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Old Sep 17th, 2006, 14:37 PM   1
Wobbles
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Miscarriage Facts & Myths


There are very few miscarriage that can be prevented and more than often the woman blames herself or a situation for her loss. It is important to realise what are facts and what are myths. I found a very useful source www.pregnancyloss.info where all the below information is sourced from and put together for easy reading.

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When a miscarriage is occurring, there is no magic way to stop it from happening. By the time you begin bleeding, the baby has almost always already died. This is a frustrating and terrible situation to be in, and when it happens to you, you will initially have no idea that it is so common. Before your research is done, though, you will find that one out of every 10 pregnancies ends in miscarriage, and that one in every four women will have one at some point in her reproductive years.

An important section to read if you are sure you could have prevented your miscarriage is the post on myths. There you will find the most common things women blame for their miscarriage, and why they are not a factor.


Causes

Most early miscarriages (as many as 60% of first trimester ones) will remain unexplained. It is usually assumed these losses are genetic, where the chromosomes simply did not replicate correctly. Many people will assume that something that happened recently, such as an illness, fall, or exposure to something will have caused the miscarriage. This is rarely true, since by the time a miscarriage is diagnosed or begins, the baby has been lost for quite some time. Hopefully this section will help you understand the causes; you should also read the section on myths.

There are several categories of miscarriage causes:

Hormones
Chromosome Defects
Physical Problem with the Uterus or Cervix
Immune Disorders
Premature Rupture of Membranes and Early Labor
Other
Unknown
Blighted Ovum, Ectopic Pregnancy, Molar Pregnancy, and Stillbirth

Hormones

When we talk about a hormone problem, you have likely miscarried in less than 10 weeks. After that, the placenta has taken over hormone production and any normal deficiency you have is not a factor. Low progesterone, the most common problem, is not as easy to treat as you might hope. Progesterone suppositories, while frequently prescribed, are not proven to be helpful and often actually cause a nonviable pregnancy to last longer than it should.

The only situation where progesterone is a sure solution is with a luteal phase defect, where the corpus luteum, which is formed along with egg at ovulation, does not produce the hormones needed to sustain a pregnancy. For most women, however, this is usually not an every-month problem. Usually the situation rights itself with the next egg and the next corpus luteum. This problem, if it is a permanent one, can be diagnosed through two separate endometrial biopsies. Progesterone must be started 48 hours after ovulation to work. By the time you have missed a period, it is too late to save a pregnancy with a luteal phase defect.5

Low progesterone, however, is usually a symptom of an nonviable pregnancy, and not the cause. Doctors often prescribe progesterone suppositories out of patient pressure when the hormone levels are low, but their use is controversial and usually completely ineffective. A common treatment for a suspected progesterone problem is Clomid, a pill taken for five days early in your cycle to rev up your hormone production. Not everyone is a candidate for Clomid, and 25% of women will have decreased cervical mucus, which can actually make you less fertile. See the Sperm Meets Egg Plan for more information.

Other hormone problems may be created when you have an untreated thyroid disorder. Your thyroid function can easily be tested, and this problem is very treatable.

Chromosome Defects

There are many factors that come in to play when the egg and sperm unite and form that first cell. Even if both the egg and sperm come with perfect chromosomes, the first few cell divisions can see an abnormality crop up that would certainly be devastating. Chromosome defects that cause a newly fertilized egg to die can account for as much as 60 percent of early miscarriages.

You can usually find out if you had a baby with a chromosome problem through testing tissue from the miscarriage. This must be done RIGHT AWAY when the tissue comes out or the cells cannot grow and the test won't work. If this is your first miscarriage, however, do not go to great lengths to save tissue. Very few doctors will test it, and a chromosomal cause for the miscarriage will be assumed without testing.

Even when you have a D&C and the doctor sends the tissue immediately, it still might not work. (Mine didn't.) But if you do find your baby had a chromosome defect, find a small measure of comfort in knowing that although you lost this one precious baby, the chances of if happening again are extremely small. If you are over 35, though, your odds will begin increasing dramatically.

After the 2nd trimester begins, the number of miscarriages caused by genetic factors drops to less than 10 percent.3 If you have had several miscarriages in a row, then your odds of this being your problem are quite low, about 7%.42 If you are over 35, though, your odds will begin increasing dramatically.

Physical Problem with the Uterus or Cervix

Some women have a uterus that does not have the usual shape. Others have a cervix that may be weakened by a number of causes, including multiple D&C procedures or their mother taking DES when she was pregnant. Both of these problems can cause an early labor, usually during a critical period from 12-24 weeks. This cause is responsible for 12 percent of miscarriages during this time period. As the baby grows, especially during the very rapid growth spurt during this time frame, the irregularly shaped uterus may not be able to expand or the weak cervix may start to open up and let the baby out. There are treatments for both of these that are quite effective—corrective surgery on the uterus and a cervical stitch that holds the cervix closed. This problem WILL REOCCUR if not treated.

A uterine abnormality often causes a miscarriage due to early labor, but it can also cause fetal demise, which is what happened to our Casey. Sixteen weeks into my pregnancy with Emily, we had an abnormal AFP screening. Since we were near the point of the pregnancy when Casey died, naturally we were frantic. We saw a perinatologist, who discovered I had a septate uterus. When I was a fetus, the two sections of tissue that normally fuse together to form the uterus only fused on the bottom. Therefore, there is a huge wall going down the middle of my uterus. When Casey implanted, he chose the middle wall. This section, however, has little blood flow. As Casey grew and required more and more blood and nutrition, this area could not support him. So he died. Although Emily chose a better implantation spot, this problem caused her to be breech and required a c-section. While I did have the surgery to correct this problem, my next pregnancy still had complications, and c-section will most likely be the only way to get my babies born.

Be aware that there are varying levels of septums. Some are paper-thin and simply move out of the way for the baby, causing no problems. Others, like mine, increase your chance of miscarriage significantly. Only a high-level sonogram or an HSG dye test can uncover this problem.

Immune Disorders

While many experienced and well respected reproductive endocrinologists specialize in this field now, many "regular" ob/gyn doctors are quite resistant to the idea of this type of miscarriage cause and its treatment. Specialists in immune disorders claim up to an 80% success rate with women who have had three or more miscarriages, but there is still much skepticism even among infertility and reproductive specialists.

Antiphospholipid antibodies can cause blood clots in the placenta that block or slow down the baby's blood supply, causing growth to slow or the baby to die altogether. Your blood can be tested for these antibodies. These tests are called anticardiolipins or the associated lupus anticoagulant. These are inexpensive tests, and sometimes you can get them after only one miscarriage. If antibody levels are thought to be high enough to affect the pregnancy, treatment involves baby aspirin and sometimes a blood thinner called Heparin. In rare cases, the woman is actually found to have Lupus, which may be mild enough not to affect her, but needs management anyway to protect her pregnancies (see antinuclear antibodies). While a miscarriage due to this problem can happen at any time, often the baby will grow past the first trimester. 10 to 15% of recurring miscarriages are caused by these antibodies.6

Antinuclear antibodies are caused by an auto-immune problem, in Lupus or a Lupus-like syndrome, where the body attacks itself. The treatment for this problem is Prednisone, a corticosteroid, which calms down the inflammatory process of auto-immune disease. Prednisone, however, is really a horrible drug and will cause all sorts of terrible side effects, including swelling, bruise marks on the face, and discomfort. You do not ask for this drug without really needing it.6

Fetal-Blocking Antibodies work to protect the baby from the mother's immune system, which will recognize the father's genetic material as foreign to her body and attack it. When the sperm penetrate the egg, it provides foreign material, but it also contains histocompatibility locus antigens (HLA). The sperm's HLA will "talk" to the mother's HLA, which would normally attack the baby, and stimulate the mother's body to protect the baby. In some cases, however, the father's genetic material is too similar to the mother's. In that case, the mother's response is weak and insufficient to prevent her white blood cells from attacking the new cells. Standard testing for this is not yet available, and you would have be accepted into one of the few elite clinics working in this field. If your tests show you and your partner's DNA to be too similar, you can receive injections of your partner's white blood cells, in hopes of getting enough of his HLA in your system to stimulate a stronger protective response. This is an expensive and controversial tactic, but allegedly (a word I use since there isn't solid 3rd party data to support it) succeeds 80% of the time.7, 42 This type of problem usually causes an early miscarriage, well before 12 weeks, and is often suspected when several miscarriages have occurred at the exact same time in the pregnancy

The average OB/Gyn may not be up to date on these immune issues. Read up on it yourself and find a specialist who can determine if this is a problem that might be affecting your babies. You are not usually a candidate for the more involved testing, which is expensive and not typically covered by insurance, until you have at least three losses.

Premature Rupture of Membranes and Early Labor

Many miscarriages begin with cramping and labor-like symptoms, but true PROM and Early Labor are usually associated with babies that are in the second or third trimester. Early labor can often be treated with drugs that relax the uterus and women are placed on bed rest either at home or in the hospital.

Sometimes, however, the baby comes anyway. This is one of the most traumatic of losses, technically a stillbirth and not a miscarriage after 20 weeks, because you will hold and see your baby and beg him or her to breathe. For some women, the baby will even be born alive, but only live for a few minutes, hours or days. There really is nothing harder in life than this.

PROM is defined as your water breaking prior to 37 weeks, the age that is considered full term. Most women who have leaking or gushing amniotic fluid will be placed on antibiotics and placed in the hospital because the risk of infection is very high. Once an infection comes, the baby will almost always have to be delivered.

Babies must weigh 500 grams, or about a pound, to survive. Because I was at high risk for PROM and early labor, I kept this day on my calendar and waited with fear for it to pass. For women expecting a normal pregnancy, suddenly having your water break is very frightening. Your are stuck in the hospital, having to rely on what people tell you, and unable to get information on your own. It is scary.

PROM is thought largely to be caused by infections or inflammation of the uterus or fetal membranes. How these infections come or why they cause the membrane rupture is not completely understood. Pelvic exams and yeast infections are NOT considered to increase your risk for PROM. I do know, however, just in reality through talking with women, including a close friend of mine, that PROM tends to recur. Knowing you are at risk and taking all the appropriate precautions is essential to keeping your baby in the uterus as long as possible.

Fortunately, even though PROM cannot always be treated or prevented, most babies are able to make it far enough to survive and lead normal lives. If you have experienced unexplained PROM, I highly recommend finding a doctor with experience with this sort of pregnancy. A medical study on PROM is included in my "Books and Links" section.

Others -- Infections, Age, Chronic Disease

Many infections can cause miscarriage, but they are the big ones like syphilis, mycoplasma, toxoplasmosis, and malaria. An upper respiratory infection is NOT going to cause a miscarriage, even though it may worry you to death. Viruses are the same. Normal illnesses like the common cold will not cause a problem, but AIDS and German Measles can. Infections that directly affect the uterus are bigger risk. This does NOT include yeast infections, which are extremely common in pregnancy. See the section on Premature Rupture of Membranes for more information on these infections.

There are a few common illnesses that can cause a miscarriage or fetal malformation if you get them for the FIRST TIME during pregnancy, including Chicken Pox and Fifth Disease. The vast majority of women already have immunity to these diseases, however, and should not be concerned about exposure to them during pregnancy. If you think you may not have immunity, ask your doctor to run an antibody titer to see if you have a live antibody, or only an old antibody to the disease in your blood. Only the live antibody without the old antibody present is a danger.

An infection that causes a fever of over 101 degrees Fahrenheit should be treated immediately, however. There is a small risk that prolonged fever can affect your baby. Take Tylenol to keep your fever down and stay in touch with your doctor.

Age is only a factor in miscarriage when you consider what aging can do to your body. The first and most common is with chromosomes. It is not YOU who have a problem, it is likely your egg or sperm, which have also aged. Age can, however, bring other problems such as poor health, disease, or hormonal imbalance that can make a pregnancy harder to sustain. You don't start seeing these problems in great numbers, however, until after 40.

Health problems in the mother can create problems with the pregnancy. Diabetes, heart problems, and thyroid disorders are just a few that may complicate the pregnancy. Having these does NOT mean you will certainly have a miscarriage. You will simply have to be more careful and make sure your treatments are adapted if needed during pregnancy.

Accidents typically do not cause a miscarriage. The baby is well protected in its amniotic sac, surrounded by fluid, and even a hard blow to the abdomen will likely only rock it. Most women who have a car accident, even with a certain amount of trauma, have their babies just fine.

The Unknown

The hardest thing to accept is no reason at all. You live in fear, wondering if the same terrible cause of your first baby's death will cause another one to die. You scarcely dare to try again. I have been in this situation and I tossed my doctor's statistics aside. I had already been on the wrong side of the statistics; I didn't care for anymore. But I do know this. One miscarriage hardly raises your chances to miscarry again at all. You are simply back at square one. Try to put the risk as far back in your mind as possible and enjoy another pregnancy. But I understand if you can't.

Blighted Ovum, Ectopic Pregnancy, Molar Pregnancy, and Stillbirth

Sometimes a pregnancy ends unhappily, but it is not technically a miscarriage. This section will touch on these types of situations.

Blighted Ovum is a condition (with a terrible, unfortunate name) where the gestational sac grows, the woman gets all the pregnancy symptoms, but the baby itself never develops. The sac will continue to grow and grow, and most women do not know there is no baby until an ultrasound is done. The bleeding, if that happens before the blighted ovum is found via ultrasound, is slow and brown. Your pregnancy symptoms will seem to go away. A blighted ovum is believed to be caused by an egg or sperm with poor genetic material. When the egg is fertilized, instead of creating both a sac and a baby, the part that should be a baby never grows. A D&C is almost always needed to empty the uterus, because the body is very slow to realize there is no baby. Some women do experience more than one blighted ovum, but most women go on to later have a baby.

An Ectopic Pregnancy is a normal fertilized egg that gets stuck in the fallopian tube (although occasionally it will fall into the abdominal cavity) and implants there. This type of pregnancy cannot survive and puts the mother at great risk for severe hemorrhaging and possibly even death as the baby grows and eventually bursts the tube. When the ectopic is discovered, the mother will immediately have surgery to remove the baby. Things will happen very fast, and most likely if this has happened to you, you are reading this after it is all over. If you are afraid you have an ectopic, the symptoms that you really want to watch for are: sharp, intense pain in your abdomen or possibly in your shoulder; a pregnancy test that is positive, then turns negative a few days later; and spotty red bleeding that continues.

Ectopics are usually caused by scar tissue in the fallopian tubes that could have been caused by: previous surgery in the pelvic region, uterus, or tubes; a pelvic infection such as chlamydia or pelvic inflammatory disease; or endometriosis that blocks the entrance to the tubes. If you have had one ectopic, your risk increases for another one. See additional information on treatment.

A Molar Pregnancy is a very rare type of pregnancy where an abnormal mass forms inside the uterus after the egg is fertilized. The baby usually does not form, but the uterus is filled with big bubble clusters. A molar pregnancy is caused when a sperm fertilizes an empty egg (called a complete molar pregnancy) and no baby grows, or when two sperm fertilize an egg and both the baby grows a little as well as an abnormal placenta (called a partial molar.) Even if a baby does grow, it cannot survive. The longest documented molar pregnancy I have seen was a 24-week stillbirth, and most molar pregnancies will be diagnosed and a D&C performed before the end of the first trimester. If a molar pregnancy has been diagnosed, your medical condition will be carefully monitored. In about 15% of molar pregnancies (usually complete molars and not partial), the moles spread to other parts of the body like cancer. A mild form of chemotherapy will have to be used (with methotrexate), but rest assured that the cure rate for this type of disease is very high. The signs of a molar pregnancy include: bleeding in the 12th week of pregnancy, a uterus that is larger than normal, and hCG levels that are too high. The molar pregnancy is removed by a dilating the cervix and gently suctioning out the clusters. Women who have had a molar pregnancy are usually advised not to get pregnant again for at least a year to ensure the cancerous form is not present. It is absolutely essential to follow doctors orders on when to try again with a molar pregnancy diagnosis. Do not cheat, and have regular follow ups even after your hCG is zero, to make sure it does not rise again.8,9

A stillbirth is technically any pregnancy that ends after the 20th week and the baby does not survive. Some babies die in utero and are discovered when the heartbeat is not found. The most common causes of this are: uterine abnormalities, a knot or other umbilical cord accident, infections of the lining of the gestational sac or cord, and placental abruptions that cause the placenta to pull away from the uterine wall. These babies are usually born through the induction of labor, although some babies are small enough to be taken by D&C or D&E procedures.

Other babies are lost through early labor. The causes of early labor are Premature Rupture of Membranes, uterine abnormalities that make the uterus too small to hold the baby, and an incompetent cervix, which opens up and lets the baby out. Sometimes a stillbirth occurs during the birth, by an umbilical cord that gets pinched between the baby's head and the cervix, or the cord wraps around the baby's neck. Repeat stillbirths are extremely rare and are almost all related to uterine or cervix problems, which can be fixed or treated once found.

Myths

Sometimes after your miscarriage you will remember straining to lift something, worry over the three martinis you drank before you took the pregnancy test, or wonder if you should have still been working out. None of this matters. Miscarriage happens, whether we do our best to prevent it or not. Here is a list of commonly blamed factors that are NOT causes of miscarriage.

These things do NOT cause miscarriage:

Stress. Everyone worries about the baby. Many experience traumatic life events during pregnancy, such as family deaths, even deaths of children or the baby's father. You will get through it, and your baby will too. As a strong case in point, over 50 women were pregnant when their husbands died on September 11 in a terrorist attack on the United States. Their babies are arriving, kicking and squawling, despite the pregnancy occurring during the absolute worst days of their mothers' lives.

Sex, even the passionate kind. Orgasm may scare you when your uterus enlarges because you can feel the contractions, but it doesn't do anything to the baby other than maybe rock him to sleep (or get him to kick you to stop and let him sleep already.) Sometimes you will have spotting after sex, but this is just because the cervix is very soft and filled with blood. A little banging sometimes makes it bleed a little, but this is not a problem. You only need to curtail your loving if your doctor has told you to do so.

Lifting your toddler or older children. Your body will complain to the point of making you drop them well before you can do anything that is harmful. Remember to pick them up by squatting and lifting with your legs, not bending over and lifting with your back. This is still not a miscarriage factor, but will save you many aches and pains.

Working out. This is actually something that helps you and the baby. There are some rules, however. Do not get your heart rate above 140 (still not a miscarriage factor, but does start to reduce the amount of oxygen to the baby) or work until you feel faint or exhausted.

Getting kicked or hit in the stomach. Remember the baby is well protected, and only you will hurt. This is often done during the night by a sleepless child you have pulled into bed with you, but if it is by a partner or other adult, get help. You don't need to bring a child into a world where abuse is present. Please visit http://www.ncadv.org/ for help and information on domestic violence.

Poor eating habits. The baby will rob you of the nutrients it needs and only you will suffer. However, you can cause a low birth-weight baby with developmental problems if you refuse to have a healthy diet through the entire pregnancy. You should still eat well, but don't blame a miscarriage on your eating habits.

Drinking before you knew you were pregnant. The majority of women do this and it has no bearing on miscarriage. I personally tossed quite a few tequila shots the night I had a negative pregnancy test on the ninth month of trying. Two days later another test was positive. I didn't blink an eye. The baby doesn't get a drop of blood before implantation, and receives so little for the first few weeks that you really just don't need to worry about it. If you continue drinking once you know you are pregnant, however, you can cause a serous problem with Fetal Alchohol Syndrome. Once the test is positive, pick up baby bottles, not liquor ones.

Scaring the baby. Just because a near accident, or loud terrible noise, earthquake, or other event scared you, does not mean the baby even noticed. Even if the baby does jump upon hearing something loud, this is just a startle reflex and actually a healthy sign that he or she is developing normally. Babies do not have "heart attacks" from fright or get scared "to death." This is a persistent myth in several cultures and simply does not have any basis in fact.

The baby "knowing" it was unwanted. Just because a pregnancy surprised you, and even if you debated having an abortion, you did not cause your baby to die. This is a grief and guilt emotion you are feeling, but it is not true. The fact is, at least 10% of all babies die, whether they were desperately wanted or not.

These things may cause complications, but not typically a miscarriage:

Falling. We all become klutzes as our belly expands, joints loosen, and our center of balance changes. Most falls do not cause any harm to the baby. If, however, you experience bleeding or serious soreness afterward, or if you landed square on your belly in the second trimester or later, see a doctor to check the placenta for tears. Otherwise just be embarrassed.

Car accidents. While some people will blame their miscarriage on an accident, usually it isn't so. The baby is very well protected in its amniotic fluid, so unless the stomach and uterus is punctured, or the woman undergoes a period of cardiac arrest or without breathing, the baby should survive. Certainly get checked after a car accident, but don't worry too much about miscarriage. It is rare in this case.

Lifting something heavy. This caution is really for women who can cause a placental tear in the second or third trimester. This does not necessarily mean a miscarriage, and usually if you feel terrible pains later, it just means that you strained one of the round ligaments holding your uterus in place. A little rest will be all that is needed. If you have bleeding, however, it is time to get a sonogram just to be sure you didn't pull a bit of the placenta away, although this will almost always heal itself without incident.

BUT!

Yes, I know. You started bleeding right after sex, or right after a workout. Or your baby died the day after the car accident, or the checkup at the hospital after you fell down showed no heartbeat. These things MUST have caused the miscarriage, because babies don't just die, right?

WRONG.

Babies do just die. Over half of all miscarriages are caused by chromosomal factors that are completely out of our hands. Not preventable. Nothing we can do. The majority of the others are also unrelated to anything we personally did, but some infection that got us, a poorly formed placenta or umbilical cord, a hormone problem, or health condition we didn't know about. Don't let anyone, not even your partner or your mother (or yes, the mother-in-law) tell you this was your fault. It absolutely, positively was NOT.

Undocumented

Sometimes someone you trust, even your doctor, will suggest these might have caused your loss, but they aren't sure. I think sometimes even medical professionals will speculate when they can't narrow down a sure cause just to give you something to go on. I've investigated these things, and found no properly documented research studies on these. That does not mean it did not cause your loss, but it is not very likely. Most unexplained miscarriages are genetic.

Group Strep B--35% of all women have this at some point, and if you are pregnant when you test positive, Strep B is usually left untreated until close to delivery time. This will maximize the affect of the antibiotic to protect the baby during delivery. Strep B can infect a baby as it passes down the vaginal canal and cause serious problems, but if there were any connection between Strep B and miscarriage, doctors would not leave it untreated in pregnant women until the last few weeks.

Fibroids--the only way a fibroid could cause a miscarriage is if the egg tried to implant on it. That loss would be so early you probably would not have even been late for your period. Fibroids can, however, if they are very large, complicate a pregnancy by making it difficult for the baby to get head down. A c-section may be necessary.

Scar Tissue--This can cause difficulties getting pregnant, as the egg may have a hard time navigating the bands of tissue to find an implantation spot, but this would not even get to the point that hCG would be produced, and you would not know you had fertilized an egg.

Endometriosis--This condition itself should not cause miscarriage, although some doctors speculate that it can throw off the hormones enough to cause an early loss. Most of us who have terrible painful periods have some endometriosis. It is more likely to be an infertility problem than a miscarriage one. Pregnancy actually improves endometriosis.

Tuna Fish or Mercury--You can read more on this under news, but mercury levels would have to be extraordinarily high to cause miscarriage, and no amount of tuna would cause this. If you work directly with mercury in your job, you should be checked regularly. The greater risk is for birth defects in live babies.

Controlled diabetes--If you are on insulin or are regulating your blood sugar, as long as your levels are normal, you should not increase your miscarriage risk. This can complicate a pregnancy, but not end one.

Controlled thyroid--If you have a diagnosed thyroid disorder and are taking medication, you should be monitored periodically to make sure your dose should not be changed. Only if you get dramatically off could this affect your pregnancy.

History of STDs--Sexually Transmitted Diseases in your past could cause scar tissue and lower your fertility, but would not cause miscarriage.

Prescription Drugs--There are only a handful of drugs that can cause the baby to die--most notably some epilepsy drugs and methotrexate, which is used to end ectopic pregnancies or to perform early abortions. While many drugs are not supposed to be taken during pregnancy, they do not cause miscarriage, but increase the risk for birth defects.

Herbal remedies--This is such a large group, I hate to be general, but you should avoid all herbal drugs since their potency is not regulated. The following herbs can interrupt pregnancy (still rarely, but it can happen) if taken within two weeks of ovulation: dong quai, blue cohash, cotton root bark, pennyroyal, or tansy.



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Old Sep 17th, 2006, 14:50 PM   2
Wobbles
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Symptoms of a miscarriage

Definite Signs

You are having a miscarriage if you have already had a positive pregnancy test, then get these symptoms:

Strong cramps that make you double over or breathe in a huffy way. Bleeding will usually follow quickly.
Heavy bleeding that soaks a pad in a few hours or less.
Passage of tissue, resembling large thick blood clots in the earliest weeks up to pinkish/grayish material, with or without cramps or pain

A little bit of bleeding without cramping should be okay, but call a doctor. Small darting cramps, even if they hurt, are also okay, usually they just signal the body stretching and pulling to accommodate the growing baby. Lie down and the cramps will usually go away within the hour.

These symptoms can be other things rather than a loss of pregnancy, however, if you are not sure you are pregnant. Check the "I'm not sure I was pregnant" section.

What should you do?

If it is during doctor's regular working hours, call your regular doctor first. They will give you instructions.

If it a night or weekend, first call your regular doctor's after-hours number. Usually this will be on their answering machine or with their answering service. The nurse or doctor on call who calls you back will help you decide if you need immediate attention or not. Don't feel like you are bothering them needlessly; this is a natural and expected part of any OB practice.

If you can't get through, don't have a doctor, and you are afraid, then go to an emergency room. Be prepared for some possibly insensitive treatment. While some hospitals are well equipped for handling this situation and do a good job, often you are left alone in a room for hours, or told to sit on a toilet and catch tissue, or just sent back home because "there is nothing they can do." It may be worth the trip, though, if they draw blood for an hCG test or give you a sonogram.

There is not really a risk to waiting until Monday or the next morning if you are in your first trimester. There is no magic way to stop an early miscarriage at the hospital. What is going to happen will happen. If you are farther along than 12 weeks, though, and you are merely in labor and not bleeding, then you should take quick action to see if labor can be stopped.

If you are passing tissue at home, and it is your first miscarriage, it is not necessary to catch the tissue and take it in. You may do this if you choose, however, and you can store it in a sealed plastic bag in the refrigerator until you get to a doctor. However, it is rare that tissue caught this way will be usable. Tissue from first miscarriages is rarely tested, since it is assumed your miscarriage was due to a genetic defect. The best way to ensure testable tissue is to have a D&C.

Possible Signs

Sometimes, but not always, there may be signs that a miscarriage is pending. None of these things means a miscarriage is certain, but usually you will want additional monitoring if they happen.

Bleeding: Bleeding that starts and stops and starts and stops is often a sign that your hormone levels are falling. While you may still be okay, you need to have your blood hCG pregnancy hormone levels monitored. Heavy bleeding that soaks a pad in an hour is a sign that a miscarriage may be beginning. See the sections on "definite signs" for more information on what to do. Keep in mind that while bleeding is always scary, 70% of all pregnancies have bleeding at some point. Both of my normal pregnancies had bleeding, heavy and red. And the one I lost at 20 weeks never even spotted.

Cramping: You are going to feel a lot of random cramping down there the whole pregnancy. The only time cramping is a concern is if you are breathing in a labor-like huff, or if you also begin bleeding with the cramps.

Loss of pregnancy symptoms: This is a question I get all the time. While the complete and sudden loss of pregnancy symptoms can signal a pending miscarriage, usually it is not the first sign. You will have many days where you don't feel pregnant, when the nausea abates for a day or two, or your breasts are less sore. This is expected and not a concern at all. Around weeks 10 to 14, this is completely normal, as your hormone levels even out and the placenta takes over. The loss of pregnancy symptoms during a miscarriage is usually something you see in hindsight, not ahead of time.

A pregnancy test that is positive, then negative: This is a classic sign of an ectopic. Often you may also see spotting. If you have taken a pregnancy test that is positive, then another one a few days later that is negative, alert your doctor immediately. You want to rule out an ectopic or take care of it before you have to go the surgical route. If you are taking the tests in the same day, though, you might be right on the edge of a positive result, and urine later in the day may not be concentrated enough to keep the test positive. Test again the next morning to be sure.

You should always call your doctor when you are worried, however; because it is better to call for something that does not turn out to be a problem than to stay up half the night worrying about it.

When You're Okay

Whether it's your first pregnancy or you have already been through a loss, one thing we all have in common is worry, worry, worry. This is okay, but remember that 90% of pregnancies end with a squawling baby, regardless of the turmoil the mom has gone through to get there. Here are the most common things you will fret over, and why they are not really a problem.

Bleeding: Small amounts of brown blood (which means it's old) are expected when the egg implants in the uterus (7-10 days after ovulation) and sometimes at the point when you would have expected your period. You may also bleed slightly after having sex, but this is probably NOT from the baby. Your cervix is soft and filled with blood, so it may bleed a little from sex. This is not considered by many doctors to be a problem, but if it alarms you, call. Up to 70% of all pregnancies have bleeding.

You will be especially scared if you see bright red blood. If you are between 10 and 12 weeks, or if it is a time you would have expected your period, do not panic. Remember that until you are quite far along, much of your uterus is not involved in nourishing the baby, and can bleed with a minor hormone fluctuation. If you are not cramping, call your doctor to let them know, stay lying down on your left side, and hopefully it will slow down, start to turn brown, and eventually stop. If you push the issue, your doctor might schedule a sonogram to put your fears to rest.

When bleeding is a problem: If it is heavy enough to make you change pads or bright red, call your doctor right away.

Cramping: You are going to feel a lot of random cramping down there the whole pregnancy. Most of the time it is caused by the round ligaments expanding to accommodate your growing baby and uterus. If it goes away after a few pains or after you sit down and rest a bit, then you are probably all right. Cramping is a sign you are growing to accommodate the baby and sometimes a sign that you are overdoing it and should rest.

When cramping is a problem: If it continues or gets worse or if you start bleeding too, call your doctor immediately. If you begin to have labor-like breathing or a gush of fluid or blood.

Inability to eat or keep food down. This is normal! Remember that the baby is the size of a grain of rice and not exactly demanding steak dinners. When the baby starts to need the extra 300 calories a day, you will be eating fine. Just do the best you can with your saltines and soda, and remember that the more severe your morning sickness, the better your hormones are functioning.

Few or no pregnancy symptoms. Not everyone spends each day throwing up or sleeping all the time. Many people have symptoms that are light or nonexistent. This does not mean you will miscarry. Each pregnancy is different, and usually pregnancies after the first will be easier on your body. I had so few pregnancy symptoms the third time around that I actually ordered a margarita at a restaurant before my husband said, "Aren't you forgetting something?" This never would have happened with Emily, when I spent every non-working hour sleeping or bawling over a migraine.

You should always call your doctor when you are worried, however; because it is better to call for something that does not turn out to be a problem than to stay up half the night worrying about it.



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Old Sep 17th, 2006, 14:56 PM   3
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I am not sure if I was pregnant and miscarried or never pregnant at all.

This is a very common question. Many people who are late, but begin bleeding before taking a pregnancy test, or have a negative test, assume that they were pregnant and miscarried. The "evidence" for this piles up when the cramps are stronger, there is more blood, and maybe even clots are passed. Most likely, this was not a miscarriage. Remember that light bleeding is common in pregnancy and may not signal the end if it stops shortly after it starts. See symptoms for more information. If you have had a positive pregnancy test, this information is not for you. There is no doubt you were pregnant. Go the the miscarriage diagnosis section instead.
One important note: If your blood type is Rh negative (such as O negative, A negative, B negative, or AB negative), you MUST have a shot to prevent building antibodies after a miscarriage if the father was Rh positive. If you even suspect a miscarriage, find out your blood type and see a doctor right away (within 72 hours) to determine if you need the shot to protect your future pregnancies.

Here's some information that might help you understand unusual periods that are not miscarriages, especially if you had a negative pregnancy test:

But my period was so heavy and painful.
Any late period is going to be heavy.

A late period is caused by extra time being added to the first half of the cycle, which is when the lining is being built. If more lining is built, it will cause more blood flow and stronger cramps to get it out. Blood clots are a natural part of any lining that has had to hang around longer than intended. Late periods are often caused by illness, stress, serious physical exertion, or hormone changes.

But I timed intercourse just right, and my period came early.
An early period is almost never a miscarriage.

An early period is often caused by a lack of ovulation, or the ovulation of an egg that is not able to be fertilized. As a result, progesterone is not produced sufficiently to keep the last part of your cycle going. In this situation, a pregnancy cannot happen. Even a positive ovulation test does not mean your ovulation will surely happen or will produce a quality egg. If you are charting your temperatures, however, and see that you did not have at least 10 days between ovulation and when your periods began, you may have a luteal phase defect. Read more about it.

But I saw some tissue that must have been a pregnancy.
A baby from a pregnancy that made your period less than two weeks late is not usually visible to the naked eye.

Even if the baby had grown, it would be about the size of a grain of rice. This would be impossible to see amongst the blood and clots. What you are seeing may be part of a pregnancy, but is more likely just clots and uterine lining from an off-month cycle.

But I got this huge golf-ball sized clot I've never seen before. It had to be a baby.
Tissue that is like a ball is often what is called a corpus luteum cyst, and not a baby.

An extra long or extra short period can be caused when the shell that once housed the egg (called the corpus luteum) swells in size and throws off the hormone chain. This ball will come out in the period, leaving many women to believe they were pregnant, when actually they had a non-viable egg that month.

Without a positive pregnancy test, it is impossible to know for sure if you were pregnant. If you are actively trying to get pregnant, and have had several suspicious periods, then it is time to get tested for a luteal phase defect. You may indeed be losing babies due to low progesterone. One way to possibly find out is get to the doctor immediately when you think you are pregnant but start bleeding heavily (do not wait, even a day or two) and have a quantitative hCG blood pregnancy test done. Any hCG in your system would show that you were at one point pregnant. Otherwise, unless your blood type is Rh negative, you should not need to worry about a lost pregnancy.



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Old Sep 17th, 2006, 15:22 PM   4
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Diagnosis And Testing

Diagnosing whether or not a miscarriage is occurring

It is natural to feel the doctor is wrong, or to want to know what all they will do to prove to you your baby has been lost before performing a D&C. This is especially important if you have had no symptoms at all of a miscarriage, and can't believe the baby is not growing.

There are two ways to check the status of your pregnancy: hCG blood levels and sonograms.

It is important to make sure your diagnosis is clear before going into a D&C. While I feel absolutely confident that no live baby is ever accidentally taken via D&C it is important that YOU feel sure the baby is lost before undergoing a surgical procedure.

The D&C Checklist

If you are not already bleeding and cramping or in a lot of pain, I don't recommend a D&C unless you say yes to ALL FOUR things below:

1. I have had at least two hCG pregnancy hormone blood tests, and they are both too low or going down.
2. I have had at least two ultrasounds a week or more apart, and both have shown no progress or change.
3. I know for a fact that my dates of ovulation and cycle start are correct, and my stage of pregnancy is what the doctors say it should be.
4. I am getting distressed about this lost baby and I am ready to move on.

Once you have heavy bleeding and cramping, I think it okay to go ahead and have the D&C if you need it. If you absolutely petrified of the pain and the tissue, and you are absolutely confident (with at least two visits) that the miscarriage is inevitable, then go ahead with the D&C.

Diagnosing what caused the miscarriage

The information here is not really my opinion, although I will throw a few in there. This is just the way the medical world thinks. I wish that when we lost a baby, we could get quick and easy testing that would tell us what went wrong, then we could do something simple that would totally prevent it from happening again. But that is not the way it works. Sometimes the only way to know there is a problem for sure is to lose another baby. I hate that, and am troubled by the practice, but the medical world goes by statistics, and here is why you may not be as aggressively tested as you would like following your first miscarriage:

After one miscarriage, your odds of another one are very small. Less than 20% of women who have miscarried will have repeated losses, so most doctors will assume that if you are healthy and had only one loss, particularly in the first trimester, that you will never have another one. This is pretty much true.

There are very few treatments to help you prevent a miscarriage. Most testing will not uncover a reason for a loss anyway, as early testing is just a shot in the dark. Even if testing showed a problem, there might not be anything more you can do than to assess the amount of risk you face for another one. The biggest bulk of miscarriages are caused by a random genetic error, which cannot be predicted or avoided. Naturally, there are a few treatable problems.

Testing, which often yields no answers, can be expensive, time consuming, stressful, and make you wait longer to try again. Often by the time you do any of the more involved testing, such as endometrial biopsy, HSG, or laparoscopy, all of which require you to wait until a certain time in your cycle, you could be pregnant again with a healthy baby. After one loss, from a statistics standpoint, it makes sense just to try again since you will almost always have a healthy baby the next time. If you face another loss, it can make you angry that another baby had to die, and this is perfectly understandable. But this anger and determination will get you through the testing process and make you stronger as you face the results.

That addresses the issue of testing after one loss. Some of you, however, may have special circumstances:

If you are over 35 and had one first trimester loss, you will be even less likely to get testing since the odds that your loss was a chromosomal problem with your egg are very high. There is nothing to do in this case but to keep trying for a better egg. Some doctors, however, acknowledge that older moms might have undiagnosed health problems, and will test for the more common thyroid or lupus causes.

If you have had two miscarriages in a row, or a loss after 14 weeks, you will stand a better chance of getting some testing done. Those random genetic flaws really should not strike twice in a row, and most babies with them have already been lost before the end of the first trimester. You can usually get some testing done with minimal fuss.

After three miscarriages in a row, you really should stop trying on your own. You clearly do have a problem, and you need to find it and see if it can be treated. This, of course, if only true if you have never had a healthy baby. If you have had children between the losses, the choice to test is up to you. Your problem, if you do have one, is obviously intermittent.

The Testing Process
A number of tests are easy to perform (blood test or vaginal culture only.) All but a few require that you not yet be pregnant again. If you are comfortable with your doctor and willing to fight for some testing, you can usually ask for and get the early testing ones done even after one loss:

Early Testing Progesterone monitoring by blood test (prior to pregnancy to check for luteal phase defect, and during early pregnancy to watch for deficiencies.)

Mycoplasma bacteria culture from cervix

Antinuclear and antiphospholipid antibodies in blood

Lupus Anticoagulant in blood

Underactive or overactive thyroid by blood

Exposure to German Measles, toxoplasmosis, Group B Streptococcus, or sexually transmitted diseases even if you tested negative prior to or early in pregnancy

More Extensive Testing Progesterone Endometrial Biopsy (a bit of lining is scraped and checked)

Hysterosalpingogram (HSG) or "dye test" (dye is shot into the uterus and fallopian tubes and then x-rayed to look for malformations, fibroids, or blocked tubes)

Karyotyping of Baby or Pregnancy Tissue (tissue is grown in a dish to watch for cell division, which will reveal the chromosomal make up of the baby)

High Level Ultrasound of Reproductive Organs

Most Extensive Testing (some are limited to specialized centers and not available to regular OB/Gyns)
Laparoscopy or Hysteroscopy (minor surgical procedures where interior of reproduction organs are inspected with a lighted scope via a belly button incision (lap) or up through the dilated cervix)

Karyotyping Parents (blood cells are cultured and grown)

Genetic Counseling

Immune Factors Antipaternal Leukocyte Antibodies

Antithyroid Antibodies

DQ Alpha

DQ Beta

Immunophenotype

Natural Killer Cell Assay

Tumor Nerosis Factor

Factor II (prothrombin) Mutation

Factor V Leiden Mutation

Methylene Tetrahydrofolate Reductase Mutation

Special Situation Testing Parvovirus, or Fifth Disease (a recently active virus can be looked for if you work with small children, were exposed to the illness, or had symptoms. Most adults are already immune, but this test can see if you were not and perhaps were infected during pregnancy.)

Mercury blood levels (if exposure seemed high, usually through job function)

hCG Level Information

Human Chorionic Ganadotropin (hCG) is only produced during pregnancy. It is the hormone that home pregnancy tests look for as well as blood tests at the doctor. It is produced when the fertilized egg implants in the uterus.

An hCG blood test at the doctor can detect a pregnancy between 8 and 10 days after fertilization. Any level over 5 is considered "pregnant." Keep in mind, however, that the normal miscarriage rate is very high at this point, still over 30%. Home pregnancy tests typically require 14 days, when your period would normally be due. The level for these tests ranges between 50 and 80. By this point, the normal miscarriage rate is down to 10% since the baby is clearly well implanted and churning out proper hormones.

The rate of hCG should usually double every 2-3 days. Keep in mind that if you have been given hCG shots as fertility treatment, it will throw off your reading and could even give you a false positive.

The numbers in the chart below are only a guideline, and are so broad as to be almost useless. They are here to give you a small measure of reassurance, although the only true way to know if your hCG level is rising appropriately is to take two tests about three days apart. The reason for the large range in the chart is to assume you may be as much as 7 days off on your ovulation, and to allow for larger numbers for pregnancies with more than one baby. In my own experience and with those women who have shared their numbers on the bulletin board, if you are rock-sure of your ovulation date, your number tends to be about 2/3 of the highest number for your week.



*You will likely see the hCG rates go DOWN after the first trimester, when it is no longer a factor in pregnancy or miscarriage because the placenta has taken over. At 9 weeks, however, your baby will be monitored by ultrasound rather than hCG levels.

Slow-rising hCG. Unfortunately, even if your levels are rising, the failure to double every few days is not a good sign. This type of pregnancy can go on for several weeks, but will almost always end in miscarriage. A single set of tests that do not show a doubling can still be fine. Usually another set will be ordered if you are low or borderline.

Sonograms

While there are a few women out there who still fear sonograms and refuse them, there is no safer way of checking the status of your baby than harmless sound waves floating through your amniotic sac and silently bouncing back to a paddle to make a black and white image of your child. Seeing the little rhythmic thump of the heartbeat gives more reassurance than any blood test can provide.

A sonogram is not useful, however, until five to six weeks into a pregnancy (counting from the beginning of your last period.) Prior to that point, only a sac can be measured, but at least an ectopic pregnancy can be ruled out.

Some sonogram milestones:

4-5 weeks -- pregnancy sac visible

5-6 weeks -- fetal pole visible

7 weeks -- heartbeat visible*

Babies should grow about a millimeter a day during these early weeks. At about nine weeks, the baby's crown-rump length is easily measurable.

The margin of error in sonogram measurements is about seven days in the first trimester. By the third trimester, the measurement can be as much as three weeks off.



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Old Sep 17th, 2006, 15:35 PM   5
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Treatment

1st Trimester

Treatment for Ectopic Pregnancy

Methotrexate. This drug, which is often used in cancer therapy or for certain skin problems, will make the pregnancy stop growing and the body will expel it naturally. If the ectopic is caught early, this is a much safer option than surgery, since no incisions have to be made to the delicate fallopian tubes. You will receive the methotrexate by a single injection. You cannot get pregnant for three months following this injection, however, and must use contraception. High levels of folic acid can keep methotrexate from working properly. Make sure your doctor is aware of your prenatal vitamin and any additional vitamins you may be taking.44

Surgery. Often this is done in emergency circumstances when a pregnancy that seems to have been progressing suddenly causes terrible pain as it grows too large for the tube. Most of the time the fallopian tube can be saved, although scar tissue may develop. Even if the tube is removed, your fertility should still be preserved with your second tube. The rate of repeat ectopic if your tube is preserved in 12%. If your tube was taken, the repeat rate is 9%.45

Treatment for Miscarriage Once Bleeding Has Begun

This is usually noted on your chart as either a threatened abortion or a spontaneous abortion.

If bleeding is already heavy and the miscarriage is progressing, then you will probably be allowed a natural miscarriage.

If bleeding has been going on too heavily for more than 10 days, you may need a D&C to avoid excessive hemorrhaging.

If bleeding has been spotty and your hCG levels are not falling, you will usually be offered a D&C. Sometimes, if you meet certain qualifications with your hCG levels and size of the baby when it stopped growing, you may receive a shot and/or suppositories to bring on a natural miscarriage. This can only be done if the pregnancy was less than seven weeks in measurement, and is not yet widely offered because it may require you to wait three months before attempting to conceive again.

Some doctors will offer a D&C right away. If they are concerned about infection or leftover tissue, you may be strongly advised, or even required, to have a D&C.

Treatment for a Miscarriage Diagnosed by Ultrasound or Falling hCG Pregnancy Hormone Levels

This will usually be noted on your chart as a missed abortion.

You will often be given as much as two weeks to see if a natural miscarriage will begin. After those two weeks, you can usually request a D&C and receive it. Some doctors will advise or allow a D&C immediately if you prefer. Occasionally, if you meet certain qualifications with your hCG levels and size of the baby when it stopped growing, you may receive a shot and/or suppositories to bring on a natural miscarriage. This can only be done if the pregnancy was less than seven weeks in measurement, and is not yet widely offered because it may require you to wait three months before attempting to conceive again.

Sometimes spotting will begin within 24 hours of your learning of the loss. Even though the baby may have died weeks earlier and the body has not reacted, somehow the actual knowledge that the pregnancy is ending will make the hormone levels start to fall.

Often, however, a loss where the baby has died weeks before the diagnosis will not resolve without a D&C. Give yourself a couple of days to cope with what has happened, and then schedule the surgery. If your doctor is resistant to surgery and you want it, it is time for a new doctor. Keep in mind that this situation should not go on for more than three weeks or complications can result, including infection.

2nd Trimester

Treatment During the Second Trimester

Often if you are miscarrying in the second trimester, you have not had any warning that an ultrasound will show a baby with no heartbeat or that you will suddenly go into labor. If bleeding precedes your diagnosis, then you may be allowed to miscarry naturally if you are less than 15 weeks along. Here are the four options available during the second trimester.

Natural Miscarriage (not common unless 15 weeks or less)

D&C (for babies up to about 15 weeks in growth size, regardless of how far along your pregnancy progressed.)

D&E (for babies over 15 weeks in growth size, but less than 24 weeks, which is the cutoff for most US states and other countries' age of viability. Once the age of viability has passed, induction to labor and deliver is required.

Induction (for babies over 15 weeks in growth size or beyond the pregnancy age of viability for your country, state, or region). You will be given a drug called Pitocin to start contractions. Usually you will also be given a very strong round of pain medication and an epidural to avoid pain during the labor and delivery. The induction may only take a few hours, or can take as long as two days if your body resists the early labor. This can go smoothly or become a nightmare. It will take all your courage and strength to get through it.

3rd Trimester

If your baby is lost during the third trimester, usually the loss was diagnosed via ultrasound or a routine heartbeat check. Sometimes, if a placental abruption occurred, you did have heavy bleeding that let you know something was wrong.
Your only option at this point is an induction and stillbirth. You will be admitted to the hospital and given a drug called Pitocin to start contractions. Usually you will also be given a very strong round of pain medication and an epidural to avoid pain during the labor and delivery. The induction may only take a few hours, or can take as long as two days if your body resists the early labor. This can go smoothly or become a nightmare. It will take all your courage and strength to get through it.

If You Have a Choice

Usually you will be offered a choice between surgery and either waiting for a natural miscarriage or having induced labor. The two types of surgery are D&C (dilate and curettage) or a D&E (dilate and evacuation--for bigger babies between 14 and 20 weeks). Some doctors prefer you wait for it to happen naturally due to the small risks of dilating the cervix for a D&C. Waiting it out is typically only for those less than 10 weeks along due to the risk of blood clots and hemorrhage, but this depends on your doctor. On rare occasions, you may be offered a methotrexate shot and a suppository to bring on a natural miscarriage. (See first trimester.) As for the choosing between a D&E and actual labor, state laws vary about the age of viability, and you may fall in the gray area, which will be discussed later.


Things to think about when choosing between natural labor and D&C surgery:

Do I want to wait for a natural miscarriage?

Advantages: If you wait, you can feel certain that there was no mistake made. When the baby comes you will know that nature has run its course. You can go home instead of going immediately to a hospital or office procedure. You can take a little time to say goodbye and gather loved ones around you.

Disadvantages: This can take several days and be extremely painful and scary. You may have to have a D&C anyway if everything does not come out (called an incomplete abortion). It may be distressing to think of walking around with your baby who is no longer living. Having tissue come at home may be frightening and you may feel awkward trying to save it, although you must if you want any testing done.

Do I want a D&C?

Advantages: This is mostly painless and will get you back on track to start trying again much sooner. The physical part of the ordeal will end.

Disadvantages: There is some risk of damaging the cervix during dilation, although that has mostly been taken care of by using laminaria, or seaweed sticks to dilate you gently overnight. Some doctors now use a cream to begin dilation. (If this will not be done, ask if you are going to be dilated (very early pregnancies may not need it), and how. Mechanical dilation is riskier. Some women also worry about punctures or perforations of the uterus. While this is a possibility, the risk is small. Even if this should this happen, the uterus will usually heal without complications or harm to your next pregnancy. The main disadvantage to this procedure is that you will not get to see the baby, ever. If you are pretty far along, this may be very important.

If your doctor does not agree with your decision to either wait or to have a D&C, GET A SECOND OPINION. This is your baby and your life. If you need a second opinion, a good place to go is a women's hospital or clinic, where they usually focus on you, not the procedure, and help you make the best decision based on all the information available.

The Gray Area

The death of your baby becomes a legal issue somewhere between 20-28 weeks gestation. Some countries, or regions within a country, require labor and delivery at 24 weeks; some allow the doctor some discretion. Naturally, if you have already begun early labor, you may not have a choice. If your labor could be stopped, then the miscarriage might not happen at all. Otherwise, the cause of the miscarriage is usually Fetal Demise, and if the baby died well before the exam that showed no heartbeat, then it may measure out smaller than the pregnancy would indicate.

There will be a viability point, usually at 24 weeks, where you have no choice but to deliver the baby. To find out more about this, and whether or nor you want or will be able to have your baby's remains, you may want to read about the politics of fetal death.

Things to think about when choosing between a D&E and induced labor:

Do I want a D&E (if eligible)?

Advantages: This is mostly painless and will get you back on track to start trying again much sooner. The physical part of the ordeal will end.

Disadvantages: This is terrible to say, but it is what I think about almost every day—your baby will come out in pieces. You will never see your baby, and if you are like me, where the baby was too small to see its sex and the chromosome tests do not come out, you will never even know if your baby was a boy or a girl.

Do I want to deliver the baby through labor?

Advantages: You will get to hold your baby, take a picture if you want, and say goodbye. It will be very, very hard and sad, but it will make you feel better later.

Disadvantages: Although this is not always the case, the drugs they give you to dilate your cervix and induce labor might make you very sick—throwing up, diarrhea, some women have mentioned hallucinations and terrible fear. It can take many hours or even days to get dilated enough to get the baby out. And the result is the same: you have done all this labor to see a baby that is not alive.

Different doctors will push different options. Weigh them the best you can and make sure you get what you want. Even if you regret your decision later, remember that there simply is no good way to deliver a dead baby. It's a terrible thing no matter what.

Procedure Descriptions

Surgical Procedures

If you opted for a D&C or D&E, first you will have the procedure done. Remember that if you can, insist on some time to gather loved ones around you or to get yourself together before you do this. Don't let anyone panic you into rushing into a procedure you're not ready for. This is usually all done in one day, but if you were farther along than 14 weeks, it may be a two-day procedure, with the laminaria sticks being inserted the first day, the dilation occurring overnight, and the procedure being done the next day. If your pregnancy was very young, you may get a dilation cream instead, or even not need dilation if your cervix is already slightly open as the miscarriage is beginning.

The surgery will be pretty fuzzy to you, due to the drugs and anesthesia. You may be put completely under, or you may be given a local and laughing gas. If you are awake, you may feel some pricking or sucking sensations, but it will not be uncomfortable. You will spend a couple of hours in a recovery room to wait on the anesthesia to wear off. Some doctors will prescribe antibiotics as a precaution; but many will not unless you develop symptoms of an infection.

During the next few days, you will likely experience the following:
Mild to medium pain in your abdomen or tenderness. Most women report no pain at all, but those pain pills are not prescribed for nothing. Hopefully you will not need them.
Deep muscle soreness in your thighs from your position during the procedure.
Mild to heavy bleeding with some mild cramping.
Sun sensitivity, nausea, and weakness from the strong antibiotics.
Heavy groggy feeling, from the anesthesia and your sadness.

Call your doctor if you experience the following:
Any sort of abdominal pain after the second day. You could be developing an infection. Don't panic though, just call and you will get a stronger antibiotic and a check up.
A fever that starts to approach 100 degrees. Again, infection is a possibility.
A sudden stoppage of bleeding, then severe cramps, almost as if you are in labor. This happened to me, and I can't tell you how I panicked. I ended up passing tissue, then the bleeding resumed normally. I called the doctor and they checked on me every few hours at home, but I didn't end up having to go in (good thing, since I was 150 miles away).
Pain, flu feelings, or overall debilitating sickness that last more than a day or two.


Natural Miscarriage

If you choose to wait it out for a natural miscarriage, you will most likely have a paranoid sad wait. It may not seem real; you will harbor hope that it will never happen. Eventually the cramping and bleeding will begin, and you may react with severe grief and panic. You may feel ridiculous or morbid trying to catch tissue in a jar or plastic bag for testing. All these things are fine. Do the best you can. If all goes well, the cramps will subside and a regular blood flow will resume. Keep in mind that you may not pass all the tissue and will have to have a D&C to empty your uterus.

During the next few days you will likely experience the following:
Cramps and bleeding, sometimes quite painful and heavy.
Passage of tissue, resembling large blood clots in the earliest weeks up to pinkish/grayish material, possibly even in a discernable sack. Keep in mind that a three-week old embryo is only 2 mm long about like this: _ and you probably aren't seeing the actually baby, but only the yolk sack or placenta. A four-week old embryo is about a quarter inch long, more like this: __ , still probably impossible to see. Even a six-week old embryo is less than an inch long. Try not to traumatize yourself by searching for the baby. Believe me, I understand the impulse. Not seeing my baby was traumatizing in itself. And mine was fully formed at 20 weeks. Just do the best you can. If you collect the tissue, it may be refrigerated until you take it for testing. If this is your first miscarriage, it is not necessary to keep the tissue. It is rarely tested in this case. Any tissue that falls into the toilet is not testable, so you do not need to retrieve it.


Call your doctor if you experience the following:
Any sort of abdominal pain that lasts beyond the cramping stage. You could be developing an infection. Don't panic though, just call and you will get an antibiotic and a check up.
A fever that starts to approach 100 degrees. Again, infection is a possibility.
Cramps beyond endurance. You may need a pain medication or a D&C.
Bleeding that comes heavy and fast, soaking a pad every few hours, for more than three days. If the bleeding does not slow down after that, you may have tissue that is causing hemorrhaging, and you will need a D&C.
Bleeding that lasts longer than two weeks. A D&C may be necessary.
Bleeding that starts and stops and starts and stops for weeks. Some tissue is still causing hormones to be created, and you will need intervention.

Everyone will feel some of the following as the days and weeks wear on:
A mild start and stop bleeding pattern up to two weeks. You should have a new cycle, unrelated to the first bleeding, between 4 and 7 weeks after the miscarriage. I didn't get a fresh cycle until the last day of the 7th week, so don't panic if you are still waiting. A few women need a provera shot to jump start their cycle, but this is not terribly unusual. Call your doctor if you go much longer than 7 weeks, just for your peace of mind. You may want to start charting your temperatures after the bleeding stops to see where you are. Remember that you can get pregnant that first cycle, so use contraceptive.
Snappy, unhappy, angry feelings. Wanting to be left alone or wanting to talk about what happened with everyone you know.
A sense that it isn't real, that it never happened.
Hypersensitivity to sad TV or reading materials, being revolted or angry about happy scenes of families, seeing symbols in everything you do, from gardening to dreams to what you eat.
Anger at the baby, wishing you never knew about the pregnancy, wanting to throw out all the baby reminders, or clinging to the little angel you lost, thinking about him/her nonstop, wanting everyone to recognize that the baby was real.
Anger and/or jealousy of other pregnant women, even friends and family, to the point you don't want to even talk with them. This is okay. I felt this way for several months.



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Old Sep 17th, 2006, 15:44 PM   6
Wobbles
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Recovery

First few days

At this point, you will have either gotten through the surgery or the worst of the tissue passage and bleeding from a natural miscarriage.

It is best, if you can, to take off work, or enlist help with children. The more active you are in the 72 hours following the miscarriage, the heavier you will bleed. Your recovery will take longer if you cannot spend most of your time sitting or lying down.

Here are symptoms that are normal:

Additional passage of tissue a few days after things seem to have settled down, along with strong cramps and renewed bleeding

Start and stop bleeding patterns

Spotting

Residual cramps, sometimes quite painful

Minor abdominal pain or muscle soreness

Sudden stoppage of bleeding (which may return)

Sun sensitivity or nausea if you were given antibiotics

Continuation of pregnancy symptoms for a week or so, including breast tenderness, nausea, and frequent urination

Grogginess, inability to get out of bed (usually due to sadness or post partum depression)

Increased tenderness in breasts, even leakage of colostrum, or pre-milk

If you were in the 2nd trimester or later, you may experience engorgement, which is swollen breasts filled with milk. Ease this with hot showers or bags of frozen peas. Do not pump milk out.

These symptoms warrant a call to the doctor:

Bleeding so heavy that you constantly change pads or feel faint

Labor like contractions that do not go away with rest

Fever above 100 degrees, especially if you also have flu-like symptoms of weakness or clamminess

Waiting on period

The most common recovery:
Your bleeding will taper off to spotting within a week, and maybe random spotting will continue for another week. Your hCG drops steadily, usually hitting zero during the end of the spotting, or about 10 days after the miscarriage or D&C. When the spotting ends, you will get strange symptoms. If you use a fertility monitor, it may say you are ovulating, but you are not. You may see lots of cervical mucus coming out, sometimes still brown or yellow, but it is not a fertility sign either. In fact, most of the time, you will not ovulate in this cycle. You should not be trying to get pregnant, either.

Some women find they have mild pregnancy symptoms, or little ovulation cramps. Many many women think they could be pregnant, because strange things are happening and their period is "late" (although almost every post-miscarriage period is late.) These symptoms are due to the body's attempts to regulate its hormones again. It may kick into gear right away, and you will get a new period in four to five weeks, or it may struggle a bit, and the period will not come for seven weeks. If you chart your temperatures, they will be all over the place. This is all perfectly normal and expected. Eventually your period arrives and can be either light or heavy. There is no "normal" right now.

A less common, but still normal, recovery:

Your bleeding tapers off quickly, but with some spotting. You think it is over. Perhaps a week or even two will pass, and you begin to wait for your period. Then suddenly, it begins again. Strong cramping, heavy bleeding, and pain. You are scared and shocked and sad all over again. You hope it is just your period, but it is not. (You must not bleed at all for about 20 days for it to be a real period, otherwise you have not gone through the hormone chain properly.) You call your doctor, who may or may not be responsive. Most will just tell you to call them in a few days if it doesn't stop. You hang up very upset, and don't know why they don't care more about you and your predicament.

That's because within a few days, it does stop, and you are just spotting again. Here is what happened, some tissue was missed during your D&C or natural miscarriage. A bit of placenta clung to the wall of the uterus. It continued to draw a little blood, and the body continued to create very small amounts of pregnancy hormone. Eventually the body realized no baby was there and turned loose of this last bit of tissue. The miscarriage process begins again. Only now will your levels drop to zero and a new cycle begin. You cannot expect a normal period any sooner than four weeks from this, and up to seven weeks could still be normal. Your total wait time from original miscarriage to first period can creep up to nine or ten weeks and still be normal.

A recovery that should be monitored:

The main bleeding seems to have ended, and you are spotting. And spotting, and spotting. Three weeks pass and you are still wearing panty liners. (You call your doctor, and they said give it another week.) Spotting ends. You are relieved. A few days later it begins again. You are crushed. Sometimes you get slightly heavier bleeding. You hope it is your period, then read that you have to have NO bleeding for almost three weeks first. You are crushed again. Your ordeal seems like it will never end.

You should go in for an hCG blood test. If your doctor won't do it, take a home pregnancy test. If it is still positive, call them back. Your levels should be at zero by now.

Your levels may come back at 100, or even higher. It may be zero. Your doctor still wants you to wait and see. If your levels were high and things go well, you will suddenly get another big passage of blood and tissue, and it will be over. You will still have a good case for requesting one more blood test to be sure. If this pattern continues, you may need a D&C, or in some cases, a drug called Cytotec, to induce cramping to push out left tissue.

If your levels were zero or not very high, and you still just keep spotting and spotting, you should be able to request a shot of provera or some other form of progesterone. This big dose will put your body into thinking it is nearing the end of a cycle. When the dose is done, the sudden drop in progesterone should trick your body into thinking it is time for a period, and you will bleed. This period can be terribly heavy or light, but it counts. If this has happened, it is still a good idea to wait one more cycle before trying to conceive. If it doesn't work, your doctor may put you on birth control pills for a couple of months to get your cycle regulated.

A cycle that indicates a serious problem:

The bleeding tapered off, but then got heavy again. You are going through several pads a day. After two weeks of this you call the doctor. They tell you to see what happens. You may get a little reprieve of no bleeding or just spotting, then it begins again, as heavy as ever. You call and insist on being seen. You are feeling exhausted from the constant loss of blood and the sad ordeal just going on and on.

A blood hCG comes out high, 500 or more. The doctor tells you to wait and see, or maybe schedules another test. Your bleeding is still heavy, and sometimes you see big black gunk or tissue coming out. You feel panicky every time you go to the bathroom.

A second hCG test comes out only slightly lower than before or even higher than before. The doctor asks a few questions to rule out a new pregnancy and may do a sonogram.

The cause of this can be one of two things:

1. Leftover tissue that refuses to budge. You may need a D&C or methotrexate to kill the tissue and make it come away. If left untreated, you could hemorrhage badly, eventually losing consciousness or becoming seriously iron-deficient. Scar tissue can also form should the left tissue become infected.

2. Molar or partial molar pregnancy. It is very important to follow up on this and get a concrete diagnosis. Molar pregnancy can persist for months, and you absolutely cannot attempt another pregnancy until you have been without any hCG in your system for several months.

About follow up exams:

If you had a D&C, you will usually be called back in two weeks for a follow up exam. If you miscarried naturally, you may not need a follow up, or it could be at two or six weeks.

This exam is most likely going to hurt some. The cervix has been open and will be very tender for a while. Taking a couple of ibuprofen before you go can help. If you are able, having sex the night prior to the exam will help "break things in." You can control penetration with sex, and do it slowly, rather than have a metal speculum suddenly open you up.

This exam is your chance to ask questions. Don't be surprised if it is quick, your doctor does not have many answers, or you do not get any tests. This is pretty normal after a first miscarriage, where it is assumed you will be in the category whose next pregnancy will go perfectly (about 80%).

The hardest part of the exam will be seeing other pregnant women around you, and perhaps returning to the room where you learned you lost the baby. Be prepared for this, and if you have an option (particularly in bigger practices), ask if you can be seen in the Gynecology slots, rather than the OB slots, where you should be waiting with women getting mammograms or annual exams, rather than prenatal visits. These are scheduled differently in most practices, as OB visits are short-notice slots, and annuals are set slots done in advance.

About sex:

You should probably avoid sex while you are actively miscarrying, and certainly use a condom if you have sex within two weeks of the loss. This is because your cervix is slightly open and you are very susceptible to infection.

Sex will often hurt for a few weeks after the loss, although it often gets progressively better, because your cervix will be tender from being open and closed through the miscarriage. Sex can also be very emotionally difficult, as it will remind you of the whole process of pregnancy and conception. It is pretty important not to try again until you get a regular period. You can read why at the trying again section.

First Period

One thing that is certain is that your first period will not resemble anything you've had before.

To make sure this is really your first period, make sure it has been at least four weeks since your miscarriage AND you have had about 20 days of no bleeding or spotting. For the estrogen threshold to be met, you should not be bleeding anymore. Otherwise the lining is not being rebuilt, and you are still experiencing progesterone withdrawal.

You can expect this first period anywhere from four to seven weeks in most normal cases, although you have to restart the counter if you have a renewed case of serious bleeding. See "Waiting for Period" for more on this.

There really is no "normal" for this first period. It can be:

Very heavy (but not making you feel faint)
Very light (but more than spotting). There should be a fair amount when you wipe.
Terribly crampy, or not at all
Be heavy and drop off immediately to spotting
Be light and drop off to spotting
Spot for several days, stop, then come full-blown with heavier bleeding


These periods are not normal, and are not actually a period:

Light spotting that only spots for days on end
Light spotting that comes and goes
Heavy bleeding that makes you go through a pad every hour or two for more than a week.

Those scenarios mean the miscarriage may not have completed or your hormones are not getting back to normal and may need help.

New Cycles

Sometimes even if the first cycle seems normal, you start to see your cycles elongate or shorten. First remember that your cycles have changed now. Every pregnancy, regardless of outcome, changes your hormonal makeup. As long as your cycles are at least 24 days and not more than about 45, you are in the range of normal. Your cycles do not have to be the same every month, and most often they will not be.

About 60% of women will get pregnant again within the next four months, especially with earnest work toward that goal with the help of the Sperm Meets Egg Plan. Your fertility may not return immediately, but you should hold off on Clomid or other reproductive assistance for six months. After that point, you can ask for help from a doctor to see what is going on. It is not unusual on the boards to meet women who tried for a year before getting pregnant again. I personally did not ovulate in my first two cycles following my miscarriage, and got pregnant first try on the third.

It is very disheartening to see month after month go by without getting pregnant again, especially when your cycles are not the same as before. You will constantly feel you are pregnant but test negative, and you will feel certain you are having early miscarriages. This is a very very common feeling, but usually it is not true.

You will also face another problem. Post miscarriage cycles are all over the place, sometimes coming on day 22 (making women think they have a luteal phase defect) and other times coming weeks late (making women spend a fortune on pregnancy tests.) This is all a very common scenario in the months following the loss. It happened to me too. Just keep trying, and trust the pregnancy tests. They are accurate. Your hormones right now, however, are not. You should call a doctor when you go for seven weeks without a period. They can (sometimes, if they will) put you on a dose of provera to bring on a period, or if worst comes to worst, put you on birth control pills to regulate you.

Source: pregnancyloss.info



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Old Apr 28th, 2008, 11:12 AM   7
Shri
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Wobbles, this information is incredibly helpful. I'm very glad you have presented it here so clearly and compassionately. I have had several losses and this is the sort of information that would have helped me immensely if I had known at the time.



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Old Jun 4th, 2008, 11:11 AM   8
Lazy Leo
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Wobbles, thanks for this. I have just found out that I am expecting and am pretty scared of losing the baby - this helps to keep the fears at a rational level. Thank you xx



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Old Jun 4th, 2008, 11:13 AM   9
maybebaby
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Wow, what a great sticky!!



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Old Jun 20th, 2008, 08:03 AM   10
joannek
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Great information here i just had a misscarriage and am so devestated i was actually 11 weeks but found out just before it happened the baby only measured 6 weeks so i knew something was wrong from that moment im absolutely heartbroken and im awful to be around including my partner and my son whos 4 i keep been so snappy and feel so bad but still cant help it.



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