UNDERSTANDING MISCARRIAGE
OB/GYN RANDY A. FINK, MD, GIVES US THE FACTS ON THE M WORD
THE FAMILY GROOVE: What is a miscarriage?
Dr. Randy A. Fink: A miscarriage is a pregnancy that ends before it reaches the point beyond which the baby
could survive on the outside. Most miscarriages occur during the first trimester, and I’ll restrict my remarks to
this type of pregnancy loss. A loss during the second trimester can have other significance and is managed
differently. We classically think of a miscarriage as a pregnancy that is spontaneously expelled or passed
from the mother, but many women experience it differently. Some clinician offices routinely perform a first
trimester ultrasound to assure the pregnancy’s viability, only to find the absence of a heartbeat in the embryo.
Some will have bleeding in the first trimester resulting in a sonogram showing the same. Even though the
circumstances leading up to the diagnosis may be different, all are pregnancy losses and are considered miscarriages.
TFG: What causes a miscarriage?
RF: The most common cause for an early pregnancy loss is a chromosomal problem. This occurs from the moment of conception, when sperm meets egg. Remember, only one out of millions of sperm will meet only one out of millions of eggs. If something isn’t perfect in the genetic material of either, then the sperm and the egg don’t “handshake” correctly and the embryo formed will be abnormal. Some babies with abnormal genetic material can continue to grow and even be born. But many will be too sick when they are only a few cells in size, and will stop growing. As women age, the risk increases for chromosome problems in pregnancy. And since chromosome problems are the most common reason for miscarriage, the risk of miscarriage also increases with age.
The second largest category is simply unexplained. That is, there is no recognizable reason the pregnancy didn’t continue. Finally, we must also consider factors about the mom, such as the shape of her uterus, her body mass index (obese women and underweight women are at increased risk), the make-up of her blood, exposure to infection, trauma, chemicals, and even certain hormonal factors. Understand that, sadly, it is usually not possible to determine the exact cause for most miscarriages.
TFG: Do you think there's a link to the chemicals and other pollutants in our environment and miscarriage?
RF: There is certainly a relationship of pregnancy loss to certain common chemicals. Women who smoke a half-pack or more of cigarettes are at an increased risk for miscarriage, as are those who consume at least a moderate amount of alcohol. Women who consume more than 100mg of caffeine daily during the first trimester are at an increased risk, as are users of cocaine. Women who take non-steroidal anti-inflammatory drugs (i.e. ibuprofen) around the time of conception increase their risk. But, it is hard to know how much the chemicals in our environment, such as those in the food and water supply, play a role since this is nearly impossible to study in a clinically meaningful way.
TFG: Do miscarriages run in families?
RF: There can be certain problems identified in couples with recurrent pregnancy loss (defined as three or more losses) that may run in families. However, in that miscarriage itself is so common, almost everyone can point to a family member who has suffered at least one. This usually has no bearing on miscarriage risk for most women.
TFG: Are miscarriages indicative of something else wrong like disease?
RF: Recurrent pregnancy loss may be indicative of genetic problems in mom and dad or a type of blood problem in the mother known as the anti-phospholipid antibody syndrome. These problems are uncommon in most patients who suffer a single miscarriage.
TFG: How common are miscarriages?
RF: Miscarriage is the most common complication of early pregnancy, occurring in up to twenty percent of clinically recognized pregnancies. Similarly, a large number of pregnancies miscarry before the mom is even aware she is pregnant. Eighty percent of miscarriages occur before 12 weeks of gestation.
TFG: What are the symptoms?
RF: Vaginal bleeding and pelvic pain are the most common symptoms. However, it is important to realize that up to forty percent of women with normal pregnancies will have bleeding or pain, so even heavy bleeding does not necessarily mean there is an impending miscarriage. Bleeding during the first trimester is an important event to bring to your clinician’s attention, as an ectopic pregnancy (i.e. “tubal pregnancy”) can present the same way and can be life threatening. Once an ultrasound confirms the pregnancy is inside the uterus where it is supposed to be and that there is a heartbeat, at least ninety percent of these pregnancies for most women continue normally without miscarriage.
TFG: What can a woman do to prevent a miscarriage before and during her pregnancy?
RF: There is unfortunately little a mom can do to directly influence whether she will miscarry. If it is going to happen, there have been no meaningful interventions shown that will stop it. However, pre-conceptually mom should be taking a vitamin with at least 400 micrograms of folic acid for at least three months prior to conceiving. This decreases the risk for certain types of birth defects. She should stop smoking and refrain from drug and alcohol use.
TFG: How soon after a miscarriage can a couple begin trying to get pregnant?
RF: The classic wisdom was always that a couple should wait three months before trying to conceive again. In some cases, emotionally, this may be advantageous. However, there is good evidence that they may resume trying after the first normal menstrual period without increasing their risks for recurrent miscarriage. Conception before completion of the first normal period increases the risk.
TFG: What should all women know about miscarriages?
RF: Many miscarriages occur before a woman even knows she is pregnant, and in one-third, a baby (or embryo, more correctly) has never even developed. Miscarriages are so very common that a woman should know she is not at fault, and there is little different she could have done to prevent the outcome. But, just as it is a common occurrence, it is still a loss of a family member. Grieving over this loss is appropriate like it would be for any loss, but there is often a wide array of feelings. Your clinician can help you through the process, and can help guide you if your feelings are strong and long lasting. It make be comforting to know that despite an early pregnancy loss, for most women there will be happier pregnancy times ahead.
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