The term Miscarriage has been used to replace the old term called abortion which to a lay man could be referred to as illegal termination of pregnancy. Miscarriage is an unfortunate event in early pregnancy which has both psychological and emotional effect on the mother and the family in view of their expectation of successful pregnancy. Miscarriage can occur spontaneously which refers to spontaneous loss of pregnancy before viability, but become recurrent if it occurs about 3 to 4 consecutive times before the pregnancy become viable. In Nigeria, the age of viability is considered from 28 weeks while in other countries, from 24 weeks based on their respective neonatal care for survival after birth. Miscarriage can occur in the first trimester (below 12 weeks) or second trimester after 12 weeks and up till 23 weeks and 6 days or 27weeks 6 days in underdeveloped countries. About 50-80 % of miscarriage occur in the first trimester and in some cases, miscarriage can occur without the mothers knowing they have miscarried.
The risks and causes of miscarriage are numerous and also depend on the trimester it occur. Most miscarriages are associated with chromosomal abnormalities which are the building blocks of body genetics. More abnormal building blocks in babies, if significant or few will make the baby not to survive in the uterus leading to miscarriage. Other contributory causes are mothers’ disease conditions which could be before or during pregnancy; this include diabetes, renal disease, thyroid disease, anti-phospholipid syndrome, infection in pregnancy such as viral illness, use of drugs, abnormality in the uterus (structure that carry the pregnancy), fibroids, in the second trimester after 12 weeks the causes include cervical structural defect (that is problem with the neck of the womb) which can be due to abnormal formation of mother’s cervix, cervical weakness that is due to surgical procedure in the past for treatment of cervical disease, underlying infection in the genital tract or body system. Other conditions to note are thrombophilia, polycystic ovarian syndrome (PCOS), immunological disorder and also unknown causes. Associated risks with miscarriages are previous miscarriage, age above 30 years (older parents), obesity, etc.
Most common symptom of miscarriage is vaginal bleeding, however it is to be noted that light bleeding is common in pregnancy. Vaginal bleeding could be spotting (minimal), brightly red blood, brownish discharge, or heavy bleeding. The bleeding can be on and off for some days. Associated crappy abdominal pain may occur. Sometimes miscarriage do occur without the symptoms where the fetus is still in the uterus called missed miscarriage. It is important to contact your Gynaecologist or GP once you experience symptoms of miscarriage.
The diagnosis of miscarriage involve review by the doctor which involve detailed history taking, examination, laboratory investigation and ultrasound scan when necessary. The mode of treatment of miscarriage varies depending on the type of miscarriage (1st and 2nd trimester of pregnancy loss). The diagnosis by the doctor help to outline the mode of treatment. (Different terminologies used threatened miscarriages, inevitable miscarriages, incomplete miscarriages, complete miscarriages to mention but a few).
Management of miscarriage involves expectant, medical, and surgical options in the first trimester.
Expectant management is used in view of the fact that nature will take its course in pregnancy by spontaneously expelling the miscarried pregnancy within 2- 6 weeks of diagnosis. During this period mothers experience lower abdominal pain and bleeding with passage of the tissues.
Medical management of miscarriage involves use of medications to stimulate the process of pregnant loss which may require admission for some hours or 2-3 days depending on the situation with good success rate when compared with expectant.
Surgical treatment is the one that involves uterine evacuation that is done in the hospital with the use of medications in some cases to soften the neck of the womb before evacuation. This is also used in emergency when the bleeding is heavy, to complete the process of incomplete or to initiate and remove the product of pregnancy loss. Medication may be given to some women depending on the blood group status (rhogam) and age of pregnancy.
In the case of recurrent miscarriage, the underlying cause if identified will be treated accordingly, though challenging. Treatment of underlying medical conditions such as antiphospholipid syndrome, thrombophilia, thyroid disorder, diabetes etc, the use of cervical cerclage (which is a procedure used to support the neck of the womb) could be beneficial for some mothers. Some medications such as aspirin have been added for patients with recurrent miscarriage.
Prevention of miscarriage involves a lot of factors by first identifying the cause of the miscarriage if any to prevent future recurrent. Good pre-pregnancy care in relation to health helps by having healthy diet, prompt treatment of underlying medical condition if any, reducing or avoiding alcohol intake, avoiding the use of recreational drugs and only use medication if necessary, with direct prescription from the physicians. Others propagate the use of herbal and vitamin supplements but the concrete evidence of its effect has not been found. Women usually have successful healthy pregnancies after miscarriages.
Miscarriage is always laden with emotional and psychological impact on the mother and relatives hence the need for counseling and assistance from everyone both medical staff, relatives, friends, and associates.
Dr Oluseyi Adeniji
Obstetrician and Gynaecologist
South Shore Women’s and Children’s Hospital