Miscarriages or Pregnancy Terminations (including Stillbirths)

Overview

Miscarriages, also known as spontaneous abortions, refer to the unintended loss of a pregnancy before 20 weeks of gestation. Stillbirths are defined as fetal deaths occurring after 20 weeks of gestation or when the fetus weighs more than 500 grams. Pregnancy terminations encompass both spontaneous losses (miscarriages and stillbirths) and induced abortions, though in Sri Lanka, induced abortions are legally restricted to cases where the mother's life is at risk, leading to a focus on spontaneous events in clinical practice. Globally, miscarriages affect 10-20% of recognized pregnancies, while stillbirths number around 1.9 million annually (2023 data). In Sri Lanka, the overall pregnancy termination rate is 16.14%, with stillbirths at approximately 6.0-6.9 per 1,000 total births (2021-2022), contributing to perinatal mortality. These events can have profound psychological, physical, and social impacts on women and families, increasing risks of maternal morbidity, future pregnancy complications, and mental health issues like depression. Management follows guidelines from the Sri Lanka College of Obstetricians & Gynaecologists (SLCOG) and the Family Health Bureau, emphasizing compassionate care, investigation of causes, and prevention in subsequent pregnancies. Key resources include the SLCOG Management of Stillbirth guideline (2022) available here and the National Guidelines on Post-Abortion Care (2015) from the Ministry of Health referenced here.

Classification

• Miscarriage (Spontaneous Abortion): Loss before 20 weeks. Subtypes include threatened (bleeding with closed cervix), inevitable (open cervix), incomplete (retained products), complete (all products expelled), missed (fetal demise without symptoms), and recurrent (≥3 consecutive losses).

• Stillbirth: Fetal death after 20 weeks or >500g. Classified as antepartum (before labor) or intrapartum (during labor); macerated (death >24 hours before delivery) or fresh.

• Induced Termination: Rare in Sri Lanka due to legal restrictions; includes medical (mifepristone/misoprostol) or surgical methods only for maternal health indications.

In Sri Lanka, perinatal deaths are reviewed under the Perinatal Death Surveillance system for classification and cause attribution.

Signs and Symptoms

• Miscarriage: Vaginal bleeding, cramping abdominal pain, passage of tissue, or cessation of pregnancy symptoms. In missed miscarriage, no symptoms but absent fetal heartbeat on ultrasound.

• Stillbirth: Reduced or absent fetal movements, no fetal heartbeat on auscultation or ultrasound, sometimes accompanied by maternal symptoms like pain or bleeding if due to abruption.

Psychological symptoms post-event include grief, anxiety, and guilt. In Sri Lanka, women are encouraged to report reduced fetal movements promptly.

Causes and Pathophysiology

Causes of miscarriage include chromosomal abnormalities (50-60%), maternal factors (e.g., infections, endocrine disorders), uterine anomalies, or antiphospholipid syndrome. Stillbirths often result from placental insufficiency, infections (e.g., syphilis), congenital anomalies, maternal hypertension, diabetes, or cord accidents. Pathophysiology involves fetal hypoxia, inflammation, or vascular issues leading to demise. In Sri Lanka, common contributors include non-communicable diseases (NCDs) like anaemia and obesity, though stillbirths are not significantly linked to NCDs in some studies. Unsafe induced abortions, though illegal, contribute 10-13% to maternal deaths.

Risk Factors

From Sri Lankan data: Increasing maternal age (>35 years), obesity (36% higher odds), high parity (decreased odds), contraceptive use (24% higher), cohabiting (57% higher), employment (15% higher), domestic violence (14% higher), urban residence, and indoor smoking (13% higher). Regional variations show lower risks in Northern/Eastern provinces compared to Western. Other global/Sri Lankan factors: NCDs, infections, poor antenatal care, and socioeconomic disparities.

Diagnosis

• Miscarriage: Clinical history, pelvic exam (cervical status), ultrasound (gestational sac, yolk sac, fetal pole, heartbeat), and beta-hCG levels.

• Stillbirth: Confirmed by absent fetal heartbeat on ultrasound or Doppler; further investigations include autopsy, placental histology, and maternal tests (e.g., for infections, thrombophilia).

In Sri Lanka, SLCOG guidelines recommend multidisciplinary review, including psychological support, and registration of all perinatal deaths.

Treatment

• Miscarriage: Expectant management (wait for natural expulsion), medical (misoprostol), or surgical (dilation and curettage). Rh-negative women receive anti-D immunoglobulin.

• Stillbirth: Induction of labor (mifepristone + misoprostol or oxytocin), with pain relief and psychological support. Post-delivery: Autopsy consent, bereavement care, and follow-up.

Sri Lankan guidelines stress respectful care, infection prevention, and counseling on future pregnancies. Post-abortion care includes antibiotics and contraception advice.

Prevention

Antenatal care: Early booking, NCD screening, infection prevention (e.g., rubella vaccination), folic acid supplementation, and lifestyle advice (weight management, no smoking). For recurrent losses: Investigations and aspirin/heparin if indicated. Sri Lanka's National Strategic Plan aims for planned pregnancies via family planning to reduce terminations. Policies address domestic violence and education on health.

Prognosis

Most women recover physically, but emotional recovery varies; 20-30% experience depression/anxiety. Recurrent risk: 1-2% for miscarriages, higher with factors. Future pregnancies: Increased monitoring. In Sri Lanka, stillbirths contribute to ~2,000 annual losses, with declining trends due to improved care.

Epidemiology

Sri Lanka's stillbirth rate has declined (5.9/1,000 in 2018 to 6.2/1,000 in 2022), lower than South Asian averages, thanks to universal antenatal care. Pregnancy terminations: 16.14% overall, with higher rates in urban areas and among older/obese women. Globally, South Asia bears a high burden, with Sri Lanka hosting international efforts like the 2024 Stillbirth Alliance conference.

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