**Abstract**

Miscarriage also known as spontaneous abortion is the termination of pregnancy before the age of fetal viability or expulsion of fetus or embryo weighing less than 500g. It occurs naturally without any human intervention and complicates about 15–20% pregnancies globally. The age of fetal viability varies from country to country depending on the level of technological development and fetal salvage rate. The age of fetal viability in Norway is 16 weeks, in Australia its 20 weeks, 24 weeks in the UK, 26 weeks in Spain and Italy while in Nigeria the age of fetal viability is 28 weeks of gestation. Causes of miscarriage include morphologic/genetic/chromosomal abnormalities, immunological and endocrine factors, structural uterine anomalies, cervical incompetence, maternal infections and toxins. It is classified into threatened miscarriage, inevitable miscarriage, incomplete miscarriage, septic miscarriage, missed miscarriage and complete miscarriage. Miscarriage has profound and tremendous psychologic and emotional effects on mothers before or during subsequent gestations. Every effort must be made to show understanding and empathy.

**Keywords:** pregnancy loss, maternal health, miscarriage, women's health, introduction

## **1. Introduction**

Miscarriage also known as spontaneous abortion is the termination of pregnancy before the age of fetal viability or expulsion of fetus or embryo weighing less than 500g. It occurs naturally without any human intervention and complicates about 15–20% pregnancies globally. The age of fetal viability varies from country to country depending on the level of technological development and fetal salvage rate. The age of fetal viability in Norway is 16 weeks, in Australia its 20 weeks, 24 weeks in the UK, 26 weeks in Spain and Italy while in Nigeria the age of fetal viability is 28 weeks of gestation. Causes of miscarriage include morphologic/genetic/chromosomal abnormalities, immunological and endocrine factors, structural uterine anomalies, cervical incompetence, maternal infections and toxins. Miscarriage can be classified into threatened miscarriage, inevitable miscarriage, incomplete miscarriage, septic miscarriage, missed miscarriage, complete miscarriage and recurrent miscarriage. It profoundly affects the women. This chapter methodology derives from a synthesis of the available literature under the MESH search term miscarriage and focus group discussion of women attending a tertiary health facility in Southern Nigeria.

### **2. Miscarriage and maternal morbidity**

Miscarriage can profoundly affect the health and wellbeing of the mother, either from the complications of the process itself or from the complications

### *Complications of Pregnancy*

arising from the treatment and management of the condition or both depending on the stage of the pregnancy, the abortion type, the management instituted, the facility, the skill/expertise and quality of the care giver and the mother's prepregnancy/pre-miscarriage health condition.

The complications can arise early, during or just after the process or manifest much later following the abortion process, also depending on several factors.

### **2.1 Early morbidities**

### *2.1.1 Hemorrhage*

 Genital bleeding during or following miscarriage may be slight especially in early 1st trimester, but can also be severe and torrential with disastrous consequences in the second trimester when there is increased risk of placenta retention. This may occur more commonly in the developing countries like Nigeria where mothers may not present to health facilities for optimal management due to ignorance, illiteracy, poverty, non-availability or poor accessibility to health care facilities especially women in remote areas. Even when they do, they may present late to the health facility, at that further complications including severe anemia, sepsis, shock etc. may have set in, worsening maternal health and making management difficult in resource poor setting.

Management entails controlling the bleeding with use of oxytocics and delivery of the placenta by skilled and experienced care provider either by careful controlled cord traction or piece meal removal with sponge holding forceps and antibiotic therapy.

### *2.1.2 Anemia*

 Anemia may occur more commonly from hemorrhage or occasionally from sepsis due to hemolysis or both. Management of anemia in developing countries, especially when severe, may be particularly difficult because of the problems enumerated earlier. Even when mothers access health facility, there may not be blood banking services or when available may not be functioning optimally because of endemic problems of electricity and corruption with its negative multiplier effects in sub-Saharan Africa.

### *2.1.3 Septic incomplete abortion*

Incomplete miscarriage occurs when some of the products of conception have been expelled while some are still retained in the uterus. This may cause bleeding which may range from mild to severe, causing blood loss anemia that may require blood transfusion. When bleeding is severe and not properly managed in time, post abortal pituitary necrosis resulting in Sheehan's syndrome may occur, which later causes infertility which causes infertility later.

When some of the products of conception have been expelled and some retained, as may happen at gestational age 10 and above, this becomes substrate for microbial colonization and eventual infection. This infection may become severe causing systemic effects like fever, vomiting and prostration. Long term complications will include Asherman's syndrome, chronic pelvic inflammatory disease, frozen pelvis and infertility as discussed in late maternal morbidities. Septicemia may occur and if not properly managed may result in multiple organ injury with sequelae.

### *2.1.4 Post-abortal sepsis*

Post abortal sepsis usually results from complete miscarriage managed with inadequate or without prophylactic antibiotics. It may also occur if incomplete miscarriage is evacuated in an unhygienic environment or by unskilled care provider.

 Mothers may present days, weeks or even months following miscarriage with varying degrees of abdominal pain, vaginal discharge or subfertility. These can be distressing and negatively affected maternal health. This can lead to loss of man hours in work place, school resulting in economic loss. Marital disharmony may also arise from infertility especially in sub-Saharan Africa where high premium is placed on child bearing. There is also a huge burden on health care delivery occasioned by these health challenges.
