19.14 Pregnancy Loss and Fetal Demise

Any pregnancy loss that occurs before 20 weeks’ gestation is referred to as an abortion. There are several types of abortion^[1]:

• An elective abortion, also known as induced abortion, refers to a deliberate decision to terminate a pregnancy for a variety of personal or medical reasons.
• A spontaneous abortion, commonly known as miscarriage, refers to the natural loss of a pregnancy before the 20th week of gestation for a variety of reasons. Most spontaneous abortions are caused by chromosomal abnormalities. The term early pregnancy loss refers to an empty gestational sac or absent fetal heart rate before 13 weeks of pregnancy. Examples of early pregnancy loss include blighted ovum, molar pregnancy, and ectopic pregnancy. A blighted ovum is the development of a gestational sac in the uterus without an embryo. A molar pregnancy occurs when abnormal cells grow in the uterus instead of a healthy fetus. An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the Fallopian tube.
• A threatened abortion refers to vaginal bleeding that occurs during the first trimester of pregnancy, but the cervix is closed and there is no tissue passage. The pregnancy may still continue without any issues, or it may progress to a miscarriage. Signs and symptoms include vaginal bleeding, abdominal cramping, and back pain. While vaginal bleeding during the first trimester occurs in approximately 25 percent of pregnancies, only about half of those clients experience a spontaneous abortion. However, this incidence increases to approximately 80 percent if cramping coincides with bleeding.^[2]
• Inevitable abortion, also called imminent miscarriage, refers to vaginal bleeding associated with cervical dilation, indicating a spontaneous abortion is likely to occur.
• In a complete abortion, all of the pregnancy tissue is expelled from the uterus after a spontaneous abortion. The cervix closes, and bleeding and cramping subside. Because the uterus is empty, no additional intervention is indicated. Medical or surgical interventions may be required if only part of the pregnancy tissue is expelled during a spontaneous abortion, referred to as an incomplete abortion. Symptoms of an incomplete abortion include persistent bleeding, cramping, or abdominal pain with increased risk of infection. Medical interventions may include administration of misoprostol, a synthetic prostaglandin that stimulates uterine contractions to expel the uterine tissue. A surgical procedure called cervical dilation and curettage (D&C) may be performed to remove the contents of the uterus by dilating the cervix and using surgical instruments to evacuate the uterine tissue and lining.
• A missed miscarriage, also known as a silent miscarriage, refers to the absence of fetal heartbeat or fetal growth detected on ultrasound, but the pregnant woman’s body does not naturally expel the pregnancy tissue. This condition may be discovered during a routine prenatal checkup.
• When a woman experiences three or more consecutive miscarriages, it is referred to as recurrent miscarriage and often requires additional medical evaluation to identify underlying causes.

Emotional support is a vital component of nursing care for women experiencing potential or actual pregnancy loss. Nurses provide a supportive and empathetic environment, encourage the client and her partner to express feelings and concerns, and provide health teaching about treatment options and follow-up to help the client make informed decisions.

Health care providers assess the client and order diagnostic testing such as ultrasound or serial human chorionic gonadotropin (hCG) blood tests to diagnose threatened or spontaneous abortion. Low or decreasing levels of hCG can be a sign of spontaneous abortion. In some cases of spontaneous abortion, medication or surgical procedures may be performed to remove any remaining pregnancy tissue from the uterus. Follow-up appointments are scheduled to ensure that the uterus is healing properly and that any complications are addressed.^[3]

Grieving is a natural response to loss and the depth of grief associated with pregnancy loss is often underestimated. Nurses assist women and their partners to cope with the loss by providing emotional support and resources to promote coping. For example, nurses may encourage the following actions for clients to facilitate grieving and talking about shared loss, based on the client’s preferences:^[4]

• Seeing and holding the baby, taking pictures, and making footprints.
• Naming the baby.
• Keeping the baby in the room for family members to visit and express condolences. A cooling bed may be provided for the baby.
• Promoting spiritual or religious support or rituals, such as a blessing, baptism, or ritual bathing. Nurses may offer to consult a hospital chaplain or the client’s spiritual leader for these purposes before discharge.
• Facilitating other memory-making activities, such as planting a tree, placing special stones in a garden or special space, or hanging windchimes in memory of the baby.
• Suggesting volunteering for meaningful organizations or donating children’s books to a library with a certificate on the inside sharing why this book was donated.