If you are reading this after your first trimester, you can probably stop; for the most part, miscarriage usually occurs in the first 10 weeks of pregnancy. The second trimester is truly a milestone, and couples can breathe a little more easily when they’ve reached this point. In fact, pregnancy loss after twelve weeks is almost always due to a rare catastrophic event or an even rarer genetic mishap that took a little longer to catch up.
Yet we all live our mortal lives at the mercy of the biological rules that govern survival. And, sometimes bad things happen: one such bad thing is miscarriage. Some say miscarriage is a good thing, assuring the health of our species. But couples aren’t thinking about the survival of our species when they choose to have a child. No one thanks evolution for a miscarriage. In fact, miscarriages usually cause pain and anger. But such a complex creature as a human being is exceedingly special by the very nature of what it takes to build one.
Doctors love lawyer jokes (probably too much), but there is this joke that comes to mind:
Q: What do a sperm and a lawyer have in common?
A: They each have a one in 60 million chance of being a human being.
My brother, the lawyer, hates lawyer jokes. When he gives me that look, I remind him about the arithmetic involved: a 1 in 60,000,000 chance for him to have been conceived, and then another 1 in 60,000,000 to be the great guy that he is. He’s one in three and a half quadrillion! The point is that each person is a unique individual that is the result of infinitesimal odds.
We don’t consider these odds because we look around at everyone and see, well … everyone. But each and every person we encounter—those people in the elevator with us, in those partially obstructed seats at rock concerts, in line at the DMV, in the park with their kids—they’ve all made it through a process much more challenging than winning all the Grand Slams in a year. But not every entrant in the field gets to the finals. Even when there is conception (a long-shot event anyway), some further process in the nine-month plan to create a human being can go awry, and a pregnancy ends when this process is no longer compatible with life.
Why Miscarriage Happens
Miscarriage is nature’s way of discarding a pregnancy that didn’t proceed in a way compatible with life. Even though it may be mere “disposal,” to prospective parents it is a real tragedy—hopes and dreams and a certain romantic vision of their child-to-be dashed before their broken hearts. But the fact remains that it does happen, and it happens for a reason.
The science of in vitro fertilization (IVF) has brought about advances in our knowledge of conception and survival of the zygote and subsequent embryo. We now know that there are many miscarriages that go undiagnosed, a fertilized egg unsuccessfully implanting or unable to do so because of severely distorted fusion of chromosomes. Since a lot of these miscarriages happen very early, even before implantation, a woman may not even miss a period. Such miscarriages are completely absorbed or fall away with what is seen as the routine menstrual flow. Taking this type of miscarriage into account, we’re careful now to say that miscarriage happens in 20 percent of all diagnosed pregnancies. But total miscarriage risk is probably closer to 60 percent to 80 percent when the silent ones are considered.
At first the thought of such an increased miscarriage rate seems astonishing, but when one realizes how many things must go perfectly to make a baby, it’s a wonder that it happens at all. “Miracle” is never a worn-out word for a baby.
As physicians, we obstetricians must treat the discarding aspect of miscarriage scientifically and the human tragedy aspect with compassion and understanding.
Miscarriage can happen for a number of reasons. Almost always it is because of some random genetic mismatch making the fetus unsuited to progressing all the way. Once again, we’re at the mercy of the biological rules. It is nature’s way of assuring a continuing healthy species.
Miscarriage can also happen due to infection, maternal diseases like lupus, diabetes, and thyroid problems, and abnormalities with the anatomy of a woman’s reproductive tract. Sometimes it happens to the same couple more than once, prompting evaluation for known causes. But it’s frustrating that most of the time there is no known cause, and the couple feel they are being sent away with only an invitation to return to the obstetrician for the next try—as if finally pulling it off tomorrow would undo today’s tragedy.
Treating the Loss
Most couples will feel that the loss is their own private catastrophe. And they are somewhat left on their own, because there are no rituals for this type of human loss. There are no funerals or memorial services. Friends and relatives, often misguided into thinking that mentioning the miscarriage will only be upsetting, are instead seen as uncaring in their silence. The grieving couple have only each other, and that may not be enough for the feelings of guilt and self-examining retrospection. And anger.
After all, this isn’t just some tissue that was discarded, like an appendix or a gallbladder. This was their son or daughter. There were dreams of seeing Little League events, helping with homework, attending dance recitals, walking down an aisle. And the whole sense of what might have been is lost to a clinical world of procedures, blood tests, and insurance forms. As an obstetrician, I can assure any couple that their miscarriage is not just any clinical event. I’ve been delivering babies long enough to see some that I delivered wearing a mortarboard. In a way I grieve with the parents, too, because I know what is being lost in a miscarriage. I’m right there in the middle of it as well. I put it on a different level from the clinical protocols I employ to deal with it.
Perhaps it is fortuitous that the majority of miscarriages go unnoticed, for we would be one bummed out species. Even the 20 percent rate is overwhelming—just ask someone it’s happened to. I think people who experience a miscarriage really do appreciate how special each person is. After all, it lands in their faces when the rug gets pulled out from under them. It takes about three months before a couple can deal effectively with their loss. This requiem only underscores the importance of what has been lost. My advice for those who know such mourners is to ask them how they’re doing, acknowledge the loss, don’t leave them alone in all of this. At the appropriate time they’ll file their tragedy away for safe keeping and get on with the rest of their lives. Until then, let them share their grief.
I manage the complication of miscarriage, but that doesn’t reduce my feelings for what might have been. So I do not merely send a couple on their way with an invitation to return for the next try. Instead, I applaud them for going back into the world to once again to play by the biological rules. They will have that baby not to replace the permanent little hole in the heart left by a miscarriage, but because they want a baby.
Risks for Miscarriage
Soap opera babies usually don’t stand a chance. Miscarriages there occur easily and frequently. The loss of a baby is one of the most powerful misfortunes, and these programs are all about the human condition in all of its tragic splendor. Thank goodness real pregnancy isn’t like pregnancy on the daily dramas. An actress falls and she has a miscarriage. A character discovers that her husband is having an affair with her best friend’s Tupperware distributor and the stress causes her to lose the pregnancy. Overworking may put her in the hospital for tests that take weeks of prime-time daily viewing. There is no managed care on soap operas.
So just how tough is your baby anyway? First, we must consider that the human race has survived a big disadvantage in reproduction—we generally only have one at a time. For other species nature guarantees survival by allowing multiple births, so that the most vulnerable of life, the infant, is exchangeable for the next that may survive where the first did not. This protection is taken to an extreme with insects, in which reproduction involves thousands of offspring in a very short time, so that even if most die during this vulnerable period, still there are many that survive to keep the species going. Human beings have not only survived but thrived in spite of only having one at a time.
Our big compensation, however, is our brain, which allows us the see the importance of protecting and raising a child. It also lets us sense and foresee danger, so a baby in your womb is well protected indeed, since you yourself are smart enough to keep from personal harm. What all of this means is that it’s tough to accidentally hurt your baby.
Surely babies aren’t invulnerable. If you were to try, it can be done. Alcohol, smoking, other drugs, and trauma can hurt your unborn child. Normal everyday activity, however, is not only harmless, but often helps the health of your baby. Patients often ask me if stress is hurting the baby. Only on soap operas. And the thing to remember is that everyone has stress. Life is stress. It’s a normal part of our lives. It’s why we have adrenalin.
Exercise especially is maligned unfairly, due in part to that soap opera mentality that pregnant women should merely glide along life on an air cushion without so much as a speed bump. All of the studies have shown conclusively that not only is exercise good for you and your baby, but it also decreases the likelihood of a C-section. The only warning is against overheating and dehydration. Aside from that, it seems all exercise is acceptable. Except kick-boxing. You should probably stay away from that.
Many patients and their husbands ask me when they should stop intercourse. The only time you shouldn’t have intercourse during pregnancy is in the delivery room. Please. I think that says it all. Of course, this is advice in normal pregnancy. High risk pregnancy complicated by bleeding, premature labor, or infection have a completely different set of criteria, but generally all normal pregnancies are sex-worthy till the very end. Even orgasm, which is known to cause contractions of the uterus, seems harmless in normal pregnancies. A good rule of thumb is that you should avoid intercourse if it becomes uncomfortable; otherwise, sex is not a problem.
So far I’ll bet I’m saying all of the things you want to hear, but they bear repeating. Sex is important in a marriage. Exercise is important to the mother. A baby is important in a daytime TV drama only if it moves the story line. Real people don’t have story lines—they have lives. Just because you’re pregnant doesn’t mean you should stop living life as you know it. The simple joys of life are not only safe for baby, but good for maternal and marital well-being on many different levels.
Types of Miscarriage
The word abortion refers to any interruption of a pregnancy. In today’s media, abortion is assumed to mean elective termination, but medically the word also refers to all of the types of spontaneous miscarriage. It is sometimes abbreviated AB. Under the heading of abortion, there are several designations that are clinically important:
Threatened abortion/Threatened miscarriage: any bleeding in the first trimester until other innocent causes are ruled out. Serial hCG levels can determine well-being or danger. Ultrasound is also important in following such a condition.
Missed abortion: a pregnancy that is no longer viable but hasn’t passed or caused any bleeding yet.
Incomplete abortion/Incomplete miscarriage: a spontaneous miscarriage that hasn’t completely passed. This situation may lead to heavy bleeding and serious infection if some tissue were to remain in the uterus. A dilation and curettage (D&C) is warranted.
Inevitable abortion/Inevitable miscarriage: when the cervix begins to dilate, which is a sure sign of impending expulsion of products of conception within the uterus, but before actual expulsion has begun.
Complete abortion/Complete miscarriage: miscarriage in which the entire gestational sac, placental tissue, and fetus are expelled. No further treatment is necessary.
Septic abortion/Septic miscarriage: any type of miscarriage associated with an infection of remaining pregnancy tissue or of the uterus itself.
Ectopic pregnancy: This is a pregnancy that implanted anywhere but the right place, the uterus. Most are in the fallopian tubes, but they can be seen in the pelvis, ovary, and even the higher abdomen. Since almost all of them are in the tube, however, this makes diagnosis much easier. The tube has limited capacity for a growing process, and soon it will stretch enough to cause pain. The very rare ectopic, in the pelvis for example, may get further along before symptoms hint at trouble, making blood loss worse with surgical treatment. Nonsurgical treatments are also available.
Molar pregnancy: These types of conceptions span the gamut of looking nothing like a pregnancy to looking a lot like a normal pregnancy (“incomplete mole”). It is actually a tumor of pregnancy tissue, but usually only pre-cancerous.
Most couples expect to get pregnant at some point, and when they do for the first time it suddenly dawns on them what a gamble pregnancy actually is. One of the most frightening things is to experience bleeding in the first part of the pregnancy. Termed first trimester bleeding, it is any bleeding noted during the first 12 weeks, and it is one of the most common symptoms to send a woman to her obstetrician. And rightly so, because until a non-threatening cause is identified, all first trimester bleeding is labeled “threatened miscarriage,” or “threatened AB.”
First Trimester Bleeding
No bleeding in early pregnancy is to be considered normal. That’s the bad news. But the good news is that most of the time it’s caused by something fairly harmless. Typical causes are:
Cervicitis is a condition in which the delicate cells at the mouth of the uterus (cervix) can bleed due to the mechanical action of intercourse, the alteration of acidity (pH) in the vagina, or the effects of infections on these cells.
- Ectopy. With the hormonal changes of pregnancy, the fragile internal cells peek out a bit onto the external portion of the cervix, which is a harsher environment for them. When these internal cervical cells are brought to a more external position, this is called ectopy. Normally nestled more deeply away from sexual activity and the acidity of the vagina, now they can be battered both chemically and mechanically. They’re easily damaged, causing bleeding. Of course, we’re not talking about a whole lot of bleeding here—merely what is perceived as spotting. It must also be noted that these cells usually don’t bleed with sex. Usually there is a predisposing condition, like cervicitis.
- Infection. Cervicitis is inflammation due to infection. Yeast is the most common culprit, and a simple prescription or even over-the-counter cream can end this concern quickly. Other infections are more worrisome.
- STDs.Sexually transmitted diseases, like gonorrhea, chlamydia, trichomonas, and Gardnerella can cause inflammation too, so a microscopic evaluation is the best approach rather than just assuming it’s yeast. Some infections may be silent for years, meaning that even though there is no question about fidelity in a couple, still there may have been an infection long before they even met each other. Therefore doing cultures for STDs has become standard in all pregnancies.
2. Cervical polyps.
Harmless small polyps can cause bleeding also. They are overgrowths of benign tissue, probably owing their existence to estrogen which made them grow. Usually they can be gently and painlessly twisted off during a physical exam. If not, then they’re usually destroyed by the very act of delivering the baby. But it’s worth getting them off in the office, otherwise your doctor will be obligated to be on alarm every time there’s spotting, forcing you into a lot of extra tests you don’t need.
3. Subchorionic hemorrhage.
This sounds disastrous, but it usually represents a small clot that causes bleeding then dissolves away harmlessly. Rarely the clot can come between the placenta and the attachment to mother, causing miscarriage.
4. Decidual tissue.
Sometimes a small piece of tissue becomes loose and disintegrates through some unknown cause, causing spotting. It’s usually a hormonally stimulated collection of menstrual-like tissue that can be confused with a miscarriage. If it’s just tissue debris, it can mean nothing. No one knows why such a phenomenon occurs, but it is harmless. It’s the passage of tissue for sure, though, so it’s very disturbing until the pathology report can ease everyone’s mind. In my practice, such shedding of only decidual tissue has had no impact on whether a pregnancy would miscarry. If it’s actual tissue of the pregnancy (fetal or placental), then there should be serious concern, because now this “threatened miscarriage” is re-labeled “incomplete miscarriage.”
5. Implantation bleeding.
People have long thought that an egg eroding into the uterine lining would cause bleeding at the time because of a burrowing effect. It’s doubtful whether there’s any bleeding when this happens, and if so, it’s too small an amount to notice. The myth persists because there are bleeding episodes in which no cause is ever identified and in which the pregnancy goes on successfully to term. Such a mystery that starts off so menacingly but ends so well begs for an explanation that must include a natural process. Implantation makes sense under these criteria, but can’t be proven. This may be a myth.
6. Periods during pregnancy.
Many women ask me about having regular periods during their pregnancies. They’re concerned because Grandma or a cousin reported having periods every month during their pregnancies, and they wonder if it could happen to them. They swear that these periods during pregnancy really happened. It’s false, all the swearing notwithstanding. Shedding a layer of menstrual tissue is not compatible with life. The closest thing we have to this is shedding of decidual tissue (see above). When Grandma swears that it happened, it’s certainly the polite thing to listen with an open mind—just be sure to slam it shut by thinking about what’s really going on in pregnancy. The cycling of hormones stops because a pregnancy causes the hormone levels to stay high. This is necessary for pregnancy to continue. There are no drops in hormone levels, which is what causes a period, except right before labor. Most likely, Grandma experienced a subchorionic hemorrhage (see above), bleeding intermittently, misinterpreted as cyclic.
Although the above instances describe the causes of bleeding that do not indicate miscarriage, still miscarriage should be ruled out if you have any bleeding at all. And when one considers that the cramping of a threatened miscarriage can feel exactly like the growing pains of a normal uterus, it is fortunate that there are other tools to give you peace of mind.
Blood tests can prove that the pregnancy hormone is increasing as expected, which confirms a healthy pregnancy; ultrasound can demonstrate the physical well-being of a growing baby by showing a healthy heart rate or by ruling out an ectopic (tubal) pregnancy. Although most miscarriages begin with first trimester bleeding, first trimester bleeding isn’t always indicative of a miscarriage. Doctors always respect first trimester bleeding until a cause can be determined. Usually it has a good outcome. So although first trimester bleeding can cause a lot of anxiety and worry, your doctor can usually find something unrelated to the pregnancy—and treatable—to blame it on.
Courses of Treatment
Unfortunately, miscarriage can be a time-consuming event, and most couples wish to get it over with once they know for sure this pregnancy won’t succeed. But your doctor will want to know such a thing with absolute certainty, because he wouldn’t want to intervene against a normal pregnancy. While looking for all of the other innocent reasons to explain away bleeding, blood work and ultrasound are used to find answers as soon as possible.
There’s nothing like seeing a normal fetal impression with a good fetal heart motion to reassure you when there are even the most troubling symptoms. Besides documenting the health of the fetus, ultrasound can put another worry to bed—ectopic pregnancy. Seeing the pregnancy within the uterus itself will rule out a pregnancy in a tube or anywhere else, except in the rare occurrence of twins—one in the uterus and one in the tube. And if there is an ongoing concern, like a subchorionic hemorrhage, serial ultrasounds weekly can watch a blood clot shrink away.
Progesterone is maintained at high levels throughout the pregnancy. Although a pregnancy can be in trouble with a low progesterone, most of the time the opposite is true: The progesterone is low because of a faulty pregnancy. There are absolute values that give obstetricians comfort (15-20 ng/ml). If the progesterone were to come back low, this could indicate a problem even if the hCG is reassuring (usually the hCG will not be reassuring with an abnormally low progesterone). Borderline low may warrant progesterone supplementation, but really low values can be assumed to be because of the likelihood of miscarriage.
Human chorionic gonadotropin (hCG), made by the placenta, rises and accumulates until it plateaus around the end of the first trimester. By that time its levels can reach the hundreds of thousands, but in early pregnancy the numbers are much smaller. This makes it possible to quantify interval increases in this hormone. In early pregnancy, the amount of hCG should double every two days or so. For example, an hCG of 1800 should rise to about 3500-4000 over 48 hours. If it doesn’t, but it’s close, then another repeat sample two days after that will be helpful. If it does in fact double, this is a good indication that everything is going fine. If it exceeds the doubling tendency, twins or molar pregnancy may be brewing.
Your Rh-factor is a necessary item of information, but this was probably obtained with your initial blood work. If you’re Rh-negative, you will need a RhoGam injection with any bleeding episode to prevent your blood from making antibodies to the baby’s blood. This assumes that any bleeding involves mixing of the two to some extent. Studies of the immune system, anti-nuclear antibody (ANA), antiphosolipid, lupus prep, and other such tests are usually reserved for women who have had recurrent miscarriages.
Usually a threatened miscarriage will commit itself within days of the first bleeding. Some do linger, but eventually the truth will become evident. Either the cervix will open, making it an inevitable AB; tissue will pass, converting it to an incomplete AB; or the entire gestational sac will pass, as a complete AB. Or it will go on to be a normal pregnancy. There’s no such thing as an incomplete miscarriage that goes on to term. Patients sometimes fear that if they get over the hump of a threatened miscarriage, that what’s left will result in a terribly abnormal baby at the end. This simply does not happen. Miscarriage is an all-or-none event. It’ll either commit to miscarriage or commit to a normal pregnancy (barring any unrelated problems). You must remember what causes a miscarriage in the first place. An abnormal genetic conception will threaten as a miscarriage because it is incompatible with life sooner or later. But later is still usually before the end of the first trimester.
Some abnormalities like Down syndrome and trisomy 18 do make it down the line, but these are obviously haughtier abnormalities and don’t usually present as a threatened miscarriage in the first trimester. Usually a miscarriage that was meant to be will present as such and then go on to ensue. Therefore, a “threatened miscarriage” that proceeds on into the pregnancy, never miscarrying, was never a real threat in the first place. But since your doctor is probably not a fortune teller, every bleeding must be treated as a threatened miscarriage till proven otherwise. And for many, even when it can’t be proven otherwise, time will rule it out.
Diagnosis and Decisions
If a miscarriage occurs, it may be merciful and make itself obvious very quickly, allowing your doctor to effect closure quickly. Or it may torment you with equivocal blood work and ultrasounds too early to even identify a fetal pole. As mentioned above, eventually a miscarriage will in fact miscarry. By that I mean the pregnancy will die, not necessarily the tissue will pass. If the tissue doesn’t pass (missed AB) or if it passes incompletely (incomplete AB), there is danger of bleeding and infection. The only type of miscarriage that will escape a D&C is a complete miscarriage. Missed and incomplete miscarriages will require a little help in the way of a surgical scraping to remove the rest of the products of conception.
The D&C (dilation and curettage) involves dilating the cervix for access if it hasn’t already opened (inevitable AB) and scraping the inside of the uterus to dislodge any remaining pregnancy tissue. An anesthetic is required. An epidural or spinal may linger hours longer than the actual procedure, turning an outpatient surgery into an overnight stay, so the more quickly reversible general anesthetic is preferred. The procedure is done under sterile technique and infection is rare unless it’s there to begin with (septic AB).
Septic ABs are a particularly hazardous matter. They’re rare, occurring with poor technique (“garage” abortions) or when bacteria have had time to colonize the tissue, as in cases in which a patient wanted to wait for an incomplete AB or inevitable AB to follow through spontaneously. It’s also possible that a septic AB isn’t the result of the miscarriage being infected, but a normal pregnancy being infected, actually causing the
miscarriage. Treatment is the same. IV antibiotics in combination with a D&C will successfully manage such a complication that in generations past would have killed a woman. It can still be dangerous, though, because a D&C can stir up the infection, possibly seeding the bacteria throughout the bloodstream. I am always a little nervous the night of the D&C, waiting for that temperature spike from the temporary sepsis I created with the D&C. But the D&C is necessary and the sepsis usually responds well to a full course of antibiotics. So this would not be an outpatient procedure, several days of IV antibiotics necessary to completely eradicate the infection.
In a straightforward D&C for a miscarriage that isn’t infected, a patient can be at normal activity the next day, although she may feel a little washed out by the anesthetic.
Contrary to popular belief, a D&C is not always necessary to finish a miscarriage. There really is such a thing as a complete miscarriage, and an OB/GYN would serve her patient well by trying to avoid surgery for her patient if possible. Unfortunately, a D&C is often needed, but it can create for the patient a definitive end to a sad chapter in her life, allowing her to plan for her next pregnancy.
Infection: Since a D&C is an invasive procedure, there is always the risk of infection. This is rare, however. In fact, the most likely complication may be a bladder infection because of the routine use of a urinary catheter to empty the bladder before the procedure. This will haunt a patient within a week when she begins to complain of pressure or pain associated with urination. Antibiotic pills will treat this common complication.
Synechiae: Thankfully, the more serious complications are infrequent. The aforementioned infection of the uterus could cause scarring withing the uterine chamber (the intrauterine cavity), such scarring stringing across from internal uterine wall to internal uterine wall. These are called synechiae and can interfere with fertility if severe or threaten miscarriage if mild.
Perforation: If your doctor is properly trained, she should know how to use the curette to gently scrape your uterus without pushing the curette through. But surprises can happen if your uterus is thinned out, as in a late first trimester D&C. Also, if there’s an infection already, the tissue can be very mushy and won’t provide a consistency that is normally felt—the accustomed resistance a doctor knows. But even if there’s a perforation, an overnight stay for observation and antibiotics is all that’s necessary. The observation is for bleeding and that will be obvious quickly, a stable blood count the next morning being plenty of assurance that a patient can go home with her antibiotics.
Psychological: If the clinical aspects of a miscarriage rudely eject you from the fairytale land of pregnancy and rest-of-your-life-with-baby, the loss is all the more of a thud into cruel reality because of the unfriendliness of a surgical procedure. True, closure can be the best thing, but a D&C is more than just a closure—it’s a slamming shut of the door. And it’s another thing you have to do. You can’t just mind your own business and miscarry; you have to go places and do things with other people. It’s still better to get the whole painful crisis over with, but a D&C, although quick, is not an easy let-down. Then again, nothing would be. As mentioned before, it takes about three months to get over such a loss no matter how the miscarriage is addressed.
The loss of a baby prior to term for any reason is a miscarriage. The medical dictionary writers will argue that if it’s past the first trimester, fetal death is no longer called a miscarriage but instead called a fetal demise. These names are useful for a frame of reference and I use them myself. But from the parents’ point of view, it’s still a miscarriage—a ravaging of their dreams. And intrauterine death, be it a miscarriage or a fetal demise, is no more a loss than the other ways in which a pregnancy can go astray: Ectopic pregnancy, molar pregnancies, and absorbed twins will rob a couple of their futures just as terribly as a “conventional” miscarriage.
Gerard M. DiLeo, MD, is a board certified obstetrician-gynecologist who has been in private practice since 1981 and has served as chief of the medical staff at Lakeview Regional Medical Center in greater New Orleans. He is also the author of The Anxious Parent’s Guide to Pregnancy.