Miscarriage & Abnormal Pregnancies

Most couples expect to get pregnant at some point, and when they do for the first time it suddenly dawns on them what a gamble pregnancy actually is. One of the most frightening things is to experience bleeding in the first part of the pregnancy. Termed "first trimester bleeding," it is any bleeding noted during the first twelve weeks, and it is one of the most common symptoms to send a woman to her obstetrician.

No bleeding in early pregnancy is to be considered normal--that's the bad news. But the good news is that most of the time it's caused by something fairly harmless--cervicitis. This is a condition in which the delicate cells at the mouth of the womb (cervix) can bleed due to the mechanical action of intercourse, the alteration of acidity in the vagina (pH), or the effects of infections on these cells.

With the hormonal changes of pregnancy, the fragile internal cells peek out a bit onto the external portion of the cervix, which is a harsher environment for them. Normally nestled more deeply away from sexual activity, now they can be battered. They're easily damaged, causing bleeding. Of course, we're not talking about a whole lot of bleeding here--merely what is perceived as spotting. It must also be noted that these cells usually don't bleed with sex--usually there is a predisposing condition, like cervicitis.

Cervicitis is inflammation due to infection. Yeast is the most common culprit, and a simple prescription or even over-the-counter cream can end this concern quickly. Other infections are more worrisome. Sexually transmitted diseases (STDs), like gonorrhea, chlamydia, trichomonas, and Gardnerella can do the same, so a microscopic evaluation is the best approach rather than just assuming it's yeast. Some infections may be silent for years, meaning that even though there is no question of fidelity in a couple, still there may have been an infection long before they even met each other. Therefore cultures for STDs has become standard in all pregnancies.

Harmless small polyps can cause bleeding also. If these can't be gently and painlessly twisted off during a physical exam, then they're usually destroyed by the very act of delivering the baby. Sometimes a small piece of tissue becomes loose and disintegrates through some unknown cause, causing spotting. It's usually an hormonally stimulated collection of menstrual-like tissue that can often be confused with a miscarriage. If it's just tissue debris, it can mean nothing. If it's actual tissue of the pregnancy (fetal or placental), then there should be serious concern, because now this "threatened miscarriage" is re-labeled, "incomplete miscarriage."

Although the above instances describe the causes of bleeding that do not indicate miscarriage, still miscarriage should be ruled out when there's any bleeding. And when one considers that the cramping of a threatened miscarriage can feel exactly like the growing pains of a normal uterus, we obstetricians are fortunate to have other tools to give a patient (and her doctor) peace of mind. Blood tests can prove that the pregnancy hormone is increasing as expected, which confirms a healthy pregnancy, and ultrasound can demonstrate the physical well-being of a growing baby by showing a healthy heart rate or by ruling out an ectopic (tubal) pregnancy.

It's true that miscarriage is a fact of life as we know it, and usually it's due to some sort of doomed genetic mismatch; but although most miscarriages begin with first trimester bleeding, first trimester bleeding isn't always indicative of a miscarriage. But we always respect first trimester bleeding until we can determine the cause. Usually it has a good outcome. So although it's understandable how first trimester bleeding can cause a couple a lot of anxiety and worry, we can usually find something unrelated to the pregnancy--and treatable--to blame it on.

Miscarriage is Nature's way of discarding a pregnancy that didn't proceed in a way compatible with life. Even though it may be mere discarding, to prospective parents it is a real tragedy, hopes and dreams and a certain romantic vision of their child-to-be dashed before their broken hearts. But the fact remains that it does happen, and it happens for a reason.

As physicians, we obstetricians must treat the discarding aspect scientifically and the human tragedy aspect with compassion and understanding. Often it happens very early. In fact, many researchers feel that a lot of miscarriages happen even before implantation, meaning a woman would not even have a missed period. If this is true, the miscarriage rate may be much higher than the observed 20%--as high as 60%! At first, this seems to be a staggering thought. But when one realizes how many things must go perfectly to make a baby, it's a wonder that it happens at all.

"Miracle" is never a worn-out word for a baby. Usually after about the twelfth week of pregnancy, the chances of miscarriage plunge. This is truly a milestone to achieve, and couples can breathe a little more easily when they've reached this point. In fact, pregnancy loss after twelve weeks is almost always due to a rare catastrophic event or an even rarer genetic mishap that took a little longer to catch up.

Progesterone, a major female hormone necessary in pregnancy, can be a factor in preventable miscarriage. A normal pregnancy may be in trouble because the mother's progesterone level is low. Oral progesterone can correct this, and the medicine can be withdrawn after about the thirteenth or fourteenth week when the baby's own placenta manufactures enough for the pregnancy. This is not to be confused with the opposite--a low progesterone because the pregnancy is doomed to miscarriage. In this case, administering the hormone only delays the inevitable, miscarriage occurring after withdrawing the progesterone. It's often impossible to tell the difference between the two instances, but many feel they would rather delay an inevitable miscarriage than write off a normal baby. In the literature, the success of progesterone therapy is still somewhat controversial, but infertility specialists use it frequently to protect their hard-earned pregnancies. It's safe, which is reassuring after the DES debacle last generation.

Contrary to popular belief, a D & C (dilatation and curettage) is not always necessary to finish a miscarriage. There really is such a thing as a complete miscarriage, and an obstetrician-gynecologist would serve his or her patient well by trying to avoid surgery for her if possible. Unfortunately, a D & C is often needed, but it can create for the patient a definitive end to a sad chapter in her life, allowing her to plan for her next pregnancy.

Babies and Daytime Emmies Don't Mix Well Soap opera babies usually don't stand a chance. Miscarriages occur easily and frequently. I suppose the reason is because the loss of a baby is one of the most powerful misfortunes, and these programs are all about the human condition in all of its tragic splendor. Thank goodness real pregnancy isn't like pregnancy on the daily dramas. An actress falls and she has a miscarriage. A character discovers that her husband is having an affair and the stress causes her to lose the pregnancy. Overworking may put her in the hospital for tests for weeks of prime time daily viewing. There is no managed care on soap operas.

So just how tough are these babies anyway? First, we must consider that the human race has survived a big disadvantage in reproduction--we usually only have one at a time. The rest of nature guarantees the survival of the species by allowing multiple births, so that the most vulnerable of life, the infant, is exchangeable for the next that may survive where the first did not. This protection is taken to an extreme with insects, in which reproduction involves thousands of offspring in a very short time, so that even if most die during this vulnerable period, still there are many that do survive to keep the species going. Yet we have not only survived but thrived by having one at a time.

Our compensation is our brain, which allows us the see the importance of protecting and raising our child. Our brain has also given us Pediatrics and modern medicine. We also have sense and foresee danger, so that a baby in the mother's womb is well protected indeed, since she herself is smart enough to keep from personal harm. The baby is secure as well, the pregnancy interaction between mother and child providing a safe haven. What all of this means is that it's tough to accidentally hurt these babies. Surely they're not invulnerable. If one were to try, it can be done. Alcohol, smoking, other drugs, and trauma can hurt the unborn--but isn't that where that brain comes in? Normal everyday activity, however, is not only harmless, but often helps the health of the baby as well.

Patients often ask me if stress is hurting the baby. Only on the soap operas. And the thing to remember is that everyone has stress. Life is stress. It's a normal part of our lives. It's why we have adrenalin. Many patients ask me about exercise. They want to know if they're doing too much. They want to know if a particular activity is too strenuous. I tell them about the doctor's wife who jogged five miles a day with twins till very near the end of her pregnancy, after which I delivered two healthy children.

So it really is hard to hurt these babies by accident. Exercise especially is maligned unfairly, which is due in part to that soap opera mentality that pregnant women should merely glide along life without so much as a speed bump. All of the studies have shown conclusively that not only is exercise good for you and your baby, but it also decreases the likelihood of a C-section. The only warning is against overheating and dehydration. Aside from that, it seems all exercise is acceptable.

Except kick-boxing. Stay away from that.

Many patients and their husbands ask me when they should stop intercourse. The only time intercourse is unacceptable in pregnancy is in the delivery room. I think that says it all. Of course, this is advice in normal pregnancy. High risk pregnancy complicated by bleeding, premature labor, or infection have a completely different set of criteria, but generally all normal pregnancies are sexworthy till the very end. Even orgasm, which is known to cause contractions of the uterus (womb), seems harmless in normal pregnancies. A good rule of thumb is that intercourse should be avoided only if it becomes uncomfortable; otherwise, sex is not a problem.

I know that so far I'm saying all of the things people want to hear. But they also very much need to hear these things. Sex is important in a marriage. Exercise is important to the mother. But a baby is only important in a daytime TV drama if it moves the story line. Real people don't have story lines--they have lives. Just because a woman is pregnant doesn't mean she should stop living as we know it. The simple joys of life are not only safe for baby, but good for maternal and marital well-being on many different levels.

In these shells, our bodies, we live our mortal lives at the mercy of the biological rules that govern survival. So sometimes bad things happen. One such very bad thing is a miscarriage. Miscarriage occurs in about a fifth of all clinically diagnosed pregnancies. This is a staggering amount of tragedy since most couples never consider this possibility when they choose to have a child. And if one were to include the very early miscarriages that happen around the time of an expected period, the numbers may be much higher.

Miscarriage can happen for a number of reasons. Almost always it is because of some random genetic mismatch incompatible with life. Once again, we're at the mercy of the biological rules. It is nature's way of assuring a continuing healthy species. Miscarriage can also happen due to infection, maternal diseases like lupus, diabetes, and thyroid problems, and abnormalities with the anatomy of a woman's reproductive tract. The sad fact is that it does happen to people who are blind-sided by this loss. Sometimes it happens to the same couple more than once, prompting evaluation for known causes. But it's frustrating that most of the time there is no known cause, and the couple feel they are being sent away with only an invitation to return to the obstetrician for the next try.

This is the illusion, especially in a couple's eyes who feel that the loss is their own private tragedy they can't seem to share enough with others no matter how hard they try. This is because there are no rituals for this type of human loss. There are no funerals or memorial services. Friends and relatives, often misguided into thinking that mentioning the miscarriage will only be upsetting, are instead seen as uncaring in their silence. The grieving couple have only each other, and that may not be enough for the feelings of guilt and self-examining retrospection.

And anger.

After all, this isn't just some tissue that was discarded, like an appendix or a gallbladder. This is just not one of their parts. This was their son or daughter. There were dreams of seeing little league events, helping with homework, attending dance recitals, walking down an aisle. And the whole sense of what might have been is lost to a clinical world of procedures, blood tests, and insurance forms.

As an obstetrician, I can assure any couple that their miscarriage is not just any clinical event. I myself have not been doing it quite long enough to see anyone I delivered wearing a mortarboard. But I wait in happy expectation when I can see that sort of thing happening. In a way, I grieve with the parents, too, because I know what is being lost in a miscarriage. I'm right there in the middle of it as well. And I put it on a different level than the clinical protocols I employ to deal with it.

A mathematician can count on his fingers, but that in no way reflects the beauty of mathematics. This word processor can lay down words at the direction of certain keystrokes, but that in no way compares to the actual beauty of what is written. I manage the complication of miscarriage, but that doesn't reduce my feelings for what might have been. So I do not merely send them on their way with an invitation to return for the next try. Instead, I applaud them for going back into the world to once again play by the biological rules. They will have that baby not to replace that permanent little hole in the heart left by a miscarriage, but because they want a baby.

On Mother's Day, let's not forget those who also should be mothers. Let us also honor the ones who are determined to be.

The fertile woman has all of the necessary anatomy to house a normal pregnancy to term. Implantation of a fertilized egg in the uterus (womb), however, depends on unencumbered transport along the fallopian tube where fertilization took place to spill into and implant within the uterus. If there is scarring in the tube from a previous infection (Chlamydia, gonorrhea, even tuberculosis of the pelvis) or from endometriosis, or even from the "bump" where an old tubal ligation was rejoined together, the migration of the fertilized egg can get hung up before entering the uterus.

This is not good.

Places like the tube, or even more unlikely, the abdomen, cannot accommodate a pregnancy like the uterus can. The uterus is the specific organ with the ability to keep an expanding phenomenon like pregnancy self-contained until maturity of the baby. The tube on the other hand, can't stretch to any great extent, and when it does, it can cause pain or even burst, causing a hemorrhagic emergency. Commonly the pregnancy dies in the tube, with resolution via surgery or spontaneous absorption. Surgical treatment now can be done with a laparoscope, either by expressing the ectopic out of the tube or by removing that portion of the tube that holds the ectopic. The ectopic pregnancy can be expressed either from the end opening of the tube or by making a small slit above it. Unfortunately, when there is aggressive bleeding, conservative management becomes unwise, and an incision is made to handle the problem by conventional surgery.

When the ectopic is stable and unruptured, however, the small slit described above is made in the wall of the tube (linear salpingostomy) and the ectopic suctioned or irrigated out--all during an out-patient laparoscopic procedure. The tube can then be left to heal. In some cases a non-surgical approach is appropriate that uses the chemotherapeutic (anti- cancer) agent methyltrexate (MTX). This substance is fetocidal, leading to resorption.

The Catholic Church's position on this is that the physician must treat the mother by removing a pathologically placed pregnancy which is doomed to miscarriage or already dying or dead and which can cause mortal danger for the mother.

A pregnancy in the abdomen is a disaster of the highest danger. The placenta has aggressive attaching tendencies, much like a tumor, and since this is a vascular organ, the normal carryings-on of abdominal organs against it can lead to serious bleeding. Delivery is by abdominal operation (laparotomy), with a known mortality rate to the mother, and an almost guaranteed mortality for the infant. Very few abdominal pregnancies in the world have resulted in a mother and child who did well.

Once, when I was training, a senior resident did a hysterosalpingogram (dye swished through the tubes to test for patency). It was performed on a woman who had suffered years of infertility, and he wanted to demonstrate that her tubes were open. Unknown to him, as a fantastic coincidence, she was only a few days pregnant--for the first time in her life--and the test swished the fertilized egg out of the tube into her abdomen, creating an abdominal ectopic pregnancy that resulted in her emergency surgery 12 weeks later during which she lost her uterus, tubes, and ovaries.

A pregnancy test is often falsely negative if a woman is less than two weeks pregnant. Therefore, before any invasive procedure is done it has always been a policy in our office to insist on sexual abstinence for two weeks before a meaningful pregnancy test allows for such a test.

As with all pregnancies and with other miscarriages, Rh Neg mothers must receive Rhogam to prevent subsequent immunological attack on subsequent babies.

Today, with early hCG (pregnancy hormone) titers and vaginal ultrasound, it's becoming more commonplace to discover and treat early ectopics conservatively. Symptoms that can tip off an obstetrician include vaginal bleeding which is the result of hormone withdrawal when the ectopic dies. Since bleeding in early pregnancy is usually first suspected as a threatened miscarriage, ultrasound and hCG titers can establish the suspicion of an ectopic pregnancy. Also, pain is frequenty on the side where the ectopic is.

The classic symptoms are most often (but not always) pelvic pain to one side and vaginal bleeding during early pregnancy.

If the ectopic ruptures, severe hemorrhage can result, causing a woman to suddenly collapse. Slowly increasing pain over several hours can indicate a slowly bleeding tubal pregnancy. If things are stable, however, blood work can usually demonstrate levels that can help establish the diagnosis. If there is ever any doubt, a diagnostic laparoscopy can be done to make the diagnosis certain. This is a handy tool, for it is otherwise safe with a normal pregnancy if an ectopic is ruled out by this method.

An ectopic is just as tragic as a miscarriage, except the grieving is short-changed by worry because of the added danger an ectopic poses--to the women's fertility and to her life.