Understanding Miscarriage

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Miscarriage is very common and it’s a topic talked about a great deal in our online support group. It is estimated that 1:6 of pregnancies will end in miscarriage.

Despite being common, this does not take away the heartbreak that suffering from a miscarriage causes. Each individual acts differently to a pregnancy loss. Emotions that women and couples feel range from anger, grief, disappointment and guilt, to fear of it happening again and sadness or depression. These emotions are completely normal and if you have had a miscarriage it is important to allow yourself the time to grieve for your loss.

Often what adds to the emotional turmoil of miscarrying is not understanding what has happened or indeed why it’s happened. In this blog, I hope to explain miscarriage a little and if this has happened to you give you some advice on what happens next and where you can turn for help.

What is a miscarriage?

The term miscarriage refers to a pregnancy loss that occurs in the first 23 weeks of pregnancy. The main sign of miscarriage is vaginal bleeding which may be accompanied by lower abdominal pain, however not all miscarriages will be identified by bleeding (We’ll look at the different types of miscarriage later in this article). Some women report signs of no longer feeling pregnant such as loss of breast tenderness or no longer feeling nauseated.

Please bear in mind however that light bleeding early in pregnancy and indeed losing the early pregnancy symptoms is common and doesn’t necessarily mean that you are miscarrying.

What causes a miscarriage?

There are many reasons why a miscarriage may happen and for many of these the cause is unknown. We do know however that many miscarriages are caused by abnormal chromosomes, meaning that the pregnancy will not develop properly. Some miscarriages can occur due to immunological or blood clotting problems, maternal health problems, infection or due to anatomical reasons such as the cervix is unable to stay closed. There is also some evidence to suggest that women with PCOS may have an increased risk of miscarriage, however why this may be the case is unclear.

Types of Miscarriage

There are many differing types of miscarriage and you may feel confused by the different terms you hear your doctor or nurse use. Below I explain all types and what medical intervention may be required following this type of miscarriage.

Complete Miscarriage

A complete miscarriage occurs when all the products of conception are passed from the uterus. A woman will experience bleeding and pain. The examination by a doctor and an ultrasound scan will show that the uterus is empty and a miscarriage has occurred. In this situation, generally no medical intervention is required.

Incomplete Miscarriage

On occasions, not all the products of conception are passed from the uterus and are therefore seen on ultrasound scan. In general a woman is given a choice with regards to on-going care. She can choose to go home and pass the products of conception naturally, by continuing to bleed and then be reviewed by a doctor a few days later; or she may choose to have a short medical procedure called an ERPC (sometimes this is referred to as a D&C) to remove the products surgically.

An inevitable Miscarriage

If a woman is bleeding, an examination may show that the cervix (the neck of the womb) is open and it is very likely that a full miscarriage will occur and either progress in to a complete or incomplete miscarriage.

Missed Miscarriage

In this situation the pregnancy fails to develop and very often the first time a woman will be aware is at her routine scan when no heartbeat will be seen. Some women however will report the loss of pregnancy symptoms and this might prompt an early scan. In this situation a woman can choose to either let nature take it’s course and miscarry in a few weeks or choose to have an ERPC.

Ectopic Pregnancy

An ectopic pregnancy occurs when a fertilised ovum implants in the fallopian tubes or less commonly, elsewhere in the pelvis. The embryo will not survive outside the uterus or in the fallopian tube. A woman may experience severe pain on one side of the abdomen and heavy bleeding. This situation can be life threatening and therefore one-sided pain in early pregnancy should always be reported to your doctor. An ectopic pregnancy is confirmed by ultrasound and a surgical procedure called a Laparoscopy is required to remove the ectopic pregnancy. Often the fallopian tube will be damaged and will also be removed.

Anembryonic Miscarriage (or blighted ovum)

In this situation an ultrasound scan is unable to identify an embryo. It may be that the embryo was reabsorbed in to the body early on in its development. Most Anembryonic miscarriages are due to severe chromosomal abnormalities and would not be able to thrive. Most women would require an ERPC in this case.

Hydatidiform Mole (Molar pregnancy)

This is a rare form of miscarriage (1:714 live births in the UK) where the placenta grows abnormally and the embryo dies. The placenta continues to grow erratically and a molar pregnancy may be diagnosed on ultrasound. The Hydatidiform mole will need to be removed via surgery and sent to the laboratory for examination. A hydatidiform mole is part of a group of disorders called gestational trophoblastic disease (GTD). Moles are benign (not cancerous) forms of GTD. However, there is a risk that a hydatidiform mole can develop into a cancerous (malignant) type of GTD, known as gestational trophoblastic neoplasia (GTN). A woman requires close follow-up following a molar pregnancy and it is generally recommended that you wait for a year before trying for another baby.

Investigations

Most hospitals and clinics will investigate the reasons for your miscarriage but unfortunately this is only done after you have suffered 3 or more losses. This may feel frustrating and it is totally normal that you should want to know why you have miscarried, regardless of how many you have suffered. However the rationale for this policy is that because miscarriage is so common, many women will suffer one or two miscarriages but then go on to carry a pregnancy successfully to term.

The investigations detailed below are recommended by the Royal College of Obstetricians and Gynecologists and are evidence based.

Antiphospholipid syndrome (APS)

This is a blood test to look for APS. This is a clotting disorder and the test looks for the presence of lupus anticoagulant antibodies and anticardiolipin antibodies. It is recommended that two separate tests are performed, 6-12 weeks apart. If you are diagnosed with APS you are likely to be treated with low dose aspirin and heparin injections once you have a confirmed pregnancy test.

Other blood clotting disorder

You may be able to receive testing for other blood clotting disorders such as Factor V Leiden, factor 11, gene mutation and protein S. It is worth discussing this with your doctor to see if these tests are pertinent to your individual situation.

Genetic Testing

Your hospital should be able to test you for any chromosomal abnormalties that may be the cause of your recurrent miscarraiges. It is worth bearing in mind that often miscarriages caused by chromosomal abnormalities are often ‘one off’ occurrances and it is very likely that you will go on to have a healthy pregnancy the next time that you conceive.

Anatomical abnormalities

Some women can suffer from either uterine or cervical abnormalities and won’t be aware until they conceive and subsequently suffer a miscarriage. Some late miscarriages may occur due to the uterus being an abnormal shape and what is often termed a bicornate or a unicornate uterus. You should be offered tests to check your uterus such as a scan, hysteroscopy or laparoscopy. Cervical weakness or ‘incompetence’ as it is often called is hard to diagnose and treat. You may be offered regular scans to once you are pregnant. Some women are offered a cervical stitch to hold the cervix closed during pregnancy

Other tests and treatments

There are other tests and treatment that your doctor may suggest however these are currently not recommend as there is little research to prove that they are either effective treatments for miscarriage or that they cause no harm. However as new research comes to light more and more options may be available to you.

Progesterone supplements: Progesterone is often prescribed for infertility or in early pregnancy to help prevent miscarriage. However recent research showed that progesterone supplementation had no benefit in preventing early pregnancy and women have just the same chance of miscarrying if they do not take the treatment.

HCG Supplementation: HCG is a important hormone vital to support a pregnancy, however there is no evidence to suggest that HCG supplements prevent miscarriage.

Metformin treatment: Metformin is often prescribed for women suffering with PCOS who are trying to conceive. Small studies have shown that metformin use may reduce the chance of miscarriage in women with PCOS, however more research is required to confirm this.

Suppression of high levels of LH: Using drugs to suppress high levels of LH is not associated with improving the chances of a woman carrying a pregnancy to term.

Steroid treatment: Some women may benefit from steroid treatment, however a larger study is required to support this and to look at any potential harmful effects of this treatment during pregnancy.

Prevention

Often it’s not possible to prevent against miscarriage and a miscarriage is unlikely to be due to anything you did or didn’t do. However there are a number of things you can do to help your chances of having a healthy pregnancy.

  • Weight – being overweight increases the likelihood of miscarriage as well as problems for both you and the baby during pregnancy and after birth. Try to get to a healthy weight with a BMI of under 30 before trying to conceive.
  • Stress – it is unsure why but it appears that stress can increase your chances of miscarrying. We can’t stop stress in our general life, whether it be work stress, family, relationships or even trying to conceive. However what you can do is develop strategies to help you cope with stress. Consider what support you need and where you can get help.
  • Lifestyle – eat healthily, keep your alcohol levels low, don’t smoke and enjoy moderate exercise.

Emotional impact

Some times the emotional impact of a miscarriage is felt immediately but for some women this might occur at a later date. Giving yourself the time and space to grieve before you move on to trying again is very important.

Don’t forget that your partner is very likely to feel the impact of your miscarriage too. It may help to ensure that you can both communicate and talk about your feelings openly.

There are many places that you can go to for support and your hospital or clinic should be able to put you in touch with support within your local area. However you can get advice and find local support networks and information on the following websites:

UK: http://www.miscarriageassociation.org.uk

Ireland: http://www.miscarriage.ie/index.html

USA: http://themiscarriageassociation.com