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Miscarriage

A miscarriage is a very trying time. Parents often feel helpless, or wonder what they might have done wrong. The truth is these events sometimes just happen – and the reason is never known. Moreover for many miscarriages, there are no medications or treatments that could stop the event from happening. For better or worse, a miscarriage is largely an act of nature.

Miscarriage is the term used to describe spontaneous pregnancy loss occurring before 20 weeks of gestation (development). Miscarriage can be non-recurrent, (one time event) or recurrent (happening in two or more pregnancies). There are a variety of reasons women miscarry.

The following topics may help you understand more about miscarriage, including common causes, methods of diagnosis and treatment, and normal grief reaction with pregnancy loss.

  • Common Causes of Non-Recurrent Miscarriage

    The greatest incidence of non-recurrent (one-time) miscarriage is attributed to: genetics, environmental exposure or infection.

    Genetics

    In early first trimester, more than 60% of miscarriages are related to major chromosomal abnormalities in the developing embryo. This occurs even when both parents have normal chromosomes. In most cases, this is a single event and there is no increased risk of genetic abnormality in future pregnancies.

    Environmental Exposure

    Exposures such as high dose radiation, chemicals, chemotherapy drugs, cocaine, alcohol, smoking, heavy caffeine consumption and extreme hyperthermia (greatly increased body temperature, as occurs in using a hot tub) may affect the blood circulation to the placenta, and cause damage to the growing embryo – leading to miscarriage.

    Viral & Bacterial Infection

    In some cases, infection with certain bacteria or viruses, including Rubella, Listeria, Syphilis, Cytomegalovirus, Toxoplasmosis, Brucella, and Mycoplasma has been linked to miscarriage. Following a miscarriage, you will be tested for the presence of any of these organisms, and when necessary, a course of therapy will be given.

  • Grief after Miscarriage

    It is not uncommon to experience profound grief with any form of miscarriage. Understanding what is unique to miscarriage in comparison to other losses will help you put your feelings in perspective.

    • Miscarriage is often sudden, so you have had little chance to prepare
    • Most parents (especially mothers) feel somehow responsible that their baby has died. They review the weeks of pregnancy trying to associate the death on something they may have done.
    • Bereaved parents often find that their friends don't mention the baby, or stay away because they don't know what to say.
    • Your pregnancy still feels a part of you – and there are feelings of loss that you may experience more intensely.

    You may experience some signs of grief, including:

    • loss of appetite
    • problems with sleep (waking up multiple times or very early, or have difficulty falling asleep)
    • loss of energy
    • sadness and teary spells
    • lack of motivation to do things
    • loss of enjoyment in things you used to enjoy

    These feelings will gradually lessen, but the healing process takes time. If you are still struggling with these feelings 3 to 6 months later, discuss this with your health care provider. Some women find professional counseling is helpful in assisting them with the grief process.

    Support for grieving families
    • Acknowledge the pregnancy loss with friends and family. Once you tell someone, you will be surprised at how many women have experienced an early pregnancy loss.
    • Talk openly with your partner about any feelings of guilt you may have
    • Find support from others through pregnancy loss support groups
    • Anticipate a resurfacing of grief around your due date. This is a normal response, this date has been in your mind in anticipation of what might have been.
    • The decision to become pregnant again is very individual. Give consideration to the physical and emotional impact of any decision. Be sure to give yourself adequate time to grieve and come to terms with your loss.

    Ensure that you are physically ready to begin a new pregnancy. Your clinician will help you make that determination.

  • Ectopic Pregnancy

    An ectopic pregnancy is any conception that implants somewhere other than the inside wall of the uterus. This can mean the fallopian tube, ovary, cervix or abdominal cavity. Ectopic pregnancies are estimated to occur in 1 out of 200 pregnancies.

    Risk factors that can lead to ectopic pregnancy include:
    • Use of IUDs for birth control
    • Any condition or treatment that may cause tubal scarring such as previous infection with gonorrhea or Chlamydia and pelvic inflammatory disease (learn more about sexually transmitted disease
    • Salpingitis (infection of the fallopian tube)
    • Induced or elective abortion
    • Tubal ligation (for permanent sterilization)
    • History of previous ectopic pregnancy.

    Ectopic pregnancies pose serious risks including hemorrhage and death, so must be treated as soon as possible. The most common site of ectopic pregnancy is the fallopian tube. Early symptoms of ectopic pregnancy are lack of menstrual period, abdominal pain, and vaginal bleeding different from a normal menstrual period (milder, intermittent, dark red or brown). If the ectopic goes on to rupture (burst) the diagnosis is more obvious.

    Symptoms include abdominal pain and swelling; sometimes shoulder pain, sweating, increased heart rate, dehydration and changes in blood pressure.

    There are several tests that can help identify the presence of an ectopic pregnancy before complications arise. They are beta-hCG, serum progesterone and transvaginal ultrasound.

    Human Chorionic Gonadotropin (beta-hCG)

    This is a hormone secreted by the fetus that can be measured in maternal serum during pregnancy. Serial beta-hCGs may aid in early identification of ectopic pregnancy. Beta-hCG is the same substance measured in most pregnancy tests. In a normal pregnancy the beta-hCG rises predictably during the first ten weeks. With ectopic pregnancy the rate of rise of beta-hCG starts to look abnormal and then levels off at about six weeks. If the beta-hCG is rising abnormally, an ultrasound may help confirm the suspicion of ectopic pregnancy.

    Serum Progesterone

    In a normal pregnancy the serum progesterone level is greater than 25 ng/ml. If the level is below 15 ng/ml an ectopic is suspected.

    Transvaginal Ultrasound

    Using transvaginal ultrasound, the characteristic changes of ectopic pregnancy can be identified with accuracy. The use of the vaginal probe permits close placement of the ultrasound to better visualize the pelvic structures and identify the location of an ectopic pregnancy.

    Treatment of Ectopic Pregnancy

    Once an ectopic pregnancy has been detected it must be managed quickly to avoid further growth and possible rupture into the abdominal cavity.

    Two surgical procedures are most commonly used, laparoscopy and laparotomy.

    A laparoscopy uses a fiber optic scope to look at the fallopian tubes, uterus and abdominal cavity. Location and repair of the ectopic pregnancy can be performed using the laparoscope. Recovery is very quick because only small incisions are made into the abdomen to insert the laparoscope and remove the ectopic pregnancy.

    Sometimes, a laparotomy must be performed to remove the ectopic pregnancy. Laparotomy involves an open incision in the lower abdomen usually along the bikini line to remove the ectopic pregnancy and repair the area where the rupture occurred. Recovery is longer after laparotomy due to the type of incision made through the abdomen and muscles. This is usually performed when the mother’s health is unstable, the ectopic pregnancy is too large for safe removal with a laparoscope, or previous scarring or adhesions make use of a laparoscope difficult.

    Methotrexate injections are a non-surgical method to treat ectopic pregnancy. Methotrexate is a chemotherapy agent that interferes with cell multiplication, causing the ectopic mass to dissolve. Methotrexate may be used in an otherwise healthy woman with early-identified ectopic pregnancies. This therapy requires blood tests to be sure that you are not anemic and that your liver and kidneys are functioning well. Following Methotrexate injection, you will have beta-hCGs drawn to make sure that the result returns to zero. This treatment has the quickest recovery though there are short-term side effects of the medication including anemia, stomach cramping, nausea and diarrhea.

  • Screening Tests Associated with Recurrent Miscarriage

    With some miscarriages there may be indications of a specific condition that may have been the cause. Others will not provide enough information to determine a specific reason. Your health provider may recommend one of these common screening tests to rule out causes of recurrent miscarriage:

    Blood tests
    Ultrasound
    Endometrial Biopsy
    Karyotyping
    Hysteroscopy
    Hysterosalpingogram

  • Molar Pregnancy

    Hydatiform mole or molar pregnancy, is a condition where the chorionic villi, which help form the placental attachment to the endometrium, evolve into an abnormal mass of cells. The mass forms into cysts which cluster and have a grape like appearance. The embryo does not form or is abnormal and cannot survive. Molar pregnancies can be complete, where the embryo contains genetic material only from the male partner, or partial where the embryo has both partner’s genetic material, but the mother’s genes are absent or inactivated. Although molar pregnancy is an abnormal condition, the early symptoms mimic pregnancy, such as a missed period, positive pregnancy test and morning sickness.

    Symptoms of a Molar Pregnancy
    • vaginal bleeding that is brownish in color and may be spotty or constant
    • uterus will be either larger than expected for gestational age (time of pregnancy) with a complete mole, smaller that expected for gestational age with a partial mole
    • severe nausea and vomiting
    • abdominal cramps (due to the growth of the uterus from the cysts)
    • high blood pressure.

    Your clinician will confirm molar pregnancy with ultrasound and beta-hCG levels (the amount of circulating hormone found with pregnancy) which often are much higher than expected for gestational age.

    Treatment for Molar Pregnancy

    This involves removing the mole by a procedure called dilation and evacuation. After removal of the molar pregnancy, weekly beta-hCG levels will be drawn for 12-16 weeks to be sure the level returns to normal. If it does not, that means that molar cells continue to be present, a condition called persistent gestational trophoblastic disease (GTD).

    Gestational trophoblastic disease is treated using chemotherapy such as Methotrexate, the chemotherapy agent that interferes with cell multiplication, causing the mass to dissolve. This therapy cures GTD nearly 100 percent of the time. In very rare circumstances, GTD may be associated with choriocarcinoma, a type of cancer. Treatment with multiple chemotherapy agents is very successful in treating this cancer.

    If a woman has a molar pregnancy, her outlook for a future pregnancy is promising. The risk of developing a second molar pregnancy only is 1-3%.

  • Common Causes of Recurrent Miscarriage

    When there are recurrent miscarriages (more than two), it is important to find a common link that may explain why this happened. Sometimes, the cause may be an abnormality in the uterus or cervix, a medical condition (you might not have even known about!), an imbalance in your hormones, a reaction to pregnancy by your immune system, or an abnormality with chromosomes.

    Chromosomal Abnormalities

    In recurrent miscarriages, part of the genetic information may not “line up” correctly or the parts may have a missing, extra, or defective piece. In such cases, you and your clinician should discuss the value in seeing a geneticist or genetic counselor to help identify the cause, and to plan for future pregnancies.

    Pre-existing Medical Conditions

    Some medical conditions associated with recurrent miscarriage include systemic lupus erythematosus (SLE), hypothyroidism (an underactive thyroid) and uncontrolled diabetes mellitus. In such cases, your clinician will work with your internist or medical specialist to help identify the cause, and work with you on future pregnancy attempts.

    Uterine and Cervical Defects

    Other maternal factors commonly involved in miscarriage are related to abnormalities of the cervix and uterus. Cervical incompetence is a condition where the cervix is abnormally weak. Under pressure of the growing fetus, the cervix begins to open prematurely. Cervical incompetence is most commonly found in women who have had previous treatments to the cervix such as cone biopsy, dilation procedures (for abortion or miscarriage), or DES exposure in-utero

    DES (diethylstilbestrol) is a synthetic estrogen widely prescribed during 1940’s to 1970’s to prevent miscarriage. It later was found that DES crossed the placenta causing damage to the reproductive system of the fetus. With early identification, cervical incompetence may be treated with cerclage, a procedure in which the cervix is surgically sewn closed to add strength to the cervix. The stitches are removed before labor.

    Most uterine defects are present since birth though an abnormality may not be detected until problems with pregnancy require further investigation. Defects such as an abnormally shaped uterus, (heart shaped, or with a septum [wall] dividing it) may interfere with maintaining a pregnancy. Uterine fibroids (non-cancerous smooth muscle tumors that grow from the wall of the uterus) can protrude inside and outside the uterus impeding embryo implantation and carrying a pregnancy to term.

    In such cases, your clinician should discuss the available treatment alternatives and work with you as you consider future pregnancy attempts.

    Luteal Phase Defects (LPD)

    Some women who monitor their basal body temperature (BBT) may find that the luteal phase (time in the menstrual cycle after ovulation and before your period) temperatures do not stay reliably elevated, as is necessary to support pregnancy. BBT is used to observe for ovulation by monitoring your temperature every day at the same time for several menstrual cycles. Normally when you are pregnant, the temperature after ovulation is elevated and remains that way.

    With a luteal phase defect, the temperature doesn’t stay elevated which effects the development and implantation of the embryo. For those women who don’t follow their BBT or ovulation and miscarry, LPD may go unrecognized.

    Luteal phase defect is a failure of the uterine lining to be in the right phase at the right time. Since embryo implantation is very dependent on the lining being just right, LPD may interfere with a woman's ability to get pregnant and carry a pregnancy successfully. The uterine lining relies on the hormone progesterone to support the early stages of pregnancy before implantation has occurred. In some cases of LPD there is decreased progesterone. In other cases, LPD can stem from poor follicle production earlier in the menstrual cycle or, from premature failure (does not persist as long as it should) of the corpus luteum.

    In such cases, your clinician should discuss the treatment alternatives available and work with you as you consider future pregnancy attempts.

    Immunology

    Recent research suggests that couples who experience multiple miscarriages may do so because of immune system problems. The immune system is the first line of defense against disease. Antigens are markers on your cells that identify substances as natural or foreign. When antigens recognize a foreign substance, they will start production of antibodies to defend the body. An abnormal antibody response occurs when the pairing of genes from the man and woman are recognized as unrelated. This immune reaction can be either autoimmune or alloimmune:

    • Autoimmune — a woman rejects her own body proteins
    • Alloimmune — a woman reacts against the foreign proteins from the man.

    Treatment for these responses is based on the type of reaction and may include steroids to suppress the reaction, medications to thin the blood and immunization therapy. Your clinician will work with you if your recurrent miscarriages are caused by immune factors.

  • What is miscarriage

    A miscarriage is defined as spontaneous loss of a pregnancy before 20 weeks, which is the time before the fetus has developed enough to survive outside the mother. This term has two categories - early miscarriage, occurring before 13 weeks of pregnancy, and late miscarriage, occurring between 13 and 20 weeks of pregnancy.

    Common terms related to miscarriage:

    • Blighted Ovum - Embryo does not develop after fertilization
    • Threatened - Pregnancy is in doubt. There may be vaginal bleeding and cramping, but the cervix is closed.
    • Inevitable - The pregnancy loss is occurring, there is bleeding, cervical dilation, rupture of membranes, and contractions
    • Complete - The products of conception (embryo or fetus and placenta) have been fully expelled (pass through the cervix) from the uterus
    • Incomplete - Only some of the products of conception are expelled (pass through the cervix), and part of the products is retained (held) in the uterus
    • Missed - Embryo or fetus dies but is retained (held) in the uterus. There may be bleeding or spotting, and worrisome signs like no growth or movement
    • Septic - The products of conception have become infected. There will be fever usually accompanied by uterine tenderness and foul smelling vaginal discharge.
    • Recurrent - Two or more successive pregnancies have ended in miscarriage

    In the early weeks of pregnancy, you may have no worrisome symptoms. From about 8 –10 weeks on, early signs that may indicate a threat to pregnancy are:

    • nagging or worsening lower back pain
    • pink mucus discharge
    • cramping which becomes regular
    • vaginal bleeding

    Women with late miscarriage between 16 –20 weeks often pass the fetus vaginally. This is a difficult and emotionally stressful event – however seeing the baby is very helpful to some women in understanding and expressing their loss.

    If there are any worrisome symptoms, your physician will likely do the following:

    • perform a vaginal exam to see if the cervix is open or not
    • check for pregnancy with a blood test (called a beta-sub unit or beta hCG)
    • perform an ultrasound

    Treatment of miscarriage may include D & C (dilation and curettage), a scraping of the uterus to remove products of conception and/or antibiotics when an infection is suspected.

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