Prognosis
Short term
After the 12th week of pregnancy, up to 90% of pregnancies in which vaginal bleeding occurred in the first trimester will be carried to term. It is, however, important to arrange specific surveillance for the rest of the pregnancy, as women with first-trimester bleeding in the first pregnancy have an increased risk of complications later in the pregnancy (placental abruption, very preterm delivery [28 to 31 weeks], preterm delivery [32 to 36 weeks]) and of recurrent first-trimester bleeding and similar complications in the subsequent pregnancy.[129] One systematic review of 14 published studies found increased rates of antepartum haemorrhage of undetermined origin (odds ratio [OR] 2.47), perinatal mortality (OR 2.15), preterm delivery (OR 2.05), and low-birth-weight babies (OR 1.83) in women with threatened miscarriage in the first trimester.[88]
If the uterus needs to be evacuated, nearly 97% of women will resume menstruation within 6 weeks. Amenorrhoea following uterine evacuation for miscarriage is rare. The majority of surgical specimens sent for histological confirmation of pregnancy are normal and it is probably not cost effective to examine every miscarriage specimen histologically. Practitioners should always consider sending tissue obtained for histological examination to confirm pregnancy and to exclude differentials.[130] Persistence of vaginal bleeding or spotting should raise the possibility of gestational trophoblastic disease, particularly if a histological examination of expelled or evacuated early pregnancy tissue is not routinely undertaken.
Follow-up and counselling should be part of the overall management plan.[131][132] The patient’s physician should be promptly informed of the loss of the pregnancy, to avoid upsetting enquiries about a presumed on-going pregnancy. The patient's partner may also be emotionally affected by the event.[133][134] Loss of an early pregnancy can affect couples as significantly as a neonatal death. The patient may experience guilt in addition to her grief.
Long term
Psychological upset after a miscarriage event is not uncommon, but the severity varies.[135] The role of the patient's premorbid personality may be critical. The anniversary syndrome may also follow early pregnancy loss, wherein the patient may be upset, sad, or in a mood of grief of variable intensity, on the anniversary of the pregnancy loss. Women who are more distressed following the pregnancy loss can have continued psychological morbidity up to one year after the event.[136] This finding may be culture-specific.
Persistent reduced menstrual bleeding should raise the possibility of Asherman's syndrome, but other causes of reduced menstrual bleeding must be excluded. Asherman's syndrome is a rare consequence of presumed 'overzealous' use of the curette as a uterine evacuation tool for induced abortion, incomplete miscarriage, or retained early pregnancy tissue after childbirth. It is not clear if it is less likely after use of a plastic, suction-dominant tool for the same procedure. Patients typically complain of a relative reduction in menstrual blood loss volume or sub-fertility. Hysteroscopy and/or hysterography usually show 'synechiae'.[137]
Studies of reproductive performance after a complete spontaneous miscarriage are variable depending on the trimester at which the event occurred or identification of a cause. Self-reported pregnancy and live-birth rates, 5 years after the index management of miscarriage in 762 women, were found to be comparable between women who chose expectant, medical, or surgical methods. A history of past miscarriage and increasing maternal age were subsequent adverse prognostic factors.[100]
Recurrent miscarriage of pregnancies with the same partner affects 1% to 2% of otherwise healthy women. These patients will require a complete assessment to identify the cause.
A woman who has experienced multiple miscarriages and a GP summarise the importance of open discussions between women affected by miscarriage and their healthcare professionals.
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