Spontaneous Abortion - Risk Factors, Etiology, Clinical Manifestations, and Diagnostic Evaluation - UpToDate PDF

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Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation
Authors: Togas Tulandi, MD, MHCM, Haya M Al-Fozan, MD

Section Editors: Deborah Levine, MD, Robert L Barbieri, MD
Deputy Editor: Kristen Eckler, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2017. | This topic last updated: Jan 19, 2017.
INTRODUCTION Spontaneous abortion, or miscarriage, is defined as a clinically recognized pregnancy loss

before the 20th week of gestation [1,2]. The World Health Organization (WHO) defines it as expulsion or
extraction of an embryo or fetus weighing 500 g or less. The term "fetus" will be used throughout this
discussion, although the term "embryo" is the correct developmental term at 10 weeks of gestation.
The etiology, risk factors, and diagnostic issues relating to spontaneous abortion are reviewed here. Recurrent
abortion and management issues are discussed separately. (See "Evaluation of couples with recurrent
pregnancy loss" and "Spontaneous abortion: Management".)
TERMINOLOGY
Intrauterine pregnancy of uncertain viability Transvaginal ultrasonography shows an intrauterine

gestational sac with no embryonic heartbeat (and no findings of definite pregnancy failure) [3].
Pregnancy of unknown location A urine or serum pregnancy test is positive and there is no
intrauterine or ectopic pregnancy seen on transvaginal ultrasonography.
INCIDENCE Spontaneous abortion is the most common complication of early pregnancy [1]. The frequency
decreases with increasing gestational age. The incidence of spontaneous abortion (miscarriage) in clinically
recognized pregnancies up to 20 gestational weeks is 8 to 20 percent. However, the incidence among women
who have previously had a child is much lower (5 percent) [4,5]. The overall risk of spontaneous abortion after
15 weeks is low (about 0.6 percent) for chromosomally and structurally normal fetuses, but varies according to
maternal age and ethnicity [6].
Loss of unrecognized or subclinical pregnancies is even higher, occurring in 13 to 26 percent of all

pregnancies [4,5,7]. Early pregnancy losses are unlikely to be recognized unless daily pregnancy tests are
performed. A study that compared women's bleeding following a pregnancy loss before 6 weeks of gestation
with their typical menstruation found that mean bleeding length following a pregnancy loss was 0.4 days longer
than the woman's average menses and the amount of bleeding was light [8].
These data derive from studies such as the following representative examples:
In a classic study in which daily urinary human chorionic gonadotropin (hCG) assays were performed, the
total rate of pregnancy loss after implantation was 31 percent; 70 percent of losses (22 percent of all
pregnancies) occurred before the pregnancy was detected clinically [4].
In another study, daily urinary hCG assays were performed on 518 nulliparous, newly married women
aged 20 to 34 years who were attempting to conceive and had no known infertility factors [5]. Among 586
conceptions with a known outcome, 26 percent ended in preclinical loss, 8 percent ended in a clinically
recognized loss, and 64 percent resulted in a live birth; the remaining 2 percent were induced abortions,
ectopic pregnancies, molar pregnancies, and stillbirths.
https://www.uptodate.com/contents/spontaneous-abortion-risk-factors-etiology-clinical-manifestations-and-diagnostic-evaluation/print?source=search_res 1/23
If preimplantation losses are considered, approximately 50 percent of fertilized oocytes do not result in a live
birth [9].
RISK FACTORS Numerous risk factors are associated with an increased risk of pregnancy loss. The best
documented risk factors for spontaneous abortion are advanced maternal age, previous spontaneous
abortion, and maternal smoking.
Maternal age Advancing maternal age is the most important risk factor for spontaneous miscarriage in
healthy women. The effect of maternal age on pregnancy outcome was illustrated in a review of over 1 million
pregnancies with known outcomes involving admission to a hospital [10]. The overall rate of spontaneous
abortion was 11 percent and the approximate frequencies of clinically recognized miscarriage according to
maternal age were: age 20 to 30 years (9 to 17 percent), age 35 years (20 percent), age 40 years (40
percent), and age 45 years (80 percent) [10]. (See "Effects of advanced maternal age on pregnancy", section
on 'Spontaneous abortion'.)
Reproductive factors
Previous spontaneous abortion Past obstetrical history is an important predictor of subsequent

pregnancy outcome. The risk of miscarriage in future pregnancy is approximately 20 percent after one
miscarriage, 28 percent after two consecutive miscarriages, and 43 percent after three or more
consecutive miscarriages [11]. By comparison, miscarriage occurred in only 5 percent of women in their
first pregnancy or in whom the previous pregnancy was successful. (See "Definition and etiology of
recurrent pregnancy loss", section on 'Previous pregnancy loss'.)
Gravidity Some studies have shown an increased risk of miscarriage with increasing gravidity [12],
others have not [13,14]. Possible explanations for an association include (1) compensatory reproductive
behavior (pregnancy failure is likely to be associated with repeated attempts at conception, resulting in
higher gravidity) and (2) short interpregnancy intervals in multigravid women. (See "Interpregnancy
interval and obstetrical complications".)
Prolonged ovulation to implantation interval Early losses have been related to delayed
implantation (ie, >10 days between ovulation and implantation), which might result from fertilization of an
aging ovum, delayed tubal transport, or abnormal uterine receptivity [15].
Prolonged time to conception Observational studies have suggested that prolonged time to
achieving pregnancy correlates with an increased risk of miscarriage [16].
Medications or substances
Smoking Heavy smoking (greater than 10 cigarettes per day) is associated with an increased risk of
pregnancy loss (relative risk 1.2 to 3.4) [17-19]. The association is stronger after controlling for other causes
of pregnancy loss, such as limiting analysis to chromosomally normal abortuses [20]. The mechanism
responsible is unknown, but may relate to the vasoconstrictive and antimetabolic effects of tobacco smoke.
Paternal smoking may also increase the risk of pregnancy loss [21], as may exposure to second hand smoke
during childhood [22]. Smoking cessation should be recommended for its overall health benefits (see
"Cigarette smoking: Impact on pregnancy and the neonate" and "Overview of smoking cessation management
in adults").
Alcohol Observational studies have generally, but not consistently, found that moderate to high alcohol
consumption increases the risk of spontaneous abortion [23-27]. As an example, in one study, there was an
increased risk of miscarriage in women who consumed more than 3 drinks per week during the first 12 weeks
of pregnancy [23].
Interpretation of studies examining alcohol use in pregnancy is complicated by the difficulty of making accurate
adjustments for the many confounding factors and underreporting of actual alcohol consumption. Women
planning pregnancy should avoid alcohol consumption because alcohol is a known teratogen and a safe level
of alcohol intake has not been established for any stage of pregnancy. (See "Alcohol intake and pregnancy"
and "Substance misuse in pregnant women".)
Cocaine Use of cocaine is associated with preterm birth, and may also be a risk factor for spontaneous
abortion [19]. In one study involving 400 women having had a spontaneous abortion and 570 controls who
reached at least 22 weeks of gestation, the presence of cocaine in hair samples was independently associated
with an increase in the prevalence of spontaneous abortion after adjustment for demographic and drug-use
variables (OR 1.4; 95% CI 1.0-2.1) [19]. (See "Substance misuse in pregnant women".)
Nonsteroidal anti-inflammatory drugs The use of nonsteroidal anti-inflammatory drugs (NSAIDs), but
not acetaminophen, around the time of conception may be associated with an increased risk of miscarriage
[28,29]. The postulated mechanism is that prostaglandin inhibitors interfere with the role prostaglandins play in
implantation, thus potentially leading to abnormal implantation and pregnancy failure [30]. Although data are
limited, it is reasonable to suggest that women trying to conceive should best avoid use of NSAIDS to minimize
the risk of miscarriage, particularly when effective alternatives (eg, acetaminophen) are available.
Caffeine Based upon systematic reviews, it appears that caffeine intake is not associated with an
increased risk of SAB, with the possible exception of intake of very high levels (ie, 1000 mg, or 10 cups of
coffee, over 8 to 10 hours). However, studies examining the question have methodologic limitations relating to
selection and recall bias, confounding factors, the difficulty of quantifying caffeine consumption accurately (ie,
variations in size of the cup, brand of coffee, and brewing method), and the failure to account for fetal
karyotype, differences in caffeine metabolism, uncertainties in the time of fetal demise, and the possibility that
any effect of caffeine may be gestational age-specific. The mechanism responsible for an association between
high levels of caffeine intake and an increased risk of spontaneous abortion may relate to differences in
maternal metabolism and clearance. This issue is discussed in detail separately. (See "The effects of caffeine
on reproductive outcomes in women", section on 'Spontaneous abortion'.)
Other factors
Low folate level Low plasma folate levels appear to be associated with spontaneous abortion only
when the fetal karyotype is abnormal. A well-designed, population-based, case-control study observed
that low plasma folate levels (2.19 ng/mL [4.9 nmol/L]) were associated with an increased risk of
spontaneous abortion at 6 to 12 weeks of gestation in pregnancies with abnormal fetal karyotype [31].
Low folate levels in pregnancies with normal fetal karyotype and high folate levels had no impact on rate
of abortion. Of note, less than 5 percent of women received folate supplementation.
Whether low folate levels increase the risk for embryo aneuploidy and subsequent abortion is under
investigation; some investigators have suggested that maternal polymorphisms in the
methylenetetrahydrofolate reductase (MTHFR) and methionine synthase (MTRR) genes may increase the
risk of meiotic nondisjunction. Whether or not MTHFR polymorphisms independently increase the risk of
pregnancy loss is unclear [32,33]. (See "Congenital cytogenetic abnormalities", section on 'Trisomy 21
(Down syndrome)'.)
There is no evidence that vitamin supplementation prevents miscarriage [34]. There is no specific
evidence that folate supplementation reduces the risk of miscarriage in women with
hyperhomocysteinemia, although the possibility has been suggested [35]. However, folate supplements
are routinely recommended for all pregnant women for prevention of neural tube defects.
Extremes of maternal weight Prepregnancy body mass index (BMI) less than 18.5 or above 25
kg/m2 has been associated with an increased risk of infertility and spontaneous abortion [36-40]. In a
meta-analysis of 32 studies that included over 265,000 women, small but significantly increased risks of
miscarriage were reported for underweight (relative risk [RR] 1.08, 95% CI 1.05-1.11), overweight (RR
1.09, 95% CI 1.04-1.13), and obese women (RR 1.21, 95% CI 1.15-1.27) [41]. We encourage women who
desire pregnancy to maintain a normal BMI to maximize their reproductive health. (See "Optimizing natural
fertility in couples planning pregnancy" and "Obesity in pregnancy: Complications and maternal
management".)
Fever Fevers of 100F (37.8C) or more during pregnancy may increase the risk of miscarriage, but
the only two large studies have yielded inconsistent and inconclusive results.
One study compared women having euploid abortions or aneuploid abortions to women delivering at
28 weeks of gestation or later (controls), reasoning that if fever was an antecedent (rather than a
symptom) of spontaneous abortion, fever would be associated with euploid, but not aneuploid,
abortions [42]. Results of the study were consistent with that hypothesis: fevers were significantly
more prevalent among women having a euploid abortion than among controls (18 versus 7 percent),
but not more prevalent among women with aneuploid abortions. Moreover, the risk of abortion related
to the proximity of the febrile episode; the OR for abortion was 6.0 when fever occurred in the same
calendar month, 3.3 when it occurred during the preceding month, and 1.4 when the febrile episode
was two or more months before a euploid abortion.
Another study analyzed data from more than 24,000 Danish women who were interviewed during the
first 16 weeks of pregnancy to obtain information on the number of febrile episodes, the highest
temperature, duration of fever, and gestational age at the time of the occurrence [43], which was
subsequently linked with a pregnancy outcome registry. Fever occurred in 18.5 percent of
participants. There was no association between fever or any specific fever characteristic and first,
second, or third trimester fetal death, before or after adjustment of risk factors. However, the low rate
of first trimester pregnancy loss (2.3 percent) suggested that some women with spontaneous
abortions were not included, potentially masking an effect of fever on early loss.
Celiac disease Untreated celiac disease may be associated with a higher risk of spontaneous
abortion. (See "Definition and etiology of recurrent pregnancy loss", section on 'Celiac disease'.)
ETIOLOGY Spontaneous abortion is most commonly caused by chromosomal abnormalities in the embryo
or exposure to teratogens. It is often difficult to determine the cause of a spontaneous abortion in an individual
case. In one-third occurring at 8 weeks of gestation or earlier, no embryo or yolk sac is observed in the
gestational sac. In the remaining two-thirds of cases in which an embryo is identified, approximately half are
abnormal, dysmorphic, stunted, or too macerated for examination [44].
Fetal factors
Chromosomal abnormalities Chromosomal abnormalities account for approximately 50 percent of all

miscarriages [45]. Most such abnormalities are aneuploidies; structural abnormalities and mosaicism are
responsible for a small proportion. As an example, cytogenetic abnormalities were found in 59 percent of 2389
post-miscarriage product-of-conception samples, analyzed using a high-resolution single-nucleotide
polymorphism (SNP)-based microarray platform [46]. Abnormalities included: aneuploidy (85 percent); triploidy
(10 percent); and tetraploidy (4.2 percent) Most such abnormalities are aneuploidies that occur with
increasing frequency as maternal age increases.
The earlier abortion occurs, the higher the incidence of cytogenetic defects [47,48]. In one study, for example,
the prevalence of abnormal fetal karyotypes is 90 percent in empty sac pregnancies, 50 percent in abortions
occurring at 8 to 11 weeks of gestation, and 30 percent in those occurring at 16 to 19 weeks [47].
Trisomy 16 is the most common autosomal trisomy and is always lethal. Most chromosomal abnormalities in the
embryo arise de novo. Rarely, the abnormality is inherited from a parent who may have a balanced
chromosomal translocation. (See "Definition and etiology of recurrent pregnancy loss", section on 'Genetic
factors'.)
Genetic abnormalities not detected by conventional cytogenetic analysis (G-banded karyotype) account for an
undefined proportion of spontaneous abortions and include small deletions, duplications, and point mutations.
Congenital anomalies Congenital anomalies may be caused by chromosomal or other genetic

abnormalities, by extrinsic factors (eg, amniotic bands), or by exposure to teratogens. Potential teratogens
include maternal disorders (eg, diabetes mellitus with poor glycemic control), drugs (eg, isotretinoin), physical
stresses (eg, fever), and environmental chemicals (eg, mercury). (See "Birth defects: Approach to evaluation".)
Trauma Invasive intrauterine procedures such as chorionic villus sampling and amniocentesis, or trauma
increase the risk of abortion. By contrast, during early pregnancy, the uterus is generally protected from blunt
trauma to the maternal abdomen [49]. (See "Chorionic villus sampling" and "Diagnostic amniocentesis".)
Maternal factors
Uterine structural issues Pregnancy loss may also be related to the host environment. As an example,
congenital or acquired uterine abnormalities (eg, uterine septum, submucosal leiomyoma, intrauterine
adhesions) can interfere with implantation and growth [50].
A few studies found that the only uterine anomaly that impairs reproductive outcome was a septate uterus.
Removal of the septum significantly increased live birth rate and was associated with a high spontaneous
conception rate in infertile women [51-53].
The effect of leiomyomas on the risk of spontaneous abortion is discussed in detail separately. (See
"Reproductive issues in women with uterine leiomyomas (fibroids)".)
Maternal disease Acute maternal infection with any of a large variety of organisms (eg, Listeria
monocytogenes, Toxoplasma gondii, parvovirus B19, rubella, herpes simplex, cytomegalovirus, lymphocytic
choriomeningitis virus [54]) can result in abortion due to fetal or placental infection. At least one case report
has linked Zika virus infection with first-trimester abortion [55]. The virus was isolated in the fetal tissue.
Maternal endocrinopathies (eg, thyroid dysfunction, Cushing's syndrome, polycystic ovary syndrome) can also
compromise the host environment. Since corpus luteum progesterone production is essential for the success
of early pregnancy, it is plausible that early losses might result from corpus luteum dysfunction, but the concept
is controversial. Some well-designed studies comparing maternal serum progesterone levels during the
midluteal phase (when corpus luteum progesterone production is critical) found no difference between
concentrations observed in continuing pregnancies and those that subsequently failed [56]. The use of
progesterone to distinguish between a nonviable (missed abortion or ectopic pregnancy) and a viable
pregnancy when the location of the pregnancy is unknown is addressed separately. (See "Ectopic pregnancy:
Clinical manifestations and diagnosis", section on 'Progesterone'.)
The effect of thyroid disease and thyroid peroxidase antibodies on abortion risk is also reviewed separately.
(See "Overview of thyroid disease in pregnancy".)
A hypercoagulable state due to an inherited or acquired thrombophilia and abnormalities of the immune
system (eg, systemic lupus erythematosus, antiphospholipid syndrome) that may predispose to immunological
rejection or placental damage are active areas of investigation. (See "Inherited thrombophilias in pregnancy"
and "Pregnancy in women with antiphospholipid syndrome".)
Unexplained The cause of abortions of chromosomally and structurally normal embryos/fetuses in

apparently healthy women is unclear. As discussed above, genetic abnormalities not detected by a standard
karyotype (small deletions, duplications, and point mutations) account for an undefined proportion of
spontaneous abortions. In a study where embryoscopy, embryo biopsy, and karyotype were performed in more
than 200 patients with missed abortion, 18 percent of embryos having a normal karyotype exhibited grossly
abnormal developmental morphology [57].
CLINICAL PRESENTATION Spontaneous abortion usually presents as vaginal bleeding or pelvic pain or is
an incidental finding on a pelvic ultrasound performed in an asymptomatic patient [58].
Some women who present with spontaneous abortion have a previously unrecognized pregnancy. This is
particularly likely for women with irregular menses or those who had another recent episode of vaginal
bleeding that was interpreted as menses.
Symptoms The typical symptoms of a spontaneous abortion are vaginal bleeding or pelvic pain. Any
bleeding or pelvic pain in a pregnant woman warrants further evaluation. (See 'Differential diagnosis' below.)
Decreased fetal movement is only rarely a presentation of spontaneous abortion, since most abortions occur
before fetal movements are perceptible to the patient.
Vaginal bleeding The bleeding associated with spontaneous abortion ranges from scant brown spotting
to heavy vaginal bleeding. The volume or pattern of bleeding does not predict a spontaneous abortion. Vaginal
bleeding is common in the first trimester, occurring in 20 to 40 percent of pregnant women [59]. Even heavy,
prolonged bleeding can be associated with a normal outcome. As an example, in a prospective study of over
4000 pregnant women, 12 percent of women with first trimester vaginal bleeding had a miscarriage, but
miscarriage also occurred in 13 percent of women without bleeding [60]. In 90 to 96 percent of pregnancies in
which vaginal bleeding occurs between 7 to 11 weeks of gestation and fetal cardiac activity is observed,
pregnancy continues; success rates increase with gestational age when bleeding occurs [61]. (See 'Differential
diagnosis' below and 'Threatened abortion' below.)
Vaginal bleeding may be accompanied by passage of fetal tissue, which typically is solid and has the
appearance of a white mass covered with blood. Patients may mistake a blood clot for fetal tissue. Passage of
fetal tissue is usually accompanied by severe cramping.
Pelvic pain The pain that accompanies a spontaneous abortion is typically crampy or dull in character
and may be constant or intermittent.
Incidental finding on ultrasound Spontaneous abortion may be detected due to the absence of fetal
cardiac activity on a hand-held Doppler or pelvic ultrasound examination.
DIAGNOSTIC EVALUATION
History The gestational age should be calculated based on menstrual history or ultrasound assessment.
(See "Prenatal assessment of gestational age and estimated date of delivery".)
The history should focus on the presence and characteristics of any vaginal bleeding and pelvic pain, and on
the passage of fetal tissue. (See 'Symptoms' above.)
Physical examination
Hand-held Doppler device A hand-held Doppler ultrasound device may be used to detect fetal cardiac
motion in the late first trimester. Loss of a previously detected fetal cardiac activity on such a device should
raise suspicion for a missed abortion. However, because the failure to detect fetal cardiac activity with a hand-
held device may result merely from incorrect placement of the device, further evaluation with ultrasonography
is required. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Findings on physical
examination'.)
Pelvic examination A complete pelvic examination should be performed. The speculum examination is
used to confirm that the uterus is the source of bleeding (rather than a cervical or vaginal lesion) and to
assess the volume of bleeding. The most important component of the examination is to determine whether the
cervix is dilated and whether products of conception are visible at the cervix or in the vagina. These features
are used to classify the status of the spontaneous abortion, which impacts management. (See 'Post-diagnostic
classification' below.)
A bimanual pelvic examination is performed to determine uterine size; an abdominal examination may also be
useful when gestational age is greater than 12 weeks. In normal pregnancy, the size of the uterus should be
consistent with gestational age. The uterus may be enlarged due to multiple gestation or the presence of
uterine leiomyomas. A small for gestational age uterus raises suspicion of a spontaneous abortion. (See
"Clinical manifestations and diagnosis of early pregnancy", section on 'Findings on physical examination'.)
A purulent cervical discharge or uterine tenderness suggests a possible septic abortion, which also should be
suspected in women who appear ill or are febrile. (See 'Septic abortion' below.)
Pelvic ultrasound Pelvic ultrasonography is the most useful test in the diagnostic evaluation of women
with suspected spontaneous abortion [62]. The most important finding is fetal cardiac activity, which is typically
first detected at 5.5 to 6 weeks. Other important findings are the size and contour of the gestational sac, the
presence of a yolk sac, and the fetal heart rate. In general, these early pregnancy sonograms are performed
transvaginally, as the gestational sac and its contents are best evaluated in early gestation through a
transvaginal approach. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Ultrasound
examination'.)
Normal versus failed pregnancy The normal sequence of fetal development during very early
pregnancy is summarized below and discussed in detail separately. (See "Ultrasonography of pregnancy of
unknown location".)
Gestational sac During embryologic development, the gestational sac develops, followed by the yolk
sac, and then the embryo. The diagnostic criteria for a failed pregnancy are based upon the development
of a yolk sac or embryo once the gestational sac has reached a size threshold. This size threshold used
must have a high specificity, since a false positive diagnosis of spontaneous abortion may result in an
intervention that harms a normal pregnancy. Early studies found that the absence of a yolk sac in a
gestational sac >8 mm mean sac diameter (MSD) or the absence of an embryo in a gestational sac >16
mm suggested an abnormal pregnancy [63]. However, based upon data from a systematic review of eight
observational studies and a large prospective study, the minimum threshold (to achieve a specificity of 95
percent for the diagnosis of a failed pregnancy) is a gestational sac 25 mm MSD without a yolk sac or
embryo [64,65]. American College of Radiology (ACR) and United Kingdom Royal College of Obstetricians
and Gynaecologists (RCOG) guidelines use 25 mm gestational sac MSD as a criterion for the diagnosis
of a failed pregnancy in the absence of a yolk sac or embryo [66-68].
Fetal cardiac activity Fetal cardiac activity confirms a live pregnancy. The absence of cardiac activity
in an embryo of any crown rump length (CRL) raises suspicion of an abnormal pregnancy. In a systemic
review of eight observational studies, the minimum threshold to achieve a specificity of up to 100 percent
for the diagnosis of a failed pregnancy was an embryo with no cardiac activity and a CRL of >5 to 6 mm
[67]. However, for >6 mm, the lower limit of the confidence interval was a specificity of 87 percent, which
would result in a false positive rate that is clinically unacceptable. Based upon these data and the
presence of inter-operator variability in measurement, the ACR and the RCOG use 7 mm CRL as a
criterion for the diagnosis of a failed pregnancy [66-68].
The finding of fetal cardiac activity does not exclude the possibility of a subsequent miscarriage. When
fetal cardiac activity was detected at 5 to 6 weeks of gestation in women less than 36 years of age, the
risk of subsequent spontaneous abortion was 4.5 percent. However, the risk of miscarriage despite
previous detection of heart activity increased to 10 percent in women aged 36 to 39 years and 29 percent
in women age 40 years or older [61]. In women with recurrent pregnancy loss, the risk of spontaneous
pregnancy loss after observation of embryonic heart activity remains high, about 22 percent [69].
Growth rate Slow growth of an early pregnancy is concerning, but there are insufficient data to
establish a growth rate that is diagnostic of a failed pregnancy. Growth rates between healthy and
abnormal pregnancies overlap and inter-observer variability is also a factor [70].
Potential predictors of failed pregnancy The following ultrasound findings are predictive of
impending pregnancy loss. If any of these ominous findings are noted, a repeated ultrasound examination in
approximately one week is indicated. When more than one concerning finding is present, the risk of
subsequent abortion increases several-fold [71]:
Abnormal gestational sac A gestational sac that is abnormally small or large in relation to the embryo
within is associated with an increased risk of spontaneous abortion [72,73]. Small MSD is diagnosed when
the difference between the MSD and CRL is less than 5 mm (MSD - CRL <5). In one small series, 15 of
the 16 patients (94 percent) with normal embryonic heart rates and small sacs noted on first trimester
sonogram had a subsequent miscarriage, compared to only 4 of the 52 control patients (8 percent) having
a normal sac [72].
Other findings suggesting a poor pregnancy outcome include a gestational sac with an irregular contour, a
decidual reaction <2 mm in thickness, absence of the double decidual sac sign, decreased echodensity of
the choriodecidual reaction, and low sac position in the uterus [62].
Abnormal yolk sac An abnormal yolk sac may be large for gestational age, irregular, free floating in the
gestational sac rather than at the periphery, or calcified. In one study, a yolk sac diameter more than two
standard deviations of the mean for the menstrual age had a sensitivity, specificity, positive predictive
value, and negative predictive value for pregnancy loss of 65, 97, 71, and 95 percent, respectively [74].
Slow fetal heart rate Embryonic heart rate below 100 beats per minute (bpm) at 6 to 7 weeks of
gestation is slower than is observed in the large majority of normally progressing early pregnancies [75].
In one study, the first trimester survival rate was 62 percent among 531 embryos with slow early heart
rates (less than 100 bpm at less than 6.2 weeks or less than 120 bpm at 6.3 to 7.0 weeks), compared with
92 percent survival among 1501 embryos having a normal heart rate above those threshold values [75].
Higher rates of pregnancy loss are associated with lower embryonic heart rates; survival is zero at heart
rates below 70 bpm at 6 to 8 weeks of gestation [76]. Embryos having an abnormally slow heart rate
between 6 and 7 weeks of gestation that subsequently increases to a normal rate at 8 weeks of gestation
remain at increased risk for loss [76]. When a slow embryonic heart rate is observed, it is prudent to
perform a follow-up ultrasound examination (in seven days) to document unequivocal loss of cardiac
activity before proceeding to a diagnosis of failed pregnancy.
Subchorionic hematoma A subchorionic hemorrhage or hematoma is a risk factor for spontaneous

abortion (image 1 and image 2) [77], particularly when it amounts to 25 percent or more of the volume of the
gestational sac. A meta-analysis of seven comparative studies found that women having a subchorionic
hematoma had a significantly increased risk of spontaneous abortion, compared to women without such
findings (18 versus 9 percent; OR 2.18, 95% CI 1.293.68) [78]. The findings also are associated with an
increased risk of placental abruption (4 versus 1 percent; OR 5.71, 95% CI 3.918.33) and preterm premature
rupture of membranes (4 versus 2 percent; OR 1.64, 95% CI 1.222.21). The increased risks of preterm labor
and stillbirth appeared to be dependent upon the presence of vaginal bleeding.
Pregnancy outcome associated with subchorionic hematoma also relates to location, with worse outcomes
observed for retroplacental hematomas, compared to marginal hematomas. The location, rather than the size,
of a subchorionic hematoma may be the most important predictor of pregnancy outcome. Evidence relating to
the size of the hematoma and the risk of adverse outcomes is inconclusive [79].
The only management option for subchorionic hematoma is expectant. There is insufficient evidence regarding
whether bed rest decreases the risk of pregnancy loss when a subchorionic hematoma is present. Some
clinicians repeat an ultrasound in one to two weeks to confirm fetal viability and assess any change in size of
the hematoma, primarily to provide reassurance to the patient. A subchorionic hematoma is not an indication
to conduct a diagnostic evaluation for an acquired or inherited thrombophilia.
Laboratory evaluation
Human chorionic gonadotropin A serum human chorionic gonadotropin (hCG) should be drawn. A
single hCG concentration is not informative in the diagnosis of spontaneous abortion, but a baseline is useful if
the ultrasound findings are nondiagnostic or if ectopic pregnancy is suspected. In such cases, serial hCG
measurement may be necessary. (See 'Diagnosis' below and 'Differential diagnosis' below.)
In failed pregnancies, a decline in serum hCG is usually apparent based upon two measurements at least two
days apart. At a baseline serum hCG level of 500 IU/L, a drop in hCG of >21 percent is strongly predictive of
miscarriage [80]. At a baseline serum hCG of 5000 IU/L, a drop in hCG of >35 percent is strongly predictive of
miscarriage. Results from different laboratories may vary and should not be used to demonstrate a decrease.
In addition, in some cases, the hCG concentration may plateau.
Blood type and antibody screen A Rh(D) typing and antibody screen should be drawn if not
previously performed during the current pregnancy. Women with bleeding in pregnancy who are Rh(D)-
negative should be given anti-D immune globulin. (See "Prevention of Rhesus (D) alloimmunization in
pregnancy", section on 'Prophylaxis after antepartum events associated with placental trauma or disruption of
the fetomaternal interface'.)
Other testing A serum progesterone of <5 ng/mL is associated with a nonviable pregnancy. However, in
our practice, we do not routinely use this test to evaluate women with a suspected miscarriage.
A hematocrit should be drawn if significant blood loss is suspected. A white blood cell count should be drawn
only if septic abortion is suspected. (See 'Septic abortion' below.)
DIAGNOSIS The diagnosis of a spontaneous abortion is generally based upon pelvic ultrasound findings.
The diagnosis of spontaneous abortion should be made in a timely fashion, but caution should be exercised to
confirm that the diagnostic criteria are met to avoid terminating a healthy pregnancy [3]. Expectant
management for a short period of time to allow further assessment has few risks.
The criteria for spontaneous abortion on pelvic ultrasound are [66-68] (see 'Normal versus failed pregnancy'
above):
A gestational sac 25 mm in mean diameter that does not contain a yolk sac or embryo.
An embryo with a crown rump length (CRL) 7 mm that does not have cardiac activity.
If the gestational sac or embryo is smaller than these dimensions, pelvic ultrasound should be repeated in one
to two weeks.
For pregnancies that do not meet the size criteria above, in 2013, the Society of Radiologists in Ultrasound
(SRU) added criteria for the diagnosis of a failed pregnancy based upon lack of development over time [3].
The time intervals in these guidelines were based upon consensus opinion.
After a pelvic ultrasound showed a gestational sac without a yolk sac, absence of an embryo with a
heartbeat in 2 weeks.
After a pelvic ultrasound showed a gestational sac with a yolk sac, absence of an embryo with a heartbeat
in 11 days.
There is no standard period of follow-up of a pregnancy with a pelvic ultrasound finding of an embryo with a
CRL <7 mm and no heartbeat. In such cases, we repeat the ultrasound in one to two weeks. If there is no
heartbeat, we diagnose a spontaneous abortion.
It is important to exclude an ectopic pregnancy in women with a pregnancy of unknown location. (See
"Ultrasonography of pregnancy of unknown location" and "Ectopic pregnancy: Clinical manifestations and
diagnosis", section on 'Diagnostic evaluation'.)
The possibility of multiple gestation must always be considered because, in such cases, the serum hCG
concentrations can be misleading; levels may increase or decrease, depending upon viability of the other
fetuses.
In multiple gestations, loss of one or more fetuses may occur. If miscarriage is suspected, women with a
multiple gestation should be followed with serial ultrasound examinations until definitive criteria are met for
diagnosis of spontaneous abortion in at least one fetus. (See "Twin pregnancy: Prenatal issues", section on
'Risk of early, late, and postnatal loss'.)
DIFFERENTIAL DIAGNOSIS The classic symptoms of spontaneous abortion are vaginal bleeding and
pelvic pain.
The differential diagnosis of bleeding or pain early in pregnancy includes [66]:
Physiologic (ie, believed to be related to implantation)

Ectopic pregnancy
Gestational trophoblastic disease
Cervical, vaginal, or uterine pathology
Subchorionic hematoma
Non-uterine sources of bleeding can be identified by physical examination. Screening for cervical cancer
should also be performed, as appropriate (table 1). (See "Differential diagnosis of genital tract bleeding in
women" and "Screening for cervical cancer".)
Even if another source of bleeding is identified, all women with first trimester bleeding should be evaluated by
transvaginal ultrasonography. If an intrauterine pregnancy is not confirmed, the possibility of ectopic
pregnancy must be considered and the patient followed with serial ultrasound and serum human chorionic
gonadotropin (hCG). When the hCG concentration is unusually high for the gestational age, gestational
trophoblastic disease should be suspected. The evaluation of first trimester vaginal bleeding is outlined in the
algorithm (algorithm 1) and is discussed separately. (See "Overview of the etiology and evaluation of vaginal
bleeding in pregnant women" and "Ectopic pregnancy: Clinical manifestations and diagnosis" and "Hydatidiform
mole: Epidemiology, clinical features, and diagnosis".)
POST-DIAGNOSTIC CLASSIFICATION During the evaluation process and following the diagnosis of a
spontaneous abortion, the abortion is classified based upon the location of the products of conception and the
degree of cervical dilation, which is determined mainly by pelvic examination, although pelvic ultrasound often
helps to define the location of the products of conception. The categorization of an abortion impacts its clinical
management.
Threatened abortion Threatened abortion describes cases in which the diagnostic criteria for
spontaneous abortion have not been met, but vaginal bleeding has occurred and the cervical os is closed. The
exact etiology of bleeding often cannot be determined and is frequently attributed to marginal separation of the
placenta.
The term "threatened" abortion is appropriate because pregnancy loss does not always follow vaginal bleeding
in early pregnancy, even after repeated episodes or large amounts of bleeding. (See 'Vaginal bleeding'
above.)
First trimester bleeding may be associated with adverse outcomes later in pregnancy. A systematic review
found a modest association (odds ratio 2) between first trimester bleeding and various adverse outcomes
(eg, miscarriage, preterm birth, premature rupture of membranes, growth restriction, antepartum bleeding)
[81]. The prognosis is worse when the bleeding is heavy or extends into the second trimester [82-84]. As an
example, in one large prospective series, the frequency of preterm delivery with no, light, or heavy first
trimester bleeding was 6, 9.1 and 13.8 percent, respectively, and the frequency of spontaneous loss before 24
weeks of gestation was 0.4, 1.0, and 2.0 percent, respectively [82]. Of note, all of these pregnancies had
cardiac activity at the time of enrollment at 10 to 14 weeks of gestation. Because the subjects were enrolled
late in the first trimester and with sonographically confirmed fetal cardiac activity, women with very early
https://www.uptodate.com/contents/spontaneous-abortion-risk-factors-etiology-clinical-manifestations-and-diagnostic-evaluation/print?source=search_re 10/23
bleeding that went on to miscarry had already been excluded. These findings were further supported by a
subsequent population-based study involving almost 800,000 women, which also found that first trimester
bleeding in a woman's first pregnancy was associated with recurrent bleeding in a second pregnancy [85].
(See "Preterm birth: Risk factors and interventions for risk reduction", section on 'Vaginal bleeding in early
pregnancy'.)
Management of threatened abortion is discussed separately. (See "Spontaneous abortion: Management",

section on 'Threatened abortion'.)
Missed abortion The term missed abortion refers to a clinical abortion in which the products of conception
are not expelled spontaneously from the uterus (eg, the woman has a nonviable intrauterine pregnancy that
has not been passed and her cervical os is closed) [86]. Women may notice that symptoms associated with
early pregnancy (eg, nausea, breast tenderness) have abated and they do not "feel pregnant" any more.
Management of missed abortion is discussed separately. (See "Spontaneous abortion: Management", section
on 'Inevitable, incomplete, and missed abortion'.)
Empty sac A pregnancy with an empty gestational sac is a pregnancy in which embryonic development
arrested at a very early stage or failed altogether. This type of gestation has been referred to as an
anembryonic pregnancy or a blighted ovum, but these terms are not preferred and their use, particularly
blighted ovum, should be discouraged [87].
An empty sac pregnancy is defined sonographically as the presence of a gestational sac larger than 25 mm
without evidence of embryonic tissues (yolk sac or embryo) [64].
A high incidence of chromosomal abnormalities is found in empty sac pregnancies [88], which also may display
early hydatidiform degeneration of the chorionic villi. Although some experts have suggested that these
gestations are associated with molar pregnancy [89], empty sac pregnancies are of mixed maternal and
paternal genetic origin, whereas complete moles are of solely paternal origin [90].
An empty sac pregnancy may present as a missed, inevitable, incomplete, or complete abortion. Management
is based upon the clinical presentation.
Inevitable abortion The term inevitable abortion refers to cases in which the patient has vaginal bleeding,
typically accompanied by crampy pelvic pain, and the cervix is dilated. Products of conception can often be felt
or visualized through the internal cervical os.
Management of inevitable abortion is discussed separately. (See "Spontaneous abortion: Management",

section on 'Inevitable, incomplete, and missed abortion'.)
Incomplete and complete abortion Incomplete abortion refers to cases in which vaginal bleeding and/or
pain are present, the cervix is dilated, and products of conception are found within the cervical canal on
examination. Complete abortion refers to cases in which the products of conception are entirely out of the
uterus and cervix, and on examination the cervix is closed and the uterus is small and well contracted; vaginal
bleeding and pain may be mild or may have resolved.
When an abortion occurs before 12 weeks of gestation, it is common for the entire contents of the uterus to be
expelled, thereby resulting in a complete abortion. In such cases, the uterus is small and well contracted and
there is typically scant vaginal bleeding and only mild cramping.
After 12 weeks, the membranes often rupture and the fetus is passed, but significant amounts of placental
tissue may be retained, leading to an incomplete abortion, also called an abortion with retained products of
conception. In such cases, the uterine size is smaller than expected for gestational age, but not well
contracted. The amount of bleeding varies, but can be severe enough to cause hypovolemic shock. Painful
cramps/contractions are often present.
Pelvic ultrasound may be helpful to determine whether retained products of conception are present. The
evaluation and management of retained products of conception is discussed separately. (See "Retained
products of conception".)
Management of incomplete or complete abortion is discussed separately. (See "Spontaneous abortion:

Management", section on 'Inevitable, incomplete, and missed abortion' and "Spontaneous abortion:
Management", section on 'Complete abortion'.)
Septic abortion Septic abortion refers to a complicated form of spontaneous abortion accompanied by an
intrauterine infection. Septic abortion is uncommon in women with spontaneous abortion and is more frequently
associated with induced abortion. It is important to recognize the signs and symptoms of septic abortion,
because the condition can be severe and life-threatening.
Common clinical features of septic abortion include fever, chills, malaise, abdominal pain, vaginal bleeding,
and discharge, which is often sanguinopurulent. Physical examination may reveal tachycardia, tachypnea,
lower abdominal tenderness, and a boggy, tender uterus with dilated cervix.
Infection is usually due to Staphylococcus aureus, Gram negative bacilli, or some Gram positive cocci. Mixed
infections, anaerobic organisms, and fungi, can also be encountered. The infection may spread, leading to
salpingitis, generalized peritonitis, and septicemia.
Management of septic abortion is discussed separately. (See "Spontaneous abortion: Management", section
on 'Septic abortion'.)
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and
Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles
are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on patient info and the keyword(s) of interest.)
Basics topics (see "Patient education: Miscarriage (The Basics)" and "Patient education: Threatened
miscarriage (The Basics)")
Beyond the Basics topics (see "Patient education: Miscarriage (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
Spontaneous abortion, or miscarriage, is defined as a clinically recognized pregnancy loss before the 20th
week of gestation. Spontaneous abortion is the most common complication of early pregnancy, occurring
in 8 to 20 percent of clinically recognized pregnancies and a comparable number of preclinical
pregnancies. (See 'Introduction' above and 'Incidence' above.)
The best documented risk factors for spontaneous abortion are advanced maternal age, previous
spontaneous abortion, and maternal smoking. (See 'Risk factors' above.)
Most spontaneous abortions are due to structural or chromosomal abnormalities of the embryo. (See
'Etiology' above.)
Women with spontaneous abortion most commonly present with menstrual delay, vaginal bleeding, and
pelvic pain. (See 'Clinical presentation' above.)
The key elements of the evaluation of a woman with a suspected spontaneous abortion are the pelvic
examination and pelvic ultrasound. (See 'Diagnostic evaluation' above.)
The diagnosis of a spontaneous abortion is generally based upon pelvic ultrasound findings. The
sonographic criteria for spontaneous abortion are (see 'Diagnosis' above):
A gestational sac 25 mm in mean diameter that does not contain a yolk sac or embryo
An embryo with a crown rump length (CRL) 7 mm that does not have cardiac activity.
If the gestational sac or embryo is smaller than these dimensions, pelvic ultrasound should be repeated in
one to two weeks. The criteria for pregnancy failure in such cases may be based upon lack of
development over time (see 'Diagnosis' above):
Absence of an embryo with a heartbeat 2 weeks after a pelvic ultrasound showed a gestational sac
without a yolk sac.
Absence of an embryo with a heartbeat 11 days after a pelvic ultrasound showed a gestational sac
with a yolk sac.
Potential predictors of a failed pregnancy include: abnormal gestational sac, abnormal yolk sac, slow fetal
heart rate, and subchorionic hematoma. (See 'Potential predictors of failed pregnancy' above.)
The differential diagnosis of spontaneous abortion includes: uterine or other genital tract bleeding in a
viable pregnancy, ectopic pregnancy, and gestational trophoblastic disease. (See 'Differential diagnosis'
above.)
Spontaneous abortions are classified according to the location of the products of conception and whether
cervical dilation is present. Categories include: missed abortion, inevitable abortion, incomplete abortion,
and complete abortion. (See 'Post-diagnostic classification' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
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Topic 5439 Version 30.0
GRAPHICS
Distinction between subchorionic hematoma and unfused

amnion in patient with vaginal bleeding at 13 weeks'
gestational age
Transabdominal sagittal sonogram of uterus reveals subchorionic

hematoma (H) extending posteriorly around chorion (arrow s) and lifting
edge of anterior placenta (P). Appearance should not be confused w ith
that of unfused amnion. Amnion is the thin membrane continuous along
anterior placental edge, but limited by umbilical cord insertion;
subchorionic bleeding leads to edge of placenta.
Reproduced with permission from Trop, I, Levine, D. Hemorrage During

Pregnancy: Sonography and MR Imaging. AJR Am J Roentgenol 2001; 176:607.
Copyright 2001 American Roentgen Ray Society.
Graphic 76333 Version 2.0
Subchorionic bleeding in fetus at 5.5 weeks' gestational age
(A) Transverse transvaginal sonogram reveals intrauterine gestational sac w ith yolk
sac. Note small amount of blood (arrow ) adjacent to gestational sac. B, Transvaginal
sagittal sonogram obtained 2 w eeks after (A) because of vaginal bleeding show s
subchorionic hematoma (arrow ) w ith debris. Collection could be mistake for second
gestational sac w ith embryonic demise.
Reproduced with permission from Trop, I, Levine, D. Hemorrage During Pregnancy:

Sonography and MR Imaging. AJR Am J Roentgenol 2001; 176:607. Copyright 2001
American.
Causes of abnormal genital tract bleeding in women
Genital tract disorders Trauma

Uterus Sexual intercourse
Benign growths: Sexual abuse
Endo m e tria l po lyps Foreign bodies (including intrauterine device)

Endo m e tria l hype rpla sia
Pelvic trauma (eg, motor vehicle accident)
Ade no m yo sis
Straddle injuries
Le io m yo m a s (fibro ids)
C ancer: Drugs
Endo m e tria l a de no ca rcino m a C ontraception:
Sa rco m a Ho rm o na l co ntra ce ptive s
Infection: Intra ute rine de vice s
P e lvic infla m m a to ry dise a se Postmenopausal hormone therapy

Endo m e tritis Anticoagulants
Ovulatory dysfunction Tamoxifen
Cervix C orticosteroids
Benign growths: C hemotherapy
C e rvica l po lyps
Phenytoin
Ectro pio n
Antipsychotic drugs
Endo m e trio sis
Antibiotics (eg, due to toxic epidermal necrolysis
C ancer:
or Stevens-Johnson syndrome)
Inva sive ca rcino m a
Me ta sta tic (ute rus, cho rio ca rcino m a ) Systemic disease
Infection: Diseases involving the vulva:
C e rvicitis C ro hn's dise a se
Vulva Be hce t's syndro m e

P e m phigo id
Benign growths:
P e m phigus
Sk in ta gs
Ero sive liche n pla nus
Se ba ce o us cysts
Lym pho m a
C o ndylo m a ta
Bleeding disorders:
Angio k e ra ta o m a
vo n W ille bra nd dise a se
C ancer
T hro m bo cyto pe nia o r pla te le t dysfunctio n
Vagina
Acute le uk e m ia
Benign growths: So m e co a gula tio n fa cto r de ficie ncie s
Ga rtne r duct cysts Adva nce d live r dise a se
P o lyps Thyroid disease
Ade no sis (a be rra nt gla ndula r tissue )
Polycystic ovary syndrome
C ancer
C hronic liver disease
Vaginitis/infection:
C ushing's syndrome
Ba cte ria l va gino sis
Hormone-secreting adrenal and ovarian tumors
Se x ua lly tra nsm itte d infe ctio ns
Atro phic va ginitis
Renal disease
Upper genital tract disease Emotional or physical stress
Pelvic inflammatory disease Smoking
Fallopian tube cancer Excessive exercise
Ovarian cancer Diseases not affecting the genital tract
Pregnancy complications Urethritis
Bladder cancer
Urinary tract infection
Inflammatory bowel disease
Hemorrhoids
Other
Endometriosis
Vascular tumors and anomalies in the genital tract,

including enhanced myometrial vascularity (also
known as uterine arterial venous malformation)
Algorithm for the evaluation of first-trimester uterine bleeding
* This step may be omitted in women who are known to have an intrauterine pregnancy.
Proceed directly to ultrasound examination.
Contributor Disclosures
Togas Tulandi, MD, MHCM Consultant/Advisory Boards: Genzyme [Adhesions (Bioresorbable barrier
membranes)]. Haya M Al-Fozan, MD Nothing to disclose Deborah Levine, MD Nothing to disclose Robert
L Barbieri, MD Nothing to disclose Kristen Eckler, MD, FACOG Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
Conflict of interest policy

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25/7/2017 Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation - UpToDate

Official reprint from UpToDate

Authors: Togas Tulandi, MD, MHCM, Haya M Al-Fozan, MD

INTRODUCTION Spontaneous abortion, or miscarriage, is defined as a clinically recognized pregnancy loss

Intrauterine pregnancy of uncertain viability Transvaginal ultrasonography shows an intrauterine

Loss of unrecognized or subclinical pregnancies is even higher, occurring in 13 to 26 percent of all

Previous spontaneous abortion Past obstetrical history is an important predictor of subsequent

Chromosomal abnormalities Chromosomal abnormalities account for approximately 50 percent of all

Congenital anomalies Congenital anomalies may be caused by chromosomal or other genetic

Unexplained The cause of abortions of chromosomally and structurally normal embryos/fetuses in

Subchorionic hematoma A subchorionic hemorrhage or hematoma is a risk factor for spontaneous

The differential diagnosis of bleeding or pain early in pregnancy includes [66]:

Physiologic (ie, believed to be related to implantation)

Management of threatened abortion is discussed separately. (See "Spontaneous abortion: Management",

Management of inevitable abortion is discussed separately. (See "Spontaneous abortion: Management",

Management of incomplete or complete abortion is discussed separately. (See "Spontaneous abortion:

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 5439 Version 30.0

Distinction between subchorionic hematoma and unfused

Transabdominal sagittal sonogram of uterus reveals subchorionic

Reproduced with permission from Trop, I, Levine, D. Hemorrage During

Graphic 76333 Version 2.0

Subchorionic bleeding in fetus at 5.5 weeks' gestational age

Reproduced with permission from Trop, I, Levine, D. Hemorrage During Pregnancy:

Graphic 64570 Version 2.0

Causes of abnormal genital tract bleeding in women

Genital tract disorders Trauma

Benign growths: Sexual abuse

Endo m e tria l po lyps Foreign bodies (including intrauterine device)

Infection: Intra ute rine de vice s

P e lvic infla m m a to ry dise a se Postmenopausal hormone therapy

C e rvicitis C ro hn's dise a se

Vulva Be hce t's syndro m e

Upper genital tract disease Emotional or physical stress

Pelvic inflammatory disease Smoking

Fallopian tube cancer Excessive exercise

Ovarian cancer Diseases not affecting the genital tract

Pregnancy complications Urethritis

Inflammatory bowel disease

Vascular tumors and anomalies in the genital tract,

Graphic 74527 Version 9.0

Algorithm for the evaluation of first-trimester uterine bleeding

Graphic 68130 Version 4.0

Conflict of interest policy

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