* What is a miscarriage?
Miscarriage is a loss of a pregnancy (after confirmation following a urine test) before first 23 weeks or if gestation is not known, birth weight of lost fetus(baby) being less than 500 grams. Why 23 weeks? That is the edge of viaibility.ie before that the fetus is not viable or cannot survive if born, with or without medical help. A loss after this time is called a stillbirth. More than 90% occur before 12 weeks of pregnancy, but some occur later.
* How Common are Miscarriages?
The incidence is said to be around 15 – 20 % .ie if 100 women fall pregnant , 15 to 20 would end up in having a miscarriage. This is the incidence of miscarriage after confirmation of pregnancy. But the incidence of it before a pregnancy test (Usually pregnancy test is done after missing a period and at that time usually embryo is about 2 weeks old)may be around 50% according to research. This is because in many cases a very early pregnancy can end up in a miscarriage even before you miss a period, and therefore , before you are aware that you are pregnant.
* What causes Miscarriage?
Most occur spontaneously as ‘nature’s selection’. Most of these fetuses are found to have some abnormality in their chromosomes, arising by chance during cell division. Usually there are no abnormalities found in parents of these cases. ie -It is thought that most early miscarriages are caused by a 'one-off' chromosome fault. This is usually an isolated genetic mistake, and rarely occurs again. There are other less common causes of miscarriage including: hormonal imbalance; abnormalities of the womb; weakness of the cervix; certain infections like listeria and rubella. Investigations into the cause of a miscarriage are not usually carried out unless you have 3 or more miscarriages in a row. This is because most women who miscarry will not miscarry again. Even two miscarriages are more likely to be due to chance than to some underlying cause. If it happens for once or twice usually there is no specific cause for it. But if this happens consecutively for three times or more one has to investigate to find a cause as there can be a treatable cause.
* Some wrong ideas about the causes of miscarriages
After a miscarriage it is common to feel guilty and to blame the miscarriage on something you have done or failed to do. This is almost always not the case. In particular, miscarriage is not caused by lifting, travelling in bus, motor bicycle, trishaw ,straining or working, constipation or straining at the toilet, stress or worry, sex, eating spicy foods pineapple, papaw, or normal exercise. There are many such myths about the causes of miscarriages. As this is so common it is easy to point your finger at something you have done as a cause for the miscarriage.
* What are the signs and symptoms of Miscarriage?
- Bleeding – red or brown, heavy, with clots or light spotting.
- Abdominal pain, backache, period like pain(NB- severe abdominal pain, faintness,slight bleeding with a positive pregnancy test can be features of an ectopic pregnancy,specially in early pregnancy.If you are high risk for ectopic pregnancy an ultrasound scan is needed to exclude an ectopic pregnancy- a pregnancy outside the womb)
- Loss of pregnancy symptoms(ie-feeling sick etc will vanish)
* What are the types and possible outcomes of Miscarriage?
There are four types of miscarriages that you should be aware of. They are:
a. Threatened miscarriage- It is common to have some light vaginal bleeding sometime in the first 12 weeks of pregnancy. This does not always mean that you are going to miscarry. Often the bleeding settles and the growing baby is healthy. This is called a 'threatened' miscarriage. You do not usually have pain with a threatened miscarriage. If the pregnancy continues, there is no harm done to the baby. In some cases, a threatened miscarriage progresses to a miscarriage. If the heartbeat is seen in the Ultrasound scan, there is more than 98% chance of an uneventful pregnancy.
b. Delayed miscarriage(also called early fetal demise, missed miscarriage,silent miscarriage)- In some cases there are no symptoms, and sometimes there may be very minimal symptoms. The baby dies, but remains in the womb. In some cases the small embryo may not be seen and only the empty gestation sac is seen. Some may have no pain or bleeding. Sometimes there may be slight brown colour discharge. This may not be found until you have a routine ultrasound scan. Ultrasound can demonstrate heart beat in 95% of pregnancies at 6 weeks when the embryo(the growing baby) is as small as 5 millimetres!.Therefore a competent doctor can make this diagnosis without repeating after a week.
c. Incomplete miscarriage- The usual symptoms are vaginal bleeding and lower abdominal cramps. You then pass some 'tissue' from the vagina. In many cases, the bleeding then gradually settles. The time it takes for bleeding to settle varies. It is usually a few days, but can last 2 weeks or more. In most cases, the bleeding is heavy with clots, but not severe - more like a heavy period. However, it can be severe in some cases. In these cases there will be some pregnancy tissue left inside the womb and therefore is called an incomplete miscarriage.
d. Complete miscarriage- Symptoms may be similar to an incomplete miscarriage ,but bleeding settles, neck of the womb closes and ultrasound scan will show an empty cavity of the womb. Do I need to go to hospital? You should always report any bleeding in pregnancy to your doctor. It is important to get the correct diagnosis as miscarriage is not the only cause of vaginal bleeding. If you bleed heavily with clots, go to the hospital immediately. Most women with bleeding in early pregnancy are seen by a doctor who specialises in pregnancy. It is usual to have an ultrasound scan. This helps to determine whether the bleeding is due to:
i. A 'threatened' miscarriage, (the baby will be seen to be alive).
ii. A miscarriage.
iii. Some other cause of bleeding (such as an ectopic pregnancy or bleeding from the neck of the womb).
* What do the doctors do when I go to the hospital
A complete history will be taken before the examination. A general examination will be done to see if you are pale, blood pressure will be checked, abdomen will be examined and finally a speculum ( an instrument inserted through the vagina to visualize the neck of the womb) examination may be done. Speculum examination is usually uncomfortable but not painful and will not harm the pregnancy in any way. Speculum examination may be done after or before an Ultrasound scan. Your blood group and haemoglobin level will also be checked.
* How is the diagnosis made?
With the history ,examination and an ultrasound scan usually a diagnosis can be made. For most patients an ultrasound scan is needed unless one can see pregnancy tissue in the neck of the womb during speculum examination. Occasionally a repeat ultrasound scan will have to be done to arrive at a diagnosis.
* Do I need any treatment?
Once the cause of bleeding is known, and the type of miscarriage is confirmed, your doctor will advise on options you have.
If it is a threatened miscarriage there is more than 98 % chance of a good outcome to have a normal pregnancy and a healthy baby. According to research bed rest will not improve the outcome. Some doctors give a medication by mouth or as an injection and it contains a hormone called Progesterone. But there is no scientific evidence to suggest that it is effective and therefore one should not regret of not having this hormone injection as it is not proven to prevent a miscarriage.
For many years it was common to do a small operation(Surgical management) to 'clear the uterus' (Commonly called in our country as a ‘womb wash’ and the correct word is evacuation or D & E) following a missed miscarriage or partial (incomplete) miscarriage and this is done under general anaesthesia. The logic was that this would make sure all pregnancy tissue was gone, and may prevent infection or prolonged bleeding. However, if ultrasound reveals no or very minimal tissue, an evacuation is not needed as it is a complete miscarriage.
Many women in developed countries now opt to 'let nature take its course'. In most cases the pregnancy tissue is passed out naturally and the bleeding will stop within a few days. It is called expectant management. As this is a natural form of cure not involving anaesthesia or medication these are considered as the advantages of this kind of management. Since there is no threat to the mother’s life it is safe to wait and see for this ‘natural cure’. The main disadvantage is its unpredictability as to when this is going to happen. An ‘operation’ to 'clear the uterus' can still be an option if the bleeding does not stop within a few days, or if bleeding is severe.
Other option is to have some medication to make the womb contract and expel the products and is called ‘medical management of miscarriage’. Unfortunately we do not have this medications as termination of pregnancy for social reasons in not legal in our country. The advantages in this method are its quick nature and , it does not involve any anaesthesia and therefore minimal side effects.
* How long can I have bleeding or discharge
After a miscarriage usually one can bleed for a week or two and occasionally for about 3 weeks. If the discharge or bleeding is increasing or if it is smelly or if you have fever and lower abdominal pain you should contact your doctor. Those may be signs and symptoms of infection,but infection is not a common occurrence following a miscarriage.
* When can I plan a pregnancy again?
It is up to you and your husband to decide on this. There is no hard and fast rule not to get conceived for 3- 6 months. Some may consider a miscarriage as a loss to their family, and need some time before planning a pregnancy again. But they should understand that after a miscarriage an ovulation can take place at any time and one can become pregnant even before missing a period. If you are planning for a pregnancy soon, it is always better to wait until you have your first period after miscarriage so that you can date the pregnancy.
* When can I have sex again
Usually when the discharge or bleeding stops. Otherwise it can give rise to infection as blood is a good culture medium for bacteria etc.. If you are not planning a pregnancy very soon , it is always necessary that you use a reliable method of contraception(Family planning) as you can get pregnant even before missing a period.
* Emotional Challenges due to Miscarriage
It is only a couple who have had a miscarriage who feel how distressing it is. Although some take it lightly, feelings of shock, grief, depression, guilt, loss, and anger are common among these couples. It is best not to 'bottle up' feelings. Talking and discussing with your husband , friends, or with a doctor , or with someone who can listen and understand will help them to overcome that. As time goes on, the sense of loss usually becomes less. However, the time this takes varies greatly. Pangs of grief sometimes recur 'out of the blue'. The time when the baby was due to be born may be particularly sad especially if it is a late miscarriage after 12 weeks.
අපගේ සම්පත් දායකයකු වන කොළඹ "ලංකා හොස්පිටල්ස්" ආයතනයේ නාරී හා ප්රසව රෝග පිළිබඳ විශේෂන්ඥ වෛද්ය විජිත් විද්යාභුෂණ මහතා විසින් සකස් කල ලිපියක් ඇසුරිනි. Thanks to our kind resource person Dr Vijith Vidyabhushana, Consultant VOG at Lanka Hospitals, Colombo 05. Dr Vijith Diyabhushana, MBBS (Colombo), MS (Colombo), MRCOG (UK), DFFP (UK), RCR/RCOG, Dip Advanced Obstetric Ultrasound (UK), Accredited Ultrasound Specialist
මෙම ලිපිය ඔබට ප්රයෝජනවත් වුනානම් හෝ ඔබේ මිතුරියකට ප්රයෝජනවත් වේ යයි සිතනවානම්, කරුණාකර පහත ඇති "recommend" ක්ලික් කිරීමෙන් එය බෙදා හදා ගැනීමට අමතක කරන්න එපා. තවද, මෙම ලිපිය පිළිබඳව ඔබේ අදහස්, යෝජනා සහ අනෙකුත් මවුවරුන්/කාන්තාවන් හට ප්රයෝජනවත් වන ඔබේ අත්දැකීම් පහත ලියා තැබීමටද අප ආරාධනා කරමු. ස්තුතියි!
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