Miscarriage

From Freepedia

Miscarriage
ICD-10 code: O03
ICD-9 code: 634

"Miscarriage" is the common term for the natural or accidental termination of a pregnancy at a stage where the embryo or the fetus is incapable of surviving. Miscarriages are the most common complication of pregnancy.

In medical terms, any terminated pregnancy is an "abortion," whether the abortion is deliberately induced or not. Natural deaths (miscarriages) are termed "spontaneous abortions." However, the medical terms can be confused with "deliberate abortion," and the term "miscarriage" is used outside of medical circles. In medical terms, no political or moral distinction is made between deliberate and spontaneous abortions —all pregnancy losses prior to 20 weeks gestation are considered "miscarriages."

Contents

Experience

Women experiencing a miscarriage may bleed for 2 weeks or more. Bleeding for more than 10 days, or the presence of abdominal pain, may indicate incomplete miscarriage and warrant review by a doctor. Although much of the literature suggests that a miscarriage should not be much heavier than a period, a miscarriage from 8 weeks or so can involve extremely heavy bleeding, to the extent that it may be difficult to go out. Severe bleeding may require medical attention.

An incomplete miscarriage (as confirmed with ultrasound may resolve itself with the next menstrual cycle, or may require a dilation and curettage. Pain or unpleasant odor associated with the bleeding could indicate infection.

Prevalence

Miscarriages occur more often than most people think. About 25% of women will experience one in their lives. Up to 78% of all conceptions may fail [1], in most cases before the woman even knows she is pregnant. A fifth of confirmed pregnancies have some bleeding occuring in the first 20 weeks and in all 15% proceed to miscarriage [2]. After the age of 35, the risk of miscarriage increases considerably: 1 in 5 or 6. After 40, the risk increases to 1 in 3, and after 45 it is 1 in 2.

Medical aspects

Timing

Most such terminations occur very early in pregnancy, during the first trimester, and many people restrict the term "miscarriage" (or early miscarriage) to early losses. Pregnancy losses in the second trimester (or late miscarriage) are much less common.
Miscarriages frequently occur so early that the woman is not even aware that she is pregnant; these are preclinical pregnancy losses. Some women are prone to miscarry; the term "habitual abortion" is more and more replaced by "recurrent pregnancy loss" (RPL) or recurrent miscarriage[3] and describes the condition where three consecutive pregnancies have terminated before 20 weeks gestation.

Types

If a pregnant woman has vaginal bleeding, she is said to have a "threatened abortion," many patients with first trimester bleeding will be found to have a subchorionic hematoma and do well. In about half[2] such bleeding will progress to a pregnancy loss.

With pain and opening of the cervix a woman is about to have an "inevitable abortion," which indicates that she has an absolute probability of miscarrying.

If some of the tissue remains in the uterus after a passing some tissue, this is called an "incomplete abortion." If the tissue in the uterus gets infected, it is a "septic abortion". In some cases the fetus dies, but the uterus does not expell the pregnancy:- this is called a "missed abortion." A "blighted ovum" pregnancy is a form of a miscarrage where the fetus either did not form, or died early, and the pregnancy consists only of trophoblastic tissue.

A specific form of a miscarriage is the ectopic pregnancy.

Threatened abortion

A threatened abortion is a type of miscarriage (aka abortion) that happens when there is bleeding with or without cramps or low back pain. With such a presentation of bleeding, 50% proceed to miscarriage of the pregnancy.

Management of these patients involves an examination to assess for cervical dilatation, an ultrasound to assess fetal viability, and bedrest for the mother, though there is no scientifically-proven benefit for the latter. When a threatened abortion occurs, no hormones or medications have been shown to prevent it.

Inevitable abortion

The miscarriage of a pregnancy is inevitable when any of the following symptoms are present:

When any of these symptoms are detected, management involves conservative observation, monitoring for heavy bleeding and sepsis, and a dilatation and curettage (D&C).

Incomplete abortion

An incomplete abortion is the miscarriage of a fetus in a pregnancy when tissue has been passed, but some remains in utero. It can result in severe bleeding, infection or intrauterine scarring. Management consists of a dilatation and curettage (D&C).

Septic abortion

The infection of the womb carries risk of spreading infection (septicaemia) and is a grave risk to the life of the mother. It may follow an incomplete miscarriage and previously was a problem for pregancies that occurred if a Dalkon Shield IUD had failed in its contraception. This has been particularly associated with abortions in breach of sterile procedures, common in ones carried out illegally or in absence of adequate medical resources.[4]

Missed abortion

A missed abortion is the miscarriage of a fetus in a pregnancy when the fetus has died, but remains in the uterus.

Pathology

When looking for gross or microscopic pathologic symptoms of miscarriage, one looks for the products of conception.
Microscopically, these include villi, trophoblast, fetal parts, and background gestational changes in the endometrium. Cytogenetic studies show that half or more of first trimester pregnancy losses have abnormal chromosome arrangements.

Causes

Miscarriages can occur for many reasons, not all of which can be identified. They are most frequent during the first trimester. About 30% of fertilized eggs are actually lost before the woman knows she is pregnant and may only be noticeable by slightly more important blood loss.

First trimester losses are in many cases due to aneuploidy. A chromosomal abnormality occurs where the genetic material from the sperm and egg do not fuse together appropriately. The resulting baby does not develop properly. In other cases, a "blighted ovum" occurs, where the amniotic sac and placenta develop but not the fetus.

Other possible but much less common causes include physical trauma, exposure to certain chemicals, infection, and immune factors. A number of studies have examined lifestyle factors. Thus obesity, high caffeine intake (> 300 mg/day), alcohol consumption, and use of NSAIDs have all been linked to higher miscarriage rates in general. Also women undergoing fertility therapy tend to have higher miscarriage rates.

In the US, smoking label warnings must be displayed to inform women that smoking can lead to "low birth weights"[5] [6] .

Pregnancy losses in the second trimester may be due to fetal abnormalities, uterine malformation, cervical problems, infection, trauma, immune factors, and medical disease.

Management

  • Threatened miscarriages with little blood loss or pain may be managed be seeing one's doctor the next working day to arrange an ultrasound scan to verify that the pregnancy is continuing (i.e., that a fetal heartbeat can be seen).
    • However, if the bleeding is heavy or accompanied by considerable pain, then emergency medical attention should be sought.
  • If a miscarriage is complete and bleeding is contained and limited, only expectant management may be necessary (Ankum et al 2001[7]). Excessive or prolonged bleeding needs medical attention. Often a dilation and curettage is indicated to remove tissue from the uterus. Tissue examination, including cytogenetic studies, are helpful to determine the cause of the pregnancy loss (but no routine investigations are undertaken for non-habitual early miscarriages in the UK).
  • A miscarriage accompanied by a fever needs emergency medical attention.
  • Severe lower abdominal pain may indicate an ectopic pregnancy and needs emergency medical attention.

Habitual abortion

Habitual abortion (recurrent pregnancy loss or recurrent miscarriage) is the occurrence of 3 consecutive miscarriages. The majority (85%) of women who have had two miscarriages will conceive and carry normally afterwards, so statistically the occurrence of three abortions at 0.34%[3]) is regarded as "habitual".

There are various medical conditions associated with this problem, some of which may be corrected with medication.

Psychological aspects

Although a woman physically recovers from a miscarriage quickly, psychological recovery can take a long time. Women can differ a lot in this regard: some are 'over' it after a few months, others take more than a year.

What is the same for many women is that they will go through a process of grief, often as if the baby had been born but died. How short a time the child in her womb has lived does not matter for the feeling of loss. From the moment a woman becomes aware that she is pregnant she can start to bond with her unborn child. When the child turns out not to be viable, dreams, fantasies and plans for the future are disturbed roughly.

Besides the feeling of loss, incomprehension from the environment is often important. Someone who hasn't gone through a miscarriage themselves can't know what it is and how upsetting it is. People around the woman may think that after weeks or maybe months, she will be over it. The pregnancy and miscarriage are hardly mentioned anymore in conversation, often too because the subject is too painful. This can make the woman feel isolated.

Interaction with pregnant women and newborn children is often also painful. Sometimes this makes the interaction with friends, acquaintances and family very difficult. Immediately after a miscarriage some women don't want to go out at all for fear of meeting acquaintances or pregnant women.

Some things a woman can do to deal with a miscarriage better are:

  • naming the child
  • keeping photos
  • arranging a funeral for the child
  • reading books on the subject
  • talking about it
  • finding others who have gone through a miscarriage
  • finding professional help: although it is a natural grieving process, it may take a long time. In such cases, a psychologist or grief counselor may be of help.

Notes

  1. ^ Roberts CJ, Lowe CR. Where have all the conceptions gone? Lancet 1975;1:498-9
  2. ^ a  Christopher Everett. Incidence and outcome of bleeding before the 20th week of pregnancy: prospective study from general practice BMJ 1997;315:32-34 (5 July) Full article
  3. ^ a ) Royal College of Obstetricians and Gynaecologists The Investigation and Treatment of Couple with Recurrent Miscarriage Guideline No 17 PDF document
  4. ^  Septic abortion GP Notebook
  5. ^ Ness, R., Grisso, J., Hirschinger, N., Markovic, N., Shaw, L., Day, N., and Kline, J. (1999). Cocaine and Tobacco Use and the Risk of Spontaneous Abortion. New England J. Med. 340:333-339; Oncken, C., Kranzler, H., O'Malley, P., Gendreau, P., Campbell, W. A. (2002). The Effect of Cigarette Smoking on Fetal Heart Rate Characteristics. Obstet Gynecol 99: 751-755.
  6. ^  Venners, S.A., X. Wang, C. Chen, L. Wang, D. Chen, W. Guang, A. Huang, L. Ryan, J. O'Connor, B. Lasley, J. Overstreet, A. Wilcox, and X. Xu. (2004). Paternal Smoking and Pregnancy Loss: A Prospective Study Using a Biomarker of Pregnancy Am J Epidemiol 159: 993-1001.
  7. ^ Ankum WM, Wieringa-de Waard, M, Bindels PJE. Management of spontaneous miscarriage in the first trimester: an example of putting informed shared decision-making into practice. bmj 2001;322:1343-6 [8]


See also

External links

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