the rate of miscarriages (Abortion) are extremely high in The Gambia
What is a miscarriage (Abortion)
A miscarriage is the loss of a fetus before the 20th week of pregnancy. The medical term for a miscarriage is spontaneous abortion, but “spontaneous” is the key word here because the condition is not an abortion in the common definition of the term.
According to the March of Dimes, as many as 50% of all pregnancies end in miscarriage -- most often before a woman misses a menstrual period or even knows she is pregnant. About 15-25% of recognized pregnancies will end in a miscarriage.
More than 80% of miscarriages occur within the first three months of pregnancy. Miscarriages are less likely to occur after 20 weeks gestation; these are termed late miscarriages.
What Are the Symptoms of a Miscarriage?
Symptoms of a miscarriage include:
Bleeding which progresses from light to heavy
If you experience the symptoms listed above, contact your obstetric health care provider right away. He or she will tell you to come in to the office or go to the emergency room.
What Causes Miscarriage?
Most miscarriages happen when the unborn baby has fatal genetic problems. Usually, these problems are unrelated to the mother.
Other causes of miscarriage include:
Medical conditions in the mother, such as diabetes or thyroid disease
Immune system responses
Physical problems in the mother
A woman has a higher risk of miscarriage if she:
Is over age 35
Has certain diseases, such as diabetes or thyroid problems
Has had three or more miscarriages
A miscarriage sometimes happens because there is a weakness of the cervix, called an incompetent cervix, which cannot hold the pregnancy. A miscarriage from an incompetent cervix usually occurs in the second trimester.
There are usually few symptoms before a miscarriage caused by cervical insufficiency. A woman may feel sudden pressure, her “water” may break, and tissue from the fetus and placenta may be expelled without much pain. An incompetent cervix can usually be treated with a “circling” stitch in the cervix in the next pregnancy, usually around 12 weeks. The stitch holds the cervix closed until it is pulled out around the time of delivery. The stitch may also be placed even if there has not been a previous miscarriage if cervical insufficiency is discovered early enough, before a miscarriage does occur.
How Is a Miscarriage Diagnosed and Treated?
Your health care provider will perform a pelvic exam, an ultrasound test and bloodwork to confirm a miscarriage. If the miscarriage is complete and the uterus is empty, then no further treatment is usually required. Occasionally, the uterus is not completely emptied, so a dilation and curettage (D&C) procedure is performed. During this procedure, the cervix is dilated and any remaining fetal or placental tissue is gently removed from the uterus. As an alternative to a D&C, certain medications can be given to cause your body to expel the contents in the uterus. This option may be more ideal in someone who wants to avoid surgery and whose condition is otherwise stable.
Blood work to determine the amount of a pregnancy hormone (hCG) is checked to monitor the progress of the miscarriage.
When the bleeding stops, usually you will be able to continue with your normal activities. If the cervix is dilated, you may be diagnosed with an incompetent cervix and a procedure to close the cervix (called cerclage) may be performed if the pregnancy is still viable. If your blood type is Rh negative, your doctor may give you a blood product called Rh immune globulin (Rhogam). This prevents you from developing antibodies that could harm your baby as well as any of your future pregnancies.
Blood tests, genetic tests, or medication may be necessary if a woman has more than two miscarriages in a row (called recurrent miscarriage). Some diagnostic procedures used to evaluate the cause of repeated miscarriage include pelvic ultrasound, hysterosalpingogram (an X-ray of the uterus and fallopian tubes), and hysteroscopy (a test in which the doctor views the inside of the uterus with a thin, telescope-like device inserted through the vagina and cervix).
How Do I Know if I Had a Miscarriage?
Bleeding and mild discomfort are common symptoms after a miscarriage. If you have heavy bleeding with fever, chills, or pain, contact your care provider right away. These may be signs of an infection.
Can you Get Pregnant Following a Miscarriage?
Yes. At least 85% of women who have miscarriages have subsequent normal pregnancies and births. Having a miscarriage does not necessarily mean you have a fertility problem. On the other hand, about 1%-2% of women may have repeated miscarriages (three or more). Some researchers believe this is related to an autoimmune response.
If you’ve had two miscarriages in a row, you should stop trying to conceive, use a form of birth control, and ask your health care provider to perform diagnostic tests to determine the cause of the miscarriages.
How Long Will I Have to Wait Before I Can Try Again?
Discuss the timing of your next pregnancy with your healthare provider. Some health care providers recommend waiting a certain amount of time (from one menstrual cycle to 3 months) before trying to conceive again. To prevent another miscarriage, your health care provider may recommend treatment with progesterone, a hormone needed for implantation and early support of a pregnancy in the uterus.
Taking time to heal both physically and emotionally after a miscarriage is important. Above all, don’t blame yourself for the miscarriage. Counseling is available to help you cope with your loss. Pregnancy loss support groups may also be a valuable resource to you and your partner. Ask your health care provider for more information about these resources.
Can a Miscarriage Be Prevented?
Usually a miscarriage cannot be prevented and often occurs because the pregnancy is not normal. If a specific problem is identified with testing, then treatment options may be available.
Sometimes, treatment of a mother’s illness can improve the chances for a successful pregnancy.
What will the doctor look for during an examination with suspected miscarriage?
A woman’s cervix might have some bloody discharge, but nothing else unusual will be characteristic of threatened abortion. Some women will have mild uterine tenderness during the manual examination of the uterus.
The doctor may look to see if the cervix is dilated and will check to see if the uterus is enlarged to an extent appropriate for gestational age of the pregnancy.
How is threatened abortion evaluated?
Pelvic ultrasound is used to visualize foetal heartbeat and to determine whether a pregnancy is still viable. The ultrasound examination can also distinguish between intrauterine and ectopic pregnancies. The doctor may also order blood levels of serial human chorionic gonadotrophin (HCG) to help determine the viability of a pregnancy if the ultrasound examination is not conclusive. During the evaluation, the woman may be advised to rest and avoid sexual intercourse (activity).
What happens during miscarriage?
The symptoms you experience will depend on the cause of the miscarriage and how advanced the pregnancy is/was so may take hours, days or even weeks to complete. Usually the foetus, placenta and blood from the uterus leave the body through the vagina. You may discover during a routine scan that there is no heartbeat, or even an empty foetal sac.
Usually, by the time bleeding begins your baby has already died, unless it is around the 6 weeks period when only a small amount of blood is lost and then there is an 80% your baby will be fine.
99% of foetal deaths occur in the first 12 to 14 weeks of pregnancy (1st trimester), although the actual miscarriage may not happen for some weeks after the baby dies. Medically this is called a ‘missed abortion’. (The baby is an “embryo” to the 8th week and a “foetus” after that.)
What is an Ectopic pregnancy?
An ectopic pregnancy is when the fertilized egg settles and grows outside the inner lining of the uterus, instead of inside.
Around 1% of all pregnancies are ectopic. Left untreated they can be fatal - because of internal bleeding - and the risk of losing the baby is increased.
Symptoms of an ectopic pregnancy are:
- Shoulder tip pain - where the shoulder ends and the arm begins, more evident when the patient is lying down
- Severe abdominal pain
- Feeling light-headed
What treatment can a woman expect when she has had a miscarriage?
The central goal of the doctor in this situation will be to try to figure out whether the woman has passed all of the tissue from the foetus and placenta. If she has passed all the tissue, she may only require observation by medical personnel. On the other hand, a woman who has not passed all of the tissue (incomplete abortion) will usually need suction dilation and curettage (D&C) of the uterus to remove any retained products of the pregnancy.
This procedure is done with local anaesthesia, and sometimes antibiotics may be prescribed for the woman to prevent infection.
Can something be done to prevent future miscarriages?
The treatment of recurrent miscarriage depends on what is believed to be the underlying cause. This often is not as simple as it sounds. Careful evaluation may turn up several potential factors which alone or together may be responsible for the pregnancy losses.
If a chromosomal problem is found in one or both persons, then counselling as to future risks is the only option for the couple, since there is currently no method to correct genetic problems.
If a structural problem is encountered with the uterus, surgical correction could be contemplated. It should be emphasized that just because a structural abnormality is found, it does not necessarily mean that it caused the miscarriage.
Removal of a fibroid or uterine septum does not guarantee a future successful pregnancy, since the fibroid or uterine septum may not have been the cause of miscarriage in the first place.
For further information visit The Governments Hospital and Clinics throughout the country, Mother and Child Department Ministry of Health, number of NGO and Private Clinics, E Mail email@example.com, and text on 002207774469/3774469 working days from 3-6 pm
Author DR AZADEH Senior Lecturer at the University of the Gambia, Senior Consultant in Obstetrics and Gynaecology, Clinical Director at Medicare Health Services