IT has been a traumatic week for the nation and it must have been a particularly trying one for an expectant mother, especially one who is threatening to miscarry. But pregnant women, and their families, should take comfort from the fact that Irish hospitals are among the safest in the world in which to have a baby. The tragic case of Savita Halappanavar is a very rare one.
Miscarriage, defined as the loss of a pregnancy before 24 weeks, is a sad fact of life. At least 30-40pc of pregnancies end this way. Most happen within the first 12 weeks (first trimester). After the 12th week – in the second trimester – the risk of miscarriage is 2pc-3pc.
Miscarriage in the second trimester might be caused by chromosomal (genetic) abnormalities, cervical insufficiency (weakness of neck of the womb), early pre-term labour, abdominal trauma, congenital birth defects in the baby, blood clotting disorders or problems with the placenta such as placental abruption or separation.
The symptoms of a first and second-trimester miscarriage are often the same and these include vaginal bleeding and abdominal cramping. However, none of these symptoms mean that a miscarriage will inevitably occur. Sometimes there are no symptoms and the miscarriage may only be discovered during a routine scan.
Women presenting with any of the above symptoms are assessed for both maternal and foetal wellbeing. The maternal vital signs – blood pressure, pulse rate and temperature – are measured. A comprehensive maternal examination is carried out, including a vaginal examination to assess the extent of the bleeding. It also allows for the assessment of the cervix, the neck of the womb. An ultrasound examination is also carried out to assess the baby.
Sadly, there is no treatment that can stop a miscarriage from happening. Most women in the second trimester with the above symptoms tend to be admitted to the hospital for closer observation. Our main goal is to maintain maternal wellbeing by preventing the loss of too much blood or infection.
Where the baby's heartbeat is not detected in the second trimester, the most common treatment involves taking one or more medications to cause contractions and cervical dilation (neck of the womb to open) to allow the foetus and placenta to deliver normally. In some women the womb may not empty completely and a surgical procedure called a D&C – dilation and curettage – may be required. In women presenting with very heavy bleeding where maternal wellbeing is compromised, stabilisation of the mother is our priority. In these circumstances delivery may be required in the best interests of the mother, irrespective of fetal viability. This is usually done by inducing labour and/or by doing a D&C.
Women in the second trimester with waters breaking early also tend to be admitted for observation. Although some women may go on to miscarry, others may continue with their pregnancy. Where the mother's wellbeing is compromised by infection, intravenous antibiotics and delivery by induction of labour are required irrespective of fetal viability.
The decision to deliver is made by senior clinicians after discussions with the mother and her family.
After one miscarriage most women will go on to have a normal pregnancy. Even after several miscarriages, there is a good chance of a successful pregnancy.
Dr Nadine Farah, is a consultant obstetrician and member of the Institute of Obstetricians and Gynaecologists