What to expect when you're expecting (203 page)

Miscarriage can happen to any woman, and in fact, most women who have one have no known risk factors. Still, some factors somewhat increase the risk of miscarriage. One is age; the older eggs of older mothers (and possibly their older partner’s sperm) are more likely to contain a genetic defect (a 40-year-old has a 33 percent chance of miscarrying, while a 20-year-old’s odds of losing a pregnancy are 15 percent). Other risk factors include vitamin deficiencies (especially of folic acid); being very overweight or underweight; smoking; possibly hormonal insufficiency or imbalance, including an untreated thyroid condition; certain sexually transmitted diseases (STDs); and certain chronic conditions.

You’ll Want to Know …

In a normal pregnancy, miscarriage is
not
caused by exercise, sex, working hard, lifting heavy objects, a sudden scare, emotional stress, a fall, or a blow to the abdomen. The nausea and vomiting of morning sickness, even when it’s severe, will not cause a miscarriage. In fact, morning sickness has been linked with a lower risk of miscarriage. Happily, the vast majority of women who experience miscarriage go on to have a normal pregnancy in the future.

What are the signs and symptoms?
The symptoms of a miscarriage can include some or all of the following:

Cramping or pain (sometimes severe) in the center of the lower abdomen or back

Heavy vaginal bleeding (possibly with clots and/or tissue) similar to a period

Light staining continuing for more than three days

A pronounced decrease in or loss of the usual signs of early pregnancy, such as breast tenderness and nausea

What can you and your practitioner do?
Not all bleeding or spotting means you’re having a miscarriage. In fact, many situations (other than miscarriage) could account for bleeding (see
page 139
).

If you do notice some bleeding or spotting, call your practitioner. He or she will assess the bleeding and probably perform an ultrasound. If the pregnancy still appears to be viable (in other words, a heartbeat is detected on the ultrasound), your practitioner may put you on some sort of temporary bed rest, your hormone levels will be monitored if you’re still very early in your pregnancy (rising hCG levels are a good sign), and the bleeding will most likely stop on its own.

If your practitioner finds that your cervix is dilated and/or no fetal heartbeat is detected on ultrasound (and your dates are correct), it is assumed a miscarriage has occurred or is in progress. In such a case, unfortunately, nothing can be done to prevent the loss.

You’ll Want to Know …

Sometimes it’s too early to see a fetal heartbeat or visualize the fetal sac on ultrasound, even in a healthy pregnancy. Dates could be off or the ultrasound equipment not sophisticated enough. If your cervix is still closed, you are spotting only lightly, and the ultrasound is ambiguous, a repeat sonogram will be performed in a week or so to let you know what’s really going on. Your hCG levels will also be followed.

If You’ve Had a Miscarriage

Though it is hard for parents to accept it at the time, when an early miscarriage occurs, it’s usually because the condition of the embryo or fetus is incompatible with normal life. Early miscarriage is generally a natural selection process in which a defective embryo or fetus (defective because of genetic abnormality; or damaged by environmental factors, such as radiation or drugs; or because of poor implantation in the uterus, maternal infection, random accident, or other, unknown reasons) is lost because it is incapable of survival.

All that said, losing a baby, even this early, is tragic and traumatic. But don’t let guilt compound your misery. A miscarriage is not your fault. Do allow yourself to grieve, a necessary step in the healing process. Expect to be sad, even depressed, for a while. Sharing your feelings with your spouse, your practitioner, a relative, or a friend will help. So will joining or forming a support group for couples or singles who have experienced pregnancy loss or reaching out to others online. This sharing with others who truly know how you feel may be especially important if you’ve experienced more than one pregnancy loss. For more suggestions on coping with your loss, see Chapter 23.

For some women, the best therapy is getting pregnant again as soon as it is safe. But before you do, discuss possible causes of the miscarriage with your doctor. Most often, miscarriage is simply a random one-time occurrence caused by chromosomal abnormality, infection, chemical or other teratogenic (birth defect–causing) exposure, or chance, and it is not likely to recur.

Whatever the cause of your miscarriage, some practitioners suggest waiting two to three months before trying to conceive again, though intercourse can often be resumed as soon as you feel up to it. Other practitioners let nature take over; they tell their patients that their bodies will know when it’s time to conceive again. Some studies have shown that women actually have a higher than normal fertility rate in the first three cycles following a first-trimester loss. If your practitioner does recommend a waiting period, however, use reliable contraception, preferably of the barrier type—condom, diaphragm—until the waiting time is up. Take advantage of this waiting period by getting your body into the best baby-making shape possible (see Chapter 1).

Happily, the chances are excellent that next time around you’ll have a normal pregnancy and a healthy baby. Most women who have had one miscarriage do not miscarry again. In fact, a miscarriage is an assurance that you’re capable of conceiving, and the great majority of women who lose a pregnancy this way go on to complete a normal one.

If you’re in a lot of pain from the cramping, your practitioner may recommend or prescribe a pain reliever. Don’t hesitate to ask for relief if you need it.

Can it be prevented?
Most miscarriages are a result of a defect in the embryo or fetus and can’t be prevented. There are steps you can take, however, to reduce the risk of preventable miscarriage:

Get chronic conditions under control before conception.

Be sure to take a daily prenatal supplement that includes folic acid and other B vitamins. New research has shown that some women have trouble conceiving and/or sustaining a pregnancy because of a folic acid or vitamin B
12
deficiency. Once these women begin the appropriate supplementation, they may be able to conceive and carry to term.

Management of a Miscarriage

Most miscarriages are complete, meaning all the contents of the uterus are expelled via the vagina (that’s why there is often so much bleeding). But sometimes—especially the later in the first trimester you are—a miscarriage isn’t complete, and parts of the pregnancy remain in the uterus (known as an incomplete miscarriage). Or a heartbeat is no longer detected on ultrasound, which means the embryo or fetus has died, but no bleeding has occurred (this is called a missed miscarriage). In both cases, your uterus will eventually be—or need to be—emptied so your normal menstrual cycle can resume (and you can try to get pregnant again, if you choose to). There are a number of ways this can be accomplished:

Expectant management.
You may choose to let nature take its course and wait until the pregnancy is naturally expelled. Waiting out a missed or incomplete miscarriage can take anywhere from a few days to, in some cases, three to four weeks.

Medication.
Medication—usually a misoprostol pill taken orally, or vaginally as a suppository—can prompt your body to expel the fetal tissue and placenta. Just how long this takes varies from one woman to another, but, typically, it’s only a matter of days at the most before the bleeding begins. Side effects of the medication can include nausea, vomiting, cramping, and diarrhea.

Surgery.
Another option is to undergo a minor surgical procedure called dilation and curettage (D and C). During this procedure, the doctor dilates your cervix and gently removes (either by suction, scraping, or both) the fetal tissue and placenta from your uterus. Bleeding following the procedure usually lasts no more than a week. Though side effects are rare, there is a slight risk of infection following a D and C.