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Late Miscarriage: Causes, Definitions, and Treatments

Late miscarriage, also known as late pregnancy loss, refers to the unexpected loss of a pregnancy after 14 weeks gestation but before 24 weeks gestation.

Late miscarriage is much less common than early pregnancy loss but can be deeply traumatic for expecting parents. This article will provide an extensive overview of late miscarriage, including definitions, statistics, potential causes, risk factors, symptoms, diagnosis, treatment, and coping emotionally after a loss.

Definition and Types of Late Miscarriage

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The medical terminology associated with different types of pregnancy loss can be confusing. Here are some key definitions:

  • Miscarriage: Spontaneous loss of a pregnancy before 20 weeks gestation. This includes early miscarriage (before 12 weeks) and late miscarriage (after 12 weeks and before 20 weeks).
  • Stillbirth: Fetal death that occurs after 20 weeks gestation.
  • Late miscarriage specifically refers to pregnancy losses between 14-24 weeks gestation. The risks and causes of late miscarriage have some key differences from early miscarriage.
  • Recurrent pregnancy loss (RPL): Defined as 2 or more consecutive miscarriages. RPL occurs in about 1-2% of couples.
  • Missed abortion: A nonviable pregnancy with no fetal cardiac activity detected on ultrasound but no passage of pregnancy tissue. A D&C is often needed.
  • Inevitable abortion: When bleeding and cervical dilation indicate that passage of pregnancy tissue is imminent.
  • Incomplete abortion: Miscarriage characterized by partial passage of pregnancy tissue, often with ongoing bleeding. Additional treatment is required.
  • Complete abortion: Complete passage of pregnancy tissue has occurred.
  • Septic abortion: Miscarriage complicated by infection of the uterine lining and tissue. Requires prompt treatment.

The medical community does not consider pregnancy loss before 20 weeks to be a “stillbirth”, even though grieving parents often use that term. The delineation relates more to issues like required reporting and funeral arrangements.

Statistics on Late Miscarriage

  • Late miscarriage occurs in approximately 1-2% of recognized pregnancies.
  • About 80% of all miscarriages happen in the first trimester before 12 weeks. Late miscarriage in the 2nd trimester is less common.
  • After detection of fetal cardiac activity on ultrasound at 6-7 weeks, the risk of miscarriage drops to about 4%.
  • The risk declines as pregnancy progresses: 10-15% from 6-7 weeks, 4-5% from 8-11 weeks, 1-3% from 12-15 weeks, and just over 1% from 16-24 weeks.
  • At 14 weeks, the risk of miscarriage drops to just over 1%.
  • Late pregnancy loss at 16 weeks or later occurs about 0.4-0.6% of the time.
  • The risk of miscarriage after confirmation of a living fetus in the 2nd trimester is about 1 in 200.
  • Up to 50% of all late miscarriages involve chromosomal or genetic factors.
  • Late miscarriage involving a chromosomally normal fetus occurs in just under 1% of women.

For couples who experience a late pregnancy loss, the precise statistics offer little comfort. However, they do indicate the relative rarity of losing a pregnancy in the 2nd trimester once a normal ultrasound is documented.

Related Post: How Menopause Symptoms Differ Between Women in India

Possible Causes and Risk Factors for Late Miscarriage

late miscarriage causes
Source: flo.health

Unfortunately, the cause of late miscarriage cannot be identified in around 50% of cases, even after complete evaluation. Some potential causes include:

Fetal chromosomal abnormalities

  • As pregnancy progresses, the chances of chromosomal issues leading to miscarriage rise.
  • At least 50% of 2nd-trimester losses involve abnormal fetal chromosomes.

-Trisomy conditions like Down syndrome, Edwards syndrome and Patau syndrome often lead to late miscarriage when present.

  • Unbalanced chromosomal arrangements, deletions or duplications can also lead to pregnancy loss.
  • Testing fetal tissue is important to detect or confirm genetic issues after a late loss.

Anatomic or structural issues

  • Major fetal anatomical abnormalities found on ultrasound that are incompatible with life can lead to 2nd-trimester loss.
  • These include neural tube defects, heart malformations, body wall defects, limb abnormalities, genetic disorders, etc.
  • If severe issues are found, patients may have the choice to terminate the pregnancy or let the process occur naturally.

Maternal health conditions

  • Poorly controlled diabetes increases the risk of late pregnancy loss and stillbirth.
  • Thyroid disorders like hypothyroidism or hyperthyroidism can interfere with placental function.
  • High blood pressure including chronic hypertension, preeclampsia and HELLP syndrome may impact placental abruption.
  • Kidney disease and systemic lupus erythematosus (SLE).
  • Severe maternal obesity and being underweight also raise risks.
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Uterine abnormalities

  • Congenital uterine abnormalities like a bicornuate uterus or septum.
  • Fibroid tumours inside the uterine wall or near the cervix.
  • Adenomyosis or abnormal ingrowth of the uterine lining into the uterine muscle.

Cervical insufficiency

  • Painless opening of the cervix and premature dilation before term.
  • Often happens in the 2nd trimester when the weight of the growing baby puts pressure on the cervix.

Placental problems

  • Issues with placental attachment and blood flow to the placenta.
  • Placental abruption – premature separation of the placenta from the uterine wall.

Amniotic fluid issues

  • Premature preterm rupture of membranes (PPROM) – early breaking of the water before 37 weeks.
  • Oligohydramnios: Low amniotic fluid volume in the uterus.
  • Polyhydramnios: Excess amniotic fluid volume.
  • Amniotic band constrictions on fetal limbs.

Infections

  • Certain maternal infections like syphilis, listeria, herpes and malaria.
  • Intra-amniotic infections, which cause chorioamnionitis inflammation.

Blood clotting problems

  • Antiphospholipid antibody syndrome (APS), which causes increased blood clotting.
  • Lupus anticoagulant and certain inherited thrombophilias like Factor V Leiden.

Autoimmune issues

  • Antibodies against fetal cells or pregnancy hormones.

Environmental factors

  • Smoking, alcohol use, drug use
  • Secondhand smoke
  • Toxin exposure
  • Chronic emotional stress
  • Extreme changes in environmental temperature

Traumatic causes

  • Motor vehicle accidents
  • Physical trauma to the abdomen
  • Domestic violence and physical abuse

Uterine trauma

  • Injury to the cervix or uterus during procedures like CVS (chorionic villus sampling), amniocentesis, fetal surgery, and cerclage placement.

Unknown causes

  • Despite a thorough evaluation, no cause can be found in 50% of late pregnancy losses.
  • The pregnancy and fetal development may have proceeded normally with a sudden unexplained fetal demise.

Risk Factors for Late Miscarriage

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Some key risk factors that may increase the chances of late pregnancy loss include:

  • Advanced maternal age – The risk of miscarriage rises with increasing age, especially over age 35. Older women have higher rates of abnormal embryos and decreased vascularization of the placenta. The father’s older age also contributes to the risk.
  • Previous miscarriage – After one miscarriage, the risk of another is about 15%. After two consecutive losses, the risk of recurrence is about 25%.
  • Uterine abnormalities like fibroid tumours, polyps, or septum.
  • Cervical insufficiency or weakness of the cervix.
  • Thyroid disorders like hypothyroidism or hyperthyroidism
  • Uncontrolled diabetes
  • Obesity – having a BMI over 30 increases risk.
  • Autoimmune disorders like lupus or antiphospholipid syndrome.
  • Kidney disease
  • Infections – bacterial vaginosis, listeriosis, toxoplasmosis, rubella.
  • Smoking, alcohol or drug use.
  • Genetic issues – parents are carriers for genetic conditions inherited thrombophilias.
  • Birth defects in previous pregnancies
  • Multiple gestation – risk is higher with twins or triplets.
  • Conception with IVF – slightly higher risk than natural conception.
  • Previous cesarean scar– on the uterus – risk of scar rupture.
  • Environmental toxin exposure
  • Severe emotional stress.
  • Trauma or injury to the abdomen.
  • Heavy physical exertion and lifting.
  • Recreational sex and orgasm have NOT been shown to increase miscarriage risk.

Many risk factors are not able to be modified, so it’s important not to blame yourself if a late loss occurs. Focusing on the factors you can control, like diet, prenatal care and avoiding smoking/drinking, provides the best benefits. Let your doctor know of any key risk factors.

Signs and Symptoms of Late Miscarriage

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Symptoms of a late miscarriage often mimic those of early pregnancy loss but are often more severe. They include:

  • Vaginal bleeding – from light spotting to heavy bleeding. Dark brown blood or bright red blood.
  • Abdominal cramping – the sensation of pelvic pressure and pain from cervix dilation and uterine contractions.
  • Loss of pregnancy symptoms – nausea, fatigue, and breast soreness improve.
  • Contractions – painful tightening sensation of the uterus occurring regularly.
  • Tissue passing – grey, brown or pink tissue passing from the vagina. It may contain clots.
  • Sharp back pain
  • Chills, fever, foul-smelling discharge – Signs of infection.
  • Decrease in fetal movement – Lack of expected movement.
  • Watery vaginal discharge – rupture of amniotic sac, PPROM.
  • No heartbeat found on prenatal checkup ultrasound.

Seek prompt medical care if you have heavy bleeding, fever, chills, foul-smelling discharge, or no fetal movement. Call your doctor or go to urgent care or the ER. Bleeding in pregnancy should never be ignored.

With a “missed abortion”, where the fetus has died but no tissue has passed, bleeding and cramping may eventually occur, but sometimes medical assistance is needed. Your doctor will conduct an ultrasound to check for heart activity if loss is suspected.

Diagnosis of Late Miscarriage

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To diagnose a late miscarriage, the Kapeefit doctor will check for:

  • Absent fetal heart tones on Doppler ultrasound. A transvaginal ultrasound may be done for optimal visualization if a heartbeat cannot be found through the abdomen.
  • No fetal movement felt by the mother or seen on ultrasound.
  • No fetal cardiac activity on ultrasound.
  • Physical exam showing cervical dilation and effacement.
  • Uterine contractions, evidence of labor.
  • Bleeding and cramping symptoms.
  • Tissue passing from the vagina, which will be sent for analysis.
  • Low hCG levels compared to gestational age norms on blood tests. Levels plateau or fall in miscarriage.
  • Progesterone withdrawal – dropping estradiol and progesterone levels.

A pelvic exam will NOT typically be done if miscarriage is already suspected by ultrasound. This avoids any unnecessary trauma to the cervix. Bloodwork, ultrasound and physical exam provide sufficient evidence.

If fetal demise is confirmed, the following steps are taken:

Fetal chromosomal analysis

  • Karyotype testing of fetal tissue analyzes fetal chromosomes.
  • This detects or confirms genetic abnormalities as the cause of over 50% of late losses.
  • Can provide closure about why the miscarriage occurred and inform recurrence risks.

Autopsy

  • Fetal autopsy can identify anatomical causes like congenital disabilities. This requires specialized fetal pathologists. Blood samples may also be analyzed.

Placental examination

  • The placenta is sent to pathology to identify potential abnormal features like infections, blood clotting, or adhesions that may have caused problems.
  • Placental culture swabs check for bacteria like Group B strep.

Rh testing

  • Mothers are tested for Rh-negative blood type to determine if a Rhogam shot is needed to prevent complications in future pregnancies.

Infection screening

  • Bloodwork to check for infections like syphilis, which may have led to the loss.

Imaging

Anatomic problems are further evaluated by MRI, CT scan or hysterosalpingogram if suspected. But this is uncommon without known uterine issues or recurrent losses.

Treatments for Late Miscarriage

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Source: bmj.com

The available treatments for late miscarriage depend on whether the process completes spontaneously versus requiring intervention.

Expectant management

If there are no urgent issues like heavy bleeding or infection, allowing miscarriage to progress naturally is often the first option. This avoids the risks of anaesthesia and instrumentation.

  • Close fetal monitoring until completed
  • Pain medication prescription
  • Instructions to collect tissue for analysis
  • Follow-up care to verify the completion
  • Possible medication use to hasten completion
  • Intervention if bleeding is excessive or the process stalls

Medications

  • Misoprostol – prostaglandin tablets inserted vaginally to induce uterine contractions to expel pregnancy tissue and often used with expectant management or before D&C.
  • IV or intramuscular oxytocin may be given for induction.
  • Antibiotics are used with infectious complications.

Uterine evacuation

  • Dilation and curettage (D&C) – surgical scraping of the uterine lining performed under anaesthesia. Often completed as same-day outpatient surgery and used when prompt emptying of the uterus is needed for bleeding or other risks.
  • Vacuum aspiration – uses manual suction to remove contents of the uterus. Similar to D&C.

Fetal reduction

  • For multiple gestations, selective termination of the nonviable fetus may be done while allowing the remaining fetus(es) to continue to develop. She was performed by injection of potassium chloride to stop the fetal heart.
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Blood transfusion

They are needed in some cases of severe maternal blood loss. IV fluids and iron supplements are commonly prescribed.

  • D&C risks: infection, perforation, scarring with Asherman’sAsherman’s syndrome.
  • Risk of adverse effects on the emotional grieving process – Some research shows higher depression and anxiety after surgical management versus natural completion. But, the choice depends on the medical need to avoid excessive bleeding.

Aftercare

  • Pelvic rest – Avoid intercourse for 2-6 weeks after loss to prevent infection.
  • Follow up with the care team – Monitor for complications like infection or retained tissue. Repeat ultrasound confirms uterine emptiness. Repeat D&C may be needed in some cases.
  • Emotional support – Loss counselling, support groups, therapy referrals.
  • RPL testing if multiple losses. – Bloodwork, uterine exam, and sometimes IVF techniques are used for detailed genetic embryo analysis.
  • Prenatal counselling before future pregnancies – Review risk factors, monitoring plan and prevention options.

Emotional Aspects and Coping after a Late Miscarriage

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Coping after late pregnancy loss brings intense and often unfamiliar grief compared to an early miscarriage. Expect a wide range of emotions:

Common feelings include:

  • Extreme sadness, frequent crying
  • Shock, disbelief, numbness over the loss
  • Guilt – “Did I cause this?” “Could I have prevented it?”
  • Depression, isolation, loneliness
  • Jealousy of other pregnant women or babies
  • Hopelessness about having a healthy pregnancy again
  • Fear and anxiety about the future
  • Anger at healthcare providers, family, infertility, the situation
  • Emptiness – from lost hopes and dreams for your baby’sbaby’s future
  • Relief – may be felt if pregnancy complications are present

Helpful Coping Tips:

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  • Allow yourself to fully grieve – Cry, journal, talk to trusted loved ones, attend support groups. Avoid suppressing feelings.
  • Don’t blame yourself – Nothing you did or didn’t do caused this.
  • Commemorate your baby – Hold a memorial service, write a letter, create artwork.
  • Seek counselling for help processing grief.
  • Be patient with relationships – Grief can strain your closest bonds. Seek support but allow needed space.
  • Take things day by day – It is completely normal to vacillate between sadness, numbness, and anger.
  • Look to your faith for comfort if applicable.
  • Consider joining a pregnancy loss organization for community and connection.
  • If needed, take a break from social media if constant pregnancy/baby posts feel painful.
  • For couples – Communicate openly and check in on each other’s grief. Seek counselling together if needed. Physical intimacy may need to wait until you both are ready.
  • Try not to make major decisions right away while actively grieving.
  • Focus on self-care – Get lots of rest, maintain healthy nutrition, utilize coping techniques like massage, therapy, exercise, and hobbies. Let others provide meals childcare help as needed.

The grief of late pregnancy loss brings with it much heartache but also often grows into a deep resilience and strength. Support and time help make the burden lighter.

The care team remains dedicated to helping you recover physically and emotionally. While the emptiness may always remain, joy and light can gradually return. Never hesitate to ask for help – you do not have to walk this road alone.

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