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FIRST TRIMESTER BLEEDING AND MISCARRIAGE
The medical term for a "miscarriage" prior to 20 weeks of pregnancy is "spontaneous abortion." Often, the first sign of an impending miscarriage is bleeding early in pregnancy (first-trimester bleeding). When bleeding occurs early in pregnancy, the patient and physician should both be aware of possible problems with the pregnancy. In some cases, the pregnancy may continue, while in others, the bleeding is the first sign that a miscarriage will occur. Because of the various possibilities, the knowledgeable patient will be better able to cope with circumstances as they arise. If a pregnancy is lost, no matter how early in the pregnancy, there may be a significant sense of loss and grief in addition to the actual loss of the pregnancy.
Miscarriages occur more often than many people realize. It is estimated that a miscarriage occurs in up to 25% of all pregnancies depending on the time the pregnancy is diagnosed. Most occur during the first trimester (first 13 weeks of pregnancy), while some occur even before the woman realizes she is pregnant. Because the exact cause of the miscarriage is often unknown, the miscarriage sometimes is nature's way of terminating an abnormal pregnancy before it is carried too far. The further the pregnancy advances, the less likely a miscarriage will occur.
Miscarriage Causes
Chromosomes are the structures inside the nucleus of each cell that determine the genetic makeup of a person. For miscarriages that occur during the first trimester, over 50% are associated with abnormalities of the chromosomes of the fetus. The abnormalities may include the structure of the chromosomes, number of chromosomes, or the genes of the chromosomes. The genes of the chromosome are the basic components of each chromosome that determine particular aspects of any given individual such as their height, gender, blood type, and so on. In most instances, abnormalities of the chromosome are not related to abnormalities of either parent's health. They are random or "chance" occurrences and are not expected to occur in subsequent pregnancies. Occasionally, however, genetic abnormalities may be passed from one generation to the next, but this occurs relatively infrequently.
- Mother's behavior - Some of the lifestyle choices that women make may increase the risk of miscarriage. Examples include smoking, heavy alcohol consumption, and use of illegal substances such as cocaine.
- Mother's health - Medical conditions that the mother has may affect the likelihood of miscarriage. For example, uncontrolled diabetes has been associated with a higher risk of miscarriage. Similarly, infections of the pelvic organs as well as abnormal levels of certain hormones may cause miscarriage.
Occasionally, there is a problem with the anatomy of the uterus (womb) or cervix (opening of the uterus). Either type of abnormality might lead to miscarriage later in pregnancy, possibly in the second trimester (after the 14th week and before the 26th week).
Miscarriage Symptoms
The most common symptom is vaginal bleeding. It should be noted, however, that not all pregnancies in which there is bleeding early in pregnancy go on to miscarry. In fact, many pregnancies go on to produce normal, healthy babies. Bleeding in early pregnancy is termed a "threatened miscarriage" or "threatened abortion." In addition, cramping in the lower abdomen or lower back may be associated with the bleeding. The bleeding may increase and may become as heavy as menstrual flow, with cramping similar to a period. Occasionally, there is a gush of fluid or bloodstained fluid that signals the rupturing of the fluid-filled sac that surrounds the fetus. Miscarriage almost always follows this latter event. There is no evidence that any activities or lack of activity, such as bedrest, is helpful to prevent or stop a miscarriage.
Miscarriage Diagnosis and Treatment
The primary diagnostic technique in cases of possible miscarriage is an ultrasound examination (a test in which sound waves are used to examine the condition of the pregnancy). Occasionally, blood tests may also be used. In the very earliest weeks of pregnancy, it may not be possible to know for sure whether or not a miscarriage has happened or will occur.
If a miscarriage has been diagnosed, there may be tissue that remains in the uterus that must be surgically removed by use of minor surgery. This procedure is called a dilation and curettage. With the use of an anesthetic, the mouth of the womb may be dilated (opened) with small instruments and the tissue scraped out of the uterus. A suction technique can also be used to perform this procedure. If either operation is performed, it is usually done as an outpatient or office procedure so that an overnight hospital stay is not necessary.
There are also times when a miscarriage occurs and no tissue remains in the uterus. Bleeding usually stops spontaneously in this case. In such a case, no surgical procedure is required. The patient's symptoms will determine whether or not a dilitation and cutterage is recommended.
Miscarriage Complications
Occasionally, a patient may also have fever, chills, severe pain, and bleeding. This may signal that an infection is setting in. This may require a dilation and curettage or antibiotics.
Miscarriage Myths
On occasion, "common wisdom" is incorrect with regard to miscarriage. For example, the use of birth control pills prior to getting pregnant is not associated with an increased chance of miscarriage. Also, normal activities, such as intercourse, exercise, or routine employment, do not cause miscarriage. Nausea and vomiting that are very common early in pregnancy are not associated with a greater chance of miscarriage. Except for the lifestyle choices listed earlier, what the woman does during her day-to-day routine does not contribute to a miscarriage, and there is rarely anything that a patient could have done to prevent the miscarriage.
Miscarriage Recovery
If the miscarriage occurred after the first 13 weeks or so, it may be possible for the patient's breast milk to still come in. A tight bra will control this problem. Returning to normal activities should be a gradual process with intercourse considered safe after the bleeding has ceased. It is possible for the patient to ovulate, and therefore become pregnant, as soon as 2 weeks after an early miscarriage. Discussions of contraception are appropriate even at the time that the miscarriage is initially diagnosed and treated.
If a patient's Rh blood type is negative, there may be a need for treatment with Rh immune globulin, which will protect the patient from developing antibodies that would affect future pregnancies.
In all cases, the patient should feel comfortable talking over all of her concerns with her physician so as to minimize any misconceptions and to plan the next pregnancy, if desired. It is not unusual for a significant grieving process to occur after an early miscarriage, with a sense of loss similar to that felt if an adult member of the family passes away. This should also be discussed with the physician if the patient desires.
Thomas G. Stovall, M.D.
Dr. Stovall is a Clinical Professor of Obstetrics and Gynecology at the University of Tennessee Health Science Center in Memphis, Tennessee and Partner of Women's Health Specialists, Inc.
Date Published: 2004-03-10
7800 Wolf Trail Cove, Germantown, TN 38138
Phone: (901) 682-9222; Fax: (901) 682-9505