Miscarriage/ Abortion

miscarriage

Pregnancy is a wonderful experience. The almighty has bestowed female with the power to be creator herself, by giving birth to a life. The eternal happiness of giving birth to a baby, tender touch of newborn, warmth of motherhood and satisfaction of nurturing is unmatched and priceless.

However, the aura of happiness is shattered when the baby is lost midway due to miscarriage. The world seems to come to an end and the sweet dreams, euphoria and smile is all replaced by depression, negativity and tears.

Spontaneous Miscarriage or abortion is a pregnancy loss with the natural death of an embryo or fetus before it is able to survive independently. Many countries consider the cutoff of 20 weeks of gestation or 500 grams of weight after which fetal death is known as a stillbirth! 10-25% of all clinically recognized pregnancies end in miscarriage.

However, if we consider all pregnancies, including that are positive by chemical analysis but are unrecognized the incidence may rise up to 50%. This occurs when a pregnancy is lost shortly after implantation, resulting in bleeding that occurs around the time of her expected period. The woman may not realize that she conceived when she experiences a chemical pregnancy.

In simple words, if we sow 100 seeds of same quality and provide them with similar environment, still the couple of them would fail to germinate, some would stop at the stage of plants, some at later stage and only about half of them would achieve the complete growth as tree.

What are the causes of abortions?

The causes of abortions can be classified according to:
abortion causes

1- Fetal Causes:

The nature follows the rule – “Survival of the fittest!” A baby, who is healthy in all ways, would produce enough hormones to support its own survival and the one which is abnormal would be terminated by the nature midway.  

A- Chromosomal / Genetic Abnormalities :

  • Inherited either from mother and father.
  • Developed as a result of abnormal cellular division during initial embryonic development due to mutational injury.

B- Blighted ovum – Also called an an embryonic pregnancy.

There is absence of development of fetal pole in the gestational sac. Its most common cause is due to chromosomal abnormalities.

C – Vesicular mole – Abnormal degeneration of fetal tissue into grape like structure due to genetic error during the fertilization process.

D- Multiple structural deformities- The fetus grow till it has normal structural development and when further development is erroneous, it aborts.

E- Multiple Pregnancies.

F- Ectopic pregnancy – The fertilized egg implants itself in places other than the uterus, most commonly the fallopian tube. Treatment is needed immediately to stop the development of the implanted egg. If not treated rapidly, this could end in serious maternal complications.

2- Maternal Causes:

Baby needs a favorable environment to survive. Any abnormality in the mother or its uterus that hampers the growth and development can lead to miscarriage.

1- Maternal age less than 18 years or more than 35 years of age.

2- Uterine Pathology –

  • Abnormal structural development like bicornuate or septate uterus.
  • Intrauterine adhesions due to previous pregnancy, surgery or infections like tuberculosis.
  • Incompetent cervix.- (This usually causes recurrent second trimester miscarriages, when the baby reaches a threshold weight above the holding strength of the cervix. The patient experience painless dilation of cervix.)
  • Submucous fibroids.

3- Hormonal Imbalance like progesterone deficiency, diabetes mellitus, hypothyroidism, PCOS etc.

4- Severe Chronic diseases like malnutrition, high blood pressure, kidney and liver diseases, Tuberculosis etc.

5- Genital infections:

In the females, contrary to males, the urine wets the labia. If they fail to wipe it dry, the moistness along with reduced immunity in pregnancy can lead to genital infections. This infection when ascend up can lead to infection of fetal membrane (chorio-amnionitis) or the baby and begins abortions/preterm labor cascade.

6- Abnormal placenta formation may lead to insufficient blood supply to the fetus and may lead to fetal demise. E.g. Pregnancy induced hypertension, placental maturity, placenta previa etc.

7- Thrombophilia – Certain females have inherited blood coagulation disorder leading to thick hypercoagulable blood resulting in materal fetal blood insufficiency and fetal demise.

8- Immunological Intolerance – Hypersensitive immune response of mother towards owns antigens or father’s antigens present in baby may adversely affect the baby and lead to miscarriage. E.g. – APLA syndrome, Anti-TPO antibodies, ABO incompatibility etc.

9- Drugs which are harmful to the baby such as certain anticonvulsants, anti-malarials, chemotherapy etc. 10- Radiation / Harmful chemicals exposure, smoking/ alcohol consumption etc.

11- Severe physical, mental and emotional stresses release certain hormones that affects fetus adversely. Also, in case of stress, mother utilizes more blood and energy for her increased demand, depriving baby for same.

12- There is a surrounding bag of membrane filled with amniotic fluid that protects baby from trauma and vibration injury. However, severe trauma can definitely harm the baby.

13- Lifestyle (i.e. smoking, drug abuse, malnutrition, excessive caffeine and exposure to radiation or toxic substances)

14- A woman who has had a previous miscarriage has a 25% chance of having another.

3- Paternal Causes

Baby has half of the genetic material from Father and half from mother.

Inheritance of defective genes from any of them would lead to abnormality in the baby and result in miscarriage. The following may lead to chromosomal abnormalities in sperms.

  • Inherited Chromosomal abnormality.
  • Father age > 40 years.
  • Smoking/ Alcohol consumption, Harmful substances and Radiations may adversely affect the quality of sperms leading to mutations.

4- Iatrogenic –

  • Induced abortion.
  • Miscarriage caused by invasive prenatal diagnosis (Chorionic Villus sampling (CVS) and Amniocentesis. However it is rare and about 1% only.

5- Unidentified – In spite of majority of investigations, the cause of miscarriage cannot be identified in more than 50% of the pregnancies.

What are the Warning signs of Miscarriage?abortion sumptoms1- Bleeding through vagina. This can vary from light spotting or brownish discharge to heavy bleeding and bright red blood lasting couple of days.

  • Some women may experience little bleeding during the implantation of embryo or placenta formation. This Implantation bleeding is a normal phenomenon. It does not indicate miscarriage and do not harm the baby
  • Some women may experience little bleeding in pregnancy close to time of their menses for 2 to 3 months even after conception. It is due to hormonal imbalance and may be normal.

However, kindly bring any kind of bleeding to the notice of your caretaker.

2- Mild to severe pain in abdomen occurring every 5-20 minutes.

3- Tissue with clot like material passing from the vagina

4- Sudden decrease in signs of pregnancy.

How are miscarriage diagnosed?

  • Serial levels of Progesterone or HCG hormone in Mother’s blood.
  • Ultrasonography esp. Transvaginal scan.

What are the different types of Miscarriage?abortion types -EnglishTreatment of Miscarriage:

Goals of Treatment:

  • To support desired pregnancy.
  • To terminate unwanted pregnancy.
  • To prevent excessive hemorrhage and infection.
  • Counseling of couple to avoid guilt / depression.

Management of Miscarriage:

1- Threatened miscarriage are managed by the

  • Bed rest.
  • Counseling & motivation to avoid mental and emotional stress.
  • Hormonal support with progesterone &/or HCG.
  • Avoid vaginal penetration during sexual activity.
  • Laxatives to avoid constipation.
  • Prophylactic antibiotics to prevent infection.
  • Medicine to support blood coagulation.

2- Incomplete miscarriage in early pregnancy up to 7 weeks may be managed by utero-tonic medicines and later with the help of surgical procedure known as a D&C/ Vacuum aspiration / Suction evacuation.

3- Complete abortion does not need any active medical intervention. However, bleeding and body temperature should be monitored closely.

4- The recurrent / habitual miscarriage is prevented by cause target management.

  • The chromosomal and structural abnormalities are non-modifiable causes. However, the couple may be offered genetic testing to confirm the same.
  • The infections are treated with antibiotics and further prevention with personal hygiene or vaccinations.
  • The cervical incompetence are managed by prophylactic encirclage.
  • The correctable structural abnormalities are managed by respective surgeries.
  • Thrombophilia and APLA are managed with blood thinning medicines like Ecospirin &/or Low molecular weight heparin.
  • Immunological intolerance and Antibody rejection syndrome are managed with low dose steroids.
  • Hormonal milieu is corrected by medicines and life style modification. Eg. Metformin throughout pregnancy has shown to reduce early pregnancy losses and preterm delivery.

5- In case of Rhesus incompatible couples, mother should be offered Anti-D immunoglobin after every miscarriage. 6- Plan for next pregnancy and appropriate contraceptive methods should be discussed.

7- Emotional Treatment: Unfortunately, miscarriage can affect anyone. Women are often left with unanswered questions, sense of guilt, depression and apprehension about future fertility. It is very important to have proper counseling aid for the family and the couple in particular to manage mental and emotional agony.

Prevention of Miscarriage:

Since the cause of most miscarriages is due to chromosomal abnormalities, there is not much that can be done to prevent them.

The most important goal should be- to be as healthy as possible, to provide a healthy environment for conception to occur and baby to grow in.

  • Eat healthy nutritious diet.
  • Drink plenty of water.
  • Exercise regularly. Walking and light exercise are recommended. Avoid contact sports or activities that have risk of injury.
  • Manage stress. Meditation, Deep breathing exercises are recommended.
  • Keep weight within healthy limits.
  • Take folic acid daily.
  • Avoid straining at cough or constipation.
  • Maintain personal hygiene.
  • Avoidance of smoking, alcohol, stress, addictive drugs, harmful substance and X-ray exposure etc.
  • Do not take any medicines without prescription.

Disclaimer:

The information is shared to create awareness towards Pregnancy and Childcare to reduce maternal and child deaths. Atmost care has been taken by the author to include the verified information from authentic sources. However, kindly discuss the same with your health care provider before implementation.