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technology 25 Nov 2019

Miscarriage

By Dr. Walter Odongo, Pharmacist
Member, Pharmaceutical Society of Kenya (MPSK)

A miscarriage is the loss of a pregnancy during the first 23 weeks. About 10 to 20 percent of known pregnancies end in miscarriage. Miscarriage is a somewhat loaded term — possibly suggesting that something was amiss in the carrying of the pregnancy. This is rarely true. Most miscarriages occur because the foetus isn’t developing normally.

Symptoms

Most miscarriages occur before the 12th week of pregnancy. Signs and symptoms of a miscarriage might include:

• Severe abdominal pain

•Cramps

•Gradual progression of vaginal bleeding (from light to heavy)

‘•Discharge of tissue with clots

•Fever

•Back and lower back pain

•Unexplained weakness

Seek immediate medical attention whenever you notice you are experiencing per vaginal bleeding. Keep in mind that most women who experience vaginal spotting or bleeding in the first trimester go on to have successful pregnancies.

Causes

>Abnormal genes or chromosomes. Most miscarriages occur because the foetus isn’t developing normally. About 50 percent of miscarriages are associated with extra or missing chromosomes. Most often, chromosome problems result from errors that occur by chance as the embryo divides and grows — not problems inherited from the parents. Chromosomal abnormalities might lead to: •Blighted ovum. Blighted ovum occurs when no embryo forms.

•Intrauterine foetal demise. In this situation, an embryo forms but stops developing and dies before any symptoms of pregnancy loss occur.

•Molar pregnancy and partial molar pregnancy. With a molar pregnancy, both sets of chromosomes come from the father. A molar pregnancy is associated with abnormal growth of the placenta; there is usually no foetal development. A partial molar pregnancy occurs when the mother’s chromosomes remain, but the father provides two sets of chromosomes. A partial molar pregnancy is usually associated with abnormalities of the placenta, and an abnormal foetus. Molar and partial molar pregnancies are not viable pregnancies. Molar and partial molar pregnancies can sometimes be associated with cancerous changes of the placenta.

>Maternal health conditions. In a few cases, a mother’s health condition might lead to miscarriage. Examples include:

•Uncontrolled diabetes

• Infections

• Hormonal problems

• Uterus or cervix problems

• Thyroid disease

What does NOT cause miscarriage:

• Exercise, including activities such as cycling.

• Sexual intercourse.

• Working, provided you’re not exposed to harmful chemicals or radiation. Talk with your doctor if you are concerned about work-related risks.

Risk factors

Various factors increase the risk of miscarriage, including:

• Age. Women older than age 35 have a higher risk of miscarriage than do younger women. At age 35, you have about a 20 percent risk. At age 40, the risk is about 40 percent. And at age 45, it’s about 80 percent.

• Previous miscarriages. Women who have had two or more consecutive miscarriages are at higher risk of miscarriage.

• Chronic conditions. Women who have a chronic condition, such as uncontrolled diabetes, have a higher risk of miscarriage.

• Uterine or cervical problems. Certain uterine abnormalities or weak cervical tissues (incompetent cervix) might increase the risk of miscarriage.

• Smoking, alcohol and illicit drugs. Women who smoke during pregnancy have a greater risk of miscarriage than do nonsmokers. Heavy alcohol use and illicit drug use also increase the risk of miscarriage.

• Weight. Being underweight or being overweight has been linked with an increased risk of miscarriage.

• Invasive prenatal tests. Some invasive prenatal genetic tests, such as chorionic villus sampling and amniocentesis, carry a slight risk of miscarriage.

Complications

Some women who miscarry develop a uterine infection, also called a septic miscarriage.

Signs and symptoms of this infection include:

• Fever

• Chills

• Lower abdominal tenderness

• Foul-smelling vaginal discharge

Prevention

Often, there’s nothing you can do to prevent a miscarriage. Simply focus on taking good care of yourself and your baby:

• Seek regular prenatal care.

• Avoid known miscarriage risk factors — such as smoking, drinking alcohol and illicit drug use.

• Take a daily multivitamin.

• Limit your caffeine intake. A recent study found that drinking more than two caffeinated beverages a day appeared to be associated with a higher risk of miscarriage. If you have a chronic condition, work with your health care team to keep it under control

Diagnosis

Your health care provider might do a variety of tests:

• Pelvic exam. Your health care provider might check to see if your cervix has begun to dilate.

• Ultrasound. During an ultrasound, your health care provider will check for a foetal heartbeat and determine if the embryo is developing normally. If a diagnosis can’t be made, you might need to have another ultrasound in about a week.

• Blood tests. Your health care provider might check the level of the pregnancy hormone, human chorionic gonadotropin (HCG), in your blood and compare it to previous measurements. If the pattern of changes in your HCG level is abnormal, it could indicate a problem. Your health care provider might check to see if you’re anaemic — which could happen if you’ve experienced significant bleeding — and may also check your blood type.

• Tissue tests. If you have passed tissue, it can be sent to a lab to confirm that a miscarriage has occurred — and that your symptoms aren’t related to another cause.

• Chromosomal tests. If you’ve had two or more previous miscarriages, your health care provider may order blood tests for both you and your partner to determine if your chromosomes are a factor.

Photo/courtesy

Types of miscarriage

>Threatened miscarriage. When your body is showing signs that you might miscarry, that is called a ‘threatened miscarriage’. You may have a little vaginal bleeding or lower abdominal pain. It can last days or weeks and the cervix is still closed. The pain and bleeding may go away and you can continue to have a healthy pregnancy and baby. Or things may get worse and you go on to have a miscarriage. There is rarely anything a doctor, midwife or you can do to protect the pregnancy. In the past bed rest was recommended, but there is no scientific proof that this helps at this stage.

>Inevitable miscarriage. Inevitable miscarriages can come after a threatened miscarriage or without warning. There is usually a lot more vaginal bleeding and strong lower stomach cramps. During the miscarriage your cervix opens and the developing foetus will come away in the bleeding.

>Complete miscarriage. A complete miscarriage has taken place when all the pregnancy tissue has left your uterus. Vaginal bleeding may continue for several days. Cramping pain much like labour or strong period pain is common – this is the uterus contracting to empty. If you have miscarried at home or somewhere else with no health workers present, you should have a check-up with a doctor or midwife to make sure the miscarriage is complete.

>Incomplete miscarriage. Sometimes, some pregnancy tissue will remain in the uterus. Vaginal bleeding and lower abdominal cramping may continue as the uterus continues trying to empty itself. This is known as an ‘incomplete miscarriage’. Your doctor or midwife will need to assess whether or not a short procedure called a ‘dilatation of the cervix and curettage of the uterus’ (often known as a ‘D&C’) is necessary to remove any remaining pregnancy tissue. This is an important medical procedure done in an operating theatre.

>Missed miscarriage. Sometimes, the baby has died but stayed in the uterus. This is known as a ‘missed miscarriage’. If you have a missed miscarriage, you may have a brownish discharge. Some of the symptoms of pregnancy, such as nausea and tiredness, may have faded. You might have noticed nothing unusual. You may be shocked to have a scan and find the baby has died. If this happens, you should discuss treatment and support options with your doctor.

>Recurrent miscarriage. A small number of women have repeated miscarriages. If this is your third or more miscarriage in a row, it’s best to discuss this with your doctor who may be able to investigate the causes, and refer you to a specialist.

Types of pregnancy loss

Other types of pregnancies that result in a miscarriage are outlined below.

=Ectopic pregnancy. An ectopic pregnancy occurs when the embryo implants outside the uterus, usually in one of the fallopian tubes. A foetus does not usually survive an ectopic pregnancy. If you have an ectopic pregnancy, you may not know it as first, until it bleeds. Then you may get severe pain in your lower abdomen, vaginal bleeding, vomiting or pain in the tip of one shoulder. If you have these symptoms, it’s important to seek urgent medical attention.

=Molar pregnancy. A molar pregnancy is a type of pregnancy that fails to develop properly from conception. It can be either complete or partial and usually needs to be surgically removed.

=Blighted ovum. With a blighted ovum the sac develops but there is no baby inside. It is also known as an ‘anembryonic pregnancy’. This condition is usually discovered during a scan. In most cases, an embryo was conceived but did not develop and was reabsorbed into the uterus at a very early stage. You should see your doctor to discuss treatment options.

=Chemical Miscarriage. Although it sounds ominous, this is a very early miscarriage that usually occurs around the 4th or 5th week of pregnancy and happens before the ultrasound scan can detect anything. The sperm fertilises fertilizes the egg, but the egg is unable to survive any further.

=First-Trimester Miscarriage. A pregnancy loss that happens during the first trimester (first 12 weeks) of pregnancy is a first-trimester miscarriage. Studies show that around 80% of miscarriages happen around the first trimester and can be identified by vaginal bleeding, lower back cramping and loss of pregnancy symptoms.

=Second Trimester Miscarriage. The second trimester of your pregnancy begins in the 12th week and ends around the 20th week. Any miscarriage that occurs during this period can be termed as a second-trimester miscarriage. However, this is often unexpected and relatively rare.

Treatment

=Threatened miscarriage. For a threatened miscarriage, your health care provider might recommend resting until the bleeding or pain subsides. Bed rest hasn’t been proved to prevent miscarriage, but it’s sometimes prescribed as a safeguard. You might be asked to avoid exercise and sex, too. Although these steps haven’t been proved to reduce the risk of miscarriage, they might improve your comfort. In some cases, it’s also a good idea to postpone traveling — especially to areas where it would be difficult to receive prompt medical care. Ask your doctor if it would be wise to delay any upcoming trips you’ve planned.

=Miscarriage. With ultrasound, it’s now much easier to determine whether an embryo has died or was never formed. Either finding means that a miscarriage will definitely occur. In this situation, you might have several choices:

•Expectant management. If you have no signs of infection, you might choose to let the miscarriage progress naturally. Usually this happens within a couple of weeks of determining that the embryo has died. Unfortunately, it might take up to three or four weeks. This can be an emotionally difficult time. If expulsion doesn’t happen on its own, medical or surgical treatment will be needed.

•Medical treatment. If, after a diagnosis of certain pregnancy loss, you’d prefer to speed the process, medication can cause your body to expel the pregnancy tissue and placenta. The medication can be taken by mouth or by insertion in the vagina. Your health care provider might recommend inserting the medication vaginally to increase its effectiveness and minimize side effects such as nausea and diarrhea. For about 70 to 90 percent of women, this treatment works within 24 hours.

•Surgical treatment. Another option is a minor surgical procedure called suction dilation and curettage (D&C). During this procedure, your health care provider dilates your cervix and removes tissue from the inside of your uterus. Complications are rare, but they might include damage to the connective tissue of your cervix or the uterine wall. Surgical treatment is needed if you have a miscarriage accompanied by heavy bleeding or signs of an infection. Physical recovery in most cases, physical recovery from miscarriage takes only a few hours to a couple of days. In the meantime, call your health care provider if you experience heavy bleeding, fever or abdominal pain. You may ovulate as soon as two weeks after a miscarriage. Expect your period to return within four to six weeks. You can start using any type of contraception immediately after a miscarriage. However, avoid having sex or putting anything in your vagina — such as a tampon — for two weeks after a miscarriage

Photo/courtesy

Future pregnancies

>It’s possible to become pregnant during the menstrual cycle immediately after a miscarriage. But if you and your partner decide to attempt another pregnancy, make sure you’re physically and emotionally ready. Ask your health care provider for guidance about when you might try to conceive.

>Keep in mind that miscarriage is usually a one-time occurrence. Most women who miscarry go on to have a healthy pregnancy after miscarriage. Less than 5 percent of women have two consecutive miscarriages, and only 1 percent have three or more consecutive miscarriages.

>If you experience multiple miscarriages, generally two or three in a row, consider testing to identify any underlying causes — such as uterine abnormalities, coagulation problems or chromosomal abnormalities. If the cause of your miscarriages can’t be identified, don’t lose hope. About 60 to 80 percent of women with unexplained repeated miscarriages go on to have healthy pregnancies.

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