Miscarriage

Miscarriage refers to the spontaneous or induced termination of pregnancy. The World Health Organization (WHO) defines miscarriage as the expulsion of an unborn baby weighing 500g or less, corresponding to a gestation period of up to 20 weeks,

Causes

1. Genetic Abnormalities

   The most common cause of first-trimester miscarriage is genetic abnormalities. Around 50-60% of spontaneously expelled fetuses exhibit chromosomal abnormalities. Aneuploidy, which refers to abnormal chromosomal numbers, accounts for approximately half of these abnormalities.

   

2. Maternal Infections

   – Malaria: First-time pregnant women are more vulnerable to severe malaria despite childhood exposure to the parasite, Plasmodium. Plasmodium accumulation in the placenta leads to placental malaria, affecting the blood circulation between the mother and fetus.
   – Urinary Tract Infections (UTIs): UTIs are more prevalent in pregnant women and can lead to miscarriage if left untreated. Untreated UTIs can progress to kidney infections or pyelonephritis and may further infect the bloodstream.
   – ToRCHS Infection: Maternal infections such as toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, and syphilis can cause placental damage and result in spontaneous miscarriages.

3. Maternal Diseases

   Conditions like sickle cell disease, uncontrolled hypertension, poorly controlled diabetes mellitus, and anemia have been associated with an increased risk of miscarriage.

4. Uterine Defects

   Cervical incompetence and previous uterine surgeries are common causes of second-trimester pregnancy loss.

   Cervical incompetence refers to the cervix’s inability to support a pregnancy to term due to structural or functional defects. It is a major cause of recurrent second-trimester pregnancy loss, particularly in sub-Saharan Africa.

   Previous uterine surgeries, such as fibroid removal or myomectomy, can result in uterine scarring, reducing available space within the uterus. This condition, known as Asherman Syndrome, can cause the placenta to be positioned low in the uterus, increasing the risk of miscarriage.

5. Toxic Factors

   Factors such as alcohol consumption, smoking, exposure to radiation, and cytotoxic drugs during pregnancy can increase the risk of pregnancy loss.

6. Immunological Causes

   Incompatibilities between maternal and fetal blood types, such as ABO incompatibility and Rhesus incompatibility, can contribute to miscarriage.

7. Independent Factors

   Stress and advanced maternal age have also been implicated as potential risk factors for miscarriage.

Symptoms

Symptoms of miscarriage can vary depending on the type, but the most common signs include:

• Vaginal bleeding ranging from spotting to heavy bleeding.
• Abdominal pain, usually located above the pubic region and potentially radiating to the lower back, buttocks, and upper thighs.
• Passage of tissue, is commonly observed in complete abortions.
• Symptoms of infection in cases of septic miscarriage, such as fever, chills, rapid heartbeat, and reduced urination.

Treatment

Treatment options for miscarriage include watchful waiting, medical intervention, and surgical procedures. It is important to note that once a miscarriage has started, there is no treatment that can stop it. In some cases, the body will naturally complete the miscarriage.

For threatened miscarriages, bed rest and treatment for conditions like malaria or urinary tract infections are crucial. Inevitable abortions can be managed with pain relief medications, oxytocic drugs to facilitate the abortion process, and blood transfusions for significant blood loss.

Incomplete abortions typically require the evacuation of the uterus using oxytocic medications or manual vacuum aspiration. Intravenous fluids, antibiotics, and anti-tetanus vaccination may be necessary. Complete abortions generally do not require treatment unless there is significant blood loss.

Septic miscarriages are life-threatening and require the evacuation of uterine contents, as well as the management of associated complications. Intravenous fluids, blood transfusions, antibiotics, analgesics, and tetanus prophylaxis may be necessary.

Manual vacuum aspiration is generally recommended for miscarriages occurring at 12 weeks of gestation or earlier, while induction with medications may be used for miscarriages after 12 weeks of gestation.

Recurrent miscarriages may necessitate surgical interventions, such as cervical cerclage for cervical incompetence, which involves temporarily closing the cervix with stitches to support the pregnancy in the uterus. Managing maternal medical conditions, such as poorly controlled diabetes mellitus, can improve the chances of a full-term pregnancy. Genetic screening, medication use, and lifestyle modifications also play significant roles in the management of recurrent miscarriages.

In conclusion, seeking professional medical care is crucial for the management of miscarriages to reduce complications and the risk of recurrence.

References

• Chua, C.L.L. et al. (2021) Malaria in pregnancy: From placental infection to its abnormal development and damage, Frontiers. Available at: https://www.frontiersin.org/articles/10.3389/fmicb.2021.777343/full (Accessed: 21 May 2023).
• Mavrogiannis , M. (2023) Torch infection: What is it, symptoms, treatment and more – osmosis. Available at: https://www.osmosis.org/answers/torch-infection (Accessed: 21 May 2023).
• Smikle, C. and Khetarpal, S. (2022) National Center for Biotechnology Information, Asherman Syndrome. Available at: https://www.ncbi.nlm.nih.gov/books/NBK448088/ (Accessed: 21 May 2023).
• Puscheck, E.E. (2021) Early pregnancy loss, Practice Essentials, Background, Pathophysiology. Available at: https://reference.medscape.com/article/266317-overview (Accessed: 21 May 2023).

Frequently Asked Questions About Miscarriage

• How will I know if I have a miscarriage?
  Presence of vaginal bleeding which may vary from spotting to heavy bleeding, cramping to severe abdominal pain, passage of tissue, decreased pregnancy symptoms, and symptoms of infection in the case of a septic miscarriage like fever, chills, rapid heartbeat, and reduced urination.
• What are the things that cause miscarriages?
  Genetic abnormalities, maternal infections, maternal diseases like hypertension, diabetes mellitus, smoking, alcoholism.
• What happens to your body after miscarriage?
  The breasts may feel tender, swollen, or engorged after a miscarriage. Hormone levels, particularly progesterone and estrogen, will gradually return to their pre-pregnancy state. This hormonal shift may affect the mood, energy levels, and menstrual cycle. Return of menstrual cycle within 4-6 weeks after a miscarriage.
• Which sleeping position can cause miscarriage?
  There is no specific sleeping position that has been scientifically proven to cause miscarriage. During pregnancy, it is generally recommended to sleep on your side, preferably the left side, as this can improve blood flow to the uterus and the baby. Sleeping on your back for extended periods, especially later in pregnancy, may cause discomfort and potentially affect blood circulation, but it is not directly linked to miscarriage.
• What happens if you have a miscarriage and don’t get cleaned out?
  Retained pregnancy tissue can cause persistent or prolonged bleeding. There is also an increased risk of intrauterine infections which could lead to a septic miscarriage.