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Miscarriage

Miscarriage

What To Do When Miscarriage Strikes
(From the PDR Family Guide to Women's Health Chapter 28)

Miscarriage can leave a couple severely shaken as the anticipation of having a baby suddenly turns to grief over a loss. Many feel devastated and guilty even if the miscarriage occurs during the early weeks or months of the pregnancy. However, while it's normal to blame some specific act or situation, miscarriages are rarely triggered by factors under the partners' control.

Exercising, a minor fall, or sexual intercourse does not typically cause a miscarriage. The fetus is well protected by the mother's bones and muscle as well as by the amniotic fluid in which it floats. There is also no evidence that conceiving while taking birth control pills increases the risk of miscarriage. Becoming pregnant while using an IUD, however, does make you more likely to miscarry or develop an infection.

As many as 30 percent of all pregnancies end in miscarriage, half of them before the woman even realizes she is pregnant. Fortunately, most women who miscarry, even more than once, can become pregnant again and give birth to a healthy baby. If you have had a miscarriage and want to try again, work with your doctor to learn the reason for the loss and to plan future pregnancies. Closely monitored pregnancies are especially important for women who have miscarried.

Your doctor may refer to a miscarriage as a “spontaneous abortion,” since “abortion” is the medical term for any interrupted pregnancy. A miscarriage, or spontaneous abortion, is the loss of a pregnancy before the fetus can survive outside the womb, usually within the first 20 weeks.

Warning Signs
Any bleeding from the vagina during pregnancy suggests the possibility of miscarriage. Call your doctor about any abnormal vaginal bleeding, even if you do not think you are pregnant. Bleeding or spotting may be the first sign that you are pregnant and that the pregnancy is at risk. Staining or bleeding does not necessarily mean that you will miscarry, however. About 20 to 25 percent of pregnant women have some spotting or bleeding early in pregnancy, and about half of these pregnancies continue successfully.

Bleeding that signals possible miscarriage is usually light. It can be brown or bright red and may occur repeatedly over many days. If the bleeding persists or increases, the chances of losing the baby are higher. Mild pain, such as cramping or low backache, usually develops at some point after the bleeding has started. Some women experience severe abdominal pain and dizziness.

If you have been bleeding and an ultrasound scan (sonogram) indicates that the fetus is alive, your doctor probably will ask you to rest in bed as much as possible. Avoid sexual activity. The doctor will monitor you to be sure that bleeding and cramping remain mild, that the cervical canal from the uterus stays closed in order to retain the baby in the uterus, that sonograms continue to show fetal heart movements, and that the fetus is growing. More than 90 percent of first­trimester pregnancies continue when ultrasound scans indicate that the baby is alive.

Rarely, early in pregnancy, fluid is suddenly released from the vagina without bleeding or pain. If you experience this, call your doctor immediately. You will probably be instructed to stay in bed and watch for further leakage, bleeding, cramping, or fever. If, after a few days, you have none of these things, your doctor may tell you that it is safe to go back to daily activities. Avoid intercourse and any other vaginal penetration. If you do develop bleeding, pain, or fever, however, miscarriage may be inevitable.

Types of Miscarriage
Miscarriages differ according to 2 main factors: how far the pregnancy has progressed and how much of the fetus and other elements of pregnancy, such as the placenta, have been expelled from the body. To prevent infection, it's important to ensure that all material related to pregnancy has been either expelled naturally or removed from the uterus.

Inevitable Miscarriage
When bleeding and pain are accompanied by the breaking of membranes (the amniotic sac surrounding the fetus) and the widening of the cervix, the pregnancy is viewed as lost (inevitable miscarriage). Uterine contractions to expel the fetus usually begin soon after these symptoms develop.

Incomplete and Missed Miscarriages
In some miscarriages, the body does not expel all the elements of pregnancy. This is called an incomplete miscarriage. At other times—in about 1 percent of pregnancies—the body does not discharge the fetus, the placenta, or any other elements of the pregnancy for several weeks, even though the fetus has died. This is known as a missed miscarriage. It is a possibility when a woman has neither menstrual periods nor any signs of pregnancy. Breasts may return to their prepregnancy state, for example, or the woman may lose a few pounds. Not all missed miscarriages are preceded by warning signs.

An incomplete or missed miscarriage that takes place early in pregnancy is usually removed with either suction or dilation and curettage (D&C), “opening” the uterus and scraping out its contents, through the vagina, with an instrument called a curette. These procedures not only clear the uterus but also prevent infection. When incomplete miscarriage occurs later in pregnancy, the doctor may have to induce labor to remove the fetus.

Causes of Miscarriage
In general, miscarriage is more common in women over 35 years old and in pregnancies involving more than one fetus. In some multiple pregnancies (twins, triplets, or more), one or more of the fetuses survives even after another one dies. The dead fetus leaves the mother's body when the surviving baby is born.

Some of the factors discussed in this section are more common after repeated—that is, 3 or more—miscarriages. About 1 in 200 women has repeated miscarriages, which physicians call recurrent spontaneous abortion. In many cases—perhaps most—even these miscarriages happen by chance and do not signal a problem in either or both partners. Often no cause is found.

Chromosomal abnormalities.
Problems in the chromosomes of the embryo, by far the most common reason for loss of pregnancy, are found in more than half of miscarriages occurring in the first 13 weeks. Miscarriages apparently eliminate about 95 percent of fertilized eggs or embryos with genetic problems—perhaps nature's way of ending a pregnancy in which the child would be unable to survive. Spontaneous abortions of this type usually occur before the woman knows that she is pregnant. Most chromosomal problems happen by chance, have nothing to do with the parents, and are unlikely to recur.

Sometimes, however, chromosomal abnormalities are caused by the parents' genes. This is more likely if the woman has had repeated miscarriages or if either parent has relatives or a child with birth defects. Genetic testing and analysis of fetal material from the miscarriage can help the doctor identify the problem.

Illness
Miscarriages are much less common in the third trimester. Those that occur are more likely to be due to maternal factors, such as an illness in the mother, than to genetic abnormalities in the baby.

Women with poorly controlled diabetes are at great risk for miscarriage. Those whose diabetes is controlled, however, whether it existed before the pregnancy or developed after conception (gestational diabetes), are no more likely to lose a pregnancy than other women. A woman may not know that she has diabetes, however, until it is discovered during a search for the cause of repeated miscarriages. The routine blood and urine tests given during pregnancy are an effort to identify this problem while it still can be remedied.

Other diseases and conditions linked to increased risk of miscarriage include systemic lupus erythematosus (SLE, or lupus), high blood pressure, and certain infections, such as rubella (German measles), herpes simplex, and chlamydia. Experts disagree about the role of hypothyroidism, or an underactive thyroid gland, in miscarriage, but it's likely that a severe case increases the risk.

With conditions such as diabetes, treating or controlling the problem can improve the odds of a successful pregnancy. Special monitoring may also be required.

Hormone Imbalance
Some women do not make enough progesterone, the hormone that prepares the lining of the uterus to nourish a fertilized egg; and if the uterine lining cannot sustain an egg, miscarriage will occur. Progesterone supplements, given by injection or in vaginal or rectal suppositories, can correct this problem. The medication also can make it more difficult for a dead fetus to be expelled. A blood test and a biopsy of a small amount of tissue taken from the uterine lining can determine whether you are producing enough progesterone naturally. Hormone imbalance also can be caused by diabetes mellitus or thyroid disease.

Abnormalities of the Uterus and Cervix
Anything physically wrong with the uterus or cervix can lead to a miscarriage. Some defects may be present from birth. Fibroids—noncancerous growths made of uterine muscle tissue—can also be at fault. So can a weak cervix that widens too early in pregnancy without any warning signs of labor, releasing the fetus from the uterus.

These physical problems account for up to 15 percent of repeated miscarriages. To diagnose such problems, the doctor may inject the cavity of the uterus with some fluid, then take an x­ray of your uterus and fallopian tubes. Another technique is to examine the inside of your uterus through a long, thin instrument (hysteroscope) inserted through the vagina and cervix. In another procedure, the doctor may make a small incision in the lower abdomen and insert a laparoscope, through which he or she can inspect the pelvic organs. Surgery can correct many abnormalities in the uterus but your doctor probably won't recommend it until all other causes of miscarriage have been ruled out. After surgery, 70 to 90 percent of pregnancies are successful.

Though a weak cervix is a relatively rare condition, it's almost impossible to detect before it becomes apparent during pregnancy, usually after the 15th week. Once discovered, it is likely to disrupt every pregnancy. To remedy the problem, after the first trimester, but before the cervix has dilated (widened) to a certain point, your doctor can reinforce the cervix with sutures, which will be removed when the baby reaches term. Women with bleeding, uterine contractions, or ruptured membranes should not undergo this procedure.

Immune System Problems
A developing baby is half made up of foreign genetic material from the father. Some women have repeated miscarriages because their bodies see each baby as an invading organism and attack it with antibodies. Ordinarily, many elements of the immune system work together to ensure that the mother's body does not reject the baby. But when this coordination fails, a miscarriage follows. Treatments for such problems in the immune system are experimental and should not be tried until other causes for repeated miscarriage have been ruled out. Some research centers have tried to “immunize” the mother with the father's white blood cells, but so far without good results.

Certain autoimmune diseases and abnormalities also increase the risk of miscarriage. Women whose blood contains certain types of antibodies are at particularly high risk. These women may have no symptoms other than trouble retaining a pregnancy, but a blood test can determine whether the antibodies are present. If so, heparin, prednisone, and aspirin during pregnancy can help prevent miscarriage. About 70 to 75 percent of women with lupus-associated antibodies who are treated with these drugs are able to deliver. In any case, if you have these blood abnormalities, you should have your doctor watch you closely. The baby may grow too slowly or develop other complications.

Minimizing the Risk of Miscarriage
Most miscarriages are caused by chromosomal (genetic) abnormalities and other physical factors that are beyond your control. There are, however, steps you can take to reduce the risk of losing a pregnancy.

Don't smoke. Smoking increases the risk of losing a genetically normal baby. One study showed that women who smoked more than 14 cigarettes a day were about twice as likely to miscarry, regardless of their age or use of alcoholic beverages. The risk of losing a pregnancy increases with the number of cigarettes a woman smokes. On the other hand, giving up smoking at any time during the pregnancy will benefit the baby. Since passive smoke is also dangerous, it's wisest if no one in your household smokes during the pregnancy.

Don't drink alcoholic beverages or much caffeine. Having an alcoholic drink twice weekly doubled the risk of losing normal babies in one study; drinking alcohol every day tripled the risk of such miscarriages. Similarly, consuming large amounts of caffeine—more than 4 cups of coffee per day (or the equivalent in other substances that contain caffeine) slightly increases the chance of miscarriage. The risk appears to rise with the amount of caffeine consumed; and doctors generally recommend limiting intake to one cup of coffee per day.

Avoid radiation and poisons. Exposure to high levels of radiation or toxic substances increases the risk of miscarriage. The dangers of various levels of radiation are discussed in the chapter on “Strategies for a Healthy Pregnancy.” Arsenic, lead, formaldehyde, benzene, and ethylene oxide can cause miscarriage. Make sure you are not exposed to these substances at work or anywhere else while pregnant or trying to conceive.

Prevent trauma to the abdomen. Don't participate in sports such a skiing that might involve serious falls. Stab wounds or injuries from the steering wheel or seat belt in a car, especially during the second trimester, sometimes cause miscarriage. See the nearby box for the right way to wear a seat belt when you are visibly pregnant.

Check out all medications with your doctor. Certain prescription and over­the­counter drugs are associated with fetal abnormalities and miscarriages. Consult your doctor before taking any medication when you are pregnant or trying to conceive. Some drugs can damage the fetus and cause miscarriage before you even know you are pregnant.

After Miscarriage
Miscarriages due to random natural factors are so common that they are not considered medically significant until you've had 3 in a row. At that point, the problem is officially classified as “recurrent miscarriage,” and your doctor will recommend a complete diagnostic workup.

The investigation will probably start with a detailed interview. Which tests are performed will depend on your own personal and medical history, the father's history, and how many miscarriages you have had. You will be tested for infections of various kinds, possibly including sexually transmitted diseases. Blood tests may be done for hormonal problems or a malfunction in the immune system. You and your partner may be tested for chromosomal abnormalities and genetic diseases as well. The lining of your uterus may be analyzed from a small sample. The doctor may order x­rays of your uterus and fallopian tubes to look for a blockage, fibroid, or scar tissue.

Knowing as much as possible about why the miscarriages are happening can increase the chances of having a normal pregnancy in the future. It's best to postpone trying to conceive again until your medical evaluation is complete. More than likely, you can carry a baby to term. Unless the problem involves autoimmune antibodies, chromosomal abnormalities, or a weak cervix, there's a 70 to 85 percent chance of success, even after 3 miscarriages.

Recovering Emotionally
Allow yourselves to grieve after losing a pregnancy. Many couples feel a renewed sense of emptiness and loss at the time the baby would have been born. Consider joining a self­help group such as one of those listed at the end of this book. Your obstetrician or local hospital may be able to suggest others. Try not to blame yourself. Instead, concentrate on finding out what went wrong—and how you can make it right.

Some couples want to conceive again quickly. While such a step may be physically possible, it is psychologically unwise. Nevertheless, sex can be resumed safely within 2 to 4 weeks after miscarriage. A woman's body usually is prepared for another pregnancy after 1 or 2 normal menstrual periods. Ovulation can occur as little as 2 weeks after a miscarriage.

Give yourselves enough time to recover emotionally from your loss before facing the challenges of another pregnancy. As with any major life event, it's important to balance the need to grieve with the need to move on. And remember, most couples who experience a miscarriage can go on to have a healthy baby.

More Information about Miscarriage:

The Miscarriage Association
http://www.miscarriageassociation.org.uk/

Miscarriage Support Aukland Inc
http://www.miscarriagesupport.org.nz/

FertilityPlus: Miscarriage Support, Information & Resources
http://www.fertilityplus.org/faq/miscarriage/resources.html

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