Transvaginal ultrasound scan is the mainstay of diagnosis of miscarriage. Evidence based criteria should be fulfilled in all cases, with interval scans as needed to avoid inadvertent interventions when the pregnancy may be viable. Incomplete, inevitable and complete miscarriages have specific ultrasound findings. Several ultrasound factors, including slow embryonic heart rate, small embryo or gestation sac size and an enlarged yolk sac, alone or in combination, help predict impending pregnancy loss. Uterine factors such as fibroids, adenomyosis and adhesions after previous caesarean birth may make ultrasound assessment for early pregnancy more challenging.

This chapter discusses the common occurrence of miscarriage in pregnancy and reviews the current genetic methodologies, from cytogenetics to genomics, available to aid individuals and families suffering from pregnancy loss. While often unexplored, a genetics evaluation should be offered in all cases of pregnancy loss given the high diagnostic yield and therapeutic value of providing families with answers. This chapter walks the reader through the available technologies to evaluate chromosome content, which provide an explanation for approximately half of pregnancy losses, as well as current and future genetic and genomic evaluations that can be used to further increase diagnostic yield and identify couples at increased risk of recurrence.

Progesterone is an endogenous hormone which is derived from cholesterol steroids. It is secreted in women principally by the corpus luteum in the ovaries during normal menstrual cycles. Progesterone exerts a number of essential effects vital for the support and maintenance of a pregnancy. The role of progesterone in threatened and recurrent miscarriage was a matter of debate for many decades, until the findings of the PROMISE and PRISM trials. Vaginal micronized progesterone may increase the live birth rate for women with a history of one or more previous miscarriages and early pregnancy bleeding, with likely no difference in adverse events. There remains an uncertainty over the effectiveness and safety of alternative progestogen treatments for threatened and recurrent miscarriage.

Pregnancy loss (PL) is a common complication in early pregnancy, occurring in ~25% of recognized pregnancies. Standard medical care after PL traditionally focuses on emptying of the fetus from the uterus. Historically the emotional impact of PL has been overlooked. However, research shows that PL has a negative psychological impact on women’s and their partner’s well-being, and that patients wish for post-PL care that attends to their emotional and psychological needs as well. This chapter summarizes the latest research on the psychological impact of PL, patient preferences for medical and supportive care after PL and in a new pregnancy and provides recommendations for care. Psychological impact and support after ectopic pregnancies and late pregnancy losses > 24 weeks are not specifically addressed in this chapter. Health care staff providing care to those with PL should be educated about the psychological impact of PL including that a first PL can cause emotional distress for both partners and that the psychological burden can increase with multiple losses. Informing patients that their emotional reactions to the PL are normal and to be expected without diminishing their impact is crucial. Information provision and empathic and sensitive communication is valued by patients and their partners. Structural changes are also needed to facilitate continuity in care and follow-up in order to promote overall well-being after PL.

Recurrent pregnancy loss (RPL) is a distressing condition affecting around 1-2% of women, with no universally accepted definition and many unanswered questions remaining. Causes associated with RPL include chromosomal abnormalities, anatomical uterine defects, autoimmune disorders and endometrial dysfunction. Nevertheless, around 50% of women with RPL have unexplained aetiology. This results in highly challenging and complex cases for clinicians to manage and a significant psychological impact on the couples experiencing it. Although numerous tests and treatment options have been suggested over the years, the evidence surrounding some of them is weak at best and remain controversial. Here we discuss these investigations in more detail.

Subchorionic hematoma is a common ultrasound finding in pregnant patients presenting with first-trimester bleeding or found on routine pregnancy ultrasound. Patients may be asymptomatic or have light vaginal bleeding not associated with pain or cramps. On ultrasound, a subchorionic hematoma appears as a crescent-shaped fluid collection between the chorionic membranes and the decidua. Studies show that this finding can be associated with a higher risk of miscarriage and pregnancy loss, preterm delivery, and preterm premature rupture of membranes. No intervention has been shown to reduce this risk. This finding can be associated with stress and anxiety to the expecting parents. The cause is not well understood and most resolve spontaneously by the second trimester. Management for small subchorionic hematomas is conservative with counseling and follow up at routine visits. Larger subchorionic hematomas can be followed more frequently.

Trauma occurs when the ability to envisage our future and feel safe in the world is no longer possible. While trauma is often a one-time horrific occurrence, it can also be chronic in nature.Indeed, reproductive trauma can encompass both types of anguish: the frightening and painful loss of a miscarriage, with massive bleeding and the potential need for surgery, or the seemingly endless cycle of hope and despair during fertility treatments. Sadly, for our patients, it is not uncommon to experience both infertility and pregnancy loss, and like a soldier on the battlefield, it can be protracted, leaving deep psychological wounds. This chapter not only explores the trauma that occurs in reproductive patients, but also how we, as fertility counselors, cope with being on the battlefield with them.

Fertility counselors see an array of clients who may be diverse in terms of countries of origin, ethnicity, race and/or cultural background. This chapter identifies principles to guide this conversation. These principles include understanding how we consider race, ethnicity and culture, and emphasize the importance of not essentializing race, ethnicity and culture. The chapter continues with a brief overview of the meaning and consequences of infertility in various places worldwide and among migrant and racial minorities in particular, how this can affect access to, use of and experiences with fertility treatments and assisted reproductive technologies (ARTs). Finally, we offer considerations for racially and culturally sensitive clinical approaches in fertility counseling.

Trauma occurs when the ability to envisage our future and feel safe in the world is no longer possible. While trauma is often a one-time horrific occurrence, it can also be chronic in nature.Indeed, reproductive trauma can encompass both types of anguish: the frightening and painful loss of a miscarriage, with massive bleeding and the potential need for surgery, or the seemingly endless cycle of hope and despair during fertility treatments. Sadly, for our patients, it is not uncommon to experience both infertility and pregnancy loss, and like a soldier on the battlefield, it can be protracted, leaving deep psychological wounds. This chapter not only explores the trauma that occurs in reproductive patients, but also how we, as fertility counselors, cope with being on the battlefield with them.

Recurrent pregnancy loss (RPL) is defined as the consecutive or non-consecutive loss of two or more pregnancies before viability. Established, contributory and postulated causes for RPL include advanced maternal age, anti-TPO antibodies, antiphospholipid antibodies, Müllerian anomalies, parental chromosomal aberrations, inherited thrombophilia and alloimmunity. Recommended investigations include thyroid screening, testing for antiphospholipid antibodies and imaging of the uterus. A thorough reproductive history can guide investigation to include tailored tests (e.g. metabolic and genetic profile). Despite investigation, no cause is found in about 50% of RPL cases.

Thyroid dysfunction should be treated, antiphospholipid antibodies are managed with low-dose aspirin and heparin in a subsequent pregnancy and an intrauterine septum should be resected.

Maternal age and number of prior losses are the major determinants for the prognosis of a subsequent pregnancy. Pregnancies after RPL should be managed as high-risk.

Chapter 7 looks at the distinctive ways in which people whose states of minds have been altered by traumatic events and psychological disorders make use of embodied metaphor. It looks at how stress, anxiety and depression affect the ways in which people experience and interact with embodied metaphor, and introduces work that has explored how people’s experience of embodied metaphor is shaped by the experience of pregnancy loss. It also focuses on psychological conditions, including autistic spectrum disorders, Asperger syndrome and schizophrenia, and explores the ways in which individuals with schizophrenia employ embodied metaphor. It draw parallels between these different states of mind and conditions and identifies common traits in terms of how they impact on the types of metaphors that people employ and the ways in which they employ them.