What to expect when you're expecting (204 page)

How should you decide which route to take? Some factors you and your practitioner will take into account include:

How far along the miscarriage is. If bleeding and cramping are already heavy, the miscarriage is probably already well under way. In that case, allowing it to progress naturally may be preferable to a D and C. But if there is no bleeding (as in a missed miscarriage), misoprostol or a D and C might be better alternatives.

How far along the pregnancy is. The more fetal tissue there is, the more likely a D and C will be necessary to clean the uterus out completely.

Your emotional and physical state. Waiting for a natural miscarriage to occur after a fetus has died in utero can be psychologically debilitating for a woman, as well as for her spouse. It’s likely that you won’t be able to begin coming to terms with—and grieving for—your loss while the pregnancy is still inside you. Completing theprocess faster will also allow you to resume your menstrual cycles soon, and when and if the time is right, to try to conceive again.

Risks and benefits. Because a D and C is invasive, it carries a slightly higher (though still very low) risk of infection. The benefit of having the miscarriage complete sooner, however, may greatly outweigh that small risk for most women. With a naturally occurring miscarriage, there is also the risk that it won’t completely empty the uterus, in which case a D and C may be necessary to finish what nature has started.

Evaluation of the miscarriage. When a D and C is performed, evaluating the cause of the miscarriage through an examination of the fetal tissue will be easier.

No matter what course is taken, and whether the ordeal is over sooner or later, the loss will likely be difficult for you. See Chapter 23 for help in coping.

Try to get your weight as close to ideal as possible before conceiving: Being extremely overweight or extremely underweight puts a pregnancy at higher risk.

Avoid lifestyle practices that increase the risk of miscarriage, such as alcohol use and smoking.

Use caution when taking medications. Take only those that are okayed by a doctor who knows you are pregnant and avoid those that are known to be risky during pregnancy.

Take steps to avoid infections, such as STDs.

If you’ve had two or more miscarriages, you can have tests to try to determine the possible cause so future pregnancy losses might be prevented (see box,
page 542
, for more).

What is it?
Any spontaneous expulsion of a fetus between the end of the first trimester and the 20th week is termed a late miscarriage. After the 20th week, the loss of the baby in utero is called a stillbirth.

The cause of late miscarriage is usually related to the mother’s health, the condition of her cervix or uterus, her exposure to certain drugs or other toxic substances, or to problems of the placenta.

How common is it?
Late miscarriages occur in about 1 in 1,000 pregnancies.

What are the signs and symptoms?
After the first trimester, a pink discharge for several days or a scant brown discharge for several weeks may indicate a threatened late miscarriage. Heavier bleeding, especially when accompanied by cramping, often means a miscarriage is inevitable, especially if the cervix is dilated. (There may be other causes of heavy bleeding, such as placenta previa,
page 551
; placental abruption,
page 553
; a tear in the uterine lining; or premature labor,
page 556
).

What can you and your practitioner do?
If you’re spotting light pink or brown, call your practitioner. He or she will evaluate the bleeding, possibly do an ultrasound and check your cervix, and probably prescribe bed rest. If the spotting stops, it’s likely it wasn’t related to miscarriage (sometimes it’s triggered by sexual intercourse or an internal exam), which means normal activity can usually be resumed. If your cervix has started to dilate and you have had no bleeding or pain, a diagnosis of incompetent cervix may be made and cerclage (stitching the cervix closed; see
page 47
) may prevent a late miscarriage.

Repeat Miscarriages

Though having one miscarriage definitely doesn’t mean that you’re likely to miscarry again, some women do suffer recurring miscarriages (defined as two or three in a row). If you’ve had several, you may wonder whether you’ll ever be able to have a healthy pregnancy. First, know that there’s a good chance you will, although you may need to manage future pregnancies differently. The causes of repeated miscarriages are sometimes unknown, but there are tests that may shed light on why the miscarriages took place—even if they each had a different cause.

Trying to determine the cause of a single loss usually isn’t worthwhile, but a medical evaluation might be recommended if you have two or more miscarriages in a row. Some factors that might be related to recurrent miscarriage include a thyroid problem, autoimmune problems (in which the mother’s immune system attacks the embryo), a vitamin deficiency, or a misshapen uterus. There are now many tests that may pick up risk factors for pregnancy loss and suggest possible ways of preventing it, in some cases very easily. Both parents might also have blood tests to screen for chromosomal problems that can be passed on to a fetus. You may be tested, too, for blood-clotting disorders (some women produce antibodies that attack their own tissues, causing blood clots that can clog the maternal blood vessels that feed the placenta). An ultrasound, MRI, or CT scan may be performed on your uterus, your uterine cavity may be assessed with hysteroscopy, and the miscarried fetus itself can be tested for chromosomal abnormalities.