Miscarriage – (ABORTION)
Dr. Münip B, M.D.
Obstretrician and Gynaecologist
Spontaneous abortion, or colloquially referred to as miscarriage, is defined as the termination of pregnancy due to any reason before the gestational week 20 or before the baby reaches one pound.
According to the week of miscarriage, it may be classified as an early or a late miscarriage.
Early miscarriage: Term used for miscarriages up until the end of the first trimester (12 weeks)
Late miscarriage: Term used for miscarriages from gestational week 13 to 20
Why do miscarriages happen?
The moment oocyte (egg cell) is fertilised by the sperm pregnancy develops. Embryo (fertilised egg cell) reaches the uterus through fallopian tubes and implants in the most suitable place. Following this implantation, pregnancy hormone (beta HcG) starts to rise.
Early pregnancy losses are mostly caused by genetic disorders, namely chromosomal abnormalities.
The embryo takes half of its genetic material from the mother and the other half from father. But sometimes the chromosome synapsis does not form properly. During this synapsis, some of the information transferred from the chromosomes may be lost or duplicated more than needed.
In this case, if the number of chromosomes is defective, embryo fails to divide and multiply. Pregnancy results in a miscarriage.
This situation can be interpreted as a defence mechanism of nature. This physiological mechanism called ‘natural selection’ makes sure that embryos having abnormal chromosomes unable to survive are discharged at an early stage.
As sad as it may be for a couple, miscarriage is highly important for the continuance of healthy generations. This fact may be comforting for the couple who are going through such an upsetting life experience.
As the gestational week moves forward, the potential of a miscarriage decreases. Because natural selection detects and aborts an “abnormal pregnancy” often during early gestational weeks. As a matter of fact, 80% of miscarriages develop in the first trimester and following this, risk of a miscarriage gradually decreases.
The late miscarriages (between gestational weeks 12-20) are linked with anatomical abnormalities (uterine abnormalities, septum, myomas, cervical incompetence), maternal diseases (uncontrolled diabetes, severe hypertension, thyroid diseases) or external factors (smoking, alcohol, high doses of caffeine) rather than chromosomal abnormalities.
How frequently do miscarriages occur?
Spontaneous miscarriages are observed in 12-15% of the clinically-recognized pregnancies. However, this rate goes up by 2 to 3 folds according to age in genuine early pregnancy losses, along with clinically-recognized and unrecognized ones (biochemical pregnancies). That is to say, 4 out of 5 pregnancies end in miscarriage.
Following the fertilization, a third of the pregnancies ends in miscarriage without being noticed in the absence of retention within the uterine cavity, or in other words by not getting attached to uterine wall.
How do miscarriages exhibit symptoms?
Two most significant symptoms of a miscarriage are haemorrhage and cramping pains in lower abdomen. Miscarriages do not always occur with the same symptoms.
During the weeks of early pregnancy bleeding may not happen to be accompanied by pain and just ‘partial bleedings might happen. ‘Pieces’ may happen to escape detection for their tiny sizes. It can be helpful to keep these dropped pieces and take them along while going off to examination.
Yet another type of miscarriage is the one called ‘missed abortus’, which is the phenomenon of embryo not surviving after formation. In such phenomena, sometimes haemorrhage or pain can be detected before it even starts.
Both types of miscarriage have to be ended by abortion.
Types of miscarriage
Aborti are sorted in 7 groups; i.e. threatened miscarriage, inevitable miscarriage, incomplete miscarriage, complete miscarriage, anembryonic pregnancy, missed abortus and biochemical pregnancy:
- Threatened miscarriage (Abortus imminence):
During the first half of pregnancy, threatened miscarriage can be considered in the presence of vaginal bleeding. 20 – 30% of expectant mothers may experience threatened miscarriage. In such cases, bleeding is not usually severe, and it can vary in different colours from dark brown to fresh red. Cervix is closed.
During the first weeks of pregnancy, it can be determined if fetus is positioned within the uterus and keeps its healthy development going on with ßhCG and ultrasound monitoring.
Expectant mothers experiencing a threatened miscarriage are recommended to take bed rest and avoid sexual intercourse.
Against all due precautions, threatened miscarriage may actually happen to end in miscarriage and require abortion.
- Inevitable miscarriage (Abortus incipience):
Haemorrhage occurs along with pain, and most of all cervix is open. Uterine and lower abdominal pain can occur in the type of a cramp. In such a condition, there is no way to continue the pregnancy. The only treatment is an immediate abortion.
- Incomplete miscarriage (Abortus incomplete):
It is the loss of some of the pregnancy tissues. In general, embryo and placenta are both disposed before the gestational week 6. With miscarriages that occur after this week, it is possible that some pieces of the embryo and the placenta happen to remain inside. When an incomplete miscarriage is detected, abortion is performed and additionally antibiotic therapy is practised based on the findings of infection.
- Complete miscarriage (Abortus complete):
All the pregnancy tissue has been expelled. However, to ensure that the uterus is fully clean, a surgical curettage can be conducted for the sake of revision.
- Anembryonic pregnancy (Blighted ovum): In such a case, which is also referred to as empty sac, baby is not present within the embryonic sac, only the sac and the placenta.
- Missed abortus:
It is one where the embryo has died, but remains within the uterus. It is diagnosed by an ultrasound, since it most often does not cause any bleeding or pain. To avoid any complications that can be caused by intoxication and blood clotting because of prolonged retention of the conception product, abortion should be carried out immediately.
- Biochemical abortus:
After the embryo is implanted in uterus, the body begins to secrete a hormone called human chorionic gonadotropin (hCG). The quantity of this hormone in the blood gets elevated as the pregnancy advances. Pregnancy sac can be viewed on vaginal ultrasound when the level of hCG have reached 1500 mIU/mL. In that case, pregnancy is referred to as a ‘clinical pregnancy’. However, for some reason pregnancy might end with menstrual bleeding when it ceases to keep its liveliness. That is to say, pregnancy was confirmed by examinations of the blood; though it has ended before getting to the stage, at which it could be confirmed clinically.
When is the earliest time to be able to get pregnant again?
Some of the couples may feel willing to have a new pregnancy right after the miscarriage; and some may prefer waiting for a while. They may need time to overcome the psychological trauma caused by the loss. There is no such thing as right decision in this sort of situation.
What is recommended in general, is having one normal menstrual period before getting pregnant again; it is essential for determining the age of the latter pregnancy.
Therefore, for an unprotected intercourse the couples should wait for at least one normal menstrual bleeding to take place.
You can have intercourse with your spouse whenever you feel emotionally ready…