Empty Arms -- The Lonely Trauma of Miscarriage
from the book How to Have a Baby:
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
table of contents
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An extended definition of infertility includes women who conceive but cannot
carry a pregnancy to term - women who have repeated miscarriages.
The medical term for a miscarriage is an abortion. Most miscarriages start
with vaginal bleeding which is initially slight and painless. This is called a
threatened abortion, because the pregnancy is threatened by the bleeding. This
bleeding is from the mother, and is not fetal blood. About half the time this
stops spontaneously and results in no harm to the pregnancy. At this stage, the
most useful test is an ultrasound scan (usually done with a vaginal probe). If a
fetal heartbeat can be seen, this means that there is a 95 % chance that the
pregnancy will proceed normally. On the other hand, if the ultrasound scan shows
that the fetus has not developed properly ("blighted ovum " or
anembryonic pregnancy when no fetus can be seen; or a missed abortion or
intrauterine fetal death when the fetus is seen but the heart is not beating,
then nothing can be done to save the pregnancy.
In such cases, the bleeding progresses, and the uterus starts contracting.
This is felt as painful cramps, and the mouth of the uterus ( the cervix) opens.
This is called an inevitable abortion (because it cannot be stopped). If some of
the pregnancy has already been pushed out by the contractions, this is called an
In patients with a blighted ovum, missed abortion, inevitable or incomplete
abortion, the treatment is a uterine curettage (D&C) - a short surgical
procedure which is performed to empty the uterus and remove the pregnant tissue.
Abortions which occur in the first twelve weeks of pregnancy are called first
trimester abortions. Those which occur between the 13th to 20th weeks are called
second trimester abortions.
The magnitude of the problem
Perhaps 20-30% of all women spot, bleed or suffer cramps during their first
twelve weeks of pregnancy, and about 10% miscarry. This figure may be an
underestimate, because there are a number of women who miscarry unknowingly,
thinking that their period was late or heavy. It is very common for women to
have one miscarriage during the first twelve weeks of their pregnancy . This
mostly happens by chance and is not a sign that they have a health problem
because most of them will probably have a healthy baby the next time they get
pregnant without any treatment.
If however, a patient has had two or more miscarriages consecutively, this is
called repeated or habitual abortion. Now although the risk of miscarrying again
does increase, this risk is still quite small, and increases from the 15% risk a
normal woman has to 35% - which still means there is a 65% chance that they will
not have a miscarriage again.
Fact and fiction
Most women who miscarry do so only once. Their risk for miscarrying again is
not increased and is the same as that of a normal woman's - about 15%
Women who are over thirty five are more liable to miscarry
There is an old saying that you cannot shake a good apple off a tree.
Travelling, lifting weights and sex does not threaten a healthy pregnancy.
If you've had a previous miscarriage, it is very normal to be frightened and
worried during your next pregnancy. It is important to understand that exercise,
working and intercourse do not increase the risk of pregnancy loss. Likewise,
staying at home and resting in bed probably do not prevent miscarriage.
Repeated miscarriages can happen because of any of the following:
- Chromosonal abnormalities
- Hormone imbalance
- Physical Illness
- Polycystic Ovary Syndrome
- Immune problems
- Antiphospholipid antibodies
- Problems in the uterus
- Life style of the woman
Let's discuss these in detail.
At least 60% of spontaneous miscarriages occur because of a chromosomal
abnormality at conception. This means that a genetically (chromosomally)
defective sperm or ovum gives rise to a genetically abnormal fetus. The
miscarriage is Nature's defense mechanism, which aborts a defective fetus,
rather than giving birth to a defective baby. Since most of these genetic
defects are chance occurrences, the risk of it being repeated again in the next
pregnancy is very small.
In order to establish the diagnosis of a genetic cause for repeated pregnancy
loss, a karyotye (study of the chromosomes) of the fetal tissue (if available)
may be done. It is expensive, and often the cells fail to grow in culture, so
that the study may not be possible. Moreover, since little can be done even if a
defect is detected, it has little impact on patient management. However, it does
provide an explanation for some patients with recurrent pregnancy loss.
In about 5 % of couples, a chromosome abnormality found in one of the parents
explains recurrent miscarriage. This is detected by doing a chromosomal study on
the parent's blood. The commonest problem is a structural defect (break or loss
of a piece of the chromosome; a rearrangement of a bit of a chromosome).
If the karyotype is normal, then the patient can be reassured that the
miscarriages were a chance genetic event, and they can feel comfortable
continuing with their efforts to have a baby. However, if the karyotypes are
abnormal, this is a permanent situation, which indicates an increased risk of
miscarriage. Genetic counselling should be sought to discuss the degree of risk.
Depending upon the individual problem, this risk may be anywhere from 25% to
100%. Since chromosomal rearrangement at conception (when the sperm fertilises
the egg) is a random event, there is little which can be done to treat this.
Options may include: continuing to try to conceive a baby naturally; adoption;
donor eggs (if you have the genetic problem) or donor sperms (if the husband has
the genetic problem).
Patients may miscarry because they have a luteal phase defect - that is, the
amount of progesterone hormone produced after the egg is released is reduced.
Progesterone is the hormone which supports the pregnancy. It helps implantation
of the embryo in the uterus and if this is deficient, there can be a problem
with the embryo lodging itself in the uterine lining.
A luteal phase defect is suspected if the menstrual cycles are short -
especially if the luteal phase (the time of the menstrual cycle between
ovulation and the next menstruation) is shorter than 12 days.
This diagnosis can be confirmed by a blood test (a serum progesterone level
done one week after ovulation is low) and an endometrial biopsy (which will show
that the endometrium is "out of phase").
The doctor can help provide luteal support by prescribing progesterone during
the last two weeks of the menstrual cycle after ovulation. If the woman is
already pregnant, treatment may be with vaginal suppositories of natural
progesterone for the first twelve weeks of the pregnancy; or progesterone
injections intramuscularly. However, this treatment is controversial.
Health problems that can cause repeated miscarriages are:
- Uncontrolled thyroid disease
- Uncontrolled diabetes
- Severe heart, liver or kidney disease
- Systemic lupus erythematosus an illness in which the woman produces
antibodies against her own body tissues.
What about TORCH Infections? Certain infections called TORCH - which stands
for TOxoplasmosis, Rubella, Cytomegalovirus and Herpes, may be a cause for a
single miscarriage, but are NOT a cause for repeated miscarriages. While a
number of specialists will do these tests, and even start treatment based on the
results, these tests are not worthwhile for patients who undergo habitual
Although infections of the uterine cavity (for example, due to mycoplasma)
are frequently thought to be a cause of recurrent pregnancy loss, substantial
proof of this is lacking. Studies have in fact failed to indicate a greater
incidence of infection in women with a history of miscarriage when compared to
normal fertile women.
Polycystic Ovary Syndrome
Exciting research done recently by Dr Howard Jacobs at the Middlesex
Hospital, London, shows that polycystic ovary syndrome can also be a cause of
recurrent miscarriages. In PCOS, the ovaries produce a large amount of the LH
hormone. This has a detrimental effect on the egg, so that at the time of
ovulation, the egg released is overripe and unhealthy. If such an egg is
fertilised, the embryo is also likely to be unhealthy, and is consequently
rejected by the body after 6-8 weeks as a miscarriage. The interesting point of
these studies is that it tells us that we should also be focussing on what is
happening at the time of fertilisation - and not just what goes on after the
pregnancy. Problems with the eggs and sperms at the time of fertilisation will
manifest themselves as a miscarriage later on, but these are often neglected by
The immune system plays an important protective role in maintaining health
throughout life, by defending against infection. It "rejects " the
foreign invaders (bacteria, viruses) which are recognised by the body as being
"outsiders". It is now becoming evident that inappropriate activation
of the mother's immune system may cause early first trimester miscarriages.
Current theory suggests that during a normal pregnancy, the fetus, which
carries the father's foreign genes (and is therefore immunologically foreign to
the mother) can nevertheless survive in the mother' uterus because of a special
protection from the mother's immune system - the uterus is a
"privileged" site. This is why it is not "rejected" like
other foreign tissues (such as kidney transplants) are. This means that in the
normal course of events, the fertilised egg somehow stimulates a protective
maternal immune response which allows implantation and growth. For certain
couples, this protective response does not occur, and the maternal immune system
rejects the father's foreign material in the fetus, resulting in miscarriage.
Tests are available to check for this, but these are still in the experimental
stage. Treatment is in the research phase too, and includes sensitising the
mother to the father's genes, by injecting his blood cells into her skin, the
theory being that exposure to the foreign cells will stimulate her immune system
to provide the normal protective immune response when she gets pregnant.
Some women produce antibodies against the circulating substances that cause
blood clotting. These are called lupus anticoagulant or anticardiolipin or
antiphospholipid antibodies. They severely inhibit fetal development (by
blocking off the blood supply to the fetus by causing clots in the
maternal-fetal circulation) and cause miscarriages. Their presence can be
detected by a blood test. Treatment is possible, either with low doses of
aspirin (which decreases the clot formation); or with a steroid (prednisone)
which suppresses the mother's abnormal immune system.
Miscarriages because of uterine problems usually occur after the twelfth
week. These could be because of :
- A congenital abnormality of the uterus, which the woman is born with, but
which does not cause any problems, until a pregnancy is attempted. Such a
uterus ( septate uterus, bicornuate uterus) cannot grow normally to hold and
retain the pregnancy and this is consequently expelled.
- Fibroids, which are growths of smooth muscle tissue inside the uterus.
While most fibroids will not mar a pregnancy, if the fibroid is very close
to the lining of the uterus ( submucous fibroid), it will interfere with the
implantation of the embryo in the uterus, and will cause its expulsion.
- Intrauterine adhesions ( Ashermann's syndrome). These are uncommon, and
are fibrous bands of scar tissue in the uterus, which interfere with
implantation of the embryo. They may be formed after a uterine curettage
(after an abortion) and can be diagnosed by hysteroscopy or
hysterosalpingography. They can be removed by hysteroscopic surgery,
allowing uneventful pregnancies in the future.
- Incompetent os, in which the cervix (mouth of the womb) is weakened. When
the growing fetus presses on it, the weakened cervix opens, leading to
expulsion of the growing foetus. This condition may be congenital; or
because of a cervical tear or injury during previous pregnancy or
miscarriage; or could be a result of over enthusiastic surgical dilatation
of the cervix during previous surgery. The insertion of a cervical stitch,
called the Shirodkar stitch after the Indian doctor who discovered this
condition and invented the surgical operation to correct it, can be very
effective. The cervical stitch is a simple surgical operation, usually done
after 12 weeks of pregnancy after an ultrasound shows that the baby is
healthy ; and it helps by strengthening the weakened cervix. The stitch is
removed two weeks before the baby is due, or when labor starts, whichever is
Diagnosis of these anatomic defects can be made by hysteroscopy or
hysterosalpingography. An ultrasound examination can suggest a problem exists,
but usually cannot provide a definitive diagnosis.
If patients are regularly exposed to toxic fumes and chemicals (example,
workers in chemical factories ; or nurses and anesthetists in operating rooms)
these could damage the developing fetus (which is very sensitive to poisons) and
cause a miscarriage. Recent studies show that even men exposed to environmental
toxins can cause their partner to miscarry a fetus (presumably because their
sperms are damaged by the toxins). Smokers, alcoholics and drug abusers also
have an increased incidence of miscarriages.
The emotional aspects
Human society still tends to dismiss miscarriage complacently; it is a
subject which is rarely discussed. A foetus for most people is a non-person and
a miscarriage is a non-event. But, to the would be parents, the developing fetus
is a baby with an identity, especially if you have seen it on the ultrasound
screen and heard its heart throbbing with a Doppler. When the child is lost, it
is a bereavement and your sense of loss, tinged with pain, anger, isolation and
depression, can be profound - especially when it follows a long period of
After a miscarriage, it is normal to experience a period of grief. Find
support from each other; and from others who have had a similar experience.
Healing does happen in time. Focus on getting through the grieving rather than
on the suffering.
Your next pregnancy
After a miscarriage, making the decision to go in for another pregnancy is
difficult. Collect as much information as possible to try to find out the
possible causes of the loss and whether they might influence a future pregnancy.
If you have had 2 or more miscarriages, then tests are usually done to try to
find a cause. These include the following:
- Hysterosalpingogram or hysteroscopy to make sure there are no defects in
your uterus (womb)
- Blood tests, such as serum progesterone, to rule out a luteal phase defect
- Blood tests for antiphospholipid antibodies (lupus anticoagulant)
- The VDRL (Venereal Diseases Reach Laboratory) blood test, for sexually
- Karyotype, for you and your husband, to rule out chromosomal
Often many doctors will do what is called a "TORCH" test - but
these are a waste of money for most patients, since they provide little useful
When to start the testing depends upon you. While few doctors would do
anything after one miscarriage (since your chance of having a healthy pregnancy
even without tests and treatment is better that 85%), most would start a workup
after two miscarriages. Often, nothing is found, and this can be very
frustrating to the doctor and patient. But do remember that medical technology
has it's limitations, and we still do not know a lot about the early embryo and
What about treatment? Sometimes it is possible to treat the problem - for
example, by taking a cervical stitch to treat an incompetent os; or removing a
uterine septum by hysteroscopic surgery. However, most treatment is
"empirical" and is like shooting in the dark. This could include - bed
rest; progesterone injections and tablets; and uterine relaxants, such as
Duvadilan, during pregnancy, though their real value is doubtful.
Often the only option is to try again. Remember, even if you have had 3 or
more miscarriages, your chance of carrying the next baby to term is still more
than 50 % - even with no specific treatment, and just tender loving care!
Deciding when to start the next pregnancy is a decision only you can make. It
takes a lot of courage and both of you need to be ready.
Your next pregnancy probably won't be as joyful as you would like. Insist
that your pregnancy be monitored carefully. Whenever the slightest problem
occurs, you'll feel vulnerable and terrified - but don't panic.
Everyone will make suggestions about what you should do to make your
pregnancy successful. This can be annoying - but remember they are doing it
because they care! The easiest way to handle this is to listen, and then do what
you and your doctor feel is best for you.
Your child birth experience can be bittersweet - memories surface about your
loss, especially if you are at the same hospital. You probably will need to do
some grieving in addition to celebrating the new life.
The experience of miscarriage will also affect your parenting. Bonding with
your child may also be delayed because you feel the need to protect yourself
from more sorrow - so you wait till you are certain that all is safe and sure
with your baby. Moments of panic will occur when the baby is ill or too quiet or
with someone else. You are also likely to treat your children as "extra
special" - and be less objective than other parents.
If you've experienced recurrent miscarriage, you may feel hopeless and
confused regarding a positive pregnancy outcome. Remember that miscarriage is
not an uncommon event. Your testing will focus on trying to find out the known
causes of recurrent miscarriage. But knowledge of this problem is still limited,
and no obvious cause is detected in upto 50% of couples with repeated pregnancy
loss. This can be very frustrating - both to the patient and the doctor. The
encouraging news is that the spontaneous cure rate is very high; and successful
treatment is available for treating certain uterine and endocrine causes. So
even if your evaluation does not reveal a treatable cause and you do not undergo
treatment, your chance of achieving a healthy pregnancy despite having had
several miscarriages in the past is still better than 50% - and the only
"treatment " you need is tender loving care !
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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