What are the signs of early miscarriage? Normally, vaginal bleeding does not occur after pregnancy, but if it does, it is an abnormal condition. There are many causes of early vaginal bleeding, other than miscarriage, ectopic pregnancy, gravidity, cervical polyps and, rarely, cervical cancer, so in cases of early vaginal bleeding, you should seek medical help to identify the cause of the bleeding. In early miscarriage, if the tissue of the pregnancy is expelled from the uterus, there will be a bout of lower abdominal pain, but when the tissue is cleared, there is usually no more pain. What are the conditions of early miscarriage? Premature miscarriage is a term often used in clinical practice to refer to a condition in which there is combined bleeding or abdominal pain. If the doctor finds that the cervix is dilated during the vaginal examination, then the miscarriage is inevitable and is also called “inevitable miscarriage”. An incomplete miscarriage is one in which a small amount of tissue has been expelled, but some tissue remains in the uterus. Subchorionic hemorrhage is usually diagnosed by the presence of vaginal bleeding and the presence of a blood clot between the embryo and the uterine wall on ultrasound. Empty egg is a sign of embryonic abortion in which a gestational sac is found on ultrasound but no embryo is present. Some miscarriages occur early, before there are any visible tissues of the pregnancy, and then they are just like a menstrual period, with an elevated hCG in the blood or urine, sometimes called “biochemical pregnancy”. Recurrent miscarriage (used to be called “habitual miscarriage” but no longer used) refers to the occurrence of more than 2 miscarriages. Why do early miscarriages occur? In most cases, miscarriage is a process of eugenics. More than 70% of the embryos are not well developed, and after a certain level of development, the embryo can no longer develop, and then it will show up as a dead embryo and be expelled. In some cases, chromosomal abnormalities can be detected by chromosomal examination, but genetic defects cannot be detected by chromosomal examination, and in fact, the cause of most early miscarriages cannot be found. Other causes of early miscarriage include malformation of the uterus, infection, exposure to toxic and harmful substances, radiation exposure, advanced maternal age, and luteal insufficiency. How is it determined that the embryo has stopped developing? It is a common clinical process for the embryo to stop developing and then expel the pregnancy tissue after the embryo has died. In the early stages, blood beta hCG (human chorionic gonadotropin beta), progesterone and ultrasound can be used to assist in the diagnosis of embryonic arrest. In the case of normal intrauterine pregnancy, if blood is drawn for βhCG at 4-8 weeks after menopause, it will double every 2-3 days, and if βhCG remains the same or decreases during follow-up, then it indicates an abnormal pregnancy outcome. Progesterone, on the other hand, is relatively stable, with >25 ng/dl indicating a normal intrauterine pregnancy and <5 ng/dl a higher likelihood of abnormal pregnancy (miscarriage or ectopic pregnancy). If the gestational sac is more than 18 mm, but no germ is present on ultrasound, it may indicate embryonic abortion; a germ of 5 mm or more should be visible on ultrasound, but if it is not, it also indicates the possibility of embryonic abortion. If the ultrasound results are inconclusive, the embryo should be growing by 1 mm per day. Can medication help? Progesterone is now commonly used in China for fetal preservation treatment and has been somewhat abused. I have previously written a popular science article "What to do with low early pregnancy progesterone" for reference. Pre-eclampsia miscarriages occurring for the first time are very common and treatment with progesterone does not improve the prognosis. Modern medicine places great emphasis on evidence-based medicine, and medication without evidence is not supported. It is because of the lack of valid evidence that the WHO (World Health Organization) does not recommend the use of progesterone for the treatment of early miscarriages, but is supported in cases of recurrent miscarriages. Many hospitals in China use various "birth control pills" which are the result of lack of rigorous controlled trials, so there is no need to use them. Do I have to have surgery for incomplete miscarriage or embryonic abortion? My advice for first-time preterm miscarriage patients is usually to "let nature take its course" because there is nothing we can do to improve the outcome of the pregnancy, and it is a natural process of elimination for embryonic abortion to occur. In the past, most cases of embryonic abortion required surgical evacuation to complete the treatment, which carries risks and can cause psychological fear for the patient. Medicine is changing and in recent years there has been a lot of research that is changing this traditional clinical practice. Recent studies have found that it is simply waiting that can result in 91% of incomplete miscarriages and 28% of complete miscarriages in patients with embryonic abortion. A study published in the New England Journal of Medicine found that some medications used vaginally with misoprostol assisted in the expulsion of 84% of embryos, a rate that allows most cases of early pregnancy failure to be treated without surgery, which is certainly a less invasive approach for patients. Of course, non-surgical options are not suitable for every patient; those with heavy bleeding, those at risk of infection, and those with an unclear diagnosis are not suitable for non-surgical options. What are the special notes for the next pregnancy? Generally speaking, there is no need for any special tests. After 3 months of contraception, you can try for another pregnancy, and most pregnancies will generally be normal, and the chance of another miscarriage will still be between 15 and 20%, and two consecutive miscarriages will of course exist, with about 1 to 3% of the population. For patients with more than 2 recurrent miscarriages, it is necessary to seek medical help. Do I need any special tests? As mentioned earlier, blood tests for beta hCG, progesterone and ultrasound are helpful in determining the outcome of this pregnancy and are also helpful in the diagnosis of ectopic pregnancy, but usually do not change the outcome of the pregnancy.