Miscarriage
A miscarriage is the loss of a pregnancy before 24 weeks - with the vast majority of these pregnancy losses occurring in the first trimester (12 weeks).
A miscarriage is a pregnancy which ends naturally before the baby can possibly survive outside of the womb. A miscarriage can occur at any stage of pregnancy from the time of the first missed menstrual period until 24 weeks of gestation. This wide time span means that there are many types of miscarriages and with many different causes. Experiencing a miscarriage is one of the most difficult and devastating blows that nature can deliver.
Pregnancy tests are so advanced these days, and so easily accessed that many women can test very early on when an embryo is just starting to implant in the womb. In earlier times, pregnancy tests were not so sensitive and these very early stages of pregnancy were not recognised. Some women would have experienced very early miscarriages (before implantation into the womb) without realising and may have experienced only a small delay (few days only) in their expected monthly period. There is a very high rate of pregnancy loss before a test would even show a positive result.
If a test shows positive, it is detecting the level of hCG (human chorionic gonadotropin) i.e. the pregnancy hormone in the urine or blood. It may detect it very early on, with the more sensitive testing kits that are available, and once a woman is aware that she is pregnant, it takes on a whole new emotional meaning. A miscarriage at this stage is equally as devastating as one further along.
Miscarriages can have many causes. Many of the reasons for recurrent miscarriages are the same for recurrent implantation failures during IVF. These causes include:
genetic factors
age
abnormal chromosomes in women or men
hormonal imbalances (including PCO)
blood clotting disorders
auto-immune diseases
infections
structural abnormalities in the womb
lifestyle factors (alcohol and smoking)
How Common are Miscarriages?
Miscarriages are more common than people think. For every 100 conceptions, only 50 will result in a live birth. The rates of miscarriage increase with age.
Age 20-34 = 15 %
Age 35-39= 25%
Age 40+=51%
Age 45+= 75%
When Is The Highest Risk Time?
Before 8 weeks.
What Are The Most Common Causes?
“I took rest and followed my doctor’s advice about diet and relaxation, yet I lost my baby. Why did this happen to me? Is there something wrong with me that I’m not being told?”
The belief that your body is at fault is very common following miscarriage but fortunately this is not usually the case. Factors which seem to be related to an increased risk of miscarriage are detailed below:
Errors in the development of the foetus
These errors may range from minor abnormalities in the development of the foetus to a situation where the foetus has scarcely developed at all.
The conception may fail to be embedded properly in the lining of the womb and thus not develop. In some cases, these errors in development are due to a genetic error. The majority of genetic errors are chance happenings and are unlikely to recur. Further investigation is not generally indicated, except in the case of recurrent miscarriage. As per the European Society for Human Reproduction and Embryology, investigations are warranted after 2 miscarriages, amended from earlier recommendations for to to happen after 3 miscarriages. Where there is a history of recurrent miscarriage, studies have shown that a small percentage of couples will, on investigation, have an abnormal chromosome pattern. Where the problem is identified, the couple should receive counselling from an experienced genetic counsellor.
What are the Different Types of Miscarriage?
Inevitable miscarriage
If a woman has been threatening to miscarry, there may come a point of no return. This happens when the cervix or the neck of the womb (uterus) starts to dilate and open up. Once this action starts it is unlikely the pregnancy will be saved. Bleeding and pain are the outstanding features here, the pain increases as the womb contracts - and the amount of pain varies from woman to woman and miscarriage to miscarriage. There may be associated nausea and vomiting, and it many cases large pieces of tissue, described by women as looking like “pieces of liver”, are passed. It can be frightening to experience such a miscarriage and most women find their inability to control what I happening to their bodies very distressing. An inevitable miscarriage will progress to either an incomplete or complete miscarriage.
Incomplete miscarriage
As a woman miscarries, sometimes not all of the products of conception are passed from the womb (uterus). This is called an incomplete miscarriage. Usually there is continuous bleeding and crampy pains. Some women require a blood transfusion. Sometimes an ultrasound examination is carried out to confirm the diagnosis. Preparation is then made to take the woman to theatre and to remove by curettage, the remaining pieces of tissue inside the womb. The procedure followed for curettage (more commonly referred to as a D&C) involves firstly putting the woman to sleep in theatre. Then after a gentle internal examination, the cervix may be carefully dilated and the inside of the womb curetted using a long handled spoon-like instrument. The whole procedure takes about 10-15 minutes.
Complete miscarriage
When a complete miscarriage occurs, all the products of conception are passed from the womb. This type of miscarriage occurs most frequently before 6-8 weeks or after 14-16 weeks, and seldom in the intervening period. Where a complete miscarriage is suspected, the treatment will involve continued observation of blood loss in hospital. Where bleeding is prolonged, an ultrasound scan will be necessary to confirm that the uterus is indeed empty and that no small piece of tissue remains inside. Where some tissue still remains, a curettage will be necessary. The period of stay in hospital is on average 24-48 hours. Occasionally a slightly longer stay is necessary, as for example when an acquired infection is the cause of the continued bleeding.
Missed miscarriage
In this type of miscarriage the embryo (baby) fails to develop in the womb and instead of being passed from the womb, it is retained inside. The diagnosis may be difficult to make at first because the findings and the symptoms are similar to a threatened miscarriage. Usually the symptoms of pregnancy (i.e nausea, breast tenderness, urinary frequency) disappear as the womb becomes progressively smaller. There is little or no bleeding, perhaps just a dark brown discharge from the vagina. In this situation it is usual for a woman to have several examinations and a series of ultrasound scans before a definite diagnosis is made. Treatment for a missed miscarriage can be simple, “allowing nature to take its course”, i.e. the woman will spontaneously miscarry the foetus, but this may not happen for several weeks after the initial bleed. This approach is unacceptable to may women. Alternatively, treatment can consist of a gentle curettage under general anaesthesia if the womb is not larger than 12 weeks in size by dates and on clinical examination. If, however, the womb is larger than this in size, a drug called Prostaglandin is used in the form of a jelly or tablet inserted vaginally just near the neck of the womb. This helps the woman to spontaneously expel the retained contents. It may be necessary to repeat the medication, and sometimes intravenous treatment (by drip) can also be used. The process is completed by careful curettage under general anaesthesia to ensure that no tissue remains inside. The pregnancy test usually becomes negative in seven to 10 days.
What Happens During a Miscarriage?
During a miscarriage, there are usually physical signs of cramping and bleeding. This is the body going through the physiological process of losing a pregnancy. In other cases, there may not be any immediate physical signs that the pregnancy is not progressing and it may be discovered during a routine ultrasound scan. Some women will miscarry naturally and others may not. There may be a complete or incomplete passing of the fetus and for an incomplete miscarriage, a procedure called a ERPC (evacuation of retained products of conception) may be done.
Discovering that you are experiencing a miscarriage is devastating and it’s vital to have support from your partner and loved ones.
Coping After A Miscarriage
A miscarriage at any stage of pregnancy is devastating and can be very difficult to cope with. It doesn’t matter at which stage of pregnancy the miscarriage occurred. It is a loss.
A late miscarriage of a still birth requires a huge amount of support, sometimes for months or years. An early miscarriage can be just as difficult and distressing for a couple and also requires a lot of emotional support. The most difficult thing about having a miscarriage is coming to terms with the loss of what was meant to be. When a woman finds out she is pregnant, there is a huge emotional change taking place. There is excitement and the pregnancy, regardless of the stage, has been identified as a person. A miscarriage is a loss of this unborn person.
It is really important to let yourself grieve. Grieve your loss with your partner. This may mean very different things to each individual. Men often find themselves hitting a desperate low, quite quickly after the loss but then after immersing themselves in other activities (work, exercise) and either being able to move on or else becoming unresolved. Women, unlike most men, like to talk about their feelings and what has happened. Grief has different stages; emotional numbness, denial, disbelief, separation, anxiety, despair, sadness and loneliness. It can be useful to seek the support of a Psychologist who can help you through these stages and guide you and your partner through the difficult time.
If you are experiencing a miscarriage, don’t ever feel alone. There are many support networks available to you. Don’t shy away from the support that’s on offer and in need during this difficult time.
Support
A friend who has had the same experience can be a great source of support. Some other people, even when they haven’t been through the experience, are naturally understanding and provide a listening ear. Some women can turn to their mothers or sisters for emotional support. But some people have difficulty giving support. They feel uneasy or embarrassed. They know there is nothing they can do to put things right. Sometimes people may avoid the topic altogether, sometimes they may try to reassure, try to show that it doesn’t matter. There is no right way of handling the situation and people. through feelings of helplessness and awkwardness, often get it wrong. Doctors too, can sometimes come across as uninvolved and detached because of their difficulty in dealing with emotional situations. Like may other people they may be more comfortable dealing with factual issues. Try to accept that people do differ in their ability to understand and their ability to give emotional support in this situation. Try not to allow bitterness about people's treatment of you add to your difficulties.
Support Networks
Here are some support networks available to you
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