Early Pregnancy Loss:  Miscarriage & Molar Pregnancy...

 

A normal pregnancy is about 40 weeks.  The loss of a pregnancy before 20 weeks is called early pregnancy loss.  Often, the loss is a miscarriage (sometimes called spontaneous abortion by doctors).  A rare form of pregnancy loss is molar pregnancy.  The loss of a pregnancy-no matter how early-involves more than the loss of a fetus.  For many women, miscarriage also results in feelings of loss and grief.

 

 

 

MISCARRIAGE

     Miscarriages occur in about 15-20% of pregnancies.  Most occur in the first 13 weeks of pregnancy.  Some miscarriages take place before a woman misses a menstrual period or is even aware that she is pregnant.  The process of fertilization-in which the male sperm and the female egg join-is complex.  Miscarriage can be caused by any one of a number of things before, during, or after this process.  Often, this is nature's way of ending  a pregnancy in which the fetus was not growing as it should and would not have been able to survive.  The cause of miscarriage often is not known.  Most factors that cause a miscarriage are genetic.  Sometimes a miscarriage is caused by the woman's health problems.

 

 

GENETIC FACTORS

     More than half of miscarriages in the first 13 weeks of pregnancy are caused by problems with the chromosomes of the fetus.  Chromosomes are tiny structures inside the center of each of the body's cells.  Each chromosome carries many genes, which determine the traits of a person.  Miscarriages can result from an abnormal number or structure of chromosomes.  Most chromosome problems are not inherited (passed on from parents).  They happen by chance and are not likely to occur again in later pregnancy.  In most cases, there is nothing wrong with the woman's or man's health.  The chance of these problems increase with the age of the woman. 

 

 

FACTORS OF THE WOMAN'S HEALTH

     Infections may affect the uterus and fetus and, as a result, end the pregnancy.  Problems with the woman's hormones also cause very early miscarriage.  If the woman has a chronic disease. she may have a higher risk for miscarriage.  Sometimes treatment of the illness can improve the chances for a healthy pregnancy.  This is even more true if the illness is under control before a woman becomes pregnant.  Some illnesses may need care or close watching during pregnancy.  Problems with a woman's uterus or cervix (opening of the uterus) also can lead to miscarriage.  Problems include an abnormally shaped uterus or an incompetents cervix.  An incompetent cervix begins to widen and open too early, usually at 14-26 weeks of pregnancy, without any pain or other signs of labor. 

 

 

LIFESTYLE FACTORS

     Pregnant women who smoke are more likely to have vaginal bleeding during pregnancy.  Their risk of miscarriage is higher than that of women who don't smoke.  Heavy alcohol use and illegal drug use also increase the risk of miscarriage.  This is especially true in early pregnancy.

 

 

WHAT DOESN'T CAUSE MISCARRIAGE

     Most aspects of daily life do not increase the risk of miscarriage.  For instance, there is no proof that working, exercising, having sex, or having used birth control pills before getting pregnant increases a woman's risk.  The upset stomach, often called morning sickness, that is so common in early pregnancy also does not increase the risk.  In fact, women who have morning sickness may have a lower risk of miscarriage.  Often, women who have had a miscarriage believe that it was cause by a recent fall, blow, or even a fright.  In most cases, this is not true.  In fact, in most miscarriages the embryo or fetus died some weeks before the miscarriage occurred. 

 

 

SYMPTOMS OF MISCARRIAGE

     Bleeding is the most common sign of miscarriage.  Most women who have vaginal spotting or bleeding during the early months of pregnancy have healthy babies.  Some of these women, though, will have a miscarriage.  This is why bleeding during early pregnancy is called threatened miscarriage.  If you bled while you are pregnant, you and your doctor will need to be watchful for a few days.  In the very early stages, it is hard to tell if the pregnancy is going to miscarry.  Your doctor may order blood tests or perform an ultrasound exam. 

     Sometimes mild cramping of the lower stomach or a low backache may occur along with bleeding.  Bleeding may persist, become heavy, or occur along with a pain like menstrual cramps or the breaking of the amniotic sac (the fluid-filled sac that surrounds the fetus in the woman's uterus).  If you have heavy bleeding and think have passed fetal tissue, place it in a clean container and take it to the doctor for inspection.  Your doctor will want to examine you.  If your doctor thinks a miscarriage has occurred, he or she may do a pelvic exam to see if your cervix has dilated (opened).  If the cervix has dilated and fetal tissue is lost, a miscarriage is certain.  If your doctor does not think that a miscarriage has occurred, you may be asked to rest and to avoid having sex.  Although these measures have not been proved to prevent miscarriages, they may help reduce bleeding and discomfort. 

 

 

AFTER A MISCARRIAGE

     Often when miscarriage occurs early in pregnancy, tissue is left in the uterus.  If there is concern about heavy bleeding or infection, this tissue will be removed.  The tissue can be part of the fetus, part of the placenta (tissue that provides nourishment to the fetus), or both.  The tissue that remains may be removed by dilation and curettage (D&C).  With this method, the cervix may be widened if needed.  the tissue is then removed gently from the lining of the uterus.  D&C is done in the doctor's office, emergency room, or operating room.  It often does not require a hospital stay.  Your doctor also may suggest medication to be used to help pass the tissue that remains in the uterus.  Your doctor may want to see you in a few weeks to check on your progress.  You can expect spotting and some discomfort for a few days.  You should call your doctor right away if you have any of the following symptoms:

	Heavy bleeding
	Fever
	Chills
	Sever pain

     Your recovery will take some time.  if you are beyond 13 weeks of pregnancy, you may still look pregnant and your breasts may leak milk.  Light exercise is good, but increase your activity slowly.  Ask your doctor about which exercises are best and how often you should do them.  It is safe to have sex after the bleeding stops.  You can ovulate and become pregnant as soon as 2 weeks after an early miscarriage.  if you do not wish to become pregnant again right away, be sure to use birth control.  If your blood is Rh negative, you should ask your doctor whether you need a blood product called Rh immune globulin.  This prevents you from developing antibodies that could affect a future Rh-positive baby.  If you have had a number of miscarriages in a row, your doctor may order tests to look for cause.

     Molar pregnancy, also called gestational trophoblastic disease (GTD), is rare.  It results in the growth of abnormal tissue.  In the United States, molar pregnancy occurs in 1 of every 1,000-1,200 pregnancies.  Both normal pregnancies and molar pregnancies develop from a fertilized egg.  In a molar pregnancy, though, the fertilized egg does not grow as it should.  A genetic error causes abnormal cells to grow and form a mass of tissue. 

 

 

TYPE OF MOLAR PREGNANCY 

     There are two types of molar pregnancy-complete and partial.  The mass in a complete molar pregnancy is made up of all abnormal cells that would have become the placenta in a normal pregnancy.  There is no fetus.  In a partial molar pregnancy, the mass contains the abnormal cells found in a complete molar pregnancy and, often, an abnormal fetus that has severe and fatal defects.

 

 

SYMPTOMS AND DIAGNOSIS

     Most molar pregnancies cause symptoms that signal a problem.  The most common symptom is vaginal bleeding during the first trimester.  Other signs of molar pregnancy, such as a uterus that is too large for the stage of the pregnancy or cysts (fluid-filled sacs or pouches) on the ovaries, can be found by your doctor.  If you doctor suspects a molar pregnancy, he or she may order a blood test that measures the level of a hormone called human chorionic gonadotropin (hCG).  This hormone is produced by the placenta during pregnancy or molar pregnancy.

     Your doctor may use ultrasound to find out whether you have a molar pregnancy.  If a molar pregnancy is found, a series of tests will be done to check for other medical problems that sometimes occur along with a molar pregnancy.  These problems might include preeclampsia (a condition of pregnancy in which there is high blood pressure and swelling) and hyperthyroidism (overactive thyroid gland).  These problems are treated by removing the molar pregnancy. 

 

 

TREATMENT

     To treat a molar pregnancy, the cervix is dilated, either under general or local anesthesia, and the tissue is removed by D&C.  About 90% of women whose molar pregnancies are removed require no further treatment.  However, they do need careful follow-up.  Routine tests for hCG continue for about 6 months to 1 year.  These tests can determine whether you need further treatment.  After the pregnancy has been removed, abnormal cells may remain.  This is called persistent GTD.  It occurs in as many as 10% of women after a molar pregnancy.  It also can occur after a normal pregnancy.  One sign of persistent GTD is an hCG level that remains high after the mole has been removed.  Sometimes chemotherapy may be needed to remove the abnormal cells that remain.  In some cases, hysterectomy (removal of the uterus) may be done.  Cure rates are close to 100% for persistent GTD. 

 

 

COPING WITH THE LOSS

     For many women, emotional healing takes a good deal longer than physical healing.  The feelings of loss can be intense.  Even if the pregnancy ended very early, the sense of bonding between a woman and her fetus can be strong.  Grief can involve a wide range of feelings.  You may find yourself searching for the reasons your pregnancy ended.  You may wrongly blame yourself.  You may have headaches, lose your appetite, feel tired, or have trouble concentrating or sleeping.  Your feelings of grief may differ from those of your partner.  You are the one who has felt the physical changes of pregnancy.  Your partner also may grief, but he may not express his feelings in the same way you do.  He may feel he has to be strong for both of you and may not share his hurt and disappointment  with you.  This may create tensions between the two for you when you need each other the most.   If either of you is having trouble handling the feelings that go along with this loss, talk to your doctor.  You also may find it helps to talk with a counselor.

 

 

FINALLY... 

     Don't blame yourself for the pregnancy loss.  In most cases it is not likely that it could have been prevented.  Losing a pregnancy often doesn't mean that a woman can't have more children or that there is something wrong with her health.  Most women who miscarry can have a healthy pregnancy later.  Emotional healing is as vital as physical healing.  Grieving allows you to accept this painful loss and go on with your life.  Counseling can help both you and your partner if you can't deal with these feelings alone.  You should allow enough time for physical and emotional healing before trying to get pregnant again.  Your doctor can give you some guidance.

 

ACOG PATIENT EDUCATION