Miscarriage

Classification according to ICD-10
O03	Spontaneous abortion
O03.0	Incomplete, complicated by infection of the genital tract and pelvis
O03.1	Incomplete, complicated by bleeding late or increased bleeding
O03.2	Incomplete, complicated by embolism
O03.3	Incomplete, with other and unspecified complications
O03.4	Incomplete, without complication
O03.5	Complete or unspecified, complicated by infection of the genital tract and pelvis
O03.6	Complete or unspecified, complicated by bleeding late or increased bleeding
O03.7	Complete or unspecified, complicated by embolism
O03.8	Complete or unspecified, with other and unspecified complications
O03.9	Complete or unspecified, without complication
ICD-10 online (WHO version 2019)

A miscarriage , also called (spontaneous) abortion ( Latin abortus ; outdated also called displeasure ), is a premature termination of the pregnancy by expulsion and / or death of a fruit weighing less than 500 grams.

Definition of terms

Miscarriages are divided into early and late abortions . The delimitation is not uniform, the 12th week of pregnancy is often used as the separation time. If the fetus weighs more than 500 g, one speaks of a stillbirth . This weight can be expected from the 22nd week of pregnancy. Miscarriages are different from the stillbirth in Germany not the civil reporting requirements . Miscarriages, including those that occurred in the past, have been officially certified since May 2013 upon submission of appropriate evidence upon request. There is still no obligation to report.

Miscarriages from natural causes are also called spontaneous abortions , while artificial abortions are terminations of pregnancy . To record and differentiate the number of pregnancies and births, see Parietät .

Epidemiology

The number can only be estimated, since miscarriages in the first few weeks of pregnancy are often subclinical and are therefore misinterpreted as irregularities in the menstrual cycle . It is assumed that in the group of 20 to 29 year old women about half of the fertilized egg cells perish spontaneously. Clinically, for the reasons mentioned, only about 15% to 20% of these are recognized as miscarriages, and about 30% of women are affected by one or more miscarriages in their lives.

In women who wanted to have children, highly sensitive HCG tests were systematically carried out in the urine after the contraception was discontinued. So the existence of a pregnancy could be proven very early. Miscarriage occurred in 22% of clinically proven pregnancies. Another 43 of 221 women had an increase in urinary hCG without clinical pregnancy. If these cases are included, 31% of the pregnancies terminated unintentionally. The women with clinically unrecognized early pregnancies became pregnant 95% of the time within the next two years.

to form

The forms of miscarriage listed below differ in stage and form.

Abortus imminens - threatened abortion

The impending abortion is a working diagnosis from a time when there were neither quantitative HCG determinations nor high-resolution ultrasound devices . The main symptom is a sometimes excessive bleeding from the uterus. The cervix is closed and labor does not occur. In the past it was not possible to differentiate between a bleeding in early pregnancy and an abortion (with a dead embryo ) in such a situation , but today a more precise diagnosis is possible: Can it be proven that

the embryonic heart is beating (using ultrasound ) and / or
the HCG concentration in the blood rises within a normal range within a few days

The diagnosis of bleeding in early pregnancy can be made, even if a limited, retroplacental hematoma can be made visible: This can organize and heal. If there are no other pathological findings besides the bleeding, a successful outcome of pregnancy can be expected in approximately 95 percent. This means that the rate of successfully carried pregnancies is just as high as that of pregnancies without such early bleeding. There are no therapeutic options, only traditional recommendations such as bed rest and physical rest for the duration of the vaginal bleeding. Proof of the effectiveness of these measures has not yet been provided.

However, if no embryonic heartbeat can be detected during a bleeding and the concentration of HCG in the maternal blood does not rise, the diagnosis of abortus incipiens can be made.

In labor should a pregnant woman with living fetus from 22 weeks Tocolytics , d. H. contraceptive drugs. A prescription of progestins is at Corpus luteum - insufficiency indexed until about the 14th week of pregnancy, generally has the abortion but lost its meaning.

Abortus incipiens - incipient abortion

This is the first stage in an abortion that has started. Even at this stage the pregnancy is irreversibly disturbed and the process can no longer be stopped. Compared to the abortus imminens, the vaginal bleeding and the pain are stronger here and the cervix is open. During the vaginal examination, pregnancy material can sometimes be felt. Fetal vital signs are partly still present, partly they are already missing.

Abortus incompletus - incomplete abortion

An abortus incipiens usually turns into a complete or incomplete abortion. When abortion incompletus became a part of pregnancy, often embryo or fetus , already exhausted, often remain placenta parts in the uterus back to that persistent vaginal bleeding, ascending, d. H. ascending, infections or even malignant degeneration . In the clinical examination, the expelled parts of the pregnancy are in the cervical canal resp. visible in the vagina. These parts are incomplete.

This type of abortion is mainly seen in late abortions. In the case of incomplete abortion, curettage is indicated to protect against the complications described . However, in this situation there is an increased risk of bleeding and perforation . After complete curettage, the often excessive bleeding from the uterus, which is dangerous for women, usually stops. The physiological uterine contraction can be additionally supported by the administration of the natural hormone oxytocin released by the pituitary gland in the course of labor .

Complete abortus - complete abortion

This is a complete and simultaneous departure of the entire fruit, which includes the embryo or fetus, the membranes and the placenta. Mostly this is an early abortion. A complete abortion after the 16th week of pregnancy is rare. In this form of miscarriage, curettage can be avoided if the bleeding subsides spontaneously, the uterus recedes immediately and the abortion material is complete. In the event of uncertainty, curettage should be performed for the reasons mentioned above. However, it is absolutely necessary that the pregnancy leading to a complete abortion has been reliably proven in the uterus in advance; an ectopic pregnancy must be definitely excluded.

Missed Abortion - restrained abortion

The fruit system has died, but is not expelled from the uterus. Apart from a lack of vitality signs, which include fetal heart and child movements, there are no external indications such as bleeding or tissue loss. The cervical canal is closed. The growth retardation of the uterus in routine pregnancy control or the lack of movement of the child is noticeable. The subjective signs of pregnancy such as nausea or breast tenderness are also minimized. The final diagnosis of the embryo with missing vitality signs that can be detected in the uterus is carried out sonographically .

Up to the 12th week of pregnancy, suction curettage of the uterus is used as therapy. For this purpose, prostaglandins are administered preoperatively in women who have not yet given birth to the cervix to enlarge and soften the cervix, so as not to endanger a later pregnancy through injury to the cervix with cervical insufficiency. If the 12th week of pregnancy is exceeded, a birth is initiated by means of oxytocin or prostaglandin infusions, which is then followed by curettage.

Dead fetus syndrome is a rare complication of missed abortion. Here, the dead fetus remained in the uterus for several weeks after the 12th week of pregnancy, whereby thromboplastic material can flood into the maternal bloodstream, resulting in life-threatening disseminated intravascular coagulation .

Cervical abortion

It is an extremely rare form of missed abortion, in which the dead abortion cannot pass due to a scarred cervix.

Abortus febrilis - febrile abortion or septic abortion

This term describes a febrile miscarriage. In the uncomplicated form, there is only a local infection of the uterine lining ( endometritis ). The complicated form involves inflammation of the uterus and adnexa . The most severe form, septic abortion, is accompanied by a massive bacterial load of the blood, inflammation of the pelvic organs and peritoneum inflammation associated and can be used as septic-toxic shock ( Sanarelli Shwartzman-reaction ) lethal end.

Abortive fruit

This is a faulty development of a fertilized egg, in which the embryonic system is stunted or completely absent. The abortive fruit (also called diaper) perishes in the first few weeks of pregnancy. In 50–90% of spontaneous abortions in the 2nd month of pregnancy it is an abortion. In addition to genetic defects, external factors such as intoxication and lack of oxygen are also considered as the etiology . The uterus does not grow. Subjective pregnancy symptoms are only weakly pronounced, sometimes there is spotting. The diagnosis is made after an ultrasound scan. The gestation system usually measures less than 3 cm. There is no embryo in the empty amniotic sac, which is surrounded by chorionic villi (although, since 1995, modern ultrasound devices have sometimes been able to make small embryoblasts visible; this may be early forms of restrained abortion). Curettage can be considered as therapy, but the natural abortion can also be awaited.

Abortus habitualis - habitual abortion

Three or more abortions (in a row) before the 20th week of pregnancy are referred to as “ habitual abortions ” or “repeated miscarriages”. Around one percent of all couples who want to have children are affected , although no cause can be found in 40 percent of the cases.

Since the embryonic or fetal karyotype is more often normal, a disturbed interaction between maternal and child tissue is assumed to be a possible explanation for repeated miscarriages.

causes

Miscarriages can have many causes. In general, triggering factors can lie in problems with the development of the womb (fetoplacental reasons) or in acute and chronic illnesses, physical anomalies , mental suffering or external physical influences (maternal and other reasons). When looking for the cause, clear reasons can sometimes be identified, but sometimes the actual reason remains hidden.

Examples of the complexity of the maternal and fetoplacental interactions are the hormonal regulation of pregnancy and the not always sufficient tolerance to the new antigens of the fruit by the immune system of the host organism . Quite a few pregnancies fail before they are noticed.

Fetoplacental reasons

As fetoplacental unit are in gynecology , obstetrics and Developmental Biology fetus and placenta designated and distinguished from so pregnant organism.

Serious problems of early development or non-developable malformations form an important background here .

Most of the early obstacles to development originate in the genome of at least one germ cell .

Chromosomal aberrations are estimated to cause 50–70% of all spontaneous abortions. Such changes in the genetic material can occur in all cell divisions. Changes occurring during the maturation of germ cells that arise are relevant here ; sometimes also those that occur during the cleavage of the zygote emerging from both germ cells . (This is an essential principle of life; ontogenetically successful changes are considered to be the basis of phylogenesis .) Larger chromosome mutations and numerical aberrations in particular can prove to be fatal. Mutagenic influences such as ionizing radiation can play a role. Even if more than one sperm cell is absorbed into the egg, this will lead to numerical aberrations.

Sometimes changes that were already present in one or both parents also have an unfavorable effect. In the sense of a recessive change, they must be present and come together on both sides. Balanced translocations on one side can lead to imbalances in the genome of the fruit after the union of the two haploid chromosome sets. Human genetic examinations are offered by andrological and gynecological side.

With the nidation of the blastocyst in the uterine wall, there is direct contact between tissues. The trophoblast establishes the connection to the endometrium , is supposed to nourish the developing embryo and develop into the placenta . Functional disorders can be diverse. Hormonal interactions have to work; the maternal immune system is now also important. The trophoblast can become atrophic before blood vessels develop or the vessels can develop poorly. Also hypertrophy can lead to fetal death and weeks as to their disposal Hydatidiform be recognized. If the implantation took place in an unfavorable place, it can later lead to an abortion in connection with a placenta previa .

Fatal embryopathies or fetopathies can also be triggered by teratogenic influences during pregnancy. In addition to ionizing radiation and toxic chemicals , various drugs and stimulants such as alcohol and substances from tobacco smoke, infections and vaccinations during pregnancy must be observed. An example of a viral infectious disease affecting the fruit is rubella embryo fetopathy . Specific problems caused by bacteria also occur; a classic example is syphilis . The pathogen of toxoplasmosis originates from the (biologically and systematically obsolete) kingdom of the protozoa .

Maternal, paternal and other reasons

Anatomically, a distinction can be made between uterine (primarily located in the uterus ) and extrauterine triggers.

Uterine malformations include malformations (double formation), tumors (especially myomas , located in the muscle wall), inflammation (endometritis of the uterine lining ), intrauterine adhesions or adhesions ( synechiae ) and weakness of the cervix (cervical insufficiency including so-called connective tissue weakness ).

Backgrounds are diverse, different and for their part can be functionally divided for practical reasons. For example, they can be present before the woman is born, be hormonal , infectious , caused by injuries or other harmful effects.

By definition, uterine hypermotility is a functional disorder of this organ, and labor leading to miscarriage is an effect ( often below the sensory threshold during early pregnancy ). Fever can be a triggering factor (basically similar effects are being discussed for heat-generating short-wave radiation ). Central nervous factors can be mediated vegetatively or endocrine (hormone oxytocin ). Various bio-psycho-socio-cultural connections must be emphasized here; one keyword is stress . (Generally understandable backgrounds could be war, flight or separation; examples of medical explanations are vegetative dystonia , somatoform disorder and conversion .)

The inner genital organs located in the extrauterine region are the ovaries . After ovulation , a corpus luteum forms there , the ongoing hormone-producing activity of which is essential for maintaining an early pregnancy. Insufficiency of the corpus luteum causes an endocrine disorder , but can also be the result of endocrine insufficiency of the fetoplacental unit. Fruits usually pass with the shedding of the uterine lining.

General illnesses and illnesses of other organs can also lead to miscarriages. Examples would be systemic endocrine disorders ( diabetes mellitus , thyroid dysfunction ), acute and chronic viral , bacterial and parasitic infectious diseases (infectious or toxic fetal damage including teratogenic effects of vaccinations has its effects in the fetoplacental area), electrolyte disorders ( e.g. as a result of kidney diseases), anemia (for example vitamin B ₁₂ deficiency, pernicious anemia ) or epilepsy . So-called consuming diseases (severe forms of cancer , AIDS- associated diseases, autoimmune diseases , tuberculosis, etc.) and deficiency diseases can also be assigned here.

Rupture of the amniotic sac such as the use of labor can also be triggered by physical strain (possibly certain types of sport), primarily labor also through medication and other drugs.

The consequences of mechanical external influences that lead to termination of the pregnancy are also not attributable to fetoplacental factors. Unintentionally artificially induced iatrogenic abortions can occur, for example, as part of prenatal diagnosis using amniocentesis , chorionic villus sampling or umbilical cord puncture . Traumatic consequences can also arise from accidents or criminal assaults .

Recent studies suggest a link between the man's age and the likelihood of miscarriage. The risk of miscarriage in one large study averaged 16.7% in men between 30 and 34 years of age. This rate rose to 19.5% in men between 35 and 39 and to 33% in men 40 or older. The likelihood of having a child with Down syndrome , for example , also increases with the age of the man. The pregnancy rates - regardless of the age of the partners - decreased with increasing age of the man.

clinic

The main characteristic of a miscarriage is vaginal bleeding, which varies in intensity depending on the type of abortion. Sometimes the patient also feels labor-like pain in the lower abdomen or lower back pain. In early pregnancy there is often bleeding, in late pregnancies labor or loss of amniotic fluid are often the first signs of an abortion. As the name suggests, these characters are missing in missed abortion. Your clinic consists in a standstill in the growth of the uterus and a lack of vital signs such as the child's movements that the mother can perceive. In febrile abortion, fever and purulent discharge are associated with the clinic.

Diagnosis

The gynecological examination reveals various findings depending on the stage and course of the abortion. In the case of abortion imminens (threatened miscarriage) and missed abortion , the cervical canal is closed. In other forms it is open. Sometimes abortion material can also be found in the cervical canal in addition to blood. In some cases, the uterus has an increased tone of contraction. In febrile abortion , the uterus is also tender on pressure.

The most important examination to classify the abortion is the ultrasound. It can also be used to prove children's vitality signs, such as the child's heart action from the 6th to 7th week of pregnancy. A progress check is also possible with the ultrasound. In the case of an abortion , the embryo or fetus is still vital. A retroplacental hematoma may be shown on sonography. The pregnancy can be preserved through appropriate therapeutic measures.

If a clear assessment of the situation by means of sonography is not possible, a serial measurement of the pregnancy hormone hCG can be used to monitor the progress.

Differential diagnosis

All diseases that can present with vaginal bleeding during pregnancy must be taken into account.

therapy

The therapy depends on the form and stage of the abortion and the possibility of maintaining pregnancy. A medical consultation is definitely recommended. A medical therapy for a womb that died prematurely is curettage (scraping), especially of remaining placenta . In more advanced stages of pregnancy (from around the 12th week) the womb usually has to be born naturally. In any case, childbirth is possible; a midwife or nurse accompanying you in the case of a small birth is the ideal case. A natural birth in earlier weeks of pregnancy (“small birth” or “waiting behavior”) is more painful, but for many women it is more psychologically healing than scraping. Both options entail different, equally low risks, which is why the choice is up to the woman in most cases.

Complications

Complications can arise from the miscarriage itself or from medical interventions. Untreated miscarriages are often associated with significant blood loss and subsequent anemia . Also thrombosis and pulmonary embolism can occur. The most important complication, however, is infection. The bacterial colonization first affects the endometrium and then spreads to the fallopian tubes and paracolpium . A tubo-ovarian abscess can develop from this, which prevents further pregnancies. While the prophylactic administration of antibiotics during abortion could reduce the rate of infections, the AIMS study did not achieve a significant reduction in the infection rate with a preoperative administration of 400 mg doxycycline and 400 mg metronidazole before clearing a miscarriage. Pelvic infections occurred with antibiotics in 4.1%, without antibiotics in 5.3% of the miscarriages.

Community grave for miscarriages at the main cemetery in Karlsruhe

Due to the usually psychologically stressful situation, it helps many women (couples) to cope with a miscarriage to get therapeutic support or support through contact with other affected women ( self-help group ). If such counseling, a psychological conversation or a conversation with other affected persons, if possible together with the partner, is made use of before a possible curettage or small birth, this can make the subsequent grief work much easier and prevent or reduce traumatic experiences.

If a woman unintentionally suffers multiple miscarriages, genetic counseling can be helpful to find out the cause and narrow down the possible causes. This should be about examining the parents as well as (if possible) examining the dead child.

literature

Barbara Künzer-Riebel, Gottfried Lutz: Just a breath of life. Kaufmann, Lahr 1988, ISBN 3-7806-0951-7 .
Hannah Lothrop : Good hope, sudden end . Kösel, Munich 1998, ISBN 3-466-34389-5 .
Manfred E. Beutel: The early loss of a child. Coping with and help with miscarriages, stillbirths and sudden infant deaths. (= Psychosocial Medicine. Volume 2). 2nd Edition. Hogrefe, Göttingen 2002, ISBN 3-8017-1472-1 .
Michaela Nijs: There is a time to grieve. Farewell rituals for the early death of a child. (= Psychosocial Medicine. Volume 7). 2nd Edition. Hogrefe, Göttingen 2003, ISBN 3-8017-1808-5 .
Klaus Schäfer: A star that couldn't shine. The book for parents whose child died prematurely . Herder spectrum, Herder, Freiburg im Breisgau / Basel / Vienna 2005, ISBN 3-451-05510-4 .
Alexandra Bosch (Ed.): Our children, actually. How mothers and fathers experience the early loss of their child . MaximilianProjekt, Baden-Baden 2004, ISBN 3-00-015296-2 .
Ute Horn: As quiet as a butterfly. Farewell to the miscarried child. 4th edition. Hänssler, Holzgerlingen 2008, ISBN 978-3-7751-4378-3 .
Detlef Hecking, Clara Moser Brassel: When birth and death coincide . TVZ, Zurich 2006, ISBN 3-290-20029-9 .
Manfred Stauber, Thomas Weyerstahl: Gynecology and Obstetrics. (= Dual row). 3. Edition. Thieme, Stuttgart 2007, ISBN 978-3-13-125343-9 .
Maureen Grimm, Anja Sommer: Born quietly . Panama Verlag, Berlin 2011, ISBN 978-3-938714-13-3 .

Web links

Wiktionary: miscarriage - explanations of meanings, word origins, synonyms, translations

»Early farewell« - A child loses early information from the Federal Center for Health Education (BZgA)

Individual evidence

↑ displeasure. on: zeno.org

↑ ^a ^b Pschyrembel: Clinical Dictionary

^ I. Gerhard, B. Runnebaum: Endocrinology in pregnancy. In: B. Runnebaum , T. Rabe : Gynecological endocrinology and reproductive medicine. (= Reproductive medicine. 414). Volume 2, Springer Verlag, 1994, ISBN 3-540-57347-X .

^ AJ Wilcox, CR Weinberg, JF O'Connor, et al .: Incidence of early loss of pregnancy. In: The New England Journal of Medicine . tape 319 , 1988, pp. 189-94 .

↑ atcgene.de ( Memento of the original from June 20, 2007 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2
↑ M. Madsen, T. Jørgensen, ML Jensen, M. Juhl, J. Olsen, PK Andersen, A.-M. Nybo Andersen: Leisure time physical exercise during pregnancy and the risk of miscarriage: a study within the Danish National Birth Cohort. In: BJOG - An International Journal of Obstetrics and Gynaecology . (OnlineEarly Articles). doi: 10.1111 / j.1471-0528.2007.01496.x .
↑ K. Kleinhaus, M. Perrin, Y. Friedlander, O. Paltiel, D. Malaspina, S. Harlap: Paternal Age and Spontaneous Abortion . In: Obstetrics & Gynecology . tape 108 , no. 2 , 2006, p. 369-377 , doi : 10.1097 / 01.AOG.0000224606.26514.3a , PMID 16880308 .
↑ R. Slama, J. Bouyer, G. Windham, L. Fenster, A. Werwatz, SH Swan: Influence of Paternal Age on the Risk of Spontaneous Abortion . In: American Journal of Epidemiology . tape 161 , no. 9 , 2005, p. 816-823 , doi : 10.1093 / aje / kwi097 , PMID 15840613 .
↑ Tadele Melese, Dereje Habte, Billy M Tsima, Keitshokile Dintle Mogobe, Kesegofetse Chabaesele: High Levels of Post-Abortion Complication in a Setting Where Abortion Service Is Not Legalized . In: PLOS ONE . tape 12 , no. 1 , January 6, 2017, ISSN 1932-6203 , p. e0166287 , doi : 10.1371 / journal.pone.0166287 , PMID 28060817 , PMC 5217963 (free full text) - ( plos.org [accessed March 19, 2019]).
^ W. Cates, TM Farley, PJ Rowe: Worldwide patterns of infertility: is Africa different? In: Lancet (London, England) . tape 2 , no. 8455 , September 14, 1985, ISSN 0140-6736 , p. 596-598 , PMID 2863605 .
↑ Nicola Low, Monika Mueller, Huib AAM Van Vliet, Nathalie Kapp: Perioperative antibiotics to prevent infection after first-trimester abortion . In: The Cochrane Database of Systematic Reviews . No. 3 , March 14, 2012, ISSN 1469-493X , p. CD005217 , doi : 10.1002 / 14651858.CD005217.pub2 , PMID 22419307 .
↑ David Lissauer, Amie Wilson, Catherine A Hewitt, Lee Middleton, Jonathan RB Bishop: A Randomized Trial of Prophylactic Antibiotics for Miscarriage Surgery . In: New England Journal of Medicine . tape 380 , no. 11 , March 14, 2019, ISSN 0028-4793 , p. 1012-1021 , doi : 10.1056 / NEJMoa1808817 ( nejm.org [accessed March 19, 2019]).

[1] displeasure. on: zeno.org

[Pschyrembel-2] Pschyrembel: Clinical Dictionary

[3] I. Gerhard, B. Runnebaum: Endocrinology in pregnancy. In: B. Runnebaum , T. Rabe : Gynecological endocrinology and reproductive medicine. (= Reproductive medicine. 414). Volume 2, Springer Verlag, 1994, ISBN 3-540-57347-X .

[4] AJ Wilcox, CR Weinberg, JF O'Connor, et al .: Incidence of early loss of pregnancy. In: The New England Journal of Medicine . tape 319 , 1988, pp. 189-94 .