MISCARRIAGE

by D E Tucker MRCOG

Why did it happen - was it my fault?

When you conceive and a baby is created, it takes half its genes from the sperm and half from the egg that ovulated that month. At the exact time of conception, the cross-over of these genes takes place. Sometimes, for no reason other than bad luck, some information is lost and the pregnancy is destined from that point not to be. It might be that this lost information is not needed for many weeks, and the pregnancy will continue as normal until that time. When the needed information is not there, it is then that the baby dies and you begin to miscarry. Sometimes when this happens, the miscarriage doesn't happen right away. This is called a 'missed' miscarriage and may not be picked up until some weeks later, following a slight loss or period-type pains.

Another cause might be that the baby did not implant, or bury itself, into the womb lining properly - once again, just due to bad luck.

These are the most common reasons that women miscarry. Not because of something you did or didn't do, but just because of chance. Not because you drank alcohol, ate some unpasteurised cheese, or didn't take folic acid. Certainly not because you had sex or didn't rest enough. Whether you laid in bed from the day of your positive pregnancy test or went hang-gliding every day wouldn't have changed things. Its nature's way of making sure that when you do have a baby, it has the best chance for all of its life. Miscarriage does not mean that you won't be able to get pregnant again.

How long will this bleeding last and when will my periods return?

The loss will probably continue for about 7-10 days, tailing off toward the end of this time. It shouldn't be heavier than a period, and shouldn't have an offensive odour. If you're worried, see your GP or practice nurse for some advice. Normally your next period will come by 6 weeks or so. If they were irregular before, then it may be longer. Also, your fertility returns before your next period, so if you feel pregnant again a pregnancy test might be useful.

I had a D&C - will this cause any problems?

A D&C (dilatation and curettage) or evacuation is carried out to reduce the chance of infection and ensure that you don't continue bleeding over the following weeks. Very rarely, it can cause infection of the womb lining with persistent loss or an offensive odour. We believe that the chance of this is less likely than had you not undergone a D&C. If this happens it usually responds well to a short course of antibiotics. The D&C doesn't weaken your cervix or make you more likely to miscarry in subsequent pregnancies.

How common is miscarriage?

When considering this question, it is helpful to ask how often pregnancy occurs on average each cycle. Studies looking at very sensitive pregnancy tests suggest that pregnancy will occur in at least 60% of natural cycles in fertile couples.

The risk of miscarriage decreases as pregnancy progresses. It is possible that as many as 50% of pregnancies miscarry before implantation in the womb occurs. Early after implantation, pregnancy loss rate is about 30% (ie this is still before a pregnancy is clinically recognised). After a pregnancy may be clinically recognised (between days 35-50), about 25% will end in miscarriage. The risk of miscarriage decreases dramatically after the 8th week as the weeks go by.

I've miscarried before - is it more than bad luck?

Many women miscarry more than once in their life. Considering the frequency of miscarriage, about 1 in 36 women will have 2 miscarriages due to nothing more than chance. Any miscarriages after that might prompt your doctors to suggest some tests to ensure that it isn't happening for some other reason. If you're worried have a chat with your GP or one of the Gynaecologists.

Miscarriage may be more common after a previous miscarriage, or less common following previously normal pregnancies. One London study from Prof. Regan's Recurrent Miscarriage clinic found that the risk of miscarriage is related the the past pregnancy history in the following way:

Other things which may contribute to early pregnancy loss include:

• multiple pregnancy
• maternal age - there is a rise in miscarriage risk as maternal age increases. For women less than 35, the clinical miscarriage rate is 6.4%, for age 35-40 it is 14.7% and over the age of 40y it is 23.1%.
• poorly controlled diabetes - but not that which is well controlled
• scleroderma - a soft tissue disease
• fever over 100F
• smoking - 30-50% increased risk (even after correction for socioeconomic status)
• previous contraceptive pill use results in a sight reduction in the risk of miscarriage
• occupational exposure to solvents increases the risk of miscarriage

When can we start trying again?

Some couples decide that they want to begin trying for a pregnancy right away, while others feel that this is too soon and need time to get over this loss. There is no 'right' thing to do, and you have to go with your feelings.

We normally recommend that you await your first period after going home, and begin trying from then, if that's what you decide. There is evidence that the risk of miscarriage in the next pregnancy is about 1.5 times higher if one cycle does not intervene the pregnancies. It is not imperative, however, and don't worry if you find yourself pregnant before you even have a period - many successful pregnancies have started that way! In any case there's no reason you can't make love as soon as you feel ready. If you don't want to get pregnant, talk to your GP soon about contraception suitable for you.

What can I do to improve my chances for next time?

As I mentioned above, the most common reasons for miscarriage can't be helped, however you can prepare yourself for pregnancy. Taking in regular exercise, a healthy diet, reducing stress and getting your weight to within normal limits gives you something to concentrate on, and improves chances for long-term fertility. Certainly reducing your alcohol intake and stopping smoking will help, too. Remember to start taking folic acid to help normal development of the baby's nervous system.

How will I feel when I go home?

Reaction to a miscarriage is very variable and once again there's no 'right' way to feel - a range of reactions are possible and normal. In addition to the grief you may feel, your body will be undergoing some profound hormonal adjustments, which may make you feel very emotionally volatile.

Grief is a very normal reaction to the loss you have expereinced and it may be as intense as that after any other loss. Many women describe a feeling of numbness and emptiness following a miscarriage. Some couples withdraw, feeling alone and isolated, others may wish to talk about their loss.

Men often feel they have to be strong for their partner and find their loss particularly difficult to talk about. Although its is difficult at first, it may help to try and tell family or close friends how you feeel.

Where can I get more information?

Bookshops such as WH Smith or Dillons stock books on pregnancy and many of these contain some information on miscarriage and optimising health for future pregnancies. Your GP may be able to give some more specific advice. The practice nurse may run a well-woman or preconception clinic - phone the practice for more details.

If you are reading this on behalf of someone else, some advice on how to help them.

• Do let your genuine concern and caring show.
• Do be available... to listen or to help with whatever seems needed at the time.
• Do say you are sorry about what has happened and about their pain.
• Do allow them to express as much unhappiness as they are feeling and are willing to share.
• Do encourage them to be patient with themselves and not to expect too much of themselves, nor to impose any 'shoulds' on themselves.
• Do allow them to talk about their loss as much and as often as they want to.
• Do reassure them that they did everything they could and that it wasn't their fault.
• Don't let your own sense of helplessness keep you from reaching out.
• Don't avoid them because you are uncomfortable. Being avoided by friends may add pain to an already painful experience.
• Don't say that you know how they feel (unless you have experienced their loss yourself, and then you can be particularly supportive).
• Don't say 'you ought to be feeling better by now' or anything which implies judgment about their feelings.
• Dont tell them what they should feel or do.
• Don't change the subject when they mention their loss.
• Don't avoid mentioning their loss out of fear of reminding them of their pain (they won't have forgotten).
• Don't try to find something positive about the loss (eg. a moral lesson, closer family ties, etc).
• Don't point out that at least they have their other....
• Don't say that they can always have another.... (they wanted this one).
• Don't say that they should be grateful for....
• Don't make comments which in any way suggest that the loss was their fault (there will be enough feelings of doubt and guilt already).

The Miscarriage Association provides information and support on both a national and local level.