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Bleeding and miscarriage
 

Bleeding in pregnancy and miscarriage
When a woman bleeds during her pregnancy it is natural to fear that she is going to lose the baby. Although miscarriage is a common occurrence, for the majority of women, bleeding is harmless and go on to have a full term, healthy pregnancy. This article explores the implications of vaginal bleeding in pregnancy and the facts about miscarriage.

Bleeding and miscarriage
One of the most disconcerting occurrences for pregnant women is vaginal bleeding, which naturally raises the fear of losing the baby. However, blood loss in pregnancy is in fact quite common and, in the majority of cases there is nothing to worry about. Most often it can be put down to 'breakthrough' bleeding, normally seen at the time when a regular period is due. Up to a quarter of women experience some bleeding in the first twelve weeks of pregnancy and a good three quarters of these go to full term, with a healthy baby as a result.

Miscarriage
The loss of a baby before the 28th week of pregnancy is referred to as a miscarriage and most often occurs within the first three months. A miscarriage is almost always due to an unexpected problem arising in the process of fertilisation and in the early development of the embryo, although it can be caused by illness in the mother.

It is totally natural to be very upset if you miscarry and to imagine that you have done something yourself to have caused it to happen. Although not necessarily comforting, it is important to realise that a miscarriage is almost always nature's way of ending a pregnancy that has gone wrong and was therefore likely to be lost.

It is also normal to go through a period of grieving and it may take some time before you come to terms with the loss. It is important during this time to try to talk it over with your doctor and friends, but most importantly your partner, as he will be suffering the loss too. Also, because you have had a miscarriage does not necessarily mean that you are at greater risk of a repeat the next time you become pregnant. However, it is only natural to feel quite anxious for the first few months, until the pregnancy is well established and you and the baby are both confirmed healthy.

Warning signs of a possible miscarriage
A miscarriage most often starts with continued vaginal bleeding, combined with a low abdominal pain. You should contact your doctor if you experience either or both of these symptoms. You may also pass blood clots rather like lumps of liver. In this event, these should be saved and shown to your doctor so that he can ascertain whether they are part of the placenta. If you do suffer a miscarriage it is usual that you be taken into hospital for a D&C (dilation and curettage), which will be performed under general anaesthetic. This ensures that the entire placenta is removed to avoid any further bleeding or infection.

Types of miscarriage
The medical world tend to use different terms for the type of miscarriage a woman has suffered and it is worth understanding what each term means as medical jargon can leave you confused and unclear as to what has actually occurred.

Threatened miscarriage
Some women can experience a threatened miscarriage but then continue without any further problems until the pregnancy has reached full term. The main warning sign is vaginal bleeding that varies from a pale brown discharge to heavy bleeding with blood clots. You may also experience mild pains, rather like period pains. However, the bleeding eases off and a normal healthy pregnancy results, although there is a very slight risk of going into early labour.

Inevitable miscarriage
An inevitable miscarriage occurs when the uterus contracts enough to dilate the cervix, which is sealed by a plug of mucus during pregnancy. If this happens then it is inevitable that the baby will be lost. The symptoms are not unlike that of a threatened miscarriage, but the bleeding often becomes heavier, combined with strong, painful and regular contractions of the uterus.

Complete miscarriage
This expression is used when both the baby and placenta are expelled from the uterus. This can sometimes happen suddenly, without any obvious symptoms. The bleeding will gradually slow down and stop, and the uterus will return to its normal size.

Incomplete miscarriage
This is when some of the products of conception have been lost but some remain inside the uterus. Bleeding continues over several days.

Missed miscarriage
This happens when the baby has died but is not expelled from the uterus. There may be no symptoms, but the 'feeling' of being pregnant, such as morning sickness and tender breasts, disappears. Bleeding may have occurred but eases off.

Treatment for a miscarriage
The treatment for a miscarriage tends to depend on the policy or your hospital or GP, but in general there are three approaches:
- The miscarriage can be allowed to complete itself naturally.
- Drugs can be given, which will help the uterus to expel its contents.
- Surgery, similar to a D and C can be performed to remove the entire contents of the uterus.


Why do miscarriages happen
Most of the time the exact reason why a woman suffers a miscarriage is not known and why they are so common is a mystery. The following are the more common causes:

Ectopic pregnancy
Figures from the Miscarriage Association show that about one pregnant woman in 100 suffers an ectopic pregnancy. This occurs when the fertilised egg becomes implanted in one of the fallopian tubes and causes severe bleeding. Although surgery can usually save the tube, unfortunately it is inevitable that the baby will be lost. The first symptoms of an ectopic pregnancy usually appear around week six and include the following:
- Continued bleed over several days, which can be very dark red or brown.
- Severe abdominal pain, often on one side only.
- Shoulder pain on the same side as the abdominal pain.
- Fainting or lightheadedness.
- Pain when you either pass urine or open your bowels.
- Pain when you are making love.

If you are suffering from such symptoms it is essential that you see your doctor at the earliest opportunity, as early diagnosis of an ectopic pregnancy is imperative. The biggest problem is that as it occurs so early on in a pregnancy the symptoms can be mistaken for a normal, if late period.

If an ectopic pregnancy is left untreated the growing embryo can rupture to fallopian tube, which can be fatal for the mother. The symptoms of a ruptured tube are severe pain, excessive paleness and a fast, weak pulse. In this event an ambulance should be called immediately. However, despite these alarming implications it should be noted that only about 20% of women with an ectopic pregnancy reach this point.

Genetic abnormalities
This is probably the most frequent cause of miscarriages. The most common defects are:
Trisomy: this is when there are three chromosomes of one type rather than the normal pair. This occurs usually as the result of an imperfect egg and seems to be more common in older women. The condition is detected with a scan, which will show the characteristic indication of an empty sac or a baby, which is overly small for dates.
It has also been found that a woman who has had a miscarriage as a result of trisomy is slightly more likely to suffer a second.
One X-chromosome missing: All normal girls have two X-chromosomes, however, occasionally one of the chromosomes may by missing. This is the cause of about 10-15% of all miscarriages. Only about 1% of pregnancies with one sex chromosome survive to birth. The few children who are born with only one X-chromosome are afflicted with a condition known as Turner's syndrome, which results in poor growth, lack of periods and infertility.
Polyploidy: this means multiple or extra chromosomes. The most common situation is where there is an entire extra set of chromosomes, possibly as a consequence of an egg being fertilised by more than one sperm at once. An ultrasound scan will not necessarily pick up the defects in the baby but abnormalities in the placenta may be. Other babies may have such severe defects that they could not possibly survive.
Changes in individual chromosomes: This is a less common cause of miscarriage. Some of these anatomical changes are inherited from one of the parents, who may be a carrier of a chromosomal defect, even though they are perfectly 'normal' themselves.

Gene abnormalities
Rarely, a miscarriage may be caused by a defect in the genes. Some of these defects may cause a miscarriage, however, most result in the serious problem of a severely handicapped baby.

Age
A woman's age has an important bearing on the chances of miscarrying. This is the older a woman is, the greater the percentage of abnormal eggs she will have in her ovaries. It is possible that if such an egg became fertilised it could result in an abnormal embryo forming, that is not capable of resulting in a proper pregnancy.

Hormonal problems
Occasionally a woman does not produce the right female hormones in the correct quantities or produces too much of the male hormone, testosterone. Some women experience recurring miscarriages as the result of not making enough progesterone.

Another hormonal problem that can cause miscarriage is high levels of LH (luteinising hormone) in the blood. Abnormalities of LH hormone are often found in women with polycystic ovaries and this condition is now accepted as a very common cause of miscarriage.

Uterus abnormalities
Abnormalities of the uterus is a fairly common cause of miscarriage. Occasionally swellings in the uterus, such as fibroids, may make the cavity irregular, which may prevent an egg implanting properly. Inborn defects, such as a double uterus, are much more likely to cause miscarriage, often after the twelfth week.

Cervical incompetence
In normal circumstances the cervix is tightly closed but loosens up in labour to open and allow the baby to pass through. However, some women have an open cervix (cervical incompetence), which means that the muscles may be weak, opening the cervical canal to let bacteria in. Infection may then occur in the membranes surrounding the baby and a miscarriage most often results.

Environmental risks
It is generally accepted that some chemicals can be the cause of miscarriage as are some insecticides and poisons. Certain drugs are also dangerous, particularly illegal ones as is smoking and the use of marijuana. Abuse of these and heavy drinking can all be contributory factors in miscarriage.

Serious and chronic illness
Very rarely a serious illness may result in miscarriage, most often because the pregnancy has been harmed by a high fever. The most common is probably acute influenza.

Hydatidiform mole
A Hydatidiform mole is a type of tumour that develops when the embryo fails to grow and is a very rare condition. The main symptoms are bleeding around six to twelve weeks after your last period, severe morning sickness and breast tenderness caused by the high levels of hormones produced by the tumour.

The condition is confirmed by a scan and urine and blood tests and it treated by having a D and C operation. There is also a small risk that the mole can develop into something more serious, so women who have had one will need regular blood tests to check their hormone levels.

Recurring miscarriage
Once a woman has suffered a miscarriage she is naturally afraid about the chances of it happening again. However, the encouraging news is that if you have had one miscarriage it does not increase the odds of it happening again. In fact doctors tend not to become concerned unless there have been three or more concurrent miscarriages. If this happens to you, you will need to be screened to eliminate the possibility of infection as well as any anatomical abnormality. It is considered that the most common cause of recurrent miscarriage is immunological.

Coping with miscarriage
When a woman suffers a miscarriage she is subject to many negative emotions and fears, most commonly shock, guilt and a deep sense of grief. Furthermore, there is often a loss of focus for the future. Even if the baby is lost at a very early stage, much planning and decisions will have taken place, even if just subconsciously. This is taken away, often with little warning, leaving both parents feeling lost and disorientated. It particularly helps to talk to others who have also suffered a miscarriage, but most important, to share your feelings with your partner. Telling your friends and family can sometimes be difficult as well meaning advice, such as 'at least you are young and can try again', can sometimes sound quite tactless.

Trying for a baby after a miscarriage
It is generally recommended that you allow a few months for your hormonal balance and emotional state to settle before trying to get pregnant again. However, it is thought that following a miscarriage women are more fertile, and some do fall pregnant straight away. Your doctor can advise you what he considers best for you depending on the cause, if it is known.

Further help and advice

Miscarriage Association
Clayton Hospital
Northgate
Wakefield
WF1 3JS
Tel: 01924 200799
www.miscarriageassociation.org.uk
Information, advice and support.

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