Miscarriage

Definition

Miscarriage means loss of an embryo or fetus before the 20th week of pregnancy. Most miscarriages occur during the first 14 weeks of pregnancy. The medical term for miscarriage is spontaneous abortion.

Description

Miscarriages are very common. Approximately 20% of pregnancies (one in five) end in miscarriage. The most common cause is a genetic abnormality of the fetus. Not all women realize that they are miscarrying and others may not seek medical care when it occurs.

A miscarriage is often a traumatic event for both partners, and can cause feelings similar to the loss of a child or other member of the family. Fortunately, 90% of women who have had one miscarriage subsequently have a normal pregnancy and healthy baby; 60% are able to have a healthy baby after two miscarriages. Even a woman who has had three miscarriages in a row still has more than a 50% chance of having a successful pregnancy the fourth time.

Causes and symptoms

There are many reasons why a woman's pregnancy ends in miscarriage. Often the cause is not clear. However, more than half the miscarriages that occur in the first eight weeks of pregnancy involve serious chromosomal abnormalities or birth defects that would make it impossible for the baby to survive. These are different from inherited genetic diseases. They probably occur during development of the specific egg or sperm, and therefore are not likely to occur again.

In about 17% of cases, miscarriage is caused by an abnormal hormonal imbalance that interferes with the ability of the uterus to support the growing embryo. This is known as luteal phase defect. In another 10% of cases, there is a problem with the structure of the uterus or cervix. This can especially occur in women whose mothers used diethylstilbestrol (DES) when pregnant with them.

The risk of miscarriage is increased by:

• Smoking (up to a 50% increased risk)
• Infection
• Exposure to toxins (such as arsenic, lead, formaldehyde, benzene, and ethylene oxide)
• Multiple pregnancy
• Poorly-controlled diabetes.

The most common symptom of miscarriage is bleeding from the vagina, which may be light or heavy. However, bleeding during early pregnancy is common and is not always serious. Many women have slight vaginal bleeding after the egg implants in the uterus (about 7-10 days after conception), which can be mistaken for a threatened miscarriage. A few women bleed at the time of their monthly periods through the pregnancy. However, any bleeding in the first three months of pregnancy (first trimester) is considered a threat of miscarriage.

Women should not ignore vaginal bleeding during early pregnancy. In addition to signaling a threatened miscarriage, it could also indicate a potentially life-threatening condition known as ectopic pregnancy. In an ectopic pregnancy, the fetus implants at a site other than the inside of the uterus. Most often this occurs in the fallopian tube.

Cramping is another common sign of a possible miscarriage. The cramping occurs because the uterus attempts to push out the pregnancy tissue. If a pregnant woman experiences both bleeding and cramping the possibility of miscarriage is more likely than if only one of these symptoms is present.

If a woman experiences any sign of impending miscarriage, she should be examined by a practitioner. The doctor or nurse will perform a pelvic exam to check if the cervix is closed as it should be. If the cervix is open, miscarriage is inevitable and nothing can preserve the pregnancy. Symptoms of an inevitable miscarriage may include dull relentless or sharp intermittent pain in the lower abdomen or back. Bleeding may be heavy. Clotted material and tissue (the placenta and embryo) may pass from the vagina.

A situation in which only some of the products in the uterus have been expelled is called an incomplete miscarriage. Pain and bleeding may continue and become severe. An incomplete miscarriage requires medical attention.

A "missed abortion" occurs when the fetus has died but neither the fetus nor placenta is expelled. There may not be any bleeding or pain, but the symptoms of pregnancy will disappear. The physician may suspect a missed abortion if the uterus does not continue to grow. The physician will diagnose a missed abortion with an ultrasound examination.

A woman should contact her doctor if she experiences any of the following:

• Any bleeding during pregnancy.
• Pain or cramps during pregnancy.
• Passing of tissue.
• Fever and chills during or after miscarriage.

Diagnosis

If a woman experiences any sign of impending miscarriage she should see a doctor or nurse for a pelvic examination to check if the cervix is closed, as it should be. If the cervix is open, miscarriage is inevitable.

An ultrasound examination can confirm a missed abortion if the uterus has shrunk and the patient has had continual spotting with no other symptoms.

Treatment

Threatened miscarriage

For women who experience bleeding and cramping, bed rest is often ordered until symptoms disappear. Women should not have sex until the outcome of the threatened miscarriage is determined. If bleeding and cramping are severe, women should drink fluids only.

Miscarriage

Although it may be psychologically difficult, if a woman has a miscarriage at home she should try to collect any material she passes in a clean container for analysis in a laboratory. This may help determine why the miscarriage occurred.

An incomplete miscarriage or missed abortion may require the removal of the fetus and placenta by a D&C (dilatation and curettage ). In this procedure the contents of the uterus are scraped out. It is performed in the doctor's office or hospital.

After miscarriage, a doctor may prescribe rest or antibiotics for infection. There will be some bleeding from the vagina for several days to two weeks after miscarriage. To give the cervix time to close and avoid possible infection, women should not use tampons or have sex for at least two weeks. Couples should wait for one to three normal menstrual cycles before trying to get pregnant again.

Prognosis

A miscarriage that is properly treated is not life-threatening, and usually does not affect a woman's ability to deliver a healthy baby in the future.

Feelings of grief and loss after a miscarriage are common. In fact, some women who experience a miscarriage suffer from major depression during the six months after the loss. This is especially true for women who don't have any children or who have had depression in the past. The emotional crisis can be similar to that of a woman whose baby has died after birth.

Prevention

The majority of miscarriages cannot be prevented because they are caused by severe genetic problems determined at conception. Some doctors advise women who have a threatened miscarriage to rest in bed for a day and avoid sex for a few weeks after the bleeding stops. Other experts believe that a healthy woman (especially early in the pregnancy) should continue normal activities instead of protecting a pregnancy that may end in miscarriage later on, causing even more profound distress.

If miscarriage was caused by a hormonal imbalance (luteal phase defect), this can be treated with a hormone called progesterone to help prevent subsequent miscarriages. If structural problems have led to repeated miscarriage, there are some possible procedures to treat these problems. Other possible ways to prevent miscarriage are to treat genital infections, eat a well-balanced diet, and refrain from smoking and using recreational drugs.

Resources

ORGANIZATIONS

American College of Obstetricians and Gynecologists. 409 12th Street, S.W., P.O. Box 96920.

Hygeia Foundation, Inc. P.O. Box 3943 New Haven, CT 06525. (203) 387-3589. 〈http://www.hygeia.org〉.

KEY TERMS

Diethylstilbestrol (DES)— This is a synthetic estrogen drug that is used to treat a number of hormonal conditions. However, it causes problems in developing fetuses and should not be taken during pregnancy. From about 1938 to 1971, DES was given to pregnant women because it was thought to prevent miscarriage. Children of women who took the drug during pregnancy are at risk for certain health problems.

Dilation and curettage (D&C)— A procedure in which the neck of the womb (cervix) is expanded and the lining of the uterus is scraped to remove pregnancy tissue or abnormal tissue.

Embryo— An unborn child in the first eight weeks after conception. After the eighth week until birth, the baby is called a fetus.

Miscarriage

Miscarriage, or in medical terminology spontaneous abortion, is the termination of a pregnancy from natural causes before the time the fetus can survive for even a few minutes outside the uterus. (Induced abortion is the term used for those expulsions of an embryo or fetus that are artificially induced by mechanical means or drugs.) Miscarriage generally occurs before the twentieth week of pregnancy. A fetus born dead from natural causes after twenty weeks is called stillborn. Perhaps 50 to 78 percent of all fertilized eggs spontaneously abort. Only about 10 to 15 percent of the time are women aware that they have miscarried. Spontaneous abortions often seem to be functional in that they naturally eliminate many fetuses that may have birth defects.

Before miscarrying, a woman usually has spotting or more obvious bleeding and discharge from the vagina. The uterus contracts, causing pelvic cramps. Bleeding, discharge, and cramps become more severe if the miscarriage continues, and part or all of the contents of the uterus may be expelled. One miscarriage does not mean that later pregnancies will spontaneously abort, however, and about 70 to 90 percent who have miscarried eventually become pregnant again. Only about 1 percent of women suffer three or more miscarriages, perhaps because of anatomical, hormonal, genetic, or immunological factors.

About 85 percent of miscarriages happen in the first twelve weeks of pregnancy; the remaining 15 percent occur between thirteen and twenty weeks. The most likely reason is an abnormality in fetal development, usually as a result of extra chromosomes (about 60% of miscarriages). Occupational exposure to some chemicals may increase the chances of having a miscarriage. Other possible causes include chronic infections, unrecognized diabetes in the mother, and defects in the uterus. About one-third of the time there is no known cause for the miscarriage. Many studies have indicated that emotional disturbances in the mother's life are not usually linked with miscarriage. Miscarriage does, however, cause emotional disturbance in the lives of many women. Women tend to blame themselves: "I exercised too hard"; "Stress at work caused this"; "I fell down and hurt the baby." However, stress or physical trauma rarely results in a miscarriage, and health care professionals advise women not to blame themselves.

American society tends to define the loss of the fetus as "just a miscarriage," but most women who experience a miscarriage see the loss as a death— the death of a life or the death of a dream. Research indicates that losing a baby due to miscarriage can be a devastating experience for family members. Some women consider suicide after a miscarriage. Some couples' relationships are thrown into turmoil as a result of the loss. Some surviving siblings will feel guilt that they somehow caused the death, and will grieve in silence. However, researchers have found that families who support each other through these difficult times are likely to end up feeling stronger and more deeply committed to each other.

See also: Abortion

Bibliography

Beers, Mark H., and Robert Berkow, eds. The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Berkow, Robert, and Mark H. Beers, eds. The Merck Manual of Medical Information, Home Edition. Whitehouse Station, NJ: Merck Research Laboratories, 1997.

DeFrain, John, Elaine Millspaugh, and Xiaolin Xie. "The Psychosocial Effects of Miscarriage: Implications for Health Professionals." Families, Systems, and Health: Journal of Collaborative Family Health Care 14, no. 3 (1996):331–347.

Hyde, Janet Shibley, and John D. DeLamater. Understanding Human Sexuality, 7th edition. Boston: McGraw Hill, 2000.

Insel, Paul M., and Walton T. Roth. Core Concepts in Health, 8th edition. Mountain View, CA: Mayfield, 2000.

Larson, David E., ed. Mayo Clinic Family Health Book, 2nd edition. New York: William Morrow, 1996.

Olds, Sally B., Marcia L. London, and Patricia A. Wieland Ladewig. Maternal-Newborn Nursing: A Family and Community-Based Approach, 6th edition. Upper Saddle River, NJ: Prentice Hall Health, 2000.

JOHN DeFRAIN

miscarriage (mis-ka-rij) n. spontaneous loss of pregnancy before 24 weeks, formerly known as spontaneous abortion. complete m. miscarriage in which the cervix has closed and ultrasound scanning shows an empty uterus. incomplete m. miscarriage in which some fetal tissue remains in the uterus and the cervix is open. inevitable m. vaginal bleeding associated with crampy pelvic pain and a closed cervix, which precedes expulsion of the fetus from the uterus. late m. miscarriage occurring after 20–24 weeks. recurrent m. the loss of three or more pregnancies consecutively. silent (or missed) m. failure of a nonviable fetus to be expelled from the uterus.

miscarriage The common term for what is technically known as spontaneous abortion. A pregnancy may be lost for many different reasons and most often the cause is elusive, without a definable abnormality of either the fetus or the womb. The popular fictional instances of a shock or an accident precipitating miscarriage are rare in real life. The commonest time is at around three months of pregnancy, when the fetal tissue of the placenta is completing the takeover, from the ovary, of the production of hormones necessary to maintain the quiescence of the muscle of the womb.

Stuart Judge

mis·car·riage / misˈkarij/ • n. 1. the expulsion of a fetus from the womb before it is able to survive independently, esp. spontaneously or as the result of accident: his wife had a miscarriage | some pregnancies result in miscarriage. 2. an unsuccessful outcome of something planned: the miscarriage of the project.

Miscarriage

of justices: company of judges of magistrates—Daily Telegraph, 28 June, 1984.

miscarriage Popular term for a spontaneous abortion, the loss of a fetus from the uterus

miscarriage see abortion .

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