Sunday 22 April 2018

Untimely endings: Coping with the loss of a miscarriage

Early miscarriage may be a relatively common occurrence but it's no less upsetting for that.

A first trimester miscarriage can be as significant an event as a loss of a baby close to term or after birth.
A first trimester miscarriage can be as significant an event as a loss of a baby close to term or after birth.

Dr. Keelin O'Donoghue

Losing a baby at any stage of pregnancy can have a devastating effect on women, their partners and indeed their families. Although pregnancy loss can be a difficult subject, it is important that women arm themselves with information about it and are prepared for both the good and the bad that pregnancy can bring.

Obstetrician and gynaecologist Dr Keelin O’Donoghue says that, while it sounds unfortunate, miscarriage is a relatively normal part of reproductive life. While late miscarriages happen in just 1 to 2pc of pregnancies, early miscarriage is much more common, with anywhere from one in four to one in five pregnancies ending in miscarriage in the first trimester.

First trimester pregnancy loss is referred to as early miscarriage, while late miscarriage occurs in the second trimester, up to 23+6 weeks and with a baby who is under 500 grammes in weight.

Miscarriages happen for a number of reasons. Often when they take place in the first trimester it is because something is wrong with the developing embryo.

“That may be a major chromosomal syndrome, so the baby is carrying an extra chromosome or an extra set of chromosomes,” says O’Donoghue.

She adds that there can be a number of other risk factors for miscarriage, including previous history, obesity, excessive intake of caffeine, smoking and stress.

“There is also an age-related variation in miscarriage. The older you get, the higher the proportion of pregnancies that are lost in the first trimester, because of the increased risk of chromosomal abnormalities.”

Other conditions known to cause miscarriage are abnormal thyroid function, antiphospholipid syndrome or lupus, and some thrombophilias or blood clotting abnormalities. Also, anything that makes a woman extremely physically unwell can potentially put her pregnancy at risk.

 

DIFFICULT

Statistically, one early miscarriage does not increase your risk of having a second, and it can be difficult to uncover its cause.

“There is quite a debate at the moment as to whether two miscarriages in someone who has no living child should be investigated,” says O’Donoghue.

It is generally accepted that three consecutive miscarriages represent a diagnosis of recurrent miscarriage and should be further investigated; this affects around 1pc of couples.

“At Cork University Maternity Hospital, we investigate women who have had no successful pregnancy and two miscarriages. We recognise that we are largely doing that for reassurance. Even if you thoroughly investigate women who have had three consecutive miscarriages, you will only find a medical reason for around 40pc of those.”

When a miscarriage happens, it can be a frightening and upsetting experience. In early pregnancy, there is usually no way to stop miscarriage once it has started. In 2011, the HSE published the National Miscarriage Misdiagnosis Review Report, which led to standardised national guidelines on the diagnosis and management of early miscarriages.

“We follow fairly strict guidelines on how we diagnose miscarriage in our early pregnancy clinic. There is a standardisation of practice in early pregnancy in terms of who does the scans, where they are done, how often and on what criteria you diagnose miscarriage,” says O’Donoghue.

When having a miscarriage at five or six weeks, any pregnancy symptoms to date may or may not disappear, and bleeding will occur. Sometimes, that bleeding can seem like an exceptionally heavy period, but the vast majority of women will know they have had a miscarriage. Bleeding doesn’t always lead to miscarriage, however.

“The further on in the first trimester you get, that bleeding can be very significant, and usually requires presentation to hospital and medical,” says O’Donoghue.

 

OPTIONS

Upon diagnosis of miscarriage, women are given three options of how to manage it: you can wait and see what happens and return for a check-up at a certain point; you can take medicines to bring on a miscarriage; or you can attend the hospital for a surgical procedure under anaesthetic. Often referred to as a D&C, the correct name for the procedure is ERPC (evacuation of retained products of conception).

“It’s a particularly unpleasant combination of words for many women. It doesn’t sound appropriate in any way,” says O’Donoghue.

In the past, hospitals have been criticised for their treatment of women who experienced pregnancy loss. O’Donoghue says today they are managing miscarriages much more empathetically, and that staff are aware of the impact of their words and actions on women at such a distressing time.

“A first trimester miscarriage can be as significant an event as a loss of a baby close to term or after birth. Planning the whole pregnancy for many has begun with the first positive pregnancy test. It’s not for us as the healthcare professionals to decide whose miscarriage is more important;we assume it is a difficult time for all.”

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If you have had a miscarriage in early pregnancy, it is usually safe to try to conceive once there has been a normal period. However, it can take up to three periods for your cycle to become regular again, so a quick pregnancy can create uncertainty around dates.

If you are worried about your next pregnancy, many hospitals provide early scans for reassurance at between eight and 10 weeks. “It’s important to talk to women openly and clearly about miscarriage, make sure they understand what’s happened and don’t feel guilty or anxious, and to try to set them up for a healthy pregnancy with the best possible outcome the next time,” says O’Donoghue.

 

Dr Keelin O’Donoghue is consultant obstetrician and gynaecologist, clinical lead for Pregnancy Loss Services, Cork University Maternity Hospital, and senior lecturer, Department of Obstetrics and Gynaecology, University College Cork.

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