Miscarriage - How To Avert It?

Miscarriage refers to a pregnancy that has ended prematurely, within 20 weeks. Research shows that around 10-25% of all clinically recognized pregnancies end in miscarriages. Chemical pregnancies cause 50-75% of all miscarriages. The condition happens when a pregnancy is lost not long after implantation, bringing about bleeding that happens around the time of her normal period. The woman may not understand that she has conceived when she encounters a chemical pregnancy.

The normal period where miscarriages are expected to occur is during the first 13 weeks of pregnancy. While pregnancy can be an overwhelming and exciting experience, it is beneficial that the woman keeps herself informed about the possibilities of miscarriages.

Some types of miscarriage are:

1. Threatened Miscarriage
2. Inevitable or Incomplete Miscarriage
3. Complete Miscarriage
4. Missed Miscarriage
5. Recurrent Miscarriage
6. Blighted Ovum
7. Ectopic Pregnancy
8. Molar Pregnancy

Symptoms:
In case of any of the following signs, the doctor should be consulted immediately,

1. Mild to Severe Pain
2. White-Pink Mucus
3. Weight Loss
4. True Contractions
5. Sudden Decrease in Signs of pregnancy
6. Tissue made of cloth-like material passing from the vagina
7. Bright red or Brown bleeding with or without cramps

Investigations

Ultrasound

1. The majority of women will require a transvaginal ultrasound (TVS) and 98% of complete miscarriages can be diagnosed in this way.
2. If a transvaginal ultrasound scan is unacceptable to the woman, then a transabdominal ultrasound scan should be offered and the woman should be made aware of the limitations of this method of scanning.
3. If there is no visible heartbeat then a second scan should be performed. This is either done at a minimum of 7 or 14 days, depending up the measurements of the crown-rump length or the mean gestational sac.
4. Be aware that a woman with a pregnancy of unknown location may have an ectopic pregnancy.

Serum hCG

1. Serum hCG tests can help to exclude an ectopic pregnancy in women with a complete miscarriage (or pregnancy of unknown location), determined by ultrasound.
2. Serial tests are required but results should complement clinical assessment and not replace it. Two tests are taken as close as possible to 48 hours apart:
   • >63% increase suggests ongoing pregnancy.
   • >50% decrease suggests pregnancy is unlikely to continue.
3. A woman with results between these parameters should be reviewed in the EPAU withing 24 hours.
4. Slow doubling times are associated with miscarriage and declining values have high sensitivity of 93-97% in diagnosing a complete miscarriage.
5. Rare causes of a raised hCG should also be borne in mind, including gestational trophoblastic disease or cranial germ cell tumour, which must be considered.

Progesterone

One meta-analysis has shown that a single low progesterone measurement for women in early pregnancy, presenting with bleeding or pain and inconclusive ultrasound assessments, can rule out a viable pregnancy. However, very low serum progesterone can be seen in normal viable pregnancies, so progesterone should not be used as the definitive diagnostic test without other evidence.

Management

1. Admission to the hospital can be avoided in 40% of women with threatened or actual early pregnancy loss.
2. Following a miscarriage, all women should have access to support, follow-up and formal counselling when necessary.
3. Anti-D rhesus prophylaxis (250 IU) should be offered to all rhesus-negative women who have a surgical procedure to manage a miscarriage.

Treatment:

The main purpose of treatment is to prevent haemorrhage and infection. It is common that the body expels all the fetal fluid during the earlier stages of the pregnancy. In case it doesn’t, a procedure known as D&C (Dilation & Curettage) is performed to remove the fluid and prevent infection.

Anti D should be given in all cases of miscarriage.

Since most miscarriages occur due to chromosomal abnormalities, nothing significant can be done to prevent them.

Tips to be taken to ensure a healthy conception are:

1. Regular Exercise
2. Stress Management
3. Daily consumption of folic acid
4. Not smoking