A MISCARRIAGE, otherwise known as an abortion, is by definition the loss of pregnancy (embryo or fetus) before it can survive independently. Before we go any further I would like to clarify that a miscarriage and an abortion are just but the same even though in popular culture an abortion is deemed to be induced and a miscarriage is deemed to be natural or spontaneous. Because of this confusion we are generally moving away from the term abortion and inclining more to the term miscarriage. We generally say a fetus can survive independently outside the uterus at about 20 weeks. So we say any loss of pregnancy before the gestational age of 20 weeks is a miscarriage. If a fetus is lost after 20 weeks we call it a stillbirth.
There are several types of miscarriages. The first type is called a missed miscarriage. Like the term implies this type of a miscarriage is easily missed. It normally occurs in the early weeks of a pregnancy and you won’t even notice you were pregnant. You might not even miss a period with this type of miscarriage. At times you will just have some heavy bleeding during the time you expected your period or a few days later than you expected your period and you will just think it’s normal. A missed miscarriage is normally asymptomatic and painless. This is the most difficult miscarriage to diagnose and generally doesn’t need medical treatment.
The second type is called a blighted ovum. In this type the pregnancy does not develop well and only the gestational sac is present without any embryonal parts. Also known as an empty sac, blighted ova will make you miss your period and give you a positive result on urine or blood pregnancy test. It will also give you the usual morning sickness and other pregnancy symptoms. It is best diagnosed on ultrasound scan where an empty sac can be visualized and also the gestational age by date will be higher compared to the age on scanning. The usual treatment for this is to do a dilatation and curettage (D & C).
A threatening miscarriage is the third type of miscarriage. There is usually bleeding and associated backache in this case. The bleeding is like a threat that a miscarriage is about to happen. About 50% of women with threatening miscarriages go on to lose their pregnancies despite medical interventions. They normally occur in the first trimester. The treatment for threatening miscarriages is watchful monitoring most of the time. We can give you a bed rest, some paracetamol to manage the pain and maybe some antibiotics if we suspect an infection to be one of the causes. Otherwise we just monitor and pray for the best.
Fourthly we have what is called an inevitable miscarriage. The name says it all. This is a miscarriage that you cannot stop no matter what medical intervention you deploy. 100% of women with inevitable miscarriages lose their pregnancies. This is mainly diagnosed on ultrasound scan. The features on scanning are a widely open cervix and an absent fetal heart. In this scenario we normally counsel the mother and the father on the outcome and to emotionally support them as they go through the ordeal of a miscarriage. Normally it progresses on its own to a complete miscarriage.
A complete miscarriage is whereby all the uterine contents come out. In this type of miscarriage depending on the gestational age of the pregnancy it could just be blood that comes out if it’s in the early stages of the first trimester. If it’s in the second trimester a fetus and placenta will also be expelled during the process. A complete miscarriage generally does not need much medical treatment as all the contents of the pregnancy are expelled. You could need some pain medications if you are in pain and maybe some prophylactic antibiotics to prevent infections. Generally you don’t need a D & C. By the way dilatation and curettage (D & C) simply means cleaning of the uterus which is normally done after an incomplete miscarriage.
An incomplete miscarriage unlike a complete miscarriage is whereby there are some retained products of conception after a miscarriage. The main symptoms include persistent vaginal bleeding and a backache. The diagnosis is confirmed with an ultrasound scan of the pelvis. This one definitely needs cleaning of the uterus. Most late first trimester miscarriages and second trimester miscarriages will need a D & C. Pain killers will be needed as well as antibiotics when managing incomplete miscarriages.
If an incomplete miscarriage is not managed properly it can progress to become a septic miscarriage. In this type now there is definitely some infection in the retained products of conception in the uterus. A septic miscarriage is more like a complication of a miscarriage. If untreated the infection can spread to the rest of the body causing sepsis and eventually septic shock which can ultimately lead to death. A septic miscarriage will definitely need antibiotics. At times admission will be needed for intravenous antibiotics. A careful D & C is most likely needed to avoid perforation of the uterus. Some anti inflammatories will also be needed.
Last, but not least we have what we call recurrent miscarriages. This is whereby a woman has had three or more miscarriages in a row. The commonest cause of recurrent miscarriages in the second trimester is cervical incompetence. This is whereby the cervix (the mouth of the uterus) is failing to hold the pregnancy after a certain gestational age. Normally this occurs around the 15th week of pregnancy. And this is what we call a recurrent cause of miscarriage. The treatment of cervical incompetence is cervical cerclage. This is whereby we put a suture (stitch) around the cervix to help it hold the pregnancy. Recurrent miscarriages need proper investigation and good counselling to manage them properly.
To sum it all up, the main symptoms of miscarriages are lower abdominal pain, vaginal bleeding and a backache. If you experience any of these during pregnancy please kindly visit a doctor or medical facility as soon as possible. Most people ask me how do I minimise my chances of having a miscarriage? My answer is always very simple; pregnancy is not an emergency, plan your pregnancy and visit your doctor three months before you intend on getting pregnant.
Remember a healthy you, a healthy me to a healthy world.
By Josephat Chiripanyanga
Josephat Chiripanyanga is a Harare-based medical doctor. He can be contacted at firstname.lastname@example.org