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How is miscarriage treated? What happens after miscarriage and what support is available?

 

What happens when you go to the emergency room?

The paramedic will make you bed rest quietly and may give you medications to stop your uterus from contracting under the direction of the Emergency Room physician at the base hospital by phone.

Bring all prescription drugs, herbs, and supplements you are taking with you to the hospital. Be honest with the ER doctor if you drink heavily or use street drugs.

Your doctor may consult with a pharmacist to find out if your miscarriage could be the result of a drug interaction.

The nurse or midwife will record your vital signs (height, weight, blood pressure and temperature).

If you have been bleeding excessively, the nurse will take your pulse twice:

The maximum amount your pulse should increase when standing is 20 beats per minute. If you have bled so much that your blood volume is depleted, it will increase more.

You may require intravenous fluids (IV), antibiotics and a blood transfusion.

You will require a vaginal exam by a doctor or midwife. You must recline on the examination couch while your doctor inserts a clean clamp (speculum) to hold your vagina open and shines a bright light on your perineum to see well.

If you have not had a pap smear in the past year, the doctor scrapes your cervix with a wooden Popsicle stick, smears the sample on a slide, and sends it to the Pathology Lab for expert examination.

Some miscarriages are inevitable. Remember, if your membranes break and you go into labour, that a baby can only survive outside the uterus if it weighs at least 500 grams (1.10 pounds) and is at least 24 weeks old.

 

Molar pregnancies

Remember that a proper fetus does not form, and the cellular mass cannot survive outside your body. Your uterus is more likely filled with clusters of bubbles. Your doctor will likely suggest a cervical dilatation and evacuation with suction (D&E) to remove the products of conception by the end of your first trimester (Week 12 of pregnancy).

In 2-3% of molar pregnancies, the moles may develop into a cancer called choriocarcinoma which can spread to distant parts of the body and require methotrexate and limited cancer chemotherapy.
A miscarriage is often treatable if it is addressed immediately. Not every woman who spots during the first trimester has a miscarriage; 20% of women who spot bring the pregnancy to full term (40 weeks).

If you are pregnant and spot or bleed visit your doctor or the nearest Emergency Department at an obstetric hospital as soon as possible. Bring any tissue you pass with you in a clean container. The lab can test the tissue for many abnormalities to pinpoint your problem.

 

Finding the reason why you may miscarry and receiving medical help

If your problem is hormone related…

Daily progesterone production jumps from a non pregnant 20mg to 400mg during the third trimester.

Pregnancy is supported by the hormone progesterone. There is a great chance that you are progesterone-deficient, if you are incapable of sustaining the pregnancy once the tenth week comes.

If a woman is prone to miscarriage, from the twelfth day to the twenty sixth day of her cycle, she could try using a low dosage of natural progesterone cream, until the pregnancy is confirmed. If you are in your sixth or seventh week of pregnancy, and spotting starts to occur, a high dose of 100 to 200 mg progesterone cream is applied twice or three times daily.

Often, women use natural progesterone cream until the baby is full term (40 weeks of gestation).

If your problem is incompetent cervix related…

In weeks 14 to 16 of your pregnancy, the treatment is simply to close up the cervix (cerclage). In order to give birth, your doctor needs to remove your stitches (sutures) between weeks thirty six to thirty eight. Cerclage can’t prevent an unavoidable miscarriage, so your doctor cannot perform it if your membranes have already ruptured or if your cervix already expanded to 4 centimeters. You are also unqualified for cerclage if your cervix is bothering you. Generally, the mother and baby put up with cerclage well, but it is certainly not a cure-all. Be aware that cerclage can cause severe bleeding (hemorrhage) from lacerations of the cervix, rupture of the membranes, uterus or bladder, and premature labor.

If your problem is immune system related…
The treatment for this varies:

Many insurance companies will not cover immune testing until the woman has had at least three miscarriages. To receive advice for faulty fetal-blocking or HLA antibody issues, in particular, you might have to travel quite far.

The immune system contains several diverse kinds of white blood cells.

Another advantage of progesterone supplementation is that it can help your immune system by influencing how your white blood cells respond to your pregnancy. Here are some examples of immune responses that will impair your pregnancy:

1. T and B cells that can create placental rejection

2. Natural killer cells that dispense tumor necrosis factor (TNF) that injures the placenta and endometrium

3. Lymphocytes that become stuck in the placenta and effect it negatively

Inflammation that wounds and hurts the placenta is soothed by progesterone. Progesterone encourages the placenta to increase its HCG production, in order to block the killing power of NK cells’. Progesterone could prevent the uterus from producing irritating prostaglandins that force it to contract way too early in the pregnancy. Progesterone helps the cervix create an antibody-rich plug to defend the baby and placenta from ascending germs.

 

If your problem is autoimmune related…

Until the end of the sixteenth week of pregnancy, usually women with autoimmune disorders require progesterone supplementation.

Due to a problem with their CD 19+5+ cells, it’s possible for a newly pregnant autoimmune women to be allergic to their own hormones. This can even include progesterone.

Your doctor can use either a blood test or a skin test to see if you are allergic. CD 19+5+ cells are usually suppressed by 10 weeks of gestation. Progesterone allergy is less of a concern after you have been pregnant for
10 weeks.

 

Who to see when you experience repeated miscarriages?

Visit a gynecologist with CREI (Certified Reproductive Endocrinology and Infertility) qualifications about repeated miscarriage (habitual abortion). Besides for progesterone defiency, your doctor needs to rule out other causes.

For example, Turner’s syndrome only affects girls. It’s a chromosomal abnormality where one X chromosome is missing. In the first trimester, Turner’s syndrome is to blame for 20% of all miscarriages.  Of those pregnancies affected by Turner’s syndrome, 98% end in miscarriage.

Women who suffer from reproductive difficulties may deliver a baby successfully with the help of Assisted Reproductive Technology (ART). Depending on how complex of a method the doctor uses, the cost of ART presently ranges from $8,000 to $15,000 per cycle. There are three cycles in which ART is usually successful. Before you officially commit and make that down payment, ask your doctor to define successes for you. Some clinics would define success as any conception, while others would define it as bringing home a baby.
Two-thirds of infertile couples can have a baby. Your chances of success diminish as your age increases.

 

Do you need surgery after a miscarriage?

Surgery - If you have an ectopic pregnancy, you must have surgery to remove the fetus and products of conception from the affected fallopian tube. In most cases, the surgeon is unable to salvage the delicate tube and will remove it (salpingectomy). You have a 9% chance of another ectopic pregnancy if you only have one fallopian tube left. If you retained your damaged fallopian tube, then you have a 12% chance of a repeat ectopic pregnancy.

D&C - For unavoidable miscarriages, the method of choice is dilatation and curettage (D&C). The surgeon may place a black ‘matchstick’ of seaweed called a laminaria tent in your cervix to open it gently overnight. When you are in the operating room the surgeon gradually makes the opening of your cervix bigger by spinning a series of increasingly larger dilator wands in it. The surgeon grasps your uterus with a tenaculum clamp to hold it steady. The surgeon scrapes the lining of your uterus clean with curettes, which resemble small rakes.

D&E - Dilatation and evacuation (D&E) with a suction device is the choice for molar pregnancy.

In all cases, you will be taken to a Recovery Room for the anesthetic to wear off. Your nurse will encourage you to get up and walk soon after the surgery to prevent pooling of body fluids and pneumonia. You cannot drive yourself home. Arrange for a friend to pick you up and monitor you overnight for complications.

You can take a shower the day after your surgery. Avoid baths, douching, swimming, and intercourse for a month. Avoid heavy lifting.

Wear absorbent sanitary napkins for a few days up to several weeks after surgery to catch the drainage. Do not use tampons because infection could result. Expect breast discomfort and leaking milk to last a week.

Call the doctor if you develop fever, heavy bleeding or a foul-smelling discharge. You may need antibiotics to fight infection or ergometrine to stanch bleeding.

Barring complications, you probably can return to work in two days, but book the week off work as a precaution. Most women can resume exercising in three weeks

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What are the complications of a miscarriage?

Most miscarriages do not result in physical complications, but every surgery entails risk. Possible complications of salpingectomy, D&C and D&E include:

Adverse reaction to the anesthetic

Bleeding

Infection

Damage to the cervix causing it to become incompetent

Perforation of the uterus, bowel or bladder

The drop in progesterone that accompanies a miscarriage in late second or third trimester may result in temporary depression. Emotional strain makes depression last longer.

 

Grieving

Grief is a normal response to the death of a loved one. Many couples consider their fetus to be a person, and it is very disheartening if outsiders minimize the impact of a miscarriage.

How a person deals with grief is very personal, and each person will grieve differently. Grief puts strain on a marriage. Elisabeth Kübler-Ross identified these five stages of grief in her landmark book, On Death and Dying:

1. Denial this can’t be happening

2. Anger Why me!

3. Bargaining I’ll do anything if.

4. Depression I just can’t handle it

5. Acceptance everything will be all right

A person may not necessarily follow the stages in order, or go through each stage. A person should go through at least two of the five stages. If your grief is not progressing through the stages, or is prolonged, then see your doctor.

 

When can you try again?

At least wait 1 year before pursuing another pregnancy, if you just went through a molar pregnancy. You must wait until your HCG level has returned back to 0 to guarantee that no moles have migrated to distant parts of your body (metastasized).

In rare cases, your gynecologist will set the allowable HCG level at less than 2 mIU/ml if you can maintain it for a full year. Follow your gynecologist’s instructions exactly.
In every other case, try to wait at least 1 and preferably 3 cycles before undergoing another pregnancy.

Give yourself time to recover fully.

Take a 400 micrograms (0.4 milligrams) folic acid supplement daily and eat a nutritious diet in the meantime. Reduce the amount of caffeine you are consuming. Definitely avoid smoking, consuming alcohol, environmental hazards, contact sports, and people with infectious diseases. Make sure your doctor or pharmacist approves it, prior to using an over-the-counter medication.

 

Understand more on Miscarriage:

What is a miscarriage?

What causes miscarriage?

Signs & symptoms of miscarriage

What is natural progesterone?

Progesterone treatment and side effects

The information in this article has been taken with permission from the official Lawley booklet on Understanding Miscarriage. 

 

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