From A Medical Perspective

From A Medical Perspective

It was November 2003 when Mara Barth’s home pregnancy test revealed the happy news: She and her husband, Jeff, were going to have a baby. But just six weeks into her pregnancy, Mara, then 33, began having cramps followed by some light bleeding. After a series of tests, the doctor confirmed the Wilmette, IL couple’s worst fears: Mara was having a miscarriage. “We called it a false start,” says the athlete and former competitive swimmer. In any case, “It was devastating,” she says.

It is also devastatingly common. According to the American College of Obstetricians and Gynecologists, about 15-20% of pregnancies end in miscarriage (a pregnancy loss that occurs before 20 weeks).

When the unexpected happens, many wonder if it was something they did, ate, or drank that caused the miscarriage, compounding their pain in the process. It’s important for women to know that not only are miscarriages common, but they shouldn’t blame themselves for the loss. “It’s not your fault,” says Jonathan Scher, MD, a NewYork City obstetrician/gynecologist and co-author of Preventing Miscarriage: The Good News (HarperCollins, 2005). Most miscarriages are inevitable, he explains. Nature’s way of handling an unhealthy or abnormal embryo or fetus. What’s more, notes Dr. Scher, more than 90% of women who suffer a miscarriage go on to have a perfectly healthy, full-term pregnancy the next time around. (Mara did.)

What causes a miscarriage?

If you’re not to blame for the loss, what is? Experts believe that the vast majority – up to 70% – are due to chromosomal abnormalities in the fetus. This does not mean that there’s something genetically wrong with your eggs or your partner’s sperm; it’s a ‘chance’ occurrence as decided by G-d. “For an egg to be fertilized, two sets of chromosomes need to combine in perfect harmony. The wonder is that it happens correctly four out of five times,” says Henry Lerner, MD, an ob-gyn in Newton, MA, and the author of Miscarriage: Why it Happens and How Best to Reduce Your Risks (Da Capo Press, 2003).

Age is a risk factor: the older a woman’s eggs, the greater the likelihood that an embryo will have chromosomal abnormalities. That explains why women over 35 are at higher risk of miscarriage. “Not every egg is normal, even when you’re young,” explains Mark P. Leondires, MD, medical director of Reproductive Medical Associates of Norwalk, CT. “But younger women have a better egg pool.”

Though most first-trimester miscarriages are attributed to chromosomal abnormalities, in some cases a woman’s health or even her anatomy may be the problem. Routine viruses like a cold, or even the flu, do not cause a miscarriage (though a fever can place a pregnancy in jeopardy).

But some infections, including Lyme Disease, Fifth Disease (a viral illness similar to chickenpox or measles), and certain forms of the Coxsackie’s virus (another common childhood illness) can threaten a pregnancy.

Hormonal problems or chronic illnesses such as uncontrolled diabetes, lupus, or thyroid disease can also up the odds of miscarriage. And if the uterus contains scars, fibroids, or a septum (a wall of tissue that divides the uterus almost in half) a fertilized egg may not be able to implant securely. “But if the miscarriage occurs later, in the second trimester, we’re more suspicious that it’s something structural or an undiagnosed medical condition like diabetes or lupus,” adds Dr. Lisa Domagalski, Clinical Assistant Professor of Obstetrics and Gynecology at Brown University, School of Medicine in Providence, RI.

Lifestyle factors such as smoking, excess drinking, and recreationaldrug use may also play a role. Certain foods –undercooked meats, raw eggs and unpasteurized dairy products – could harbor listeriosis, a bacteria that’s been implicated in miscarriage.

What about the daily cup-of-caffeine habit you can’t kick? The glass of wine you drank before you knew you were pregnant? Relax. Those routine habits don’t cause miscarriage.

Warning signs

A miscarriage typically begins with a spot of blood that may or may not be accompanied by menstrual-like cramps or more severe abdominal pain. But it’s worth noting that some women experience bleeding during pregnancy. “Bleeding is not a good sign, but 30% of pregnancies are complicated by some spotting or bleeding,” says Dr. Leondires. Still, if you are experiencing any spotting or bleeding, call your doctor immediately. The loss of normal pregnancy symptoms (i.e. nausea, vomiting and fatigue) are also a red flag.

By examining the uterus, your physician can determine if it is the size it should be for a fetus’s gestational age or if the cervix has opened as the uterus tries to expel the pregnancy tissue. A pelvic ultrasound can also provide valuable information. Your doctor should be able to see the embryo and gestational sac by five or six weeks and detect a fetal heartbeat by seven. In the absence of these signs – assuming you’re far enough along and your pregnancy dates are accurate – a miscarriage is in the offing. Your doctor will also do a blood test to check your level of human chorionic gonadatropin (HCG) a pregnancy hormone that rises rapidly during the first 10 weeks of pregnancy. “In a normal pregnancy, HCG should increase by 1.5 to 2 times, preferably double, in a 48-hour time period,” says Dr. Domagalski.

Liz Holzman Hagen’s didn’t. In August 2004, after an initial blood test confirming her positive at-home pregnancy test, the Elgin, IL musician set off to her doctor for a routine follow-up to check her HCG levels. “The next day a nurse called me to say, ‘I’m sorry, Liz, it’s not a good pregnancy,” Liz, now 37, recalled. Instead of doubling, the HCG levels had declined and soon after Liz began menstruating. Her doctor assured her that this kind of very early loss is normal. Known as a chemical pregnancy, it’s a common form of miscarriage. It occurs when an embryo forms, begins producing HCG, thereby creating a positive pregnancy test, but the embryo does not survive beyond the initial infusion of egg and sperm. Until she became pregnant again, Liz wasn’t fully convinced. But three or four months later, she got past the first trimester. “It was always in the back of my head: Am I going to have another [miscarriage]?” She didn’t. Last July Liz gave birth to a healthy baby girl.

If a miscarriage is imminent or underway, your doctor will discuss the options with you. “Upwards of 80% of women are able to expulse the embryo or fetal tissue without the need for intervention,” notes Dr. Leondires. Some women prefer to let nature take its course. But waiting for the fetus to be naturally expelled can be emotionally harrowing and prolonged. For that reason many women prefer to undergo a dilation and curettage (D&C), a minor surgical procedure performed in a hospital or surgery center. In a D&C, the cervix is widened and the tissue is gently scraped away from the uterus.

Trying again

Mara Barth’s doctor told her to wait a couple of months “to get the hormones back in balance” before trying again. It’s a fairly common directive that many experts now say is unnecessary. “It usually takes four to six weeks following a miscarriage before a woman has her next period. At that point it is perfectly safe to get pregnant again,” states Dr. Lerner. Some doctors still feel that it is best to wait a couple of months to give the hormones a chance to get back in balance. Your doctor can help make the decision that is right for you.*

Remember, the odds are on your side. Miscarriage is common, but a healthy, full-term pregnancy is even more common.

Recurrent Miscarriage

It’s a good bet that even if you’ve had a miscarriage, your next pregnancy will have a happy outcome. A very small number of couples – about 1–2% experience two, three or more consecutive pregnancy losses; a heartbreaking problem known as recurrent miscarriage.

If you have had two consecutive miscarriages, an evaluation is in order to determine the cause. The workup can include everything from an in-depth medical history to blood testing, chromosomal analysis to ultrasounds, and tests that cost from $100 to $1000. In some cases, exploratory surgery, such as a biopsy to determine whether your endometrium develops properly, may be necessary.

An evaluation helps doctors identify the cause in up to 50% of cases. Some culprits: a genetic problem that causes chromosomal abnormalities in the fetus, uterine abnormalities like fibroids or a weak cervix, blood clotting disorders, or hormonal or immunologic problems. “The good news is there are tests and treatments available,” says Jonathan Scher, MD, a New York City ob-gyn.

Your doctor can’t identify a reason for recurrent miscarriage? Don’t despair. Even in the absence of an identified cause and treatment, 60–70% of couples who have experienced recurrent miscarriages eventually go on to have a successful pregnancy.

* After visiting with your physician, it is best to consult with a competent Orthodox Rabbi, who will consider your emotional and physical
well being along with the professional medical advice given to assist and guide you in accordance with Jewish Law.

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