- Parul Chopra Buttan
Miscarriage - what one needs to know
As a passionate obstetrician and a woman myself, I'm pained by the unhappy & uncomfortable situations my patients sometimes find themselves in.
Early pregnancy bleeding is one such situation. It wreaks havoc in the mind of the patient and is of grave concern to the obstetrician. I've noticed in my consultations that giving the couple or family complete knowledge about what is going on, what we can expect, and what can be done, helps them go through this challenging phase.
There are several causes of bleeding in early pregnancy. A sound obstetrician should be able to establish the exact circumstances of your situation by asking you a few questions, doing a gentle, thorough examination, and some basic investigations.
One of the foremost worries on the mind of the woman and the family is MISCARRIAGE. It is one of the most important and common causes of early pregnancy bleeding, though the only one. The other causes such as ectopic pregnancy, gestational trophoblastic disease, cervical polyp etc merit a separate article and I shall not discuss them further here.
This post focuses on miscarriage. There are types and stages to it and most importantly, all is not lost the moment the doctor utters the dreaded word.
1. THREATENED MISCARRIAGE
The pregnancy is very much alive and intact but is in a vulnerable state. The woman experiences bleeding, usually painless. The site of bleeding may be visible on an ultrasound or maybe unknown. Physical exertion needs to be avoided, though bed rest has no role. Pregnancy supportive hormonal medication has an empirical role as per evidence in the literature. Medications to control the bleeding may also be given if deemed fit by the gynecologist. At this stage, the pregnancy is salvageable and may continue without any further complications.
2. INEVITABLE MISCARRIAGE
As the name suggests, miscarriage is unavoidable and usually imminent. The mouth of the uterus may be seen to be open on examination and bleeding is usually heavier than normal menses and often accompanied by pain. The process of expulsion of the pregnancy can be enhanced by medication or by a minor surgical procedure depending on the physical findings and the preference of the patient. Waiting for spontaneous resolution may also be a practical option.
3. INCOMPLETE MISCARRIAGE
The pregnancy has been partially lost in the usually painful vaginal bleeding and is not salvageable. Again, the remaining part of the pregnancy may be removed with medicines or a surgical procedure depending on the time since bleeding, amount of tissue left behind, any other complications, the physical condition of the patient, and her preference. There is a risk of anemia from prolonged heavy blood loss and of infection involving the uterus, converting it into a dangerous septic miscarriage (explained later).
4. COMPLETE MISCARRIAGE
The whole pregnancy has passed in the bleeding. The bleeding usually reduces significantly and soon stops. Our focus is to provide emotional support and advice on recovery from the event, besides addressing the various questions that arise (why did it happen, when can the patient conceive again, does this episode put future pregnancies at risk… - these questions will be addressed in detail in a separate article.)
5. MISSED MISCARRIAGE
This entity is usually diagnosed on an ultrasound or if the pregnancy is not seen to be growing clinically. The heartbeat is absent and the pregnancy is not salvageable. The woman may have no problems or may experience a reduction in the symptoms of pregnancy (such as morning sickness, fatigue, etc). Bleeding may begin in some days and start the process of removal of pregnancy or it may remain silent for quite some time. Medicine or a surgical procedure is usually advised when the woman is ready for it. The pregnancy can be sent for testing to know the cause, though, in about 40% of the cases, no cause can be found.
6. SEPTIC MISCARRIAGE
It means any kind of miscarriage (spontaneous or voluntary) that has been complicated by infection. It is a serious condition that can quickly become life-threatening by complicating into septicemia and multi-organ failure. It usually needs prompt management and hospital admission. It may take some time to recover and may even have long-term consequences like infertility. Any woman who develops a fever, foul-smelling vaginal discharge, severe generalised pain in the abdomen while miscarrying should seek urgent medical help.
Miscarriage, though not desirable, is a reality. It is one of nature's ways of eliminating not-so-healthy pregnancies early on. Emotional support and tender loving care from the caregiver and from the family go a long way in restoring the woman's health and long-term well-being.