Miscarriage

A guide for women

The loss of a pregnancy can be a very difficult time for a woman and her family. This article aims to help-you understand why miscarriages occur, the types of miscarriage, diagnostic tests and treatment options that are available for you, and the emotional impact of a miscarriage

Definition of Miscarriage

A miscarriage is the spontaneous loss of a pregnancy that occurs during the first 20 weeks of gestation. The loss of a preg-nancy after 20 weeks is called a stillbirth.

Miscarriages are common, affecting about one in five pregnancies.

A miscarriage can occur so 'early in a pregnancy that a woman may not know that she was pregnant. These miscarriages are often unreported to the doctor.

Most occur within the first 10 weeks of gestation. Once a healthy pregnancy has reached 10 weeks, the risk of miscar-riage decreases greatly but may still occur.

Causes of Miscarriage

The cause of a miscarriage is often unknown. Generally, miscarriage occurs because the fetus did not develop properly. At least half of all miscarriages are believed to be related to a problem with the genetic makeup of the fetus. In these cases, the pregnancy did not continue because the fetus and placenta were not developing properly.

Risk Factors

Miscarriage risk increases if the woman has certain risk factors, which include:

• age (The risk increases in women older than 30 years of age, with a significant increase in women over 35; at age 40, the rate of miscarriage increases to about one in every two pregnancies).
• previous miscarriages.
• the use of some medications (tell your doctor what you are taking).
• use of alcohol, drugs or cigarettes.
• number of pregnancies; the risk increases in women who have been pregnant before.
• previous surgery of the uterus.
• abnormalities of the uterus.
• connective tissue disorders (such as lupus).
• kidney or thyroid disease.
• infections (such as toxoplasmosis or measles, among others).
• blood coagulation disorders.
• fetal chromosome abnormalities.
• trauma to the uterus, which is rare.

Types of Miscarriage

• Threatened miscarriage is a pregnancy complicated by vaginal bleeding and little or no pain before the pregnancy has reached 20 weeks. In cases of threatened miscarriage, the woman may have an increased risk of preterm labour and a premature baby.
• Incomplete miscarriage is a lost pregnancy where the uterus may still contain the fetus, placenta or membranes.
• Complete miscarriage is a lost pregnancy in which the fetus and all products of pregnancy have passed out of the uterus and vagina without the need for any medical treatment.
• Missed miscarriage occurs when a pregnancy has stopped but typically without bleeding or other symptoms. The fetus may remain in the uterus for weeks or months until bleeding occurs. Missed miscarriage is suspected when pregnancy symptoms have reduced or stopped, and the uterus has stopped growing.
• Septic Iniscarriage is a lost pregnancy complicated by an infection in the uterus.
• Ectopic or tubal pregnancy occurs when the fetus is growing in a Fallopian tube rather than the uterus.
• In early pregnancy loss, no fetus has formed but the gestation sac is present. It is also called an anembryonic pregnancy or blighted ovum.
• Recurrent miscarriage is three or more consecutive lost pregnancies.

DIAGNOSIS

Although signs and symptoms vary, they may include vaginal bleeding, abdominal cramps and pain, and the passage of tissue.

Significant vaginal bleeding is the most common sign of miscarriage. Bleed-ing can be light or heavy with blood clots. Uncommonly, bleeding can be so heavy that a blood transfusion is needed.

Blood clots may be contused with the passage of tissue. A doctor may examine tissue that is passed. A woman who is pregnant and has significant or persistent vaginal bleeding should see her doctor. In most cases of suspected miscarriage, the doctor will:

• take a detailed medical history.
• identify risk factors.
• perform a physical examination. The physical examination may consist or an abdominal and pelvic examination to determine the source of the bleeding, if possible, and to assess whether the uterus is enlarged or tender.

The doctor may also recommend further tests, including an ultrasound examination of the uterus, blood tests or a urine test. These tests allow the doctor to evaluate whether a miscarriage has occurred, and if so, whether it has been complete or whether further medical or surgical treatment may be required.

If the woman has recurrent miscarriages, the doctor may suggest further blood tests to investigate possible causes.

In some cases, it can be helpful to test fetal tissue for chromosomal abnormalities such as Down syndrome.

However, such testing is rarely done after only one or two miscarriages.

THE TREATMENTS FOR MISCARRIAGE

The approach to treatment depends on the type of miscarriage. For example, women who have had a complete miscarriage usually do not require medical or surgical treatment. Any bleeding and pain will decrease after the passage of tissue.

However, women with a missed or incomplete miscarriage often require prompt medical or surgical treatment to remove any pregnancy tissue left inside the uterus. Although the standard approach in these cases is the surgical removal of pregnancy tissue, some doctors . may suggest an expectant or a medical approach to treatment. During this time, the woman may need further scans, medicines and blood tests, and then may still need surgical treatment.

The woman's preference is important. When possible, she is encouraged to help choose the treatment approach.

Surgery after Miscarriage

Some tissues of a lost pregnancy often remain inside the uterus. If they are not removed, bleeding may continue, and an infection may develop. Prompt surgical removal of remaining pregnancy tissue is the traditional and proven approach.

The uterus is gently scraped to remove pregnancy tissues. This procedure is known as a D&C (dilatation and curettage). It is usually performed under a general anaesthetic, and the woman is often able to return home the same day.

The tissue may be sent to the laboratory to detect whether other problems are present.

In uncommon cases of a molar pregnancy, also called a hydatidiform mole, the doctor may need to undertake further evaluation and treatment.

Complications:

• some tissue from the pregnancy remains in the uterus.
• perforation of the uterus.
• formation of scar tissue in the uterus.
• damage to the cervix (which may affect future pregnancies).
• infection that requires antibiotic treatment; a severe infection can cause tissue damage that may lead to future fertility problems.

After a D&C, most women have light bleeding for five to 10 days. Contact your doctor at once if you have any of the following:

• persistent or heavy bleeding.
• passing of blood clots.
• bad-smelling vaginal discharge.
• temperature greater than 38°C or chills.
• you are not feeling better.

The Expectant Approach

In some cases, the miscarriage has occurred by the time the woman sees her doctor. If ultrasound examination shows an empty or nearly empty uterus, then no treatment may be required. The woman's condition is monitored for several days. This is called an expectant approach (or "wait and see").

In some studies of incomplete miscarriage, the expectant approach has been successful in about nine out of 10 cases. However, other studies suggest that the success rate may be only three in 10 cases, which means that D&C is an important treatment option to consider.

Depending on the case, the doctor may take an expectant approach before recommending surgical or medical treatment.

The Medical Approach

The prescription drug misoprostol can be an effective alternative to a D&C for some women with early pregnancy loss. Miscarriage is usually complete following this treatment. However, some women (as many as three in 10) need follow-up D&C treatment to remove retained products of pregnancy. Antibiotics may be required if infection is present. Women who are anaemic (low level of red blood cells) due to blood loss may need to take iron supplements; in some cases, a blood transfusion may be advised.

THE EMOTIONAL IMPACT

Women who have had a miscarriage experience a wide range of emotions that may persist. A pregnancy loss may cause profound grief and depression that may be brief or long lasting. Many women report reactions such as feelings of:

• emptiness and failure.
• anger and guilt.
• disbelief and sadness.
• disappointment and loss.

Women often struggle with feelings of self-blame and wonder whether they could have done anything to cause or prevent the loss. Doctors agree that a miscarriage is almost never caused by anything the woman did or failed to do. In most cases, the next pregnancy will be successful.

Grief is a normal and valid reaction for the woman and her husband. They should be given time to grieve and come to terms with the loss. Grief may vary in intensity and duration.

Other family members may grieve too. Family members or friends may avoid the subject of miscarriage or make well-meaning but inappropriate comments. A counsellor, community outreach program, and supportive family and friends can be helpful during the grieving period.

AFTER MISCARRIAGE

• Rest for several days.
• Avoid using tampons and having sex for about two weeks.
• Depending on your doctor's advice, you may consider becoming pregnant any time after the normal menstrual cycle has resumed.