MISCARRIAGE AND PREGNANCY LOSS

Pregnancy loss is a sad and difficult event, no matter how early in pregnancy it occurs. Even if the pregnancy was not planned it is often emotionally difficult when it does not continue. Below is a summary of some causes of loss in each trimester and some ideas about ways loss might be prevented.

First Trimester Loss

Miscarriage can be related to several factors, including fetal (problems with the baby), placental (problems with the placenta or cord which provide nourishment and oxygen to the baby) or maternal abnormalities (mother’s illnesses, infections or health conditions). In many cases the reason for a miscarriage cannot be determined. Miscarriage (also referred to as spontaneous abortion) occurs in one out of five conceptions; about 90% of miscarriages happen during the first trimester of pregnancy. Current thinking is that at least half of early pregnancy miscarriages happen because the developing embryo (first eight weeks after conception) is not normal.

In most cases, women who experience one miscarriage go on to have successful pregnancies in the future. Even a second miscarriage does not necessarily indicate a problem. But women who have had two or more known miscarriages in the first trimester, or one miscarriage in the second, may benefit from a visit with their health care provider before trying to get pregnant again. There are some tests that can be done to check for immune disorders, hormone levels, chromosome problems, clotting factors, and other conditions which appear to be associated with miscarriage. Even if no clear reason is found, 60 to 70% of women are able to carry a pregnancy full term in the future.

Second Trimester Loss

One cause of second trimester pregnancy loss is cervical incompetence, also called cervical insufficiency. This may account for up to 25% of the occurrence of all second trimester miscarriages. Cervical incompetence is when the cervix (opening of the uterus) is too weak or too short to stay closed after the growing weight of the pregnancy begins pushing on it. This loss usually occurs between the 16th and 24th week of pregnancy, with the vast majority occurring between 18 and 22 weeks. Most women have no symptoms prior to being found with a bulging bag of waters (amniotic fluid sac) in the vagina, rupture of membranes (gush of fluid from the vagina), or advanced dilation (opening) of the cervix which results in the preterm delivery of a baby too young to survive. Most women first hear the term “cervical incompetence” after losing a pregnancy in the second trimester.

If this has happened to you in the past, there are some things you should discuss with your doctor or midwife early in your prenatal care. First, you should make an appointment as soon as you become aware of the pregnancy. Your provider can arrange for an ultrasound exam no later than 12 weeks to determine the length of your cervix as a baseline measurement. Follow-up ultrasounds may be done periodically during the pregnancy to check whether the cervix is getting shorter or beginning to open, or for any other changes. In some cases it is possible for a doctor to place a cerclage, or stitch, into the cervix to help hold it together as the uterus and fetus grow, and this can be done as early as 12-14 weeks of pregnancy. A test for the presence of fetal fibronectin, which helps to predict preterm labor, may also be done after 24 weeks.

Bedrest has not been shown to improve pregnancy outcomes for women with cervical incompetence but you should discuss this with your provider. Some women are advised to avoid sexual activity, as this may cause the uterus to contract or the cervix to thin. At times, certain medications are prescribed to decrease uterine contractions. Also, it is important to make sure you are free from vaginal and pelvic infections throughout the entire course of the pregnancy.

If in the past you have given birth to a preterm baby (before 37 weeks), it is important to discuss this with your doctor or midwife at your first prenatal visit. There is a new medication, progesterone (also called 17 P), which is given as weekly injections beginning week 16 - 20 in pregnancy. 17 P is showing good results in many cases for prolonging pregnancy in a woman who has previously given birth to a premature baby.

Third Trimester Loss

Though early miscarriage is more common, tragedy sometimes strikes even in late pregnancy. This could result from genetic problems, trouble with the umbilical cord or placenta, or other (often unknown) events. In these cases there is little that can be done to prevent the loss.

The best way to decrease the chance of losing your pregnancy is to attend early and regular prenatal care appointments. You should always report any symptoms such as vaginal bleeding, leaking of fluid, back pain with uterine pressure or cramping to your care provider.

In some cases, doing regular fetal kick counts can help the mother to be aware of changes that may not be obvious even at a doctor visit. If the baby is in distress he/she may not be as active, or in some cases may become extra-active. Being aware of your baby’s typical movement patterns, beginning at week 28 (around the seventh month) in your pregnancy can give you peace of mind. Abnormal activity should be reported to your care provider and may be a reason to go to the hospital for evaluation.

How to Do Fetal Kick Counts

Sit down with your feet up or lie down on your left side after a full meal, when babies are usually most active. Make sure you are not distracted by television, cell phone or ipod. Write down the time and start counting your baby’s movements. After you feel 10 distinct movements, write down the time again. If you count movements after a meal or during the time of day when your baby is most active, this often takes much less than one hour. If you do not feel 10 distinct movements in two hours, contact your provider or the hospital where you plan to deliver. It is recommended you do this daily beginning in the 7th month of pregnancy. This is a good reason to relax, put your feet up and will also help reduce swelling in your legs.

A Kick Count Record to record your baby’s movements may be downloaded here.

Example

On Sunday, October 14th, you begin counting your baby’s movements at 7:05 PM. By 7:40 PM you have felt your baby kick or move 10 times. You would fill in your chart this way:

Day	Mon	Tues	Weds	Thurs	Fri	Sat	Sun
Start Time	7:05
Stop Time	7:40
Minutes to reach 10	35

When Loss Occurs

Sometimes a baby dies either before or after birth in spite of the best prenatal care. This may happen even to women who have never used tobacco, drugs or alcohol, and who exercised and ate well. These are tragic accidents. Loss of a child is devastating for the family. If you experience a loss, it is important to take care of yourself and seek the help of loved ones and/or professionals during this difficult time. You and other family members may suffer from depression.

Some valuable resources include mental health therapists (may be provided through insurance), employee support programs, community mental health clinics or grief services associated with hospitals. You will have lots of questions and others who have experienced a similar loss can often help. There are also some good online resources where you can go for information and support. Each person’s needs are unique but it is important to realize you are not alone in your loss.

National Stillbirth Society
Missing Angel Foundation
Share Pregnancy & Infant Loss Support
Support for Trisomy 18, 13 & Related Disorders
Utah Birth and Death Certificate information