Miscarriage: separate myth from reality

Tuesday, 20 November, 2012, 4:01pm

For many Asians, it's inauspicious to announce the news of a pregnancy before the end of the first trimester. There might be something in this: studies reveal that between 10 and 25 per cent of all pregnancies end in miscarriages during the first 13 weeks of pregnancy.

Sandra Ng had a miscarriage in the fifth week of her second pregnancy. "It was extremely traumatic for me, more emotionally than physically. I still wonder, had I not told everyone prematurely, could it have been averted," she says. "I know it was still embryonic, but to me it was still my baby."

Ng's miscarriage had less to do with superstition than science. Sporadic miscarriages occur in 15 per cent of pregnancies due to a chromosomal abnormality that prevents normal development.

A small group of women have recurrent losses. "There are a number of reasons why women have multiple miscarriages," says Dr Sangeeta Senapati, who is an obstetrician gynaecologist with the Department of Obstetrics and Gynaecology at NorthShore University HealthSystem in Chicago.

"Anatomical issues like uterine malformations or a weak cervix can cause repeated losses, says Senapati. "Chromosomal or immunological disorders, a propensity for blood clots (thrombophilia), chronic hormonal variations, and prolonged exposure to toxins such as drugs, alcohol and smoking can all cause repeated losses."

Age is another factor. With women marrying and conceiving later in life, the chromosome abnormality rates of the egg and hence the baby increase, making it more difficult to conceive and carry to full term. By the age of 40, 60 per cent of the eggs are chromosomally abnormal. It increases by about 10 per cent each year.

Paternal age also plays a role. Some studies indicate that the chance of miscarriage is higher if the father is 35 years or older. This increases with age. Genetic diseases such as thalassaemia, endocrine disorders such as thyroid disease and diabetes mellitus, and an overactive immune system with elevation in natural killer cells are other causes.

Can miscarriages be prevented? Depending on the cause, many things could help, according to Dr Mahesh Choolani, an obstetrician gynaecologist with The Choolani Clinic at Mount Elizabeth Novena Hospital in Singapore. "Some [miscarriages] have a proven 'evidence-base', whereas others are more anecdotal and experiential," she says. "I find lifestyle and dietary changes including an anti-inflammatory diet significantly enhance the well-being of the environment for the embryo."

There are medical options says Choolani. These include progesterone, aspirin, low molecular weight heparin (used to treat and prevent blood clots), higher doses of folate supplement, and intravenous immunoglobulin.

There are also procedures that could help, such as removal of the uterine septum, a thin wall of tissue inside the uterus of some women that separates the uterus into two parts, or cervical cerclage, putting stitches in the cervix to hold it closed in the case of cervical impotence.

Choolani adds: "Of course, we often have to look after patients with miscarriages with other specialists: endocrinologists for diabetes and thyroid disease, rheumatologists for autoimmune conditions such as APS [antiphospholipid antibody syndrome], SLE [systemic lupus erythematosus], Protein C/Protein S deficiency and elevated natural killer cells."

According to the American Pregnancy Association, when a miscarriage occurs during the first 13 weeks of a pregnancy, the main goal of treatment is to prevent haemorrhaging and/or infection. The earlier in the pregnancy, the more likely that the body will expel all the fetal tissue by itself and will not require further procedures.

It was previously thought that if the body doesn't expel all the tissue, an operation would be needed. But Dr Alexander K. Doo, a specialist in obstetrics and gynaecology with The Women's Clinic in Hong Kong, says there is now "very good evidence" that the infection rate is the same whether an operation is done or not.

"In 85 per cent of cases in early pregnancy, it can be passed out naturally within three weeks of diagnosis. This avoids the (albeit small) risk of the operation."

Most women have a healthy pregnancy after miscarriage, as in the case of Ng, who conceived and delivered a healthy baby girl.

Doo explains: "In general, if there is a complete cycle between the miscarriage and conception, there is no increase in risk of a further miscarriage, and within the first six months of a miscarriage, there is evidence that the chances of conception actually improve.

"Having had one miscarriage, the chance of a second is not much higher. Having had two only marginally increases the risk."

Women who've had miscarriages should allow sufficient time to heal physically and emotionally before attempting another pregnancy.

Mayo Clinic recommends healthy choices before conception and during pregnancy. Take a daily prenatal vitamin or folic acid supplement, ideally a few months before conception.

Maintain a healthy weight, include physical activity in your routine, and limit caffeine. Manage stress and avoid alcohol and smoking. If you've had multiple miscarriages, pregnancies need to be carefully planned and monitored with consultations with your health care provider.

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