Miscarriage And recurrent miscarriages, a huge heartache !!

There is nothing as uncertain and anxious, as miscarriage, which a woman may encounter and along with her the gynecologist would suffer. Miscarriage or abortions ( not a very nice terminology ) is a loss of a pregnancy before the age of viability ( 20 weeks or 5 months ) is indeed frustrating clinical condition which has many reasons to occur and many of these can be either unexplained or many may be contributing at the same time. Out of these, the very early ones are certainly frustrating as many factors may be responsible for this. Nature calling : Many pregnancies are destined to actually lose before they are even recognized and this is probably the natural selection mechanisms of the universe. Survival of the fittest and therefore conceptions which are abnormal or are not compatible with life are naturally removed by nature. This has been proved by chromosomal analyses performed by researchers that many of such early losses are a result of such an abnormality. Rising incidence : Today’s advanced diagnostic modalities and high resolution ultra- sonography help us identify the pregnancy, much early in its occurrence and therefore has lead to diagnosing increased numbers of early losses. In the olden days, women would report to the doctor, only nearing the confinement or later stage, still at the perception of baby movements, somewhere around the 4th and the 5th month ( quickening ). So, most of the nature’s filter would come into play till that time and then the healthier ones would continue . Lifestyle changes, such as stress, late marriages and consequently late conceptions, contribute to the rising incidences of miscarriages. Mis-carriages, especially in overweight, obese, stressed, older women are rising. Today with the advent of precision in diagnostics, need of perfectionism, non- acceptance of such natural negative happenings has led us to reverse the entire antenatal care prism( shall cover this in detail in upcoming posts ) targeting on identifying the abnormalities much earlier in the course of the pregnancy. But yes, it has now being accepted as a valuable means as it helps in identifying or predicting the possibilities of complications which may be there or emerge in the due course. This is increasingly seen due to underlying metabolic abnormalities such as nutritional deficiencies, obesity, carbohydrate, intolerance, stress, ageing etc .

Confirmation of pregnancy : It is important to establish a clinical pregnancy and the presence of the embryonic heart beats are important for this. Urinary pregnancy test is a qualitative test which tells us that there is a pregnancy .However confirmation by ultra-sonography (USG) or sonography in the very early part of gestation is important to ensure that there are fetal heart beats and that the pregnancy is within the womb. In the very early part of conception, when the urinary test is positive no evidence of pregnancy may be seen on USG or just a pregnancy sac without the fatal pole or the heart activity may be there. These may need to be monitored on a serial scan. These entities can also be labeled as chemical pregnancy or PUL ( Pregnancy of Unknown Location ) and investigations with blood markers may be needed to ensure that it is not a table pregnancy which can be associated with serious immediate and long term consequences. What causes miscarriages : Many factors are responsible for mis-carriages. The list is inserted here and these may cause a loss, based on its severity and also may affect the pregnancy at various times in gestation. 1. Chromosomal abnormalities : The zygote and the resultant embryo itself is non-compatible with life 2. Anaemia ( low haemoglobin levels ), very low maternal weight, Blood pressure and heart diseases. 3. Hormonal abnormalities such as diabetes, thyroid abnormalities , polycystic ovarian disease, obesity , progesterone hormone deficiency.

  1. Advanced maternal age

  2. Structural abnormalities in the uterus such as weak cervical opening, fibroids

and adenomyomas 6. Infections such as viral fever, high grade fever, vaginal infections and urinary infections

  1. Immunological disorders which cause rejection of the baby

  2. Blood disorders associated with defective coagulation problems such as

APLA(Antiphospholipid Syndrome )

  1. Excessive smoking and substance abuse

  2. Stress and some medications

Many of the above may be present and act as complimentary factors and none may be present leading to unexplained miscarriages. Recurrent miscarriages : when there are more than 2 miscarriages occurring naturally. Pregnancy losses after 20 weeks can also be due to the above mentioned causes and are then called as early deliveries or losses. Some real time examples with inferences 1. Mrs DG had a first delivery with spontaneous conception and a cesarean section done for a large baby, 10 years back when she was 26 years of age. She was diagnosed with thyroid abnormality and pregnancy diabetes during that pregnancy and was advised to make necessary lifestyle changes. She then went

abroad and has now returned after 9 years. Came for preconception counseling. She was advised weight loss, anaemia corrections, vaccinations, corrections of thyroid abnormalities and control of diabetes ( as it has now become overt diabetes ). Meanwhile she conceived, as she did not use precautions, pregnancy was confirmed at 6 weeks but she miscarried after a week. She was counseled to continue the lifestyle changes and again without results she conceived within 3 months and lost the pregnancy. Meanwhile she kept on putting on weight @ 2 kgs per fortnight. Strict weight control , supervised assistance for conception followed after 6 months of ensuring normal parameters and now at 38 years of age, she has finally taken the pregnancy to 28 weeks and I am hopeful that she will do well. Inference : Adoption of lifestyle changes and patience is important. 22 years old diagnosed PCOS was advised by me to first stabilise her menstrual cycles and hormonal parameters and then conceive under supervision. She took treatment elsewhere and conceived and lost the pregnancy at 7 weeks. Inference : PCOS causes miscarriages due to hormonal abnormalities which should be stabilised first. 2. Leena married for 8 years had never conceived and didn’t take treatment as she was married at the age of 18. She conceived recently and the family advised her not to go to the doctors for 2-3 months. At 7 weeks she passed some blood stained discharge and still was advised not to seek consultation saying it is normal. Between 8-9 weeks she had a heavy bout of bleeding for which she was brought in with incomplete abortion which had to be surgically evacuated . She was obese and had severe anaemia of 6 g/dl. Inference : completely avoidable cause of miscarriage . no preconceptions guidance about anaemia , nutritional supplements, weight were accessed by Leena. Pregnancy and childbirth are important life decisions and are to be considered seriously and after proper thought. Always take guidance before planning pregnancies and ensure that the mother is healthy, immunised, mentally prepared to undertake the pregnancy and then go ahead to face this beautiful gift that god has bestowed upon women.

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