Miscarriage

This refers to a pregnancy that fails to grow, either because no embryo is formed (blighted ovum) or there is no cardiac activity (no heartbeat). Loss of a pregnancy prior to the 23rd completed week is generally considered a miscarriage. However, some guidelines use the cut-off of 20 to 22 weeks to define it.

How common is it?

It happens in about 20% of pregnancies. Majority occurs in the first trimester. It can occur so early in some pregnancies that the woman may be unaware that she is pregnant.

Causes

During the first trimester (first 12 weeks of pregnancy), the possible causes are:

  • Genetic (chromosome abnormalities such as Down’s syndrome) or structural abnormalities of the fetus.
  • Uterine abnormalities that prevent the fertilized egg from growing normally.
    Smoking.
  • Severe stress (nutritional; psychological).
  • Use of substances that can harm the fetus (cocaine, smoking, anti-cancer drugs).
  • Infections, especially viral infections (rubella or influenza).
  • Trauma
  • Severe medical conditions (uncontrolled or complicated diabetes mellitus or hypertension, autoimmune disease).

Older women (above age of 35) will have a slightly higher rate of miscarriage.

Symptoms and signs

Some women may not have any symptoms at all and only found out during the early routine ultrasound scan of the pregnancy. Women with miscarriage may have the following presentation:

  • Lower abdominal pain, due to uterine cramps, with increasing intensity over time
  • Vaginal bleeding, from slight to heavy
  • Passing out products of the pregnancy through the vagina
  • Feeling weak, faint, slowed heart rate or low blood pressure may be present due to excessive bleeding or the presence of the product of the pregnancy at the cervix

Possible complications

  • Uterine infection – with fever, chills, abnormal vaginal discharge, and body ache
  • Excessive bleeding from the vagina
  • Incomplete‖ miscarriage, in which some placenta or fetal tissue remains in the uterus and may requires

Diagnosis

This is made by clinical history, positive pregnancy test and confirmed by ultrasound scan of the pregnancy.

 

 

 

Investigations

Ultrasound scan of the uterus is necessary to look for the viable pregnancy. Laboratory blood studies may be needed for:

  • Blood group and Rhesus status
  • Pregnancy hormone level measurement – this is performed only if the diagnosis is uncertain and more than one measurement is usually done to evaluate whether the pregnancy is progressing normally

Treatment

  • If a fetal heartbeat can be seen, this means that there is a 95 % chance that the pregnancy will proceed normally. This is labelled as a threatened miscarriage (vaginal bleeding, without any pain). You should follow your doctor advice. Rest at home is often enough to stabilize the pregnancy
  • Avoid sexual intercourse, exercise, strenuous activity or traveling until the bleeding has stopped or the outcome is known
  • Once a diagnosis is made, women can opt to wait and see if the pregnancy tissue will be expelled spontaneously or go straight for suction evacuation. If the spontaneous expulsion is complete, then no further action is required. If there is still residual pregnancy tissue seen in the uterus via the ultrasound scan, then suction evacuation is advisable
  • Following a miscarriage, expect a small amount of vaginal bleeding or spotting for 8 to10 days. Use sanitary napkins—not tampons to absorb blood or drainage
  • Wait through 2 or 3 normal menstrual cycles before attempting to become pregnant
  • After a miscarriage, antibiotics is not routinely given. It is only given if there is a risk of infection
  • If the woman is Rhesus negative and her husband is Rhesus positive, an injection consisting of an anti-D (immune globulin) is given
  • After a miscarriage, reduce activity and rest often during the next 48 to 72 hours. There is no special dietary restriction. Eat a normal and balanced diet. Feelings of loss and grief are common. Feelings of guilt may also be present. Discuss this with your health care provider. Be open about it. If these persist, seek professional psychological help
  • Avoid sexual intercourse until bleeding has stopped. Please discuss contraception with your doctor prior to resuming intercourse

Prevention

Most miscarriages cannot be totally prevented because the developing fetus is not normal. However, you should:

  • Aim for a healthy body weight before and during pregnancy
  • Ensure you are fully vaccinated for certain infectious disease prior to pregnancy
  • Obtain regular medical check-ups during pregnancy
  • Ensure that any medical illness that is currently present should be under good control or in remission. Women with medical disorders and currently on medications should discuss with their doctor regarding pregnancy, so that the doctor can adjust and chose the appropriate medications that are safe to be taken before and during pregnancy
  • Eat a normal, well balanced diet
  • Do not drink alcohol, smoke cigarettes, or use recreational drugs prior to and during pregnancy
  • Do not use any medications, including non-prescription drugs, without proper medical advice

See your doctor immediately if there is:

  • Bleeding and cramps which worsen during a threatened miscarriage or you pass tissue
  • Presence of infection, including fever, headache, muscle aches, dizziness or a general ill feeling during a threatened miscarriage or following a miscarriage
  • Increasing nausea and vomiting, short of breath or feel faint
  • Bleeding (other than vaginal) or unexplained bruising
  • Prolonged (more than 2 weeks) or very heavy vaginal bleeding (presence of clots or need to change pads frequently) following a miscarriage
  • Persistent and abnormal vaginal discharge.

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