22 Apr How To Cope With Miscarriage
Miscarriage can be heartbreaking but it is the most common pregnancy complication. We explain what it is, why it happens and what to do if it happens to you.
What is a miscarriage?
The loss of a pregnancy before 20 weeks is called a miscarriage. When this loss occurs during the first trimester, it is referred to as an ‘early miscarriage’; a ‘late miscarriage’ refers to a second-trimester miscarriage. If you experience three or more miscarriages in a row, which happens to about one percent of women, this is called a ‘recurrent miscarriage’.
Although miscarriage is the most common complication of pregnancy, the exact number per year is unknown. This is because many miscarriages happen so early that the woman does not even realise that she was pregnant, and so it is not recorded in any data. Nevertheless, it is thought that fifteen to twenty percent of confirmed pregnancies end in miscarriage, mostly before twelve weeks gestation.
Why does it happen?
Maternal age, diabetes, obesity, smoking, infection and genetic (i.e. chromosomal) factors are amongst the common causes of miscarriage at all stages of pregnancy. In late miscarriages, a weak or incompetent cervix may contribute, although this can be difficult to diagnose antenatally.
However, many miscarriages remain unexplained and more research is still needed before the reasons can be fully understood. In a first trimester miscarriage, hospitals usually offer only chromosomal/serum blood tests to try to determine the cause if yours is a recurrent miscarriage. Tests are available that can sometimes identify why a late miscarriage occurred, but bear in mind that a reason is found in only fifteen percent of cases. This can be difficult to cope with.
It is normal to want answers as to why such a loss occurred.
Some women only discover when they have a scan (usually at twelve and at twenty weeks) that they have lost the pregnancy. This ‘delayed’ or missed pregnancy can be particularly upsetting, because they may still ‘feel’ pregnant and have not yet had any symptoms of a miscarriage.
Types of miscarriage: early miscarriage of pregnancy
About one in four of all pregnancies end in miscarriage because many women miscarry before they even realise they are pregnant. However, by the eighth week of pregnancy, the chances of miscarrying have significantly reduced to approximately one in sixteen. About two-thirds of early miscarriages occur because the baby had a chromosomal defect that was incompatible with life.
This type of miscarriage is more likely to be an isolated occurrence (unless you and your partner are carriers of a particular genetic abnormality), and most women go on to have successful subsequent pregnancies. Miscarriages in the first few weeks of pregnancy resemble a late, slightly heavier period. Towards the end of the first trimester, the bleeding that occurs during a miscarriage may be accompanied by abdominal pain or cramping.
Occasionally, women have no symptoms at all.
If you have any bleeding or cramping, you will be referred to your nearest Early Pregnancy Unit for assessment. An ultrasound is often used to confirm whether a miscarriage is taking place. If you are miscarrying spontaneously, your healthcare professionals may advise you to let nature take its course (see below). It can also reveal whether your miscarriage is ‘complete’, meaning that your uterus has expelled all the pregnancy tissues.
If it shows that the baby has died but a miscarriage has not yet begun, or that the miscarriage is ‘incomplete’ (i.e. some tissues have remained), then you will be advised on the best course of treatment. It is important that all tissues from the pregnancy are removed in order to avoid infection and
It is important that all tissues from the pregnancy are removed in order to avoid infection and haemorrhage. In many cases, bleeding will begin naturally in time, but you may be offered a combination of pills and a pessary to open the cervix and start the process.
If the tissues have not been completely expelled after three weeks of bleeding (occurring in fifteen per cent of cases), they may need to be removed surgically under general anaesthesia (see below).
Types of miscarriage: late miscarriage of pregnancy
Miscarriage after twelve weeks is relatively rare.
It occurs in one to two percent of pregnancies. Miscarriages at this time are more likely to be caused by blood disorders, a structural problem with the umbilical cord, placenta, uterus or cervix, or can be the result of an infection or severe food poisonings, such as salmonella or listeria.
Losing a baby at this time is very distressing, especially very late in the second trimester and after you had begun to feel your baby moving inside you. Physical symptoms of late miscarriage can be the same as those of early miscarriage (see above) or, if your pregnancy is more advanced, you may experience a rupture of membranes (‘waters breaking’) and contractions.
As with early miscarriage, there may be no symptoms at all and you may discover that your baby has died only at your next ultrasound scan. This will come as a great shock and may be hard to comprehend.
Your obstetrician will discuss with you what the next course of action should be, and may advise induction of birth. Because the date of legal viability is 20 weeks, the death of a baby before this time will not be registered and no death certificate will be issued.
Many parents find it very upsetting that this late loss of their baby is referred to as a miscarriage.
However, there is nothing stopping you having a ceremony, similar to a funeral, to mark the death of your baby. And creating a memory box for your baby, similar to that created by many parents affected by stillbirth or neonatal death, can also be a good way of remembering the existence of your baby.
Types of miscarriage: recurrent miscarriage
Defined as three or more miscarriages in a row, recurrent miscarriages affect one in 100 couples. You should be offered referral to a specialist recurrent miscarriage clinic so that further investigations can be undertaken, although you should be aware that, even after full tests have been carried out, an explanation is only available in around half of cases. This is understandably frustrating and upsetting.
There are several known causes for recurrent first and second-trimester miscarriage.
As well as chromosomal abnormalities (which account for around 50 percent of miscarriages, recurrent or otherwise), uterine or cervical abnormalities are also factors, as are underlying health problems with the mother. But the most important treatable cause of recurrent miscarriage, affecting around fifteen percent of women with recurrent miscarriage, is where they have antiphospholipid syndrome.
This is a condition where the blood contains a higher than normal level of an antibody called antiphospholipid, which blocks the blood supply to the fetus and results in a miscarriage.
What kind of treatment is available?
Treatment involves taking a low dose of aspirin plus heparin, and can be very successful. Couples referred to a specialist clinic undergo highly specialised investigations, including blood testing, blood karyotyping of both you and your partner (to rule out chromosomal issues), pelvic ultrasounds and, where relevant, genetic counselling.
However, it has also been shown that supportive care involving regular antenatal appointments and scans at a specialist clinic, even when no actual treatment is involved (e.g. if no cause has been found for the pregnancy losses), can significantly improve the likelihood of having a successful subsequent pregnancy.
What to do if you have a miscarriage
If it is confirmed that you are miscarrying, and depending on how far advanced your pregnancy is, there are several options for you. The first is to let the body deal with the end of the pregnancy naturally. This is often preferable in a first-trimester miscarriage. The body will usually ‘resorb’ (or absorb) the small amounts of tissue associated with the pregnancy, or occasionally you will pass these vaginally.
The advantage of letting nature take its course is that no surgery is involved.
The disadvantage is that sometimes persistent bleeding occurs, which can increase the risk of infection. The second option is to deal with it medically: this involves a combination of pills and vaginal pessaries to encourage the body to expel the pregnancy tissue. The advantages and disadvantages are similar to that of the previous option.
The final option is to manage the miscarriage surgically. This involves an operation, often done under general anaesthesia, and is referred to as ‘surgical management of miscarriage’ (SMM), although many still call it an ERPC (evacuation of retained products of conception).
During the operation, the remaining pregnancy-associated tissue is removed gently using a suction tube. Many women opt for this, especially if bleeding has persisted for more than a week, or if there has been no bleeding and pregnancy tissue is still visible on an ultrasound.
How to take care of yourself emotionally after a miscarriage
At whatever stage it occurs, miscarriage is always distressing, both for you and your partner, as well as for your wider family and friends. The loss is often no less keenly felt for early miscarriages because couples have already started to plan their future as parents.
It is important that you allow yourselves time to grieve and to work through your loss.
Excerpt from Expecting A Baby? by Dr Penelope Law and Consultant Editor Dr Sarah Clements, published by Hardie Grant Books.