CHAPTER 31 Threatened Miscarriage

‘Threatened miscarriage’ refers to a collection of symptoms and signs experienced by a pregnant woman usually (but not always) during the first 3 months of pregnancy. ‘Threatened miscarriage’ is a Western medical term. In Chinese medicine, the two disease categories of ‘Vaginal Bleeding during Pregnancy’, called Tai Lou (), and ‘Restless Fetus’, called Tai Dong Bu An (), correspond to threatened miscarriage.

An actual miscarriage that occurs in the first 3 months is called duo tai (), which means ‘falling fetus’; if it occurs after 3 months, it is called xiao chan () or ban chan (), which mean ‘small labour’ and ‘half labour’ respectively. See also the discussion of habitual miscarriage in Chapter 43.

Thus, three conditions may be identified in Chinese medicine: ‘Vaginal Bleeding during Pregnancy’, ‘Restless Fetus’ and ‘Miscarriage’. These three conditions represent different stages of the same process: in the first two stages, the fetus has not yet been damaged and miscarriage can be prevented, while in the third stage the fetus has been injured or has already left the uterus and miscarriage cannot be prevented.

From a Western perspective, ‘Vaginal Bleeding during Pregnancy’ corresponds to ‘threatened abortion’ and ‘Restless Fetus’ may correspond to either ‘threatened abortion’ or to ‘inevitable abortion’ (see the end of this chapter). Thus, interestingly, the ancient Chinese were well aware of the different prognosis of these two clinical conditions, the latter indicating a worse prognosis.

I shall refer to the two Chinese disease categories of ‘Vaginal Bleeding during Pregnancy’ and ‘Restless Fetus’ together as ‘threatened miscarriage’. There are, however, differences between these two conditions: in ‘Vaginal Bleeding during Pregnancy’, vaginal bleeding is scanty and is the only symptom, while in ‘Restless Fetus’, besides vaginal bleeding, there is also backache, abdominal pain and a bearing-down feeling.

• ‘Vaginal Bleeding during Pregnancy’: scanty vaginal bleeding

• ‘Restless Fetus’: vaginal bleeding, backache, abdominal pain, bearing-down feeling

With regard to vaginal bleeding, however, it should be remembered that a slight bleeding a few weeks after becoming pregnant sometimes occurs without consequence and does not necessarily indicate a threatened miscarriage. This was called in old China ‘swimming menses’ (you jing ).

Finally, habitual miscarriage was called Hua Tai (), which means ‘slippery fetus’. To summarize, the various Chinese terms referring to miscarriage or threatened miscarriage are as follows (in order of severity):

• You Jing, ‘Swimming Menses’: a harmless vaginal bleeding during the first month of pregnancy.

• Tai Lou, ‘Vaginal Bleeding during Pregnancy’: threatened miscarriage, with vaginal bleeding.

• Tai Dong Bu An, ‘Restless Fetus’: threatened miscarriage, with vaginal bleeding, backache, abdominal pain and a bearing-down feeling.

• Duo Tai, ‘Falling Fetus’: miscarriage within the first 3 months.

• Xiao Chan or Ban Chan, ‘Small Labour’ or ‘Half Labour’: miscarriage after 3 months.

• Hua Tai, ‘Slippery Fetus’: habitual miscarriage (Fig. 31.1).

Figure 31.1 Chinese terms referring to miscarriage or threatened miscarriage.

This chapter will deal with the treatment of threatened miscarriage, i.e. the treatment of a pregnant woman who experiences vaginal bleeding and abdominal pain. The treatment of habitual miscarriage, i.e. the treatment of a woman before she becomes pregnant, is outlined in Chapter 43.

Aetiology and pathology

The pathology of threatened miscarriage is essentially a weakness of the Directing and Penetrating Vessels (Ren and Chong Mai) which fail to gather Blood and nourish the fetus. Since the Penetrating Vessel is the Sea of Blood and the Directing Vessel influences the fetus, a weakness of these two vessels leads to a deficiency of Blood and of the Kidneys nourishing the fetus: the Original Qi of the fetus becomes weak, the fetus cannot grow properly and threatened miscarriage or miscarriage results.

A weakness of the Directing and Penetrating Vessels is associated with a deficiency of the Kidneys: other related pathologies may be deficiency of Blood, deficiency and sinking of Qi, and Blood-Heat.

The main aetiological factors are as follows.

Overwork, excessive physical work

Overwork in the sense of working long hours without adequate rest for many years weakens Kidney-Yin, while excessive physical work including excessive lifting, sports or exercises, injures Kidney-Yang. The deficiency of the Kidneys may lead to weakening of the Directing and Penetrating Vessels and, in a pregnant woman, to threatened miscarriage.

Chronic illness, irregular diet

A long, chronic illness or a diet lacking in nourishment may lead to Qi and Blood deficiency. A deficiency of Qi affects the fetus’s strength, while deficient Blood fails to nourish the fetus’s Original Qi and threatened miscarriage may result. In particular, when there is Qi deficiency, vaginal bleeding results.

Emotional problems, irregular diet, febrile disease

Emotional problems such as worry, anger, frustration and resentment may lead to stagnation of Liver-Qi and, after a long time, this may turn into Liver-Fire; as the Liver stores Blood, Liver-Fire often causes Blood-Heat. A diet including an excessive amount of hot, pungent foods such as spices, curries and alcohol may also lead to Liver-Fire or Blood-Heat.

The Jade Ruler of Gynaecology (1774) says: “If a woman eats too many hot and pungent foods during pregnancy, they injure the Directing and Penetrating vessels.”¹ A febrile disease may also lead to Blood-Heat if it is not stopped at the Defensive Qi or Qi levels. Whatever the origin, Blood-Heat affects the Penetrating Vessel (which is the Sea of Blood) and the Uterus and placenta and may cause or threaten a miscarriage.

Falls, jumps, traumas

A sharp fall or jump or a trauma may all injure the Directing and Penetrating Vessels in a pregnant woman and lead to or threaten miscarriage. The Foundations of Medicine (1575) says: “If a pregnant woman jumps from a high place or lifts heavy objects, it may injure the fetus’s Original Qi.”²

Excessive sexual activity during pregnancy

Excessive or too vigorous sex during the first 3 months of pregnancy may be a cause of miscarriage akin to trauma. Although sexual intercourse during the first 3 months is not forbidden according to Chinese medicine (except for Fu Qing Zhu), it should be less frequent and less vigorous than normal. The Jade Ruler of Gynaecology (1774) says: “Many miscarriages are due to the husband having an insatiable desire for indulging in excessive sexual intercourse and to the wife liking sex a lot.”³

Wu Qian, the author of the Golden Mirror of Medicine (1742), gives prognostic guidelines for threatened miscarriage. He says that if the mother’s face is red and her tongue blue, it indicates imminent miscarriage; if her face is blue and her tongue red, the mother’s life is in danger; if both the face and tongue are blue, both the mother and the fetus are in danger of death.⁴

Chinese medicine books differentiate between threatened miscarriage and miscarriage, ‘Surging Periods’ and phantom pregnancy. During an actual miscarriage the vaginal bleeding is much more profuse than in threatened miscarriage and it is with clots: in addition, the abdominal pain is much more severe. ‘Surging Periods’ in Chinese medicine indicates the phenomenon whereby some women can continue to have periods for 2–3 months after becoming pregnant without any ill effect and without any other symptom. In some cases of phantom pregnancy, there may be morning sickness, vomiting, vaginal bleeding (sometimes with clots which Chinese books describe as tadpoles) and abdominal pain.

Abdominal pain towards the end of term does not usually indicate the possibility of miscarriage. In fact, Wu Qian says that abdominal pain that goes on for a short time and then stops during the eighth or ninth month, is called ‘Testing Fetus’ (shi tai ) and in this case one should nourish Blood and ‘calm the fetus’. If towards the end of term there is an intermittent abdominal pain without backache, this is called ‘Playing Fetus’ (nong tai ).

Identification of patterns and treatment

The first thing to establish when treating threatened miscarriage is that the fetus is still alive. It is therefore imperative that the woman is seen by an experienced gynecologist for tests. If the fetus is dead, the patient should obviously be hospitalized for a termination.

Whatever the cause and pathology of threatened miscarriage, the main treatment principle is always to ‘calm the fetus’ and strengthen the Directing and Penetrating Vessels. As explained in the introduction to Section 6, ‘calming the fetus’ should not be interpreted literally: in fact, the movement of the fetus is a good sign in threatened miscarriage. Thus, calming the fetus means using treatments that nourish the Original Qi of the fetus and strengthen the Kidneys and consolidate the Penetrating and Directing Vessels of the mother. These are precisely the treatments one wants to use in threatened miscarriage. Indeed, there are many herbs that have a long tradition of empirical application in threatened miscarriage.

The Chinese term for threatened miscarriage is ‘fetus moving and restless’ (literally ‘not at peace’), hence the use of the term ‘calming the fetus’. Of course, from a Western point of view, movement of the fetus is normal and in fact a sign that all is well. However, it is also true to say that if a previously quiet fetus suddenly becomes restless, it is not a good sign, and this is perhaps what the Chinese meant by ‘restless fetus’.

In addition to these treatment principles, others should be adopted according to the condition: these may include tonifying the Kidneys, nourishing Blood, tonifying and raising Qi and cooling Blood. The main herbs that ‘calm the fetus’, i.e. stop miscarriage, are:

• Sang Ji Sheng Herba Taxilli

• E Jiao Colla Corii asini

• Xu Duan Radix Dipsaci

• Du Zhong Cortex Eucommiae

• Huang Qin Radix Scutellariae

• Zi Su Ye Folium Perillae

• Sha Ren Fructus Amomi

• Tu Si Zi Semen Cuscutae

• Ai Ye Folium Artemisiae argyi

• Lian Fang Receptaculum Nelumbinis

• Bai Zhu Rhizoma Atractylodis macrocephalae

• Zhu Ma Gen Radix Boehmeriae

• Huang Qi Radix Astragali.

As can be seen, these herbs are from disparate categories and there is little to link them except the empirical research of past Chinese doctors. Obviously, when choosing herbs that calm the fetus, one would choose those that would also be appropriate to the pattern treated. For example, if threatened miscarriage were due to Kidney-Yang deficiency, one would naturally choose Du Zhong, Xu Duan or Tu Si Zi; were it due to Blood deficiency, one would opt for E Jiao and Sang Ji Sheng; were it due to Heat, Huang Qin; and so on.

However, in every case one would have to select at least one herb that tonifies Kidney-Yang in order to strengthen the Governing Vessel and the raising action of Yang because miscarriage is characterized by a Yin, descending movement. Tu Si Zi is a particularly important herb for threatened miscarriage because it is also astringent. Dr Cong Chun Yu, author of Chinese Medicine Gynaecology, advocates always using Tu Si Zi in threatened miscarriage for which he says it is the most important herb: he recommends its use in high doses and he says that he uses up to 150 g daily!⁵

When treating a pregnant woman with herbs, when tonifying, one should avoid using hot, pungent herbs and also herbs that make Qi descend; when regulating Qi, one should avoid fragrant, dying herbs; when clearing Heat, one should avoid too bitter, cold herbs; when invigorating Blood, one should avoid herbs that ‘break’ Blood, herbs that promote bowel movement and urination, and toxic herbs.

Also, there are three treatment methods that should not be used in pregnant women, especially in threatened miscarriage: one should not cause sweating because this may lead to collapse of Yang; one should not move downwards (promote bowel movement) because it may lead to collapse of Yin; and one should not promote urination (with herbs that drain Dampness via urination such as Yi Yi Ren Semen Coicis) as this may injure Body Fluids.

The patterns discussed are as follows:

• Kidney deficiency

• Qi and Blood deficiency

• Falls, traumas.

Kidney deficiency

Clinical manifestations

Threatened miscarriage early in the pregnancy, lumbar soreness, scanty vaginal bleeding, dizziness, exhaustion, frequent urination. Tongue: Pale if there is Kidney-Yang deficiency; without coating in a case of Kidney-Yin deficiency; without coating and Red if there is Empty-Heat. Pulse: Deep and Weak in a case of Kidney-Yang deficiency; Floating-Empty in a case of Kidney-Yin deficiency.

This pattern consists essentially in a weakness of the Directing and Penetrating Vessels and may manifest with Kidney-Yang or Kidney-Yin deficiency. However, even if there is Kidney-Yin deficiency, Kidney-Yang should be tonified as it needs the Yang action and the influence of the Governing Vessel (Du Mai) to prevent the downward movement of the fetus. In other words, in threatened miscarriage or miscarriage there is obviously always some sinking of Qi causing a downward movement of the fetus: to counteract such downward movement, we must tonify Yang and strengthen the Directing, Penetrating and Governing Vessels with Kidney-Yang tonics.

Treatment principle

Tonify the Kidneys (Yang or Yin), strengthen the Governing, Directing and Penetrating Vessels, calm the fetus.

Acupuncture

BL-20 Pishu, BL-23 Shenshu, Du-20 Baihui, Ren-12 Zhongwan (if within 3 months), ST-36 Zusanli, KI-3 Taixi, Qimen (extra point, 3 cun lateral to Ren-4). All with reinforcing method: moxa is applicable in Kidney-Yang deficiency.

Explanation

– BL-20 tonifies the Spleen and raises Qi.

– BL-23 and KI-3 tonify the Kidneys.

– Du-20 raises Qi to counteract the downward movement of the fetus.

– Ren-12, in conjunction with Du-20, raises Qi.

– ST-36 tonifies Qi and Blood in general.

– Qimen, only with moxa cones, strengthens the Uterus and prevents miscarriage. This point is situated level with Ren-4 Guanyuan and three cun from the midline. Please note that although this point’s pinyin name sounds the same as that of LIV-14 Qimen, in Chinese it is written with different characters and it means ‘Door of Qi’. Using a point in the lower abdomen runs counter to the advice against using points in this region during pregnancy: however, when a miscarriage is threatened, the use of some of the points in this region, especially with direct moxa, is indicated.

Herbal treatment

c. Prescription

– AN TAI YIN

– Calming the Fetus Decoction

Women’s Treasure remedy

– PLANTING SEEDS

This remedy tonifies and raises Qi, nourishes Blood, tonifies Kidney-Yang and calms the fetus. It can be used for threatened miscarriage in the presence of the above patterns. The tongue presentation appropriate to this remedy is a Pale body.

Kidney deficiency

Clinical manifestations

Threatened miscarriage early in the pregnancy, lumbar soreness, scanty vaginal bleeding, dizziness, exhaustion, frequent urination. Tongue: Pale if there is Kidney-Yang deficiency; without coating in a case of Kidney-Yin deficiency; without coating and Red if there is Empty-Heat. Pulse: Deep and Weak in a case of Kidney-Yang deficiency; Floating-Empty in a case of Kidney-Yin deficiency.

Treatment principle

Tonify the Kidneys (Yang or Yin), strengthen the Governing, Directing and Penetrating Vessels, calm the fetus.

Acupuncture

BL-20 Pishu, BL-23 Shenshu, Du-20 Baihui, Ren-12 Zhongwan (if within 3 months), ST-36 Zusanli, KI-3 Taixi, Qimen (extra point). All with reinforcing method: moxa is applicable in Kidney-Yang deficiency.

Women’s Treasure remedy

• PLANTING SEEDS

Qi and Blood deficiency

Clinical manifestations

Threatened miscarriage towards the end of 3 months, scanty vaginal bleeding with blood that is pale and dilute, tiredness, weariness, palpitations, pale complexion. Tongue: Pale. Pulse: Fine, Weak or Empty.

Treatment principle

Tonify and raise Qi, nourish Blood, consolidate the Directing and Penetrating Vessels, calm the fetus.

Herbal treatment

d. Prescription

– YI QI YANG XUE TANG

– Benefiting Qi and Nourishing Blood Decoction

Modifications

One would need to add some Blood tonics to the above prescriptions, such as Shou Wu Radix Polygoni multiflori preparata and E Jiao Colla Corii asini (if not already in the formula). The latter is particularly applicable as it also stops miscarriage.

• If the vaginal bleeding is profuse, add Ai Ye Folium Artemisiae argyi and Xian He Cao Herba Agrimoniae.

• If the abdominal pain is pronounced, add Bai Shao Radix Paeoniae alba and Gan Cao Radix Glycyrrhizae.

• If the woman is very worried and this is affecting the Liver and Spleen, add Chai Hu Radix Bupleuri and Chen Pi Pericarpium Citri reticulatae.

• If there is morning sickness and vomiting, add Sheng Jiang Rhizoma Zingiberis recens and Zhu Ru Caulis Bambusae in Taeniam.

• If there is poor appetite and loose stools and the tongue has a sticky coating, add Sha Ren Fructus Amomi, Shan Yao Rhizoma Dioscoreae and Fu Ling Poria.

e. Prescription

– EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai ⁷

Explanation

– Jing Jie and Qiang Huo raise the fetus.

– Chuan Bei Mu facilitates natural labour.

– Dang Gui, Chuan Xiong and Bai Shao nourish and harmonize Blood.

– Zhi Ke and Hou Po regulate Qi and open the chest. The freeing of Qi in the chest facilitates the raising of Qi.

– Ai Ye warms the Uterus.

– Huang Qi and Gan Cao tonify and raise Qi.

– Sheng Jiang warms the Centre and restores the normal direction of flow of Qi.

– Tu Si Zi tonifies the Kidneys and consolidates the fetus.

Qi and Blood deficiency

Clinical manifestations

Threatened miscarriage towards the end of 3 months, scanty vaginal bleeding with blood that is pale and dilute, tiredness, weariness, palpitations, pale complexion. Tongue: Pale. Pulse: Fine, Weak or Empty.

Treatment principle

Tonify and raise Qi, nourish Blood, consolidate the Directing and Penetrating Vessels, calm the fetus.

ST-36 Zusanli, Ren-12 Zhongwan (if within three months), BL-20 Pishu, BL-17 Geshu, BL-18 Ganshu, BL-23 Shenshu, LIV-8 Ququan. All with reinforcing method; moxa is applicable.

Blood-Heat

Clinical manifestations

Threatened miscarriage early in the term, scanty vaginal bleeding that is bright red, feeling of heat, thirst, mental restlessness, insomnia, dark urine. Tongue: Red with yellow coating. Pulse: Rapid, Overflowing.

Treatment principle

Clear Heat, cool Blood, calm the fetus.

Herbal treatment

b. Prescription

– LI QI XIE HUO TANG

– Freeing Qi and Clearing Fire Decoction

Explanation

This formula is from Fu Qing Zhu’s Gynaecology. He recommends it for threatened miscarriage caused by Liver-Fire deriving from anger. He says:

The Liver stores Blood, anger prevents it from storing [Blood]. Although the Liver pertains to Wood, within Wood there is a dragon-thunder Fire which is the Minister Fire. The Minister Fire should be quiet and not agitated: if it is quiet, there is tranquillity, if it is agitated, it burns. Because Wood has such Fire within it, it is easily agitated and seldom quiet. In people’s lives not a day goes by that this Fire is not stirred. Violent anger stirs this Fire even more … This Fire cannot generate Qi and nourish the fetus, on the contrary it eats Qi and injures the Essence; when the Essence is injured the fetus cannot grow and this may cause miscarriage.⁸

– Ren Shen and Bai Zhu tonify Qi and prevent miscarriage.

– Gan Cao harmonizes.

– Shu Di Huang, Dang Gui and Bai Shao nourish Blood and pacify the Liver.

– Qian Shi is astringent and prevents miscarriage.

– Huang Qin clears Heat and prevents miscarriage.

d. Prescription

– QING RE YANG YIN TANG

– Clearing Heat and Nourishing Yin Decoction

Explanation

This formula is used if there is Kidney-Yin deficiency.

– Sheng Di Huang, Huang Qin, Di Gu Pi, Zhi Mu, Mai Men Dong and Bai Shao nourish Yin and clear Empty-Heat.

– Du Zhong and Xu Duan strengthen the Uterus, consolidate the Directing and Penetrating Vessels and calm the fetus.

– E Jiao and Sang Ji Sheng nourish Blood and calm the fetus.

Falls, traumas

Clinical manifestations

Threatened miscarriage following a fall or a trauma, abdominal pain, scanty vaginal bleeding. Tongue: normal. Pulse: normal.

Treatment principle

Tonify Qi, harmonize Blood, consolidate the Directing and Penetrating Vessels, calm the fetus.

Acupuncture

Du-20 Baihui, Ren-12 Zhongwan, P-6 Neiguan, SP-10 Xuehai, KI-6 Zhaohai on the right and LU-7 Lieque on the left, Du-3 Yaoyangguan. Du-20 and Ren-12 should be needled with reinforcing method and the others with even method.

With acupuncture, the treatment is essentially on the one hand to tonify and raise Qi (with Du-20 and Ren-12) as a fall may cause sinking of Qi in a pregnant woman, and on the other hand to invigorate Blood as traumas often cause Blood stasis.

Herbal treatment

c. Prescription

– SHENG HUA TANG Variation

– Generating and Transforming Decoction Variation

Modifications

• In a case of miscarriage when there is always the danger of profuse bleeding, it is wise to add herbs which invigorate Blood and stop bleeding simultaneously such as Qian Cao Gen Radix Rubiae and San Qi Radix Notoginseng. If necessary, and if bleeding is profuse, one can also give the powder Yun Nan Bai Yao.

• Acupuncture can also be used to stimulate the expulsion of the products of conception with the following points:

• L.I.-4 Hegu, LIV-3 Taichong, SP-6 Sanyinjiao, BL-67 Zhiyin and BL-54 Zhibian, all with reducing method and possibly electrical stimulation.

Prognosis and prevention

The prognosis in threatened miscarriage depends entirely on the stage the process has reached (see below). If the miscarriage is just threatened, the os of the cervix is not dilated, there is no abdominal pain, the fetus is detected on the ultrasound scan and its heart can be detected with the Doppler test, then the prognosis is good. Half of the miscarriages are due to a chromosomal or structural deformity of the fetus and, in such cases, no treatment will be able to arrest a miscarriage.

As we would not know this in the beginning stages, the sensible approach is to treat a woman in these situations irrespective of the cause: if the miscarriage is threatened because of an abnormality of the fetus, it will necessarily occur; if not, there is at least a chance of stopping it. On the other hand, the woman need not fear that acupuncture or Chinese herbs may help to carry the pregnancy to term even if there is an abnormality of the fetus, as this is not the case.

From a Chinese perspective, the back soreness and abdominal pain are reliable prognostic indicators. Ever since early times the severity of the back soreness has been related to prognosis of threatened miscarriage. The Complete Works of Jing Yue (1624) says:

In women the Kidneys are in relation with the Uterus and the Kidneys also control the back. If there is severe backache in pregnancy it indicates imminent miscarriage which cannot be prevented.¹¹

In fact, there is a strong relationship between the severity of sacral pain and abdominal pain and the prognosis in threatened miscarriage: the stronger the sacral and/or abdominal pain, the worse the prognosis. Thus, when treating a woman for threatened miscarriage with abdominal and/or sacral soreness, a decrease in these two pains indicates that a miscarriage can be averted.

Western view

The possible causes of spontaneous abortions are discussed in Chapter 43 on habitual miscarriage.

Abortion can be classified as threatened, inevitable, incomplete, complete or missed.

Threatened abortion

In threatened abortion, the cervix is closed and there is only a small amount of vaginal bleeding. The uterine size is that expected for the gestational age and, if the pregnancy is at least 10 weeks old, the fetal heart may be detected with a Doppler monitor. An ultrasound scan will reveal an amniotic sac and fetus and the fetal heart can be seen pulsating if the pregnancy is at least 7 weeks old. Repeated scanning can monitor the growth of the fetus from about 8 mm at the sixth week to about 90 mm in the fourteenth week. The treatment consists only of rest and sometimes the administration of smooth-muscle relaxants. The clinical distinction between threatened abortion and inevitable abortion is based on the undilated os of the cervix, the absence of abdominal pain and the slight degree of bleeding. If the bleeding increases progressively, the prognosis is bad.

Inevitable abortion

If abortion has become inevitable, the cervix is open, the vaginal bleeding is more profuse and there is abdominal pain caused by rhythmical uterine contractions. At this stage, the pregnancy cannot continue and the abortion will be either incomplete or complete.

Incomplete abortion

In an incomplete abortion, the fetus and amniotic fluids are discharged but parts of the placental and chorionic tissue are retained. At this stage, there will also be severe abdominal pain and very profuse bleeding with passing of large clots or tissue. The os of the cervix is open, the fetal heart cannot be detected with a Doppler monitor and an ultrasound scan will reveal no fetus. The treatment consists in suction curettage under anaesthesia to evacuate the retained products of conception. During incomplete abortion there is a danger of shock from excessive blood loss and sepsis.

Complete abortion

If complete abortion takes place spontaneously, a woman will have gone through all the stages described above, after which the bleeding stops completely and the abdominal pain ceases entirely. On examination, the uterus is smaller than the expected size for the stage of pregnancy and the os of the cervix is closed. There are no fetal heart sounds audible with a Doppler monitor and an ultrasound scan shows an empty uterus. In such a case, the woman may not require hospitalization.

Missed abortion

Missed abortion consists in retention of a fetus for several weeks after its death. Death of the fetus occurs unnoticed or after vaginal bleeding, as in threatened abortion, which then ceases. Pregnancy testing will be negative about a week after death of the fetus and ultrasound scan confirms the diagnosis.

Shen Jin Ao 1774 The Jade Ruler of Gynaecology (Fu Ke Yu Chi), cited in Luo Yuan Kai 1979 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue ), Nanjing College of Traditional Chinese Medicine, Nanjing, p. 84..

Foundations of Medicine 1575 (Yi Xue Ru Men), cited in Luo Yuan Kai 1986 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue ), Shanghai Science and Technology Press, Shanghai, p. 132..

Shen Jin Ao 1774 The Jade Ruler of Gynaecology, cited in 1979 Gynaecology in Chinese Medicine, p. 84..

Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian ), People’s Health Publishing House, Beijing, Vol. 3, p. 61. First published in 1742..

Cong Chun Yu 1989 Chinese Medicine Gynaecology (Zhong Yi Fu Ke Xue ), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 135..

Golden Mirror of Medicine, pp 59–60..

Long Jiajun, Zhang Qi, Shen Kang, Lin Hongyang 1996 Dr Zhang Jian Zhai’s Experience in Treating Gynaecological Diseases (Zhang Jian Zhai Zhi Liao Fu Ke Bing Jing Yan) in Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi ), China Academy of Traditional Chinese Medicine, Beijing, No. 1, p. 17..

Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke ), Shanghai People’s Publishing House, Shanghai, p. 39. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..

Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong ), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 20. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang) and published in 1729..

Chen You Bang 1990 Chinese Acupuncture Therapy (Zhong Guo Zhen Jiu Zhi Liao Xue ), China Scientific Publishing House, Beijing, p. 904..

Zhang Jing Yue 1986 The Complete Works of Jing Yue (Jing Yue Quan Shu ), Shanghai Science and Technology Press, Shanghai, p. 652. First published in 1624..