable signs regarding the development of the fertilized egg during intrauterine pregnancy during ultrasound:

• absence of a heartbeat in an embryo with a crown-rump length of more than 5 mm;
• absence of an embryo with the size of the ovum being more than 25 mm in 3 orthogonal planes during transabdominal scanning and more than 18 mm during transvaginal scanning.

Additional ultrasound signs indicating an unfavorable pregnancy outcome include:

• an abnormal yolk sac, which may be larger than the gestational age, irregularly shaped, displaced to the periphery, or calcified;
• the fetal heart rate is less than 100 beats per minute at a gestational age of 5–7 weeks of pregnancy;
• large size of retrochorial hematoma - more than 25% of the surface of the ovum.