Miscarriages…. What we know and what we don’t

My sister and her husband lost their babies, Kristen, Brandon and Courtney, during second trimester due to Cystic Hygroma. The information about Brandon was sent to Harvard for further studies because this condition is very rare.

About 15-25 percent of clinically recognized pregnancies end in miscarriage. A miscarriage is a pregnancy loss before 20 weeks of gestation or loss of a fetus weighing less than one pound. Studies using new, improved pregnancy tests that can detect a pregnancy before a women misses one menstrual period suggest that the miscarriage rate is more than 30 percent when these very early pregnancy losses are included.

One in four women knows she has had a miscarriage. One in three hundred couples will have three or more consecutive miscarriages.

So why do we hear so little about these painfully common losses? Couples are often shocked and devastated when they suffer a miscarriage. Often they suffer in silence as family, friends and even some medical professionals fail to acknowledge their grief or do not know what to say.

These couples are often told to just try again — that the miscarriage is just nature’s way of getting rid of a defective fetus. Fortunately, however, close to 90 percent of women who have suffered one miscarriage go on to have a healthy pregnancy the next time. But without treatment, 60 percent of women who had two miscarriages go on to have a successful pregnancy, and only 25 percent after three, and less than 10 percent after four or five miscarriages.

Because it was not appreciated how much grief a miscarriage caused, and because, until recently, little was known about the causes of miscarriages, most doctors did not conduct a thorough evaluation until a woman suffered three or more pregnancy losses. As we learn more about the causes of miscarriages, doctors are beginning to evaluate their patients sooner and provide couples with better answers as to why the miscarriage occurred, whether it is likely to happen again — and whether treatment is available to prevent another miscarriage. Recent data support the practice that couples should be completely evaluated after the second pregnancy loss.

Genetic Abnormalities

Most miscarriages occur in the first trimester of pregnancy. In a first pregnancy, about 40 percent of these early pregnancy losses are associated with abnormalities in the number or structure of the chromosomes, the tiny thread-like structures in each cell that carry the genes, our basic units of heredity. Most chromosomal abnormalities result in such sever malformations the embryo cannot survive. However, less than 5 percent of recurrent miscarriages are due to chromosomally defective embryos — and therefore, many chromosomally normal fetuses are being lost.

Chromosomal abnormalities can result in an embryo that does not form at all — just an empty gestational sac often called a “blighted ovum.” When a blighted ovum is diagnosed, a miscarriage is inevitable. No treatment could prevent these miscarriages, as there is no embryo. Now that ultrasound is being used more frequently in early pregnancy, the detection of blighted ova is increasing.

We don’t know what goes wrong in the development of the egg or sperm cell or in the fertilized egg (zygote) to cause chromosomal abnormalities, or why the risk of chromosomal abnormalities increases as a woman ages.

Chromosomal abnormalities are usually one-time accidents that are unlikely to recur in another pregnancy. Nothing either parent did, or failed to do, could have caused them. Couples who have had two or more unexplained miscarriages should seek genetic testing as there is about a 5 percent chance that either partner carries a chromosomal rearrangement that makes recurrences more likely. Such chromosomal rearrangements are detected in a blood sample taken from each parent. It is also important to save tissue from a miscarriage so that it can be sent for genetic analysis.

Hormonal Deficiencies

Doctors suspect that deficiency of the hormone progesterone is an important cause of miscarriages that occur by the 10th week after conception. Progesterone deficiency generally results from a luteal phase defect.

The corpus luteum is a small cyst-like structure that forms on the ovary at the site where the egg was released at ovulation. The corpus luteum secretes progesterone — which is crucial to support an early pregnancy — and provides nutrients to the embryo until the placenta is sufficiently developed to take over these tasks. If the corpus luteum does not produce sufficient progesterone, a miscarriage may occur.

If blood tests or analysis of the tissue lining the uterus shows a luteal phase defect, it can be treated with vaginal suppositories containing natural progesterone and other treatments. Doctors are investigating the most effective treatment for this condition.

To access each situation, healthcare providers need the following information:

  1. The duration and intensity of bleeding (how long each episode lasts, and whether it produces a few drops of blood or a stream of blood).
  2. The frequency of bleeding (whether it occurs as a single episode or as constant, steady spotting).
  3. What the discharge looks like (whether or not it is mixed with mucus; whether it consists of bright red, fresh blood or dark, older blood; and whether or not tissue fragments or “grape clusters” are present).
  4. Any associated symptoms (such as cramping or sharp pain).
  5. Precipitating events (incidents that occurred prior to the bleeding).

In general, women at increased risk of miscarrying are often advised to reduce their activity levels, and in some instances, medication and/or bed rest may be indicated. Temporary avoidance of sexual intercourse is also often recommended.

Pregnancy loss can be a devastating emotional experience, often producing feelings ranging from sadness and anger to feelings of guilt. Although the majority of miscarriages occur spontaneously and for no known reason, in some instances repeated losses may be associated with genetic and immunologic factors. Women who experience repeated pregnancy loss may find that a discussion with a genetics specialist can provide helpful information that will be of benefit when planning future pregnancies. In addition, numerous consumer-oriented pregnancy loss support groups exist nationwide. Participation in such groups can also be a healing experience.

What are the symptoms?

  • Nearly all miscarriages are preceded by the warning sign of vaginal bleeding.
  • Up to 25 percent of all pregnant women have bleeding at some point in pregnancy, and of these women, about half will have a miscarriage.
  • Bleeding may be followed by cramping abdominal pain and, in some women, lower backache.

Although there may be other reasons for these symptoms, you should contact your doctor if you have any type of bleeding or severe pain in pregnancy.

Grieving Your Loss

Grieving is a process. It is ongoing, unpredictable and painful. The loss will always be there, but eventually you will think of it without tears or overwhelming sadness. You may have intense and sometimes confusing feelings about your loss. Grief is a natural and normal response to an important loss. It is a way of learning to accept the loss, to heal from it and to always remember it. You are not abnormal or unfeeling, however, if you don’t feel sorrow or grief after a pregnancy loss. Each person responds in a different way. You may feel disappointed, angry, overwhelmingly sad or confused. Regardless of your reaction to your loss, this site gives you insight into the grieving process to try and understand it, eventually coming to terms with your loss.

A Broken Bond

When you were pregnant, you may have spent hours daydreaming about what your baby would look like, and what kind of person she or he would turn out to be. This is part of the normal process of bonding, the unique attachment between a mother and baby that often begins well before birth.

Grieving is the process of letting go of your emotional attachment to your baby. You are grieving that the bond you felt with her or him now has been broken. Thus, when it comes to grief, it doesn’t matter how early in pregnancy you were struck by this loss. Your feelings are real, and they ought not be denied.

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