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Early pregnancy loss and recurrent miscarriage
Most first-trimester miscarriages come from a chromosomal abnormality in the embryo and are not in the woman's control; the diagnosis rests on strict ultrasound criteria, and treatment — waiting, drugs or aspiration — is chosen by stability and the woman's wishes.
Why it matters in the exam
Questions require separating the types of miscarriage by the state of the cervix and the uterine contents: threatened miscarriage (closed cervix, live embryo), inevitable miscarriage (open cervix), incomplete miscarriage (open cervix and retained tissue), complete miscarriage (closed cervix and empty uterus) and missed miscarriage (embryo without heartbeat with a closed cervix). Know the criteria for a definite non-viable pregnancy so that a live pregnancy is never evacuated: an embryo of 7 mm or more without a heartbeat, or a gestational sac whose average diameter reaches 25 mm or more without any embryo inside.
On the treatment side, the current recommendation for medical management of missed miscarriage is mifepristone followed by misoprostol, a combination more effective than misoprostol alone. An unstable woman, with heavy bleeding or signs of infection, is treated with immediate aspiration and antibiotics. A separate theme is recurrent miscarriage (2 or 3 losses by definition): antiphospholipid syndrome, the uterine structure (septum), thyroid function and the karyotype of both partners are investigated. Antiphospholipid syndrome is treated with low-dose aspirin and prophylactic heparin. A nearly painless second-trimester loss with a dilating cervix points to cervical insufficiency.
Key points
- The type of miscarriage is set by the cervix (open or closed) and the uterine contents.
- Definite missed miscarriage: embryo 7 mm without heartbeat or sac 25 mm without embryo.
- Medical treatment: mifepristone followed by misoprostol.
- Unstable or infected → immediate aspiration.
- Recurrent miscarriage: APS, uterus, thyroid, karyotype; APS → aspirin and heparin.
Summary table
| Type | Cervix | Ultrasound | Management |
|---|---|---|---|
| Threatened miscarriage | Closed | Live embryo | Surveillance; no treatment is proven to prevent loss |
| Inevitable or incomplete miscarriage | Open | Pregnancy tissue in the uterus or canal | Expectant, misoprostol or aspiration |
| Complete miscarriage | Closed | Empty uterus after a documented intrauterine pregnancy | Surveillance; if no intrauterine pregnancy was documented — exclude ectopic |
| Missed miscarriage | Closed | Embryo 7 mm or more without heartbeat, or sac 25 mm or more without embryo | Mifepristone 200 mg and after 24 hours misoprostol 800 µg, or aspiration |
| Septic miscarriage | Open, purulent discharge | Retained tissue | Broad antibiotics and immediate aspiration |
| Recurrent miscarriage | — | Uterine septum, fibroids | Antiphospholipid antibodies, TSH, karyotype of both partners; in APS aspirin and heparin |
A free exam question
( מהם הנוגדנים העצמיים Autoantibody) השכיחים ביותר בנשים עם אנדומטריוזיס? (the question as examined, in Hebrew)
- א. Anti Thyroglobulin and Anti Peroxidase
- ב. AntiTNF and Anti VEGF
- ג. Antitransferrin and Anti laminin-1
- ד. Anti COX 2
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Sources
- ACOG Practice Bulletin No. 200, 2018, updated 2019 — Early Pregnancy Loss
- Society of Radiologists in Ultrasound consensus (Doubilet et al., NEJM), 2013 — Diagnostic criteria for nonviable pregnancy early in the first trimester
- ESHRE guideline, 2022 — Recurrent pregnancy loss
- Williams Obstetrics, 26th edition (2022) — Abortion
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.