Nevertheless, rubella and influenza vaccination is prudent in all pregnant women, and treating bacterial vaginosis may prevent premature labor in women with a history of preterm birth.33After a second trimester loss, all patients warrant a thorough history and physical examination to look for factors that might predispose them to another loss.Ideally, this work-up should be done during preconception counseling.There is usually a history of second or third trimester loss.
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For information about the SORT evidence rating system, see page 1262 or = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series.
For information about the SORT evidence rating system, see page 1262 or Miscarriage that occurs at 13 to 14 weeks' gestation usually reflects a pregnancy loss that happened one to two weeks earlier.7 Approximately 1 to 5 percent of pregnancies are lost at 13 to 19 weeks' gestation, whereas stillbirth occurs in 0.3 percent of pregnancies at 20 to 27 weeks' gestation, a rate similar to that of third trimester stillbirth 10 Establishing a cause-and-effect relationship is difficult; causation is well established only for chromosomal and fetal structural problems.
The diagnosis suggested by history and physical examination can be confirmed with hysterography or transvaginal ultrasonography.820 The most recent reviews of randomized trials, as well as a report from the American College of Obstetricians and Gynecologists, conclude that there is insufficient evidence to recommend cerclage for a shortened cervix detected by ultrasonography.2123 There is better support for cervical cerclage in women with three or more second trimester losses or preterm deliveries and cervical change before fetal viability.
A meta-analysis of 31 studies on the effect of thrombophilic disorders in pregnancy loss showed that a nonrecurrent pregnancy loss after 20 to 24 weeks' gestation is associated with factor V Leiden, protein S deficiency, and the prothrombin mutation.24 Antiphospholipid antibodies, specifically lupus anticoagulant and anticardiolipin antibody, can occur in women with systemic lupus erythematosus or other immunologic conditions, can occur as an isolated syndrome, and can be transient.
The history should include symptoms and signs of pregnancy loss, chronic maternal medical conditions that may contribute to pregnancy loss, family history that suggests genetic problems, medication use as an indication of underlying illness, environmental exposures, substance abuse, trauma, and obstetric history.
A detailed review of the pregnancy should be performed, including vital signs, weight gain, dating parameters, ultrasonography, and laboratory tests.
Nutritional education and folic acid supplementation can improve maternal illness and help prevent neural tube defects. Wilson WA, Gharavi AE, Koike T, Lockshin MD, Branch DW, Piette JC, et al. Copyright © 2007 by the American Academy of Family Physicians. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.
Smoking, alcohol consumption, and substance abuse have been implicated in poor fetal outcomes; therefore, patients should be offered counseling and treatment, even if the roles of these activities in the pregnancy loss are not well established. Cervical cerclage for prevention of preterm delivery: meta-analysis of randomized trials [Published correction appears in Obstet Gynecol 2004;11]. International consensus statement on preliminary classification criteria for definite antiphospholipid syndrome: report of an international workshop. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
Although trauma is an uncommon cause of pregnancy loss, advocacy for the prevention of physical abuse can be initiated and coordinated by the family physician. Contact [email protected] copyright questions and/or permission requests.
Patients who have had an unexplained pregnancy loss should be offered genetic counseling with an option for karyotype analysis, even though these interventions have few measurable outcomes. Effectiveness of cervical cerclage for a sonographically shortened cervix: a systematic review and meta-analysis.
Preventive measures, including vaccination and folic acid supplementation, are recommended regardless of risk.