A Comprehensive Overview of Miscarriage: Types, Causes, Diagnosis, Recovery, and Psychological Support

Abstract

Miscarriage, or spontaneous abortion, represents the most prevalent complication of early pregnancy, affecting a substantial proportion, estimated to be between 10% and 20%, of clinically recognized pregnancies. This comprehensive report offers an in-depth, multidisciplinary examination of miscarriage, delineating its various clinical presentations and types, exploring the complex tapestry of common underlying etiological factors—including profound genetic predispositions, intricate hormonal imbalances, structural anatomical anomalies, complex immunological dysregulations, and the influence of infectious agents and lifestyle choices. Furthermore, this document meticulously details the diagnostic paradigms employed for accurate identification, outlines the spectrum of available management strategies, elucidates the intricate journey of physical and emotional recovery, and underscores the critical importance of robust psychological support and accessible resources for individuals and couples grappling with the profound impact of pregnancy loss. By synthesizing contemporary research findings, established clinical guidelines, and patient-centered care principles, this report endeavours to significantly enhance understanding among healthcare professionals and patients alike, fostering informed decision-making and compassionate care in navigating the multifaceted aspects of miscarriage.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

1. Introduction

Miscarriage, formally defined as the spontaneous loss of a fetus before the 20th week of gestation or when the fetal weight is less than 500 grams, constitutes a prevalent and often profoundly distressing event in reproductive health. While often framed within purely medical terminology, the experience of miscarriage extends far beyond a mere clinical diagnosis, encompassing a broad spectrum of physical, emotional, and psychological challenges for individuals and their partners. It ranges from early biochemical pregnancy losses, often unrecognized by the individual, to late-term spontaneous abortions, and crucially, includes the challenging condition of recurrent miscarriages, each presenting with distinct etiologies, diagnostic considerations, and implications for subsequent reproductive outcomes. The sheer prevalence underscores its significance as a public health concern, impacting millions globally each year and often leading to significant grief, anxiety, and in some cases, long-term psychological sequelae [1, 2].

Understanding the multifactorial causes that underpin miscarriage is paramount for the development of effective preventative strategies and targeted therapeutic interventions. Furthermore, a thorough comprehension of the diagnostic approaches, which often involve a synthesis of clinical assessment, biochemical markers, and advanced imaging, is crucial for timely and accurate identification. Subsequent management strategies must be tailored to the specific type of miscarriage and individual patient needs, encompassing expectant, medical, and surgical options. Beyond the immediate physical management, acknowledging and addressing the profound psychological and emotional impact of pregnancy loss is indispensable for providing comprehensive, holistic care. This report therefore aims to provide a detailed, evidence-based review of these critical aspects, facilitating improved clinical practice and enhanced patient support.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

2. Types of Miscarriage

Miscarriages are clinically classified based on their presentation, timing, and the extent of tissue expulsion from the uterus. Accurate classification guides appropriate management and prognostic considerations. The primary types include:

2.1 Threatened Miscarriage

Threatened miscarriage is characterized by the presence of vaginal bleeding, which may range from light spotting to heavier flow, often accompanied by mild abdominal cramping, but crucially, without cervical dilation. In this scenario, the pregnancy remains viable, meaning the fetus still has a heartbeat and continues to develop within the uterus. Approximately 20-30% of all pregnancies experience some form of bleeding in the first trimester, and about half of these cases resolve without progression to complete miscarriage, with the pregnancy continuing to term [3]. The aetiology of bleeding in threatened miscarriage is often idiopathic, but can sometimes be attributed to subchorionic haematomas (blood clots between the chorion and decidua), implantation bleeding, or cervical irritation. While a significant proportion of threatened miscarriages resolve, they do carry an increased risk of complications later in pregnancy, including preterm labour, placental abruption, and fetal growth restriction, necessitating careful monitoring. Management typically involves rest, avoidance of strenuous activities, and close observation, although the efficacy of specific interventions beyond supportive care remains an area of ongoing research [4].

2.2 Inevitable Miscarriage

Inevitable miscarriage signifies that the process of pregnancy loss has commenced and is irreversible. Clinically, it is diagnosed when vaginal bleeding is accompanied by cervical dilation or effacement, indicating that the cervix has opened, and often by the rupture of membranes (water breaking) if the gestational sac is visible. The uterine contractions may become stronger and more regular, akin to early labour pains, as the uterus attempts to expel its contents. Unlike threatened miscarriage, the prognosis for pregnancy continuation in inevitable miscarriage is extremely poor. The priority in management shifts from preserving the pregnancy to ensuring the complete and safe evacuation of uterine contents, preventing complications such as haemorrhage or infection. Management options mirror those for complete or incomplete miscarriage, including expectant, medical, or surgical approaches, tailored to the patient’s clinical stability and preferences [5].

2.3 Incomplete Miscarriage

An incomplete miscarriage occurs when some, but not all, of the pregnancy tissue (fetal, placental, or membranous material) has been expelled from the uterus, leaving retained products of conception (RPOC). This often presents with persistent vaginal bleeding that can be heavy, along with ongoing abdominal cramping or pain, as the uterus continues to contract in an attempt to expel the remaining tissue. The cervix typically remains open. Diagnosis is confirmed by ultrasound, which shows thickened endometrial stripe or heterogeneous material within the uterine cavity. Retained tissue poses significant risks, including heavy haemorrhage (due to sustained bleeding from placental sites and impaired uterine contractility) and ascending infection (endometritis), which can lead to fever, foul-smelling discharge, and pelvic pain. Therefore, intervention is often required to ensure complete evacuation of the uterus, typically through medical management with uterotonics like misoprostol or surgical intervention such as dilation and curettage (D&C) or vacuum aspiration [6].

2.4 Complete Miscarriage

A complete miscarriage is diagnosed when all pregnancy tissue has been expelled from the uterus spontaneously. Clinically, this is characterized by a reduction in vaginal bleeding and cessation of abdominal pain, as the uterus contracts back to its normal, non-gravid size. Upon examination, the cervix is typically closed, and ultrasound imaging confirms an empty uterine cavity, with a thin endometrial lining (usually less than 15 mm). Patients may report having passed a significant amount of tissue or clots. While no further medical or surgical intervention is usually required for uterine evacuation, follow-up is important to confirm falling beta-hCG levels and to ensure emotional and physical recovery. This type of miscarriage generally carries a lower risk of complications compared to incomplete miscarriage, as the source of bleeding and potential infection has been spontaneously removed [7].

2.5 Missed Miscarriage (Silent Miscarriage)

A missed miscarriage, also known as a silent miscarriage or missed abortion, is a particularly distressing type where the fetus has died in utero but has not been expelled spontaneously. There are often no outward signs or symptoms, such as bleeding or pain, leading to a delay in diagnosis. The individual may continue to experience pregnancy symptoms initially, or these symptoms may gradually subside. Diagnosis is typically made during a routine prenatal ultrasound scan, where the absence of a fetal heartbeat or a significantly undersized fetus for gestational age is noted. The realization that the pregnancy has ended without the body giving any prior indication can be psychologically challenging. Management options for missed miscarriage include expectant management (waiting for spontaneous expulsion), medical management (using medications to induce expulsion), or surgical management (D&C or vacuum aspiration), with the choice depending on gestational age, patient preference, and clinical factors [8]. Prolonged retention of a missed miscarriage can, in rare cases, lead to coagulopathy (disseminated intravascular coagulation), though this is more commonly associated with later fetal demise [9].

2.6 Recurrent Miscarriage (Recurrent Pregnancy Loss, RPL)

Recurrent miscarriage (RM), also known as recurrent pregnancy loss (RPL), is defined by two or more consecutive or non-consecutive pregnancy losses before 20 weeks of gestation. Historically, the definition often specified three or more consecutive losses, but contemporary guidelines from organizations like the American Society for Reproductive Medicine (ASRM) now recognize that two losses warrant investigation, particularly given the emotional toll and impact on future fertility [10]. Recurrent miscarriage affects approximately 1-2% of couples attempting to conceive and often necessitates an exhaustive investigation into underlying causes, which can be diverse and complex, spanning genetic, anatomical, hormonal, immunological, and thrombophilic factors. In a significant proportion of cases (around 50%), despite comprehensive evaluation, no specific cause can be identified, termed ‘unexplained recurrent miscarriage.’ The management of recurrent miscarriage is highly individualized and depends on the identified aetiology, often involving specific medical or surgical interventions aimed at mitigating the risk of future losses. Psychosocial support is critical for couples experiencing RM, given the chronic nature of their grief and anxiety [11, 12].

2.7 Biochemical Pregnancy Loss

A biochemical pregnancy loss, often considered the earliest form of miscarriage, occurs when a pregnancy is detected only by a positive blood or urine test for human chorionic gonadotropin (hCG) but fails to progress to a clinically recognizable pregnancy (i.e., no gestational sac or fetus is seen on ultrasound). This occurs very early, typically before 5 weeks of gestation. It often manifests as a slightly delayed or heavier than usual menstrual period. Many biochemical pregnancies are never clinically diagnosed, as they occur before a woman misses her period or takes a pregnancy test. While not typically included in the official definition of miscarriage (which usually refers to clinically recognized losses), these early losses are biologically significant and can be distressing for couples, especially those undergoing fertility treatments who are closely monitoring hCG levels. The causes are similar to those of later miscarriages, predominantly chromosomal abnormalities [13].

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3. Common Underlying Causes

Miscarriage is not a singular disease entity but rather a complex pathological outcome resulting from a myriad of interacting factors. Identifying the specific cause is often challenging due to the multifactorial nature of pregnancy maintenance and the high prevalence of random genetic errors. However, understanding the predominant contributing factors is crucial for appropriate investigation and management, particularly in cases of recurrent miscarriage.

3.1 Genetic Factors

Chromosomal abnormalities are unequivocally the leading identifiable cause of sporadic miscarriage, accounting for approximately 50% to 70% of all first-trimester losses and a decreasing percentage in the second trimester [14]. These abnormalities primarily manifest as aneuploidies (an abnormal number of chromosomes) or structural rearrangements (e.g., translocations, inversions). The vast majority of these aberrations are sporadic, resulting from errors during gametogenesis (meiosis) or early embryonic cell division (mitosis), making them random events with low recurrence risk in subsequent pregnancies. The most common aneuploidies observed in miscarriage tissue include:

• Autosomal Trisomy: The presence of an extra copy of a non-sex chromosome. Trisomy 16 is the most common autosomal trisomy, invariably lethal, accounting for up to 15% of all miscarriages. Other common trisomies involve chromosomes 21 (Down Syndrome), 18 (Edwards Syndrome), and 13 (Patau Syndrome), which can sometimes progress to live birth but are often associated with miscarriage [15].
• Monosomy X (Turner Syndrome): The absence of one X chromosome (45, XO). This is the most common single chromosomal abnormality and the most common monosomy, accounting for approximately 10-20% of all miscarriages. While some fetuses with Monosomy X survive to term, the vast majority are spontaneously aborted [16].
• Polyploidy: The presence of more than two complete sets of chromosomes (e.g., triploidy – 69 chromosomes; tetraploidy – 92 chromosomes). Triploidy typically results from the fertilization of one egg by two sperm or a diploid sperm/egg. These conceptions are almost always spontaneously aborted due to severe developmental anomalies [14].
• Structural Rearrangements: These involve deletions, duplications, inversions, or translocations of chromosomal segments. While most sporadic miscarriages are due to numerical abnormalities, inherited structural rearrangements (e.g., balanced translocations) in one or both parents can lead to the production of unbalanced gametes, resulting in recurrent miscarriages. Karyotyping of parents is therefore a standard investigation in recurrent pregnancy loss [10].

Advanced Parental Age: Advanced maternal age is a well-established independent risk factor for increased miscarriage rates due to a higher incidence of aneuploidy. As women age, the quality of oocytes declines, leading to an increased likelihood of meiotic non-disjunction during oogenesis. The risk of miscarriage rises significantly after age 35, and dramatically after age 40, primarily due to this age-related increase in chromosomal errors [17]. While less pronounced, advanced paternal age (typically defined as >40-50 years) has also been implicated, potentially contributing to an increased risk of chromosomal abnormalities, de novo gene mutations, and DNA fragmentation in sperm, all of which can compromise embryonic development and lead to miscarriage [18].

3.2 Hormonal Imbalances

Precise hormonal regulation is critical for successful implantation and maintenance of early pregnancy. Dysregulation in key endocrine systems can significantly increase the risk of miscarriage.

• Progesterone Deficiency (Luteal Phase Defect – LPD): Progesterone, primarily produced by the corpus luteum in the early stages of pregnancy, is essential for transforming the endometrium into a receptive state for implantation (decidualization) and for maintaining uterine quiescence. A deficiency in progesterone production or abnormal endometrial response to progesterone, known as Luteal Phase Defect (LPD), theoretically impairs implantation or leads to early pregnancy loss [19]. While supplemental progesterone is often prescribed for threatened and recurrent miscarriages, the definitive evidence for its universal efficacy, particularly in sporadic cases without confirmed LPD, remains debated. However, for women with a history of recurrent miscarriage, vaginal progesterone supplementation has shown some benefit in reducing the risk of a subsequent loss [20].

• Thyroid Disorders: Both overt and subclinical thyroid dysfunctions are associated with an increased risk of miscarriage. Hypothyroidism (underactive thyroid) can impair fertility and increase miscarriage rates by disrupting ovulation, affecting endometrial receptivity, or having direct adverse effects on the developing embryo [21]. Subclinical hypothyroidism, characterized by elevated TSH levels with normal thyroid hormone levels (T3, T4), is also a recognized risk factor. Conversely, severe hyperthyroidism (overactive thyroid) can also increase miscarriage risk. Autoimmune thyroiditis, specifically the presence of thyroid peroxidase (TPO) antibodies and/or thyroglobulin (Tg) antibodies, even in euthyroid women, is linked to an increased risk of miscarriage, suggesting an autoimmune component independent of thyroid function itself [22].

• Polycystic Ovary Syndrome (PCOS): PCOS is a common endocrine disorder characterized by chronic anovulation, hyperandrogenism, and insulin resistance. Women with PCOS have a significantly higher risk of miscarriage compared to the general population, with rates estimated between 30% and 50% [23]. The mechanisms are multifactorial, including:

  • Insulin Resistance and Hyperinsulinemia: Leading to altered follicular development, impaired oocyte quality, and possibly affecting endometrial receptivity.
  • Hyperandrogenism: Elevated androgen levels can directly affect endometrial function and early embryonic development.
  • Altered LH/FSH Ratio: Affecting ovarian function and potentially contributing to poor oocyte quality.
  • Endometrial Dysfunction: Reduced receptivity of the endometrium for implantation.
  • Increased Risk of Gestational Diabetes and Hypertension: Which can indirectly contribute to pregnancy complications.

• Hyperprolactinemia: Elevated levels of prolactin, whether idiopathic or due to pituitary adenoma, can disrupt the hypothalamic-pituitary-ovarian axis, leading to ovulatory dysfunction and potentially luteal phase defects, thereby increasing miscarriage risk [24].

3.3 Anatomical Abnormalities

Structural abnormalities of the uterus can impede normal implantation, compromise placental development, or lead to premature expulsion of the fetus, significantly increasing miscarriage risk. These can be congenital or acquired.

• Congenital Uterine Anomalies (Müllerian Duct Anomalies): These result from abnormal development or fusion of the Müllerian ducts during embryogenesis. Common types include:

  • Septate Uterus: The most common congenital uterine anomaly associated with recurrent miscarriage, characterized by a fibrous or muscular septum dividing the uterine cavity. The septum is poorly vascularized, making implantation within it unlikely to sustain pregnancy [25]. Hysteroscopic septoplasty (surgical removal of the septum) is highly effective in improving pregnancy outcomes.
  • Bicornuate Uterus: Characterized by a heart-shaped uterus with two horns. While often compatible with pregnancy, it can lead to miscarriage, preterm birth, and malpresentation due to reduced uterine cavity space and abnormal uterine contractility.
  • Unicornuate Uterus: A uterus with only one functional horn. Associated with lower fertility rates and increased risk of miscarriage and preterm birth.
  • Arcuate Uterus: A mild indentation in the uterine fundus. Generally considered a normal variant, with controversial association with miscarriage [26].

• Acquired Uterine Anomalies:

  • Uterine Fibroids (Leiomyomas): Benign muscular tumours of the uterus. Their impact on miscarriage depends on size, number, and location. Submucosal fibroids (protruding into the uterine cavity) and intramural fibroids (within the uterine wall) that distort the cavity can interfere with implantation, reduce endometrial blood supply, or cause irregular uterine contractions, increasing miscarriage risk [27]. Pedunculated subserosal fibroids (on the outer surface) generally have no impact. Myomectomy (surgical removal of fibroids) may be considered for symptomatic fibroids in women with recurrent miscarriage.
  • Uterine Polyps: Benign growths of the endometrial lining. While often asymptomatic, large or multiple polyps, particularly if they are sessile or located near the fallopian tubes, can act as a foreign body, interfere with implantation, or cause abnormal bleeding, contributing to miscarriage [28]. Hysteroscopic polypectomy is usually effective in removing them.
  • Asherman’s Syndrome (Intrauterine Adhesions): Scar tissue formation within the uterine cavity, often resulting from aggressive D&C procedures, infection, or prior uterine surgery. These adhesions can partially or completely obliterate the uterine cavity, reduce endometrial surface area, and impair endometrial receptivity, leading to infertility and recurrent miscarriage [29]. Hysteroscopic adhesiolysis (surgical removal of adhesions) is the primary treatment.

• Cervical Incompetence (Cervical Insufficiency): This condition refers to the premature painless dilation of the uterine cervix in the second trimester, leading to premature rupture of membranes and subsequent miscarriage or preterm birth. It is often due to congenital defects, previous cervical trauma (e.g., D&C, LEEP procedure), or uterine anomalies. Diagnosis is often retrospective (after a prior mid-trimester loss) or by ultrasound assessment of cervical length in subsequent pregnancies. Management often involves a cervical cerclage (suturing the cervix closed) typically performed between 12 and 16 weeks of gestation [30].

3.4 Immunological Factors

Immunological factors represent a complex and sometimes controversial area in the aetiology of recurrent miscarriage. They involve aberrations in the maternal immune system’s delicate balance, which normally tolerates the semi-allogeneic fetus.

• Autoimmune Disorders: These involve the immune system mistakenly attacking the body’s own tissues. The most well-established autoimmune cause of recurrent miscarriage is Antiphospholipid Syndrome (APS). APS is an autoimmune disorder characterized by the presence of antiphospholipid antibodies (aPLs) – namely lupus anticoagulant (LAC), anticardiolipin antibodies (aCL), and anti-beta2-glycoprotein I antibodies (anti-β2GPI) – in the blood. These antibodies lead to a hypercoagulable state, causing thrombotic events in both arteries and veins, and crucially, in the placental vasculature. Placental microthrombosis, infarction, and impaired placental perfusion are thought to be the primary mechanisms by which APS causes recurrent pregnancy loss, particularly in the second trimester, but also in early pregnancy [31]. Diagnosis requires both clinical criteria (recurrent pregnancy loss, thrombosis) and laboratory criteria (persistent positive aPLs). Treatment typically involves a combination of low-dose aspirin and prophylactic unfractionated or low molecular weight heparin, which significantly improves live birth rates [32]. Other autoimmune conditions like Systemic Lupus Erythematosus (SLE), Celiac Disease, and uncontrolled autoimmune thyroiditis (as mentioned previously) are also associated with an increased risk of miscarriage due to systemic inflammation, autoantibody production, or specific organ damage impacting pregnancy [33].

• Alloimmune Factors: These involve interactions between the maternal immune system and fetal antigens inherited from the father. While less well-understood and more controversial than autoimmune causes, some theories suggest that an inappropriate maternal immune response to paternal antigens on fetal trophoblast cells may contribute to miscarriage. Research has explored the role of Natural Killer (NK) cells (both uterine and peripheral), HLA compatibility between partners, and maternal blocking antibodies. However, routine testing for and specific treatments targeting alloimmune factors (e.g., paternal leukocyte immunization, intravenous immunoglobulin – IVIG) are largely experimental, lack consistent evidence of efficacy in well-designed clinical trials, and are not recommended for routine clinical use by major professional organizations [10].

3.5 Infections

Certain infections can directly or indirectly increase the risk of miscarriage by causing inflammation, placental damage, or direct fetal harm. While acute systemic infections are clearly linked, the role of chronic or subclinical infections, particularly in recurrent miscarriage, is less clear-cut.

• Bacterial Infections:

  • Bacterial Vaginosis (BV) and Vaginal Infections: Alterations in the vaginal microbiome, particularly an overgrowth of anaerobic bacteria (as seen in BV), can lead to ascending infection into the uterus, causing endometritis, chorioamnionitis (inflammation of fetal membranes), and preterm rupture of membranes, increasing the risk of early and late miscarriage [34].
  • Urinary Tract Infections (UTIs): Untreated UTIs, especially pyelonephritis, can lead to systemic inflammation and potential ascending infection, posing a risk for miscarriage.
  • Sexually Transmitted Infections (STIs): Infections like Chlamydia trachomatis, Neisseria gonorrhoeae, and Syphilis can cause pelvic inflammatory disease (PID), endometritis, and complications during pregnancy, including miscarriage. Untreated syphilis, for example, is a known cause of recurrent miscarriage and stillbirth.
  • Listeria Monocytogenes: A food-borne bacterium that can cross the placenta, causing severe systemic infection (listeriosis) in the fetus, leading to miscarriage, stillbirth, or severe neonatal illness [35].
  • Mycoplasma and Ureaplasma Species: The role of these genital mycoplasmas in miscarriage is debated, but some studies suggest an association with adverse pregnancy outcomes, including miscarriage and preterm birth, possibly by causing chorioamnionitis or influencing local immune responses [36].

• Viral Infections (TORCH infections): A group of infections that can cross the placenta and cause congenital anomalies or fetal demise.

  • Rubella (German Measles): While rare due to vaccination, rubella infection in early pregnancy can cause severe congenital abnormalities and miscarriage.
  • Cytomegalovirus (CMV): A common herpesvirus. Primary CMV infection in pregnancy can lead to fetal infection, causing developmental anomalies or miscarriage.
  • Parvovirus B19: Infection can cause severe fetal anaemia, hydrops fetalis, and fetal demise, particularly if acquired in the second trimester [37].
  • Herpes Simplex Virus (HSV): Primary HSV infection in pregnancy can lead to disseminated infection in the mother and potentially fetal infection, although miscarriage is a less common outcome than neonatal herpes.
  • Toxoplasmosis: A parasitic infection (from contaminated meat or cat faeces) that can cross the placenta and cause fetal neurological damage or miscarriage [38].

3.6 Lifestyle Factors

Maternal and paternal lifestyle choices can significantly influence pregnancy outcomes, increasing the risk of miscarriage through various mechanisms.

• Smoking: Maternal smoking (both active and passive) is associated with a dose-dependent increase in miscarriage risk [39]. Nicotine and carbon monoxide can reduce uteroplacental blood flow, cause oxidative stress, and potentially lead to placental abnormalities or direct embryotoxicity. Paternal smoking has also been linked to adverse pregnancy outcomes, possibly due to DNA damage in sperm.

• Alcohol Consumption: Alcohol is a known teratogen. Even moderate alcohol consumption in early pregnancy is associated with an increased risk of miscarriage, especially in the first trimester [40]. There is no established safe limit for alcohol during pregnancy.

• Illicit Drug Use: Use of recreational drugs such as cocaine, methamphetamine, opioids, and cannabis is strongly associated with an increased risk of miscarriage, preterm birth, and other adverse pregnancy outcomes. These substances can cause vasoconstriction, placental abruption, direct embryotoxicity, and nutritional deficiencies [41].

• Caffeine Intake: While definitive evidence remains controversial, high caffeine intake (e.g., >200-300 mg/day) has been implicated in some studies as potentially increasing miscarriage risk [42]. Most guidelines recommend limiting caffeine during pregnancy.

• Maternal Weight (BMI): Both obesity (BMI > 30 kg/m²) and underweight (BMI < 18.5 kg/m²) are associated with an increased risk of miscarriage. Obesity is linked to hormonal imbalances (e.g., insulin resistance, altered leptin levels), chronic inflammation, and increased oxidative stress, all of which can compromise fertility and early pregnancy [43]. Underweight status can reflect poor nutritional status, potentially affecting ovulation and early embryonic development.

• Stress: While it is difficult to definitively link psychological stress directly to sporadic miscarriage, chronic severe stress can impact hormonal regulation (e.g., cortisol levels) and immune function, which theoretically could affect pregnancy maintenance [44]. However, the relationship is complex, and stress is more often a consequence of miscarriage than a primary cause.

• Environmental Toxins: Exposure to certain environmental toxins, heavy metals (e.g., lead, mercury), pesticides, and industrial chemicals can be embryotoxic or fetotoxic, increasing the risk of miscarriage [45]. Occupational exposures should be carefully reviewed.

3.7 Thrombophilic Disorders

Thrombophilic disorders involve an inherited or acquired predisposition to forming blood clots, which can lead to microthrombosis in the uteroplacental circulation, impairing blood flow to the developing fetus and causing miscarriage, particularly in the second trimester, but also contributing to early losses. These conditions are a significant cause of recurrent pregnancy loss.

• Inherited Thrombophilias:

  • Factor V Leiden Mutation: The most common inherited thrombophilia, making Factor V resistant to inactivation by activated protein C, leading to increased clot formation [46].
  • Prothrombin Gene Mutation (G20210A): Leads to elevated prothrombin levels, increasing the risk of thrombosis.
  • Methylenetetrahydrofolate Reductase (MTHFR) Gene Polymorphisms (C677T and A1298C): While commonly tested, the association of MTHFR polymorphisms (leading to elevated homocysteine levels) with recurrent miscarriage is highly controversial and generally not considered an independent risk factor for recurrent miscarriage in the absence of other thrombophilic defects by most major guidelines [10].
  • Deficiencies of Antithrombin, Protein C, and Protein S: Rarer but more severe hereditary deficiencies of natural anticoagulants, significantly increasing thrombosis risk.

• Acquired Thrombophilias: The primary acquired thrombophilia relevant to miscarriage is Antiphospholipid Syndrome (APS), as detailed in Section 3.4. Other acquired hypercoagulable states, such as those associated with severe inflammatory conditions or certain medications, can also increase risk.

Treatment for recurrent miscarriage associated with thrombophilias, particularly APS, typically involves anticoagulant therapy (e.g., low molecular weight heparin) and low-dose aspirin, which improve pregnancy outcomes by preventing placental thrombosis [32].

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4. Diagnostic Process

Accurate and timely diagnosis of miscarriage is crucial for appropriate clinical management and for providing adequate emotional support. The diagnostic process typically involves a combination of thorough clinical evaluation, biochemical assays, and advanced imaging studies.

4.1 Clinical Evaluation

• Medical and Obstetric History: A detailed history is the initial and foundational step. This includes:

  • Last Menstrual Period (LMP) and Menstrual History: To establish gestational age and rule out ectopic pregnancy.
  • Previous Pregnancy History: Number of pregnancies (gravidity), number of live births (parity), history of prior miscarriages (number, gestational age, type, need for intervention), ectopic pregnancies, stillbirths, and preterm births. Understanding past reproductive outcomes can provide critical clues, especially in recurrent cases.
  • Symptoms: Detailed enquiry about vaginal bleeding (onset, duration, quantity, colour, presence of clots or tissue), abdominal pain (location, intensity, character – cramping, sharp), back pain, and presence or absence of pregnancy symptoms (nausea, breast tenderness). The presence of fever or foul-smelling discharge would raise suspicion for infection.
  • Gynaecological History: History of STIs, pelvic inflammatory disease, cervical surgeries (e.g., LEEP, cone biopsy), uterine anomalies, fibroids, or polyps.
  • Medical Conditions: Presence of chronic systemic diseases such as diabetes, thyroid disorders, autoimmune conditions (e.g., SLE), kidney disease, hypertension, or thrombophilic disorders.
  • Medication Use: Current medications, including over-the-counter drugs, herbal supplements, and illicit substances.
  • Lifestyle Factors: Smoking, alcohol, recreational drug use, dietary habits, and occupational exposures.

• Physical Examination: A comprehensive physical examination provides essential clinical information:

  • General Assessment: Evaluation of vital signs (blood pressure, pulse, temperature) to assess for signs of hypovolemia (shock) or infection.
  • Abdominal Examination: Palpation for tenderness, guarding, rebound tenderness (suggesting peritoneal irritation, as in ectopic pregnancy or infection), and assessment of uterine size (correlation with gestational age).
  • Pelvic Examination: A critical component, typically involving:
    • Speculum Examination: To visualize the cervix and vaginal vault. Assess the source and quantity of bleeding (from the cervical os or vaginal lacerations), inspect for presence of tissue in the cervical os or vagina, and check for signs of infection (discharge, inflammation). The status of the cervical os (open or closed) is paramount for classifying the type of miscarriage.
    • Bimanual Examination: To assess uterine size, consistency, tenderness, and detect adnexal masses (e.g., in ectopic pregnancy). Gentle palpation can also assess cervical consistency and tenderness.

4.2 Diagnostic Tests

• Quantitative Beta-hCG Levels: Measurement of serum human chorionic gonadotropin (hCG) is fundamental for confirming pregnancy and assessing its viability. In a healthy intrauterine pregnancy, serum beta-hCG levels typically double every 48-72 hours in early gestation. Serial measurements are crucial:

  • Suboptimal Rise or Declining Levels: Suggests an abnormal pregnancy (miscarriage or ectopic pregnancy).
  • Very High Levels: May suggest multiple gestation or molar pregnancy.
  • Discriminatory Zone: The hCG level at which an intrauterine gestational sac should be visible on transvaginal ultrasound (typically 1500-2000 mIU/mL). Failure to visualize a sac above this level raises strong suspicion for ectopic pregnancy or very early failed intrauterine pregnancy [47].

• Progesterone Levels: Serum progesterone levels can provide additional insight into pregnancy viability. Levels below a certain threshold (e.g., <5 ng/mL) are highly indicative of a non-viable pregnancy (miscarriage or ectopic), while higher levels (e.g., >20 ng/mL) are generally associated with viable intrauterine pregnancies. However, progesterone levels cannot distinguish between a viable intrauterine pregnancy and an ectopic pregnancy, and their utility as a standalone diagnostic tool is limited [48].

• Complete Blood Count (CBC): Assesses haemoglobin and haematocrit levels to evaluate for anaemia secondary to blood loss. It also measures white blood cell count (WBC) and differential, which can indicate infection (elevated WBC, left shift).

• Blood Type and Rh Status: Crucial to determine the patient’s Rh status (Rh-positive or Rh-negative). Rh-negative women who experience miscarriage are at risk of Rh alloimmunization if the fetus is Rh-positive. Rh immunoglobulin (RhoGAM) administration is necessary to prevent this, typically within 72 hours of the miscarriage [49].

• Genetic Testing of Products of Conception (POC): In cases of miscarriage, especially recurrent miscarriage, genetic testing of the expelled tissue (POC) can identify chromosomal abnormalities in the fetus. Karyotyping is the traditional method, but chromosomal microarray (CMA) offers higher resolution and can detect smaller deletions or duplications not visible on conventional karyotyping [50]. This helps differentiate between sporadic (aneuploidy) and potentially recurrent (parental balanced translocation) causes.

• Parental Karyotyping: If the POC analysis reveals an unbalanced chromosomal abnormality or if a couple experiences recurrent miscarriages with apparently euploid POC, parental karyotyping is performed to screen for balanced chromosomal translocations in either parent that could lead to recurrent unbalanced conceptions.

• Thyroid Function Tests (TSH, free T4, TPO antibodies): To screen for overt or subclinical thyroid dysfunction and autoimmune thyroiditis.

• Autoantibody Screening: Specifically for Antiphospholipid Syndrome (APS) – lupus anticoagulant (LAC), anticardiolipin antibodies (aCL), and anti-beta2-glycoprotein I antibodies (anti-β2GPI). These require repeat testing after several weeks to confirm persistence [31].

• Thrombophilia Panel: Including Factor V Leiden, Prothrombin gene mutation, and sometimes Protein C, Protein S, and Antithrombin deficiencies, especially in cases of recurrent miscarriage.

• Infection Screening: Depending on clinical suspicion, tests for specific infections (e.g., cervical cultures for bacterial vaginosis, chlamydia, gonorrhoea; serology for TORCH infections).

4.3 Imaging Studies

• Transvaginal Ultrasound (TVUS): This is the gold standard imaging modality for confirming intrauterine pregnancy, assessing fetal viability, estimating gestational age, and diagnosing miscarriage. Its proximity to the uterus provides high-resolution images. TVUS can visualize:

  • Gestational Sac: Usually visible by 4.5-5 weeks of gestation.
  • Yolk Sac: Visible by 5-5.5 weeks.
  • Fetal Pole and Fetal Heartbeat: Typically visible by 5.5-6 weeks. The presence of a fetal heartbeat is the most reliable sign of a viable pregnancy. Absence of a heartbeat when the crown-rump length (CRL) is >7 mm or mean sac diameter (MSD) is >25 mm are diagnostic criteria for failed pregnancy [51].
  • Uterine Contents: Helps distinguish between complete, incomplete, and missed miscarriage by assessing the endometrial thickness and presence of retained products of conception.
  • Uterine Anatomy: Can identify structural anomalies like septa, fibroids, or cervical length in later gestations.

• Transabdominal Ultrasound (TAS): While less sensitive in early pregnancy due to interference from bowel gas and abdominal wall thickness, TAS may be used in later first-trimester or second-trimester miscarriages, or when TVUS is not feasible or tolerated. It provides a wider field of view.

• Saline Infusion Sonohysterography (SIS) or Hysterosalpingography (HSG): These procedures are often employed in the investigation of recurrent miscarriage to evaluate the uterine cavity for anatomical abnormalities (e.g., septa, adhesions, submucosal fibroids, polyps) that might not be clearly visualized on standard ultrasound. SIS involves infusing saline into the uterine cavity to distend it, improving visualization by TVUS. HSG involves injecting contrast dye into the uterus and fallopian tubes, followed by X-rays, to assess uterine cavity shape and tubal patency.

• Hysteroscopy: A minimally invasive surgical procedure where a thin telescope is inserted through the cervix into the uterine cavity. It provides direct visualization of the uterine lining, allowing for precise diagnosis and often immediate treatment of intrauterine pathologies like polyps, fibroids, or adhesions [52]. It is particularly useful in unexplained recurrent miscarriage after other investigations are negative.

• Magnetic Resonance Imaging (MRI): Rarely used for routine miscarriage diagnosis, MRI may be employed in complex cases of suspected uterine anomalies or to further characterize masses (e.g., large fibroids) when ultrasound findings are inconclusive, or to rule out ectopic pregnancy in unusual presentations [53].

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5. Management and Recovery

The management of miscarriage is highly individualized, taking into account the type of miscarriage, gestational age, the patient’s clinical stability, preferences, and emotional state. The overarching goals are to ensure safe and complete expulsion of uterine contents, prevent complications, and provide comprehensive physical and emotional support.

5.1 Medical Management

The management options for miscarriage primarily include expectant, medical, and surgical approaches.

• Expectant Management: This approach involves waiting for the miscarriage to occur spontaneously without medical or surgical intervention. It is generally suitable for early miscarriages (typically before 10-12 weeks gestation), especially for complete or missed miscarriages without signs of infection or heavy bleeding.

  • Advantages: Avoids medication side effects and surgical risks, allows the body to complete the process naturally, and can be empowering for some patients.
  • Disadvantages: Can be unpredictable in terms of timing, lead to prolonged bleeding and cramping, and has a higher risk of incomplete miscarriage requiring subsequent intervention (up to 20-40% needing further management) [54]. The emotional uncertainty can be challenging for patients. Close follow-up with serial hCG levels and ultrasound is necessary to confirm complete resolution.

• Medical Induction: This involves using medications to induce uterine contractions and expel the retained products of conception. Misoprostol (a prostaglandin E1 analogue) is the most commonly used medication.

  • Mechanism: Misoprostol causes cervical softening and uterine contractions, leading to expulsion of uterine contents.
  • Administration: Typically administered orally or vaginally, with vaginal administration often having higher efficacy and fewer gastrointestinal side effects [55]. Dosing regimens vary based on gestational age and clinical guidelines.
  • Efficacy: High success rates (70-90%) for missed or incomplete miscarriages up to 12 weeks gestation. Success rates decrease with advancing gestational age.
  • Side Effects: Common side effects include abdominal cramping, heavy bleeding, nausea, vomiting, diarrhoea, and fever/chills. Patients need to be counseled on expected bleeding patterns and potential complications.
  • Advantages: Avoids surgery and anaesthesia, can be managed at home, and offers more control over timing compared to expectant management.
  • Disadvantages: Requires management of side effects, may still result in incomplete miscarriage requiring surgical intervention (around 10-30% of cases), and the process can be prolonged and emotionally difficult [55].

• Surgical Management: This involves procedures to physically remove the retained products of conception from the uterus. It is typically performed for incomplete or missed miscarriages, especially when there is heavy bleeding, signs of infection, or patient preference for a quicker resolution.

  • Vacuum Aspiration (Suction Curettage): The preferred surgical method for early miscarriage. A thin tube is inserted through the cervix, and suction is used to remove uterine contents. This can be performed under local anaesthesia with conscious sedation or general anaesthesia. It is generally quick, safe, and highly effective [56].
  • Dilation and Curettage (D&C): Involves dilating the cervix and using a sharp curette to gently scrape the uterine lining to remove retained tissue. While historically common, it is now less frequently used as a primary method for early miscarriage compared to vacuum aspiration due to a higher risk of complications (e.g., uterine perforation, Asherman’s syndrome) [57]. It may still be used in specific circumstances, such as larger gestations or when vacuum aspiration is not feasible.
  • Advantages: High success rates, immediate resolution, and predictable timing. It can be life-saving in cases of severe haemorrhage or infection.
  • Disadvantages: Invasive procedure requiring anaesthesia, potential risks include uterine perforation, infection, haemorrhage, cervical injury, and Asherman’s syndrome (intrauterine adhesions), which can affect future fertility. These risks are generally low but vary with operator experience and gestational age.
  • Pre-treatment: Cervical ripening agents (e.g., misoprostol) may be used prior to surgical evacuation, particularly in later first-trimester or second-trimester miscarriages, to facilitate cervical dilation and reduce procedural complications.

• Management of Recurrent Miscarriage: This is tailored to the identified underlying cause:

  • Genetic: For parental balanced translocations, genetic counselling is offered to explain recurrence risk. Options include natural conception with close monitoring, preimplantation genetic testing (PGT) with IVF, or use of donor gametes.
  • Hormonal: Progesterone supplementation for confirmed luteal phase defects (though evidence is limited for effectiveness in preventing miscarriage) or for specific subgroups (e.g., threatened miscarriage with bleeding) [20]. Thyroid hormone replacement for hypothyroidism. Metformin for PCOS, although its direct role in preventing miscarriage is debated.
  • Anatomical: Hysteroscopic septoplasty for septate uterus, hysteroscopic adhesiolysis for Asherman’s syndrome, or myomectomy for distorting fibroids. Cervical cerclage for cervical incompetence.
  • Immunological: Low-dose aspirin and prophylactic low molecular weight heparin for Antiphospholipid Syndrome [32]. Other controversial treatments for alloimmune factors (e.g., IVIG) are not routinely recommended.
  • Thrombophilic: Anticoagulation (e.g., low molecular weight heparin) for inherited thrombophilias that are strongly associated with recurrent pregnancy loss.
  • Lifestyle: Comprehensive counselling on smoking cessation, alcohol abstinence, weight management, and healthy lifestyle choices.

5.2 Physical Recovery

The physical recovery period after a miscarriage is comparable to that following childbirth, varying based on the gestational age and management method. Most individuals can expect:

• Vaginal Bleeding: Light to moderate bleeding, similar to a heavy period, for one to two weeks, gradually tapering off. Some spotting may persist for up to 4-6 weeks. It is important to advise patients on signs of excessive bleeding (e.g., soaking more than two pads per hour for several hours, passing large clots), which necessitate immediate medical attention.
• Cramping: Mild to moderate uterine cramping is common, similar to menstrual cramps, as the uterus contracts to return to its normal size. Pain relievers (e.g., ibuprofen) can help manage discomfort.
• Rest and Self-Care: Adequate rest is crucial. Hydration and a nutritious diet support the body’s healing process. Avoidance of tampons (to reduce infection risk) and vaginal intercourse for at least two weeks, or until bleeding has stopped and a follow-up visit confirms resolution, is usually recommended.
• Menstrual Cycle Return: The first menstrual period usually returns within 4 to 6 weeks, though it can vary. Ovulation may occur as early as 2 weeks post-miscarriage, so contraception should be considered if pregnancy is not desired immediately. For women desiring to conceive again, most healthcare providers recommend waiting for at least one normal menstrual cycle to allow for physical and emotional healing and accurate dating of a subsequent pregnancy [58].
• Warning Signs of Complications: Patients must be educated on signs requiring immediate medical attention, including: persistent heavy bleeding, fever (indicating infection), severe abdominal pain unresponsive to analgesics, foul-smelling vaginal discharge, and persistent symptoms of pregnancy (suggesting retained tissue).
• Follow-Up Care: A follow-up appointment is typically scheduled within 1-2 weeks to ensure complete physical recovery, confirm uterine evacuation (sometimes with ultrasound), check hCG levels (to ensure they are declining to negative), discuss contraception, and address any emotional concerns. This visit is also an opportunity to discuss potential investigations for recurrent miscarriage if applicable.

5.3 Emotional Recovery

The emotional impact of miscarriage is profound and often underestimated. It is a significant loss that can trigger a complex grief response, regardless of gestational age or prior reproductive history. The emotional recovery is highly individual and can be as challenging, if not more so, than the physical recovery.

• Grief and Loss: Miscarriage is a bereavement. Individuals and couples may experience a wide range of intense emotions, including sadness, shock, anger, guilt, shame, emptiness, anxiety, and depression. The grief can be particularly complex as the loss is often invisible to others, and societal recognition or rituals for pregnancy loss are often lacking, leading to disenfranchised grief [59]. Patients may grieve not only the loss of the pregnancy but also the loss of hopes, dreams, and the anticipated future with their child. Partners often grieve differently and may feel overlooked, leading to strain on the relationship.
• Impact on Identity and Future Pregnancies: Miscarriage can challenge a woman’s sense of identity as a prospective mother and lead to feelings of failure. Subsequent pregnancies are often associated with heightened anxiety, fear of recurrence, and a cautious optimism, often described as the ‘rainbow baby’ phenomenon (a healthy baby born after pregnancy loss) [60].
• Support Systems: Engaging with supportive partners, family, and friends is crucial. Open communication about feelings and needs can foster healing. It is important to encourage partners to express their grief and support each other.
• Professional Counseling: For many, professional psychological support is invaluable. Grief counselling, cognitive-behavioural therapy (CBT), or support groups can provide coping strategies, help process emotions, and address potential complications like depression, anxiety, or post-traumatic stress disorder (PTSD). Healthcare providers play a key role in screening for psychological distress and facilitating referrals to mental health professionals [61].
• Memorialization: For some, creating a way to remember the lost pregnancy (e.g., planting a tree, naming the baby, holding a small ceremony, keeping a memento) can be an important part of the grieving process and facilitate healing.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6. Psychological Support and Resources

Providing comprehensive psychological support is not merely supplementary but an essential component of holistic care for individuals and couples experiencing miscarriage. The emotional aftermath can be profound, and inadequate support can lead to long-term psychological distress.

6.1 Supportive Care

• Individualized Counseling: Tailored support delivered by mental health professionals specializing in grief and reproductive loss can significantly aid individuals in processing their experience. These professionals can employ various therapeutic approaches, such as grief counseling, trauma-informed care, or cognitive-behavioral therapy (CBT), to help patients navigate complex emotions, challenge maladaptive thoughts, and develop healthy coping mechanisms [62]. Counseling provides a safe space for expression without judgment and helps to normalize the grief experience.

• Support Groups: Connecting with others who have experienced similar losses can be incredibly therapeutic. Support groups, whether in-person or online, offer a unique environment for shared experiences, validation of feelings, and the exchange of coping strategies. They can reduce feelings of isolation, shame, and guilt, fostering a sense of community and understanding [63]. Many national and local organizations offer such groups, often facilitated by trained peers or professionals.

• Online Resources and Communities: The digital age has expanded access to support. Reputable websites, forums, and social media groups dedicated to pregnancy loss can provide information, peer support, and a platform for sharing personal stories. It is crucial, however, to guide patients towards credible sources to avoid misinformation or unhelpful advice.

• Memorialization and Remembrance: For many, acknowledging the lost pregnancy and creating rituals of remembrance can be a vital part of the healing process. This can take many forms: naming the baby, creating a memory box with ultrasound images or hospital bracelets, planting a tree, donating in their honor, or participating in remembrance ceremonies. These acts provide a tangible way to mourn and integrate the loss into one’s life story [64].

6.2 Role of Healthcare Providers

Healthcare providers (HCPs) are often the first point of contact and play a pivotal role in shaping the patient’s experience of miscarriage. Their approach to communication and care can significantly impact emotional recovery.

• Empathetic and Sensitive Communication: Using compassionate and clear language is paramount. HCPs should avoid euphemisms, acknowledge the significance of the loss, and validate the patient’s grief, regardless of gestational age or the perceived ‘early’ nature of the loss. Phrases like ‘I am so sorry for your loss’ or ‘This must be incredibly difficult for you’ are crucial. Providing clear explanations of medical procedures, potential complications, and what to expect physically and emotionally, helps reduce anxiety and empowers patients [65]. It’s important to ask open-ended questions about how the patient is feeling and what support they need.

• Information Provision: Offering written information about miscarriage, physical recovery, emotional coping, and available support resources can be very helpful, as patients may struggle to absorb information during moments of acute distress. This includes details about expected bleeding, pain management, warning signs, and when to seek further medical attention.

• Referral to Specialists: HCPs should be equipped to screen for signs of significant psychological distress (e.g., prolonged grief, depression, anxiety disorders, suicidal ideation) and facilitate timely referrals to mental health professionals, social workers, or specialized grief counselors. Collaboration between obstetric/gynaecology teams and mental health services (e.g., integrated behavioral health models) can ensure seamless and comprehensive care [66].

• Follow-Up Support: Emotional support should extend beyond the immediate clinical encounter. Follow-up calls or appointments can provide an opportunity to check on the patient’s emotional well-being, reiterate available resources, and address any lingering concerns. This demonstrates ongoing care and helps identify those who may be struggling in silence.

• Staff Training and Debriefing: Healthcare professionals themselves are exposed to repetitive loss and can experience emotional burnout. Training in grief counseling and communication skills, along with opportunities for debriefing and peer support, are vital for equipping HCPs to provide empathetic care while safeguarding their own well-being [67].

6.3 Partner Support

The grief experienced by partners (fathers or non-birthing parents) after a miscarriage is often overlooked and can manifest differently than the birthing parent’s grief. It’s crucial to acknowledge and support their experience as well.

• Validation of Grief: Partners may feel a need to be strong for their grieving partner and might suppress their own emotions. HCPs should explicitly include partners in discussions, acknowledge their loss, and invite them to share their feelings. Partners may grieve the loss of the child, the loss of shared dreams, and the distress of their partner [68].

• Information and Resources for Partners: Providing information specifically tailored for partners, outlining their potential emotional responses and available support resources (including partner-specific support groups or counseling), is important. They may benefit from understanding the physical recovery process of their partner to provide better practical support.

• Facilitating Communication within the Couple: Miscarriage can strain relationships. Encouraging open and honest communication between partners about their individual grief experiences and needs can help them support each other more effectively and prevent misunderstandings [69].

Many thanks to our sponsor Esdebe who helped us prepare this research report.

7. Conclusion

Miscarriage, a profoundly common yet often disenfranchised form of pregnancy loss, represents a multifaceted event with diverse aetiologies, demanding a comprehensive and nuanced approach to care. This report has meticulously detailed the various types of miscarriage, from the transient nature of threatened loss to the enduring implications of recurrent pregnancy loss, emphasizing the distinct clinical presentations and management considerations for each. The exploration of underlying causes highlights the intricate interplay of genetic abnormalities, hormonal dysregulation, anatomical impediments, immunological complexities, infectious agents, and various modifiable lifestyle factors, underscoring the necessity of a thorough diagnostic workup, particularly in cases of recurrent loss. While chromosomal aneuploidies remain the predominant cause of sporadic early miscarriages, a targeted investigation is crucial for identifiable and treatable causes in recurrent cases.

Effective management extends beyond the immediate physical resolution, whether through expectant, medical, or surgical approaches. It critically encompasses a holistic understanding of the physical recovery, which, while generally straightforward, requires careful monitoring for complications. Crucially, the emotional and psychological sequelae of miscarriage are profound and often long-lasting, demanding empathetic, sensitive, and sustained support. Healthcare providers bear a significant responsibility in fostering an environment of compassion, providing clear information, and facilitating access to essential psychological resources, including individual counseling and support groups, for both individuals and their partners. Acknowledging miscarriage as a legitimate form of bereavement and integrating robust psychosocial support into standard clinical practice is paramount for facilitating healing and improving the long-term well-being of those affected.

Continued research is vital to further unravel the unexplained causes of miscarriage, particularly recurrent pregnancy loss, and to develop more effective preventative and therapeutic strategies. Simultaneously, societal recognition and open dialogue about pregnancy loss are essential to destigmatize the experience, reduce isolation, and ensure that individuals and couples receive the understanding and support they deserve during what is often one of the most challenging experiences of their lives. By collectively addressing the physical, emotional, and psychological dimensions of miscarriage with comprehensive, compassionate, and evidence-based care, clinicians and support networks can profoundly enhance patient outcomes and facilitate the healing process for all who are affected.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

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