Miscarriage is the loss of a
pregnancy in the first 20 weeks. (In medical articles, you may see the term
"spontaneous abortion" used in place of miscarriage.) About 10 to 20
percent of known pregnancies end in miscarriage, and more than 80 percent of
these losses happen before 12 weeks.
This doesn't include situations in
which you lose a fertilized egg before a pregnancy becomes established. Studies
have found that 30 to 50 percent of fertilized eggs are lost before or during
the process of implantation – often so early that a woman goes on to get her
period at about the expected time.
Between 50 and 70 percent of
first-trimester miscarriages are thought to be random events caused by
chromosomal abnormalities in the fertilized egg. Most often, this means that
the egg or sperm had the wrong number of chromosomes, and as a result, the
fertilized egg can't develop normally.
Sometimes a miscarriage is caused by
problems that occur during the delicate process of early development. This
would include an egg that doesn't implant properly in the uterus or an embryo
with structural defects that prevent it from developing.
Since most healthcare practitioners
won't do a full-scale workup of a healthy woman after a single miscarriage,
it's usually impossible to tell why the pregnancy was lost. And even when a
detailed evaluation is performed – after you've had two or three consecutive
miscarriages, for instance – the cause still remains unknown half the time.
When the fertilized egg has
chromosomal problems, you may end up with what's sometimes called a blighted ovum
(now usually referred to in medical circles as an early pregnancy failure). In
this case, the fertilized egg implants in the uterus and the placenta and
gestational sac begin to develop, but the resulting embryo either stops
developing very early or doesn't form at all.
Because the placenta begins to
secrete hormones, you'll get a positive pregnancy test and may have early
pregnancy symptoms, but an ultrasound will show an empty gestational sac. In
other cases, the embryo does develop for a little while but has abnormalities
that make survival impossible, and development stops before the heart starts
beating.
If your baby has a normal heartbeat
– usually first visible on ultrasound at around 6 weeks – and you have no
symptoms like bleeding or cramping, your odds of having a miscarriage drop
significantly and continue to decrease with each passing week.
Vaginal spotting or bleeding is
usually the first sign of miscarriage. Keep in mind, though, that up to 1 in 4
pregnant women have some bleeding or spotting (finding spots of blood on your
underpants or toilet tissue) in early pregnancy, and most of these pregnancies
don't end in miscarriage.
You may also have abdominal pain,
which usually begins after you've had some bleeding. It may feel crampy or
persistent, mild or sharp, or may feel more like low back pain or pelvic
pressure. If you have both bleeding and pain, the chances of your pregnancy
continuing are much lower.
It's very important to be aware that
vaginal bleeding, spotting, or pain in early pregnancy can also signal an
ectopic or a molar pregnancy. If you have any of these symptoms, call your
doctor or midwife right away so she can determine whether you have a problem
that needs to be dealt with immediately.
Also, if your blood is Rh-negative,
you may need a shot of Rh immune globulin within two or three days after you
first notice bleeding, unless the baby's father is Rh-negative as well.
Some miscarriages are first
suspected during a routine prenatal visit, when the doctor or midwife can't
hear the baby's heartbeat or notices that your uterus isn't growing as it
should be. (Often the embryo or fetus stops developing a few weeks before you
have symptoms like bleeding or cramping.)
If your practitioner suspects that
you've had a miscarriage, she'll order an ultrasound to see what's going on in
your uterus. She may also do a blood test.
What should I do if I suspect I'm about
to miscarry?
Call your doctor or midwife
immediately if you ever notice unusual symptoms such as bleeding or cramping
during pregnancy. Your practitioner will examine you to see if the bleeding is
coming from your cervix and check your uterus. She may also do a blood test to
check for the pregnancy hormone HCG and repeat it in two to three days to see
if your levels are rising as they should be.
If you're having bleeding or
cramping and your practitioner has even the slightest suspicion that you have
an ectopic pregnancy, you'll have an ultrasound right away. If there's no sign
of a problem but you continue to spot, you'll have another ultrasound at about
7 weeks.
At this point, if the sonographer
sees an embryo with a normal heartbeat, you have a viable pregnancy and your
risk of miscarrying is now much lower, but you'll need to have another
ultrasound later if you continue to bleed. If the sonographer determines that
the embryo is the appropriate size but there's no heartbeat, it means the
embryo didn't survive.
If the sac or the embryo is smaller
than expected, the absence of a heartbeat might just mean that your dates are
off and you're not as far along as you thought. Depending on the circumstances,
you may need a repeat ultrasound within one to two weeks and some blood tests
before your caregiver can make a final diagnosis.
If you're in your second trimester
and an ultrasound shows your cervix is shortening or opening, your doctor may
decide to perform a procedure called cerclage, in which she stitches your
cervix closed in an attempt to prevent miscarriage or premature delivery. (This
is assuming your baby appears normal on the ultrasound and you have no signs of
an intrauterine infection.) Cerclage isn't without risk, and not everyone
agrees on what makes you a good candidate for it.
If you're showing signs of a
possible miscarriage, your doctor or midwife may prescribe bedrest in hopes of
reducing your chances of miscarrying – but there's no evidence that bedrest
will help. She may also suggest that you not have sex while you're having
bleeding or cramping. Sex doesn't cause miscarriage, but it's a good idea to
abstain if you're having these symptoms.
You may have light bleeding and
cramping for a few weeks. You can wear sanitary pads but no tampons during this
time and take acetaminophen for the pain. If you are miscarrying, the bleeding
and cramping will likely get worse shortly before you pass the "products
of conception" – that is, the placenta and the embryonic or fetal tissue,
which will look grayish and may include blood clots.
If you can, save this tissue in a
clean container. Your caregiver may want to examine it or send it to a lab for
testing to try to find out why you miscarried. In any case, she'll want to see
you again at this point, so call her to let her know what's happened.
What should I do if my practitioner tells
me I've lost the pregnancy but I still haven't passed the tissue?
There are different ways of handling
this, and it's a good idea to discuss the pros and cons of each with your
caregiver. If there's no threat to your health, you may choose to wait and let
the tissue pass on its own. (More than half of women spontaneously miscarry
within a week of finding out that the pregnancy is no longer viable.) Or you
may decide to wait a certain amount of time to see what happens before having a
procedure to remove the tissue.
In some cases, you can use
medication to speed up the process, although there may be side effects such as
nausea, vomiting, and diarrhea. If you choose to wait or take medication to try
to speed it up, there's a chance you'll end up needing to have the tissue
surgically removed anyway.
On the other hand, if you find that
it's too emotionally trying or physically painful to wait for the tissue to
pass, you may decide to just have it removed. This is done by suction curettage
or dilation and curettage (D&C).
You'll definitely need to have the
tissue removed right away if you have any problems that make it unsafe to wait,
such as significant bleeding or signs of infection. And your practitioner may
recommend the procedure if this is your second or third miscarriage in a row,
so the tissue can be tested for a genetic cause
.
The procedure doesn't usually
require an overnight stay unless you have complications. As with any surgery,
you'll need to arrive with an empty stomach – no food or drink since the night
before.
Most obstetricians prefer to use
suction curettage (or vacuum aspiration) because it's thought to be slightly
quicker and safer than a traditional D&C, though some will use a
combination of the two. For either procedure, the doctor will insert a speculum
into your vagina, clean your cervix and vagina with an antiseptic solution, and
dilate your cervix with narrow metal rods (unless your cervix is already
dilated from having passed some tissue). In most cases, you'll be given
sedation through an IV and a local anesthetic to numb your cervix.
For suction curettage, the doctor
will pass a hollow plastic tube through your cervix and suction out the tissue
from your uterus. For a traditional D&C, she'll use a spoon-shaped
instrument called a curette to gently scrape the tissue from the walls of your
uterus. The whole thing may take about 15 to 20 minutes, though the tissue
removal itself takes less than ten minutes.
Finally, if your blood is
Rh-negative, you'll receive a shot of Rh immune globulin unless the baby's
father is Rh-negative, too.
What
happens after a miscarriage?
Whether you pass the tissue on your
own or have it removed, you'll have mild menstrual-like cramps afterward for up
to a day or so and light bleeding for a week or two. Use pads instead of
tampons and take ibuprofen or acetaminophen for the cramps. Avoid sex,
swimming, douching, and using vaginal medications for at least a couple of
weeks and until your bleeding has stopped.
If you begin to bleed heavily
(soaking a sanitary pad in an hour), have any signs of infection (such as
fever, achiness, or foul-smelling vaginal discharge), or feel excessive pain,
call your practitioner immediately or go to the emergency room. If your
bleeding is heavy and you begin to feel weak, dizzy, or lightheaded, you may be
going into shock. In this case, call 911 right away – don't wait to hear from
your caregiver, and don't drive yourself to the ER.
Does
having one miscarriage mean I'm likely to miscarry again?
It's understandable to be worried
about the possibility of another miscarriage, but fertility experts don't
consider a single early pregnancy loss to be a sign that there's anything wrong
with you or your partner.
Some practitioners will order
special blood and genetic tests to try to find out what's going on after two
miscarriages in a row, particularly if you're 35 or older or you have certain
medical conditions. Others will wait until you've had three consecutive losses.
In certain situations, such as if you had a second-trimester miscarriage or an
early-third-trimester premature birth from a weakened cervix; you might be
referred to a high-risk specialist after a single loss so your pregnancy can be
carefully managed.
You may have to wait a bit. Whether
you miscarry spontaneously, with the help of medication, or have the tissue
removed, you'll generally get your period again in four to six weeks.
Some practitioners say you can start
trying to conceive again after this period, but others recommend that you wait
until you've been through another menstrual cycle so that you have more time to
recover physically and emotionally. (You'll need to use birth control to
prevent conception during this time, because you may ovulate as early as two
weeks after you miscarry.)
I can't seem to get over having miscarried. How can I cope?
Though you may be physically ready
to get pregnant again, you may not feel ready emotionally. Every woman copes
with the grief of early pregnancy loss in her own way.
Some cope best by turning their
attention toward trying for a new pregnancy as soon as possible. Others find
that months or more go by before they're ready to try to conceive again. Take
the time to examine your feelings, and do what feels right for you and your
partner.
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