Month three Miscarriage: your questions answered
Losing your unborn baby is heart-wrenching. Knowing what caused the miscarriage can never take the pain away, but it can help you understand better, says Shanda Luyt
BLEEDING IS PROBABLY the first sign that something is up. Then there might be pain, and later blood clots and parts of the foetus might appear. Or your amniotic fluid starts leaking – a sign that the amniotic sac has ruptured – without you feeling a thing. The result is the same: your pregnancy is over. A loss of pregnancy is termed a miscarriage if it happens before the foetus reaches viability, explains Dr Francois Cilliers, a maternal-foetal specialist from Bloemfontein. After that, it’s called a stillbirth or pre-term birth. “The international definition holds that it’s a miscarriage before the foetus weighs 500 grams or the pregnancy has reached the 22-week mark. The South African law regards the foetus as viable from 26 weeks.” Dr Cilliers says the biggest predictor of miscarriage is a previous one. The good news is that even if you have miscarried before, you actually still have a very good chance of a successful next pregnancy. “Many women don’t even realise they’ve had a miscarriage, as most embryos go missing before implantation. They think their cycle is just a day or two late.”
WHAT CAUSES A MISCARRIAGE?
Doctors usually look at when the miscarriage happened to determine the cause. Genetic abnormalities Roughly 50 percent of miscarriages are the result of genetic abnormalities – in other words, there was something wrong with the foetus – and these are the miscarriages that occur early in the pregnancy, Dr Cilliers says. “Genetic abnormality is the most common cause for miscarriage before eight weeks.” The older the mom, the bigger the chance of a miscarriage due to genetic abnormalities. A common genetic abnormality is when the amniotic sac develops normally but the embryo does not take shape, or stops growing. So at 12 weeks, only the empty amniotic sac is visible. Anatomical abnormalities of the uterus These usually cause miscarriages after 12 weeks, Dr Cilliers says. “There’s a whole host of these, but the most wellknown is a double uterus or a uterine septum. Another common problem is an incompetent cervix that can’t retain the pregnancy. It’s a common cause of miscarriages after 12 weeks.” Autoimmune diseases: these include illnesses such as systemic lupus erythematosus (SLE), where your own immune system attacks your body, as well as anti-phospholipid syndrome,
where your blood has an unusually high propensity to congeal, and clots form in the placenta, essentially starving the foetus of oxygen and nutrients. That’s what’s probaby happened when the doctor does a sonar at 12 weeks, and there’s suddenly no heartbeat anymore. Hormonal causes This includes an abnormality of the corpus luteum, the glandular tissue that forms in the ovary after ovulation. The corpus luteum releases progesterone to support the pregnancy up to nine weeks, after which the placenta takes over this function. If the corpus luteum doesn’t release enough progesterone, it can cause a miscarriage. For this reason, in pregnancies following fertility treatment, doctors often give progesterone treatment in the first 12 weeks. Other hormonal conditions include diabetes and polycystic ovarian syndrome (PCOS), where numerous cysts form in the ovaries. A thyroid that doesn’t work properly can also cause repeated miscarriages. Illness and infection German measles, the citomegalovirus, toxoplasmosis (which you can contract if you come into contact with infected animal waste or eat undercooked meat) and sexually transmitted diseases can all cause miscarriages. So can vaginal infections that cause inflammation in the cervix. “The hormone prostaglandin is released if there is inflammation in the cervix – that’s what causes fever. In that sense, any condition that goes hand in hand with a severe fever could cause a miscarriage,” Dr Cilliers says. Environmental factors Smoking, alcohol and drug abuse are also risk factors. Diet doesn’t play a part. If you fall while you’re pregnant, you won’t easily miscarry, Dr Cilliers says. “The uterus must be injured directly, physically before you miscarry.”
WHAT CAN YOUR DOCTOR DO?
It’s difficult treating genetic abnormalities, Dr Cilliers says. “If you get to your third miscarriage, we’ll usually try to take a sample of the foetal tissue and do a genetic analysis. If we find an abnormality, we’ll test the mom and dad’s chromosomes to see if they’re more prone to have a child with chromosomal abnormality.” A pre-implantation diagnosis is also possible, where an embryo is diagnosed before it’s implanted into the uterus. You need to take fertility treatment, and it involves removing a single cell from the embryo for testing before the embryo is placed in the uterus. “Say we know the woman has cystic fibrosis or both she and her partner carry the gene for cystic fibrosis – then the baby has a 25 percent chance of having cystic fibrosis. We then test the embryo for that specific problematic gene and ensure that only a healthy embryo is transferred. In this way we know the baby won’t have the illness. These treatments are, however, very expensive and advanced.” In the case of an incompetent cervix, the accepted treatment is a cerclage, which basically means stitching up the cervix to keep it closed and ensure it holds the embryo till term. “This works well for some women, especially where the doctor knows in advance that she has cervical incompetence and does the cerclage early in the pregnancy. Once the problems have already started, a cerclage isn’t going to be of much help.” Interestingly, Dr Cilliers says that bed rest doesn’t seem to make much of a difference to a pregnancy where there’s an incompetent cervix. Progesterone is administered when the corpus luteum malfunctions. For thyroid abnormalities, thyroid hormones are administered. If you have diabetes, you must continue with your diabetes medicine. Regarding autoimmune diseases: SLE is usually treated with steroids, and antiphospholipid syndrome with aspirin and heparin, both anticoagulants.
WHAT CAN YOU DO?
Ensure that you’ve been vaccinated against illnesses such as German measles before you fall pregnant. Ensure you’re not at risk for contracting sexually transmitted diseases. Don’t wait till after 35 to have your first baby – it raises the risk considerably. Don’t clean the cat’s sandbox while you’re pregnant, and wash fruit and veggies well before you eat them to avoid the risk of toxoplasmosis. Don’t use alcohol while you’re pregnant and avoid drugs at all cost. Don’t smoke while you’re pregnant. Stay away from any meds not vetted by your doctor. Let your doctor know if you’ve had a miscarriage before.
SHOULD YOU GO FOR A D&C?
If you had a miscarriage before six or seven weeks, a D&C is hardly necessary, Dr Cilliers says. “From six to 12 weeks there’s a chance that the foetus is not emitted in its entirety, and then a D&C procedure in theatre is necessary.”
WHEN CAN YOU START TRYING FOR ANOTHER BABY?
“If it was an early miscarriage, there’s no reason to wait,” Dr Cilliers says. “But sometimes the doctor doesn’t want you to fall pregnant again right away because they might want to do some tests first. “Women who lost their babies later in the pregnancy should give themselves a month or two before trying again.”
AND IF IT HAPPENS AGAIN AND AGAIN?
Most doctors don’t look for specific causes until you’ve had three consecutive miscarriages, Dr Cilliers says. After three miscarriages the doctor should make a concerted effort to look for the causes. If they suspect there’s a problem with the shape of the uterus, it is examined with a special tube-shaped instrument called a hysteroscope. A laparoscopy – when a thin tubeshaped laparoscope is inserted through an incision in the abdominal wall to examine what’s happening inside – might also be necessary. If the problem is an incompetent cervix, the doctor will put in a cerclage at about 14 weeks. “If it’s done any later, it can do more harm than good,” Dr Cilliers warns.