If you have any of the symptoms of a miscarriage, you need to see your doctor immediately. The doctor would check with an ultrasound or an internal examination.

If you’ve been trying to have a baby and your period this time is extra heavy and extra painful, it could just be a natural miscarriage.

Obstetrician and gynaecologist Datuk Dr Nor Ashikin Mokhtar of the Primanora Medical Centre says that sometimes women aren’t even aware that they’re having a miscarriage and because the foetus is completely expelled from the body there isn’t even a need to have a D&C (dilation and cutterage).

Here, she answers some questions on miscarriages.

What is a miscarriage?

The medical definition of a miscarriage is the expulsion of the foetus or the product of conception which usually is below 20 weeks or pregnancy. A miscarriage is also called a “spontaneous abortion”.

The types of miscarriages:

A missed abortion – The woman does not realise she’s not carrying a viable pregnancy. Usually she might have some symptoms of pregnancy and then suddenly there are no symptoms. This is where, without having any symptoms like bleeding, the foetus has already died inside. The exact time it occurred is not diagnosed but it happened earlier than when it was diagnosed.

The woman would know because she’s missed her period, she might have done a home pregnancy test and it was positive. She might have been about seven weeks pregnant but when the doctor does an ultrasound it’s either an empty sac and there’s no foetus or there might be a foetal echo in the ultrasound and a lump of flesh but there’s no heartbeat. And it’s not corresponding to the period of gestation.

An incomplete abortion
– The expulsion has gone through but there are still some tissues left behind like the placental tissue. Normally you have to evacuate it with a D&C.

An inevitable abortion – The foetus is in the process of being expelled but still within the uterine cavity and there’s nothing much the doctor can do as ultimately it will be expelled.

An infected abortion – If the woman has an infection that causes her to lose the baby.

By WHO (World Health Organisation) standards, after 20 weeks it is no longer considered an abortion or a miscarriage but a delivery. What this means is that there’s a possibility that you could save the baby at 500g and above with the new technologies available.

It is just a medical term but still you wouldn’t want to deliver a 20-week foetus.

What are the reasons for a miscarriage?

Most of the time we do not know. You could divide it into foetal causes and maternal causes.

When it comes to foetal causes, perhaps most of the time there is something abnormal about the pregnancy itself or the foetus itself. So that’s the reason why it’s not continuing as it should be.

Whereas the maternal causes can be as simple as if there is a chronic maternal illness – for example, if the mother is suffering from uncontrolled diabetes, hypertension or some auto immune disease. These are some of the underlying causes that affect the pregnancy. Or if the womb itself is abnormal, whether it’s the cavity of the uterus so it can’t implant adequately, or the uterus is normal but there is weakness in the neck of the womb.

If that’s the case there would usually be a miscarriage after the first trimester.

Not unusually also, sudden emotional trauma and stress have been associated with an increased risk of miscarriage.

An increased maternal age also increases risks of foetal abnormalities. If you’re not well, you have some underlying medical diseases – you are at risk. If you have a history of miscarriages you are also at risk of having a miscarriage.

Although the risk is slightly higher if you’ve had a miscarriage, the woman is still advised to go ahead and try because the chance of her having a successful pregnancy is 75%, even with a history of miscarriages.

What are the symptoms of a miscarriage?

If you’re in the early stages of pregnancy you might feel nauseous or want to go to toilet more often, giddiness, vomiting – these are pregnancy symptoms. If suddenly these symptoms go away, that itself shows that something is wrong. Usually the pregnancy symptoms do not go away until the 12th week or so. That could be a missed abortion where there is no bleeding or any other signs.

Not uncommonly also, she might have cramps and that might be associated with some bleeding. If it’s early stages, there might be some light bleeding but sometimes because the body is in the process of trying to expel the foetus then you might have a lot of pain. These are some of the symptoms.

She must go and see the doctor at once so the doctor can make a diagnosis of what is happening to the pregnancy.

How would the doctor check if she’s had a miscarriage?

The doctor would check with an ultrasound or an internal examination. You can detect a viable pregnancy by seeing the heartbeat from as early as six weeks. With a transvaginal ultrasound you can see that very, very well.

Sometimes if she’s bleeding so much you might not have to do an ultrasound because when you do an internal examination the foetus will expel.

Sometimes, the doctor will do the scan and it shows that the foetus is there and there is a heartbeat but when the doctor does a vaginal examination then they realise the neck of the womb is already opening up. That’s an inevitable abortion. There’s nothing much you can do there because it’s just a matter of time before the foetus is expelled.

This is where an ultrasound is required but pelvic and vaginal examinations are also required.

Is a D&C always necessary when there is a miscarriage?

Whether she has to go for a D&C depends on the outcome or the stage that she’s in. Let’s say, she comes in during the early stages of pregnancy and she bled a bit more than usual but she had cramps last night and this morning nothing is there, then there is a possibility that she had a complete abortion. So it’s completely expelled itself and when you scan you can see it’s empty. Then it may not be necessary to do a D&C.

However, in the case of an incomplete abortion or even in the case of a missed abortion, she will need an evacuation of the uterus. Then she will have to go for a D&C.

Should the couple go for counselling if there is a miscarriage?

No two women are the same. Some do take it quite willingly that whatever happens is for the best. Some can be at the other extreme and look at it as a traumatic experience and blame themselves or someone else or the environment – why is it happening to me, would it happen to me again?

In such a case of course it’s better to counsel the husband and the wife together and make them come to terms with it, that miscarriages are quite common. About 50% of pregnancies miscarry. Some women don’t even know that they were pregnant because they think their period was just slightly heavier than usual and slightly more painful.

How can you avoid from having a miscarriage?

If she knows she has some underlying medical disorders, like uncontrolled diabetes, controlling the medical illness would be good, stabilising the hypertension, so she has to correct all those issues. Make herself less stressed, take off from work if she knows she’s pregnant or going to get pregnant.

If everything else is normal, these are probably the things that you could do: See the doctor early so that if you’re due to face hormonal problems that could cause a miscarriage taking hormonal medications or injections may help to support the pregnancy. Most importantly, if she has had a miscarriage before and she thinks she’s pregnant, see the doctor early and these are the areas where we can help support the pregnancy by giving her hormonal injections or medication, or advising her to take off work, starting folic acid much earlier.

How long should she wait after a miscarriage before trying to conceive again?

For a healthy young woman with no issues, she can probably wait for one or two cycles to come on and you can get pregnant again. But just in case, if you’ve had a miscarriage and you’ve had no periods and you get pregnant again, it’s okay. In the old days, they used to say wait for two cycles before trying again so we can date your pregnancy. But now with science and technology we can date your pregnancy if you come early.

If it’s early pregnancy miscarriage, once the bleeding has stopped she can resume relations with her husband in two weeks or so. Again, that depends on her wellbeing, emotionally and psychologically.

Is there such a thing as too many miscarriages and is it a sign to give up?

Whatever you want to do and if you want it, don’t quit. Keep on trying because you still have a 75% chance of carrying the pregnancy through to full term.

I have patients who had six, seven miscarriages and came to see me and I didn’t do anything magical. I just took her off work. Everything else was normal. We did all the investigations and everything was normal, she was healthy. So all she needed was good old-fashioned rest in bed. I literally gave her an MC and took her off work and she carried the pregnancy to full term.

Source: Dr Nor Ashikin