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Miscarriage

D. Ashley Hill, M.D.

One of the most devastating events in a couple's life is the loss of their baby through a miscarriage. Even though magazines and other media sources have begun discussing this sensitive subject, most people are unaware that up to one-half of all pregnancies end in a miscarriage, usually during the first few weeks of pregnancy. Since this is such a common and serious problem, it is important to understand the causes of miscarriage, the appropriate evaluation for patients who have recurrent miscarriages, and what to say (and not say) to a friend or loved one who has had a miscarriage.

Technically, a miscarriage is any pregnancy loss that occurs before 20 weeks gestational age, which is approximately up to the 5th month. (The formal medical term for a miscarriage is "spontaneous abortion," but many doctors disagree with this terminology because of the confusion this creates with pregnancy terminations, which are also called "abortions"). Many women who lose a pregnancy do not even know they are pregnant, while others notice cramping, bleeding, and perhaps the passage of clots or tissue from the vagina. Most researchers agree that about 20% of all pregnancies end up as miscarriages that cause symptoms like these, while about an equal number cause "silent" miscarriages.

Women with symptoms like bleeding, cramping, or passing tissue or large clots should notify their doctor. Sadly, there is almost never anything you or your doctor can do to prevent a miscarriage once symptoms occur, and while some doctors and midwives advise bed rest, this has not been proven to help prevent miscarriage. Most health care providers advise limited activity and abstinence from intercourse or heavy exercise.

In some cases a thorough pelvic examination and perhaps an ultrasound (sometimes also called a sonogram) will help determine if there has been a miscarriage or if the fetus is still viable. In other cases the patient may need special blood "pregnancy hormone" studies called beta-HCG levels to help determine if the pregnancy has a chance at survival. Following these levels over many days may be useful in determining whether or not a miscarriage is occurring. Once a miscarriage is diagnosed, the patient has the option of awaiting passage of all the placental tissue, or having a D&C (dilatation and curettage) of the uterus to remove the tissue via outpatient surgery. This is a very individual decision that requires discussion between the patient and her doctor.

A number of problems can cause a miscarriage. The most common, by far, is a chromosomal abnormality where the genetic material from the sperm and egg do not fuse together appropriately. This accounts for about one-half of all miscarriages and is most commonly a random event that is, essentially, very bad luck. A variation of this is when a "blighted ovum" occurs, where the water bag and placenta (afterbirth) develop but not the fetus (baby). Fortunately, in about 9 out of 10 cases, the next pregnancy after these types of miscarriages will be normal!

Some conditions lead to recurrent pregnancy losses, where the patient loses a number of pregnancies and cannot seem to "carry" a baby. Doctors usually suggest an evaluation after 3 of these losses, although in many situations an evaluation is prudent after 1 or 2 losses. Doctors can find a cause of recurrent miscarriage about one-half of the time.

An abnormality of the uterus (womb) may cause about 15% of recurrent miscarriages. In this situation the uterine muscle is slightly malformed and the pregnancy cannot grow appropriately. This problem is diagnosed with a special x-ray or ultrasound of the uterus and surgery is usually successful in curing the problem.

Some unusual vaginal infections can cause recurrent miscarriages, although it appears that this is not common. Cultures of the vagina and antibiotics are sometimes helpful if your doctor suspects an infection.

Rarely (about 3% of the time), a chromosomal problem of one or both partners can lead to recurrent pregnancy loss. This problem, usually a "balanced translocation," is diagnosed by taking a blood or tissue sample from each partner and performing a 'karyotype' to check the chromosomes. There is a higher rate of miscarriages in patients who have such a chromosomal problem, although many go on to deliver normal and healthy babies.

Autoimmune problems, where certain chemicals in the blood stream attack cells and tissues within the body, can lead to recurrent pregnancy loss. These chemicals, called 'antibodies,' circulate in the blood stream and may not ever cause problems, or they may lead to disorders such as diabetes, lupus, antiphospholipid syndrome, or hypothyroidism. They can also lead to blood clots in the placenta, which shuts off the blood supply to the developing fetus, causing a miscarriage. Special blood tests can diagnose this problem, and treatment with low-dose aspirin and sometimes a 'blood thinner' called heparin will usually lead to a successful pregnancy. These are "high-risk" pregnancies because of an increased chance of small babies, fetal stress, preeclampsia ('toxemia', where the blood pressure rises dangerously during pregnancy), and other problems.

During pregnancy a benign cyst on the ovary, called the corpus luteum, produces the hormone progesterone which is necessary for maintaining the pregnancy during the first trimester. Although somewhat controversial, some doctors feel a "luteal phase defect" can cause recurrent pregnancy loss. This condition may occur when not enough progesterone is present to act on the lining of the uterus. Diagnosis is made when 1 (and often 2) endometrial biopsies are performed by taking a sample of tissue from the uterine lining, and treatment is usually with either progesterone supplements, or a medication called clomiphene citrate.

Finally, a very controversial potential cause of recurrent miscarriages is an allo-immune disorder, where the man and woman have too much genetic material in common. The theory is that the mother's body 'rejects' the fetus in a way similar to how a transplant patient might reject a new organ. Some doctors advocate extensive (and expensive) testing to diagnose this condition, and use injections of the male partner's white blood cells into the female partner's blood stream to help prevent future miscarriages. Many doctors disagree with this testing and treatment, saying that research is lacking to prove that it is helpful Many feel that doctors should not attempt such expensive testing and treatment until further research proves that this therapy is helpful.

If you have a friend or family member who has gone through a miscarriage, there is much you can do to help her (and her partner). First, simply letting her know that you are very sorry to hear of her loss is the kindest thing you can do. Letting her know that you are available to help or listen is another good suggestion. Most women who have had a miscarriage will find either or both of these quite adequate and helpful. Unfortunately, most of us feel awkward when faced with a friend in emotional pain, and we feel obligated to say something else. Sadly, what we attempt to say in these sensitive situations may not come across right and we may instead say something profoundly hurtful and insensitive.

In fact, most women who have had a miscarriage tell me that they have heard unbelievably insensitive comments from their friends and family, and in some cases this has led to permanently damaged relationships. Comments such as "the baby would have been deformed anyway," "it must be punishment for something you did wrong," or even "you can always have more" can be extremely painful to a woman and her partner. A similarly disturbing comment is "how can you be so upset; you were barely pregnant?" Women and their partners who suffer a miscarriage often have severe grief over the loss of their baby. It does not matter how far along the mother was at the time of her loss, and, in fact, many women grieve as much over the loss of a baby in the first trimester as they do for a stillborn baby or a baby that dies many months or years after birth. Grief is very individual, and friends and loved ones should try to be kind and supportive through this difficult process.

Miscarriage is common and may be caused by a number of problems. Fortunately, there is about a 90% chance that the next pregnancy following a miscarriage will be normal. And, patients who have recurrent pregnancy losses can often be successfully treated so that they are able to carry a baby to full term. Supportive, patient, and nonjudgmental friends and family members can be extremely helpful to the couple who has suffered a miscarriage.

Editor's note: D. Ashley Hill, M.D., a board certified obstetrician/gynecologist and editorial board member of The Medical Reporter, is Assistant Director of the Obstetrics and Gynecology department at the Florida Hospital Family Practice Residency program in Orlando, Florida USA. He is also medical director of the Orlando Planned Parenthood and has interests in medical education for patients, medical students, and young doctors. His wife, Susan, also a physician, is board certified in internal medicine with an interest in women's health. Dr. Hill may be contacted at: dahmd@gate.net

 

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