Miscarriage and Abortion

Early Pregnancy Loss (Miscarriage)

Miscarriage is the spontaneous loss of the conceptus before 20 weeks’ gestation.

• Early miscarriages (before 10 weeks) are usually due to chromosomal aneuploidy. Early miscarriage occurs in at least 10% of all clinically recognized pregnancies but likely is even more prevalent.

• Poorly controlled diabetes and thyroid disease in early pregnancy are associated with increased risk of miscarriage.

• Observational data suggest (but are inconclusive) that miscarriage may also be associated with obesity, smoking, alcohol use, and moderate-to-heavy caffeine use.

• Women with a single miscarriage typically do not require a workup and should be reassured that miscarriage is common.

• Recurrent miscarriage is defined as the loss of three or more consecutive pregnancies.

  • Causes of recurrent miscarriage include antiphospholipid antibody syndrome, uterine anomalies (bicornuate or unicornuate uterus), and genetic abnormalities.

• Miscarriages can be managed with expectant care and close follow-up, medical treatment (combined mifepristone and misoprostol therapy), or surgical evaluation with no difference in subsequent fertility between the three approaches.

The following table summarizes evidence on recurrent miscarriage investigations:

(Source: Recurrent Miscarriage: Evidence to Accelerate Action. Lancet 2021.)

Abortion

An estimated one in four women in the United States terminate a pregnancy by the time they go through menopause. This rate has been decreasing since 2008 as more couples use highly effective contraceptives.

• Safety: Some women worry about whether abortion is safe or will cause any risks to their own health. According to national data from the Centers for Disease Control and Prevention (CDC), the risks associated with pregnancy and childbirth are higher than with abortion.

  • In a recent study of 1132 women seeking abortion, 162 of whom went on to give birth, health outcomes were no worse for women who underwent abortion than for those who went on to give birth. In fact, women who did not receive a requested abortion reported worse self-reported outcomes than those giving birth after seeking abortion.

  • Abortion does not affect a women’s future risk of breast cancer, mental health problems, or infertility.

  • Placement of an intrauterine device or subdermal contraceptive at the time of abortion is safe and highly effective in preventing future undesired pregnancy.

• Access: Patients’ access to abortion medications and procedures varies widely by geographical region.

  • The June 2022 Supreme Court decision in Dobbs v. Jackson Women’s Health overturned Roe v. Wade and Planned Parenthood v. Casey, thereby eliminating the federal right to abortion and returning the decision regarding abortion access to individual states.

  • As a result, a growing number of patients seek care via telehealth (e.g., Plan C) and to self-manage their abortion with pills purchased online.

Medication Abortion

Mifepristone (200 mg taken orally) can terminate a pregnancy up to 11 weeks’ gestation when used in combination with misoprostol (800 μg, usually absorbed buccally).

• Seventy-five percent of women in the United States who seek termination services do so before 10 weeks’ gestation.

• Health care providers, including primary care physicians (and in some states, advanced practice clinicians), can provide mifepristone once they have arranged to dispense the medication from their clinic. Brief video clips demonstrating the simple counseling involved in providing these medications are available online.

Abortion Procedures

• Uterine vacuum aspiration (previously called dilation and curettage or D&C) can be performed before 14 weeks’ gestation and is a one-day procedure.

• Dilation and evacuation (D&E), for terminations after 14 weeks, requires a clinic visit for placement of cervical dilators prior to the day of procedure.