Miscarriage

Posted by Chantel Martiromo,  Article By Kyle J. Norton

Miscarriage is defined as the loss of an embryo before the 20th week of pregnancy as it is incapable of surviving independently. In medical terminology, miscarriage is a type of abortion, as it refers to the pregnancy ends with the death and removal or expulsion of the fetus, regardless of whether it is spontaneous or medically induced abortion. In US alone, over 15% of pregnancy ends in miscarriage.

Symptoms
1. Bleeding
Most common symptoms of miscarriage. 50% of bleeding during 20 weeks of pregnancy ends in miscarriage
2. Abdominal cramps and pain
Generally, it is the first sign of the incidence
3. Etc.

Causes and risk factors
1. Chorionic hematomaIt is the most common cause 0f vaginal bleeding presented in the live embryo in the first trimester, known as sonographic abnormality. It is the pooling of blood between the chorion, a membrane surrounding the embryo, and the uterine wall. The risk of miscarriage increase depending to the size of of hematoma.

2. Chromosomal abnormalities
Genetic defects such as Down Syndrome can increase the risk of miscarriage as a result of abnormal chromosomes forming of when fertilization occurs.

3. History of recurrent miscarriages

In a study of "The effect of recurrent miscarriage and infertility on the risk of pre-eclampsia." by Trogstad L, Magnus P, Moffett A, Stoltenberg C. researchers found that women with a history of recurrent miscarriages are at risk of developing preeclampsia.

4. Collagen vascular diseases
Increased risk of miscarriage for a woman with collagen vascular diseases such as antiphospholipid syndrome and systemic lupus erythematosus as a result of autoimmune disorders, that causes the immune system to attack its own tissue.

5. Diabetes
Risk of miscarriage for women with uncontrolled diabetes during pregnancy.

6. Hormonal factors
In a study presented at European Society for Human Reproduction and Embryology conference in Stockholm, researchers found that levels of progesterone and of the pregnancy hormone human chorionic gonadotrophin (hCG), are 2 of 6 hormonal factors which have greatest impact on miscarriage risk.

7. Reproductive tract infections
Sexually transmitted infections, Chlamydia, Cytomegalovirus (CMV), etc. are the greastest risk of reproductive tract infection and can lead to miscarriage.

8. Abnormal structural anatomy
Abnormal anatomy of the uterus, such as bicornuate uterus, septate uterus, and unicornuate uterus, Uterine fibroids, etc. can also increase the risk of miscarriages.

9. Prenatal Diagnosis
Medical procedure in used to test the chromosomal abnormalities and fetal infections such as amniotic fluid test or AFT, can increase the risk of miscarriage but rarely. Others such as chorionic villus sampling (CVS) use to test the chromosomal or genetic disorders in the fetus also increase the risk as well.


10. Tissue rejection
Antiphospholipid antibodies can interfere with the formation of the normal placenta involves the fusion of small cells called cytotrophoblasts into giant cells known as syncytiotrophoblasts, causing tissue rejection.

11. Smoking
In the article of "Effect of Maternal Cigarette Smoking on Pregnancy Complications and Sudden Infant Death Syndrome" by Joseph DeFranza and Robert Lew, published in the Journal of Family Practice on 4/1/95, the authors indicated that smoking causes 18,925 miscarriages a year.

14. Nonsteroidal anti-inflammatory drugs
In a study of Exposure to non-steroidal anti-inflammatory drugs during pregnancy and risk of miscarriage: population based cohort study by De-Kun Li, epidemiologist (dkl@dor.kaiser.org), Liyan Liu, programmer analyst, Roxana Odouli, research associate, researchers found that 53 women (5%) reported prenatal NSAID use around conception or during pregnancy. After adjustment for potential confounders, prenatal NSAID use was associated with an 80% increased risk of miscarriage (adjusted hazard ratio 1.8 (95% confidence interval 1.0 to 3.2)). The association was stronger if the initial NSAID use was around the time of conception or if NSAID use lasted more than a week. Prenatal aspirin use was similarly associated with an increased risk of miscarriage. However, prenatal use of paracetamol, pharmacologically different from NSAIDs and aspirin, was not associated with increased risk of miscarriage regardless of timing and duration of use.

15. Caffeine
In a report of Caffeine doubles miscarriage risk, study finds by CTV.ca News Staff, Dated Tue. Jan. 22 2008 10:30 AM ET, indicated that women who drink even moderate amounts of caffeine during pregnancy -- whether from coffee, tea, caffeinated soft drinks or hot chocolate -- have almost double the risk of miscarriage compared to women who stay away from such drinks.

16. Alcohol
In article of New Link Between Alcohol and Miscarriage Found By Colette Bouchez HealthScoutNews Reporter, the author indicated that alcohol has toxic effects on the baby, especially at the earliest stages of development.....""Any toxin, anything that can affect [egg] quality, will increase the risk of miscarriage--and alcohol is one of those toxins," says Lockwood, the director of obstetrics and gynecology at Bellevue Medical Center in New York City.

17. Polycystic ovary syndrome
Increased risk of miscarriage by over 30% if a woman is diagnosis with PCO's. In a study of "Effects of metformin on early pregnancy loss in the polycystic ovary syndrome" by Jakubowicz DJ, Iuorno MJ, Jakubowicz S, Roberts KA, Nestler JE in 2002, researchers found that the drug metformin significantly lower the rate of miscarriage in women with PCOS in one-third of the miscarriage rates of the control groups.

18. High blood pressure during pregnancy
High blood pressure during pregnancy also known as Pre-eclampsia can cause endothelial dysfunction, leading to abnormal immune respond to the developing fetus.

19. Etc.

Diagnosis and tests
Vaginal bleeding can be caused by the rupture of a small vein on the outer rim of the placenta, ectopic pregnancy or it is a sign of miscarriage. In fact, Bleeding in early pregnancy may be a sign of a threatened or early miscarriage.
1. Physical exams
If you have vaginal bleeding, your doctor after recording the family history, a physical exam includes the examine your cervix to determine the cause of bleeding if he/she can such as is the cervix is dilated? is uterus enlarged abnormally?

2. Blood test
a. Human chorionic gonadotrophin
The hCG blood tests are done over two days apart. In early pregnancy, If the hCG doubling time is slower or if the level decreases over time, It may be an early indication of miscarriage or ectopic pregnancy.
b. Antinuclear antibody
The normal titer of ANA is 1:40 or less. Any higher titers may be an indication of autoimmune disease which may cause miscarriage if it attaches the fetus tissue or organs.




3. Hysterosalpingography (HSG)
It is a radiologic test such as radiography, to look into the image of the shape of the uterine cavity and the fallopian tubes for any abnormality which can affect the progression of the pregnancy or may be an early sign of miscarriage.

4. Pelvic ultrasound
Pelvic ultrasound is an image test by using high frequency sound waves to generate the the image which will be sent to your doctor to examine for any abnormality in the pelvic.

4. Etc.

Evaluation
If you have consecutive of recurrent miscarriages or abnormal high risk of miscarriage, evaluation may be necessary to find the physical cause of the problem. There are some tests which can be beneficial to the couple and sometime, early intervention may be helpful to prevent the happening to such incidence.
A. Blood test
1. Human chorionic gonadotrophin
The hCG blood tests are done over two days apart. In early pregnancy, If the hCG doubling time is slower or if the level decreases over time, It may be an early indication of miscarriage or ectopic pregnancy.

2. Autoimmune diseases
They are diseases caused by immune system overreaction by attacking the body substances and tissues in the body. Miscarriage may be a concern, if the immune system responds against the fetus.
a. Antiphospholipid antibodies
It is a diseases of coagulation that causes blood clots in the blood vein and arteries, causing decreased blood flow to the fetus, that can lead to pregnancy-related complications including miscarriage prior to 20 week of gestation.
b. Antinuclear antibody
The normal titer of ANA is 1:40 or less. Any higher titers may be an indication of autoimmune disease which may cause miscarriage if it attaches the fetus tissue or organs.
c. Autoimmune Natural killer cells
Under nornal circuatance, the natural killer cells in the placenta is to promote cell growth, secretes growth molecules for the placenta and regulate the mother's immune response. if they are overreactive activated by the cytokine IL-2, they can which can destroy the placenta. Women with NK cells in excess of 20% are at high risk for miscarriage.
d. Etc.


4. Chromosome abnormalities
An error of chromosomal abnormalities are occurred when an egg or sperm cell develops as a result of too many or too few chromosomes.
a. Amniocentesis
Amniocentesis, also known as amniotic fluid test or AFT, is a test to diagnose the chromosomal abnormalities of the fetus such as Down syndrome (trisomy 21), Edwards syndrome (trisomy 18), , etc., by withdrawing a small amount of amniotic fluid from the sac with local anesthesia.
b. Chorionic villus sampling (CVS)
Chroinic villus sample is the test of withdrawing a fragment of chorionic villi -- tiny fingerlike projections on the placenta to test for chromosome abnormality with the use of a fine needle through your abdomen to reach the placenta.
c. Etc.

C. Hysterosalpingography (HSG)
It is a radiologic test such as radiography, to look into the image of the shape of the uterine cavity and the fallopian tubes for any abnormality which can affect the progression of the pregnancy or may be an early sign of miscarriage.

D. Etc.

Prevention
A. How to prevent
1. Taking aspirin
1. Randomized controlled trial of aspirin and aspirin plus heparin in pregnant women with recurrent miscarriage associated with phospholipid antibodies by Rai R, Cohen H, Dave M, Regan L., reserachers concluded that treatment with aspirin and heparin leads to a significantly higher rate of live births in women with a history of recurrent miscarriage associated with phospholipid antibodies than that achieved with aspirin alone.
2. Avoid smoking
3. No caffeine
4. Reduce intake of alcohol
5. Prvent infection of sexual transmitting diseases
6. Moderate exercise
7. Living a healthy style
8. Etc.

B. Diet
B.1. In nutritional Supplement perspective
Providing vary nutrition with a balancing diet is important for you and your baby. The American Pregnancy Association recommends alterations to your diet, including
1. Protein
Protein in your foods positively affects the growth of fetal tissue, including the brain. It also helps your breast and uterine tissue to grow during pregnancy,
a. 75 to 100 grams of protein per day as it can be divided into 2-3 servings of meat (1 serving = approximately 3 ounces/ size of a deck of cards) from chicken lean beef, lamb, pork, nut and tofu (1 serving = approximately ⅓ cup), etc.
b. 2-3 servings of legumes (1 serving = approximately ½ cup) such as red and white kidney beans,black beans, navy beans etc..

2. Calcium
Daily requirement of calcium is around 1000 milligrams during pregnancy. Calcium helps your body regulate fluids, and it helps build your baby’s bones and tooth buds, such as milk (1 serving = 1 cup), eggs (1 serving = 1 large egg), yogurt (1 serving = 1cup),pasteurized cheese (1 serving = approximately 1.5 ounces/ or 4 playing dice stacked together), tofu (1 serving = ½ cup), etc.

3. Iron
In combination with sodium, potassium, and water, iron helps increase your blood volume and prevent anemia. A daily intake of 27 milligrams is ideal during pregnancy.
a. 2-3 servings of green leafy vegetables (1 serving = approximately 1 cup)such as collard turnip, spinach, lettuce, etc.
b. 3 servings of whole grains (1 serving = approximately. ½ cup or one slice), such as bread, cornmeal, cereal, oatmeal, etc.

4. Folate/Folic Acid
Folic acid plays a key role in reducing the risk of neural tube defects, including spina bifida. Experts recommend 600 to 800 micrograms (.6 to .8 milligrams) daily.
a. 2 servings of dark green leafy vegetables (1 serving = approximately 1 cup), such as collard, turnip, spinach, lettuce. etc.
b. 2-3 servings of fruit (1 serving = approximately ½ cup), such as orange, strawberry, lemon, mango, tomato, etc.

5. Vitamin C
Fruits and vegetables rich in Vitamin C will help with wound healing, tooth and bone development, and promotes metabolic processes. Experts recommend at least 85 milligrams per day. 3 servings of fruit or vegetables (1 serving = approximately ½ cup), such as orange, strawberry, lemon, mango, tomato, etc. (Source)

6. Etc.

B.2. In traditional Chinese medicine perspective
Traditional Chinese medicine divides the foods into five different categories
Hot, warm, neutral, cold and cold.
Since pregnant women are susceptible to the invasion of heat and dampness, eating hot and spicy food can elevate the blood heat, while eating cold foods can increase risk of dampness accumulation that can interfere with the abnormal growth of the fetus in some case, they can cause miscarriage. Please refers to your traditional Chinese medicine practitioner for the list of recommended foods that can enhance a perfect pregnancy.

C. Herbs
Please do not use these herbs until you have consult with your herbal medicine practitioner
1. Chamomile flowers
Chamomile flowers, the dried flower heads of the herb Matricaria recutita is effectively used in herbal medicine to get rid of nauseating feeling, a common symptoms during pregnancy, as well as inducing sleep.

2. Yellow dock
Yellow Dock has been used extensively as herb to cleanse or purify the blood, thus preventing jaundice in newly born baby. Since it contains high amount of vitamin C and iron, it ensures the pregnant women and baby getting enough oxygen for a healthy pregnancy.

3. Ginger root
In a study of Complementary therapies for nausea and vomiting in early pregnancy, researcher concluded that nausea and vomiting are uncomfortable and sometimes debilitating symptoms encountered in early pregnancy. Many of the more conventional remedies offer only partial to negligible relief. Some pregnant women also express scepticism regarding the safety of the more traditionally prescribed pharmacological agents used to combat morning sickness. Vitamin B6, ginger root and acupressure are three complementary modalities that may help alleviate these self-limiting discomforts. Ginger is admired world wide for its anti-inflammatory and anti- bacterial properties. Thus, it works amazingly on morning sickness.

4. Echinacea
Echinacea, a genus of herbaceous flowering plants in the daisy family, Asteraceae has been used traditionally to treat or prevent colds, flu, and other infections by enhancing the immune system. In a study of pregnancy outcome following gestational exposure to echinacea: a prospective controlled study by Gallo M, Sarkar M, Au W, Pietrzak K, Comas B, Smith M, Jaeger TV, Einarson A, Koren G. researchers found that gestational use of echinacea during organogenesis is not associated with an increased risk for major malformations.

5. Red Raspberry leaf
Red Raspberry leaf has been used in herbal medicine as herbal tonic for pregnancy by tonifying the uterus, preventing miscarriage and decreasing constipation due to containing many minerals and vitamins, including vitamin C, calcium and an alkaloid uterus tonifier called fragrine.

6. Nettles
Nettles are species of flowering plants of the genus Urtica in the family Urticaceae contained Vitamins A, C, D and K, calcium, potassium, phosphorous, iron and sulphur of which are necessary for providing nutrients a healthy mother and her baby. The herb has been used in herbal medicine to stop excessive bleeding (vitamin K), prevent hemorrhoids, ease leg cramps and other spasms, nourish and protect the mother and unborn.

7. Etc.

D. Traditional Chinese medicine
Dang Gui Shao Yao San is one the recommended formula because it is extensively used in China and Japan and has been monitored in many large-scale clinical trials with pregnant women. The formula was first recommended for use during pregnancy in the Jin Gui Yao Lue, and has been used regularly for the past 1,800 years. In animal studies researchers found that Dang Gui Shao Yao San showed no teratogenic effects (tendency to cause birth defects). The formula has been used to treat female infertility, morning sickness, anemia during pregnancy, and to prevent miscarriage and approved by the Japanese Ministry of Health. The formula used to avoid miscarriage or to treat a variety of pregnancy disorders, but it is also employed as a blood tonic and treatment for mental distress associated with blood deficiency. It includes peony, Chinese angelica root, cnidium, atractylodes, hoelen and alisma.

Please do not use the above herbs without first consult with your herbalist or traditional Chinese medicine practitioners and your doctor.

Treatments
The objective of treatment during or after a miscarriage is to prevent hemorrhaging and/or infection. Your doctor will make sure that all the fetal tissue are cleared from the uterus.
1. Observation
If the miscarriage is confirmed, in some cases you are sent home to rest and wait for the nature to take its course with follow up instruction. Yor are also instructed to seek medical emergency if there is an excessive bleeding, a severe pain, fever, etc. It is extremely difficult for a woman to wait at home in this situation, and difficult to understand emotionally and physically unless a woman has gone through a similar miscarriage herself.

2. Vacuum aspiration
Before giving the injection anesthesia and medicine to dilate the cervix, the cervix is examined by a speculum then a small, hollow tube attached to an aspirator machine is inserted into the uterus to remove the fetus after your cervix is dilated with injection of medicine. Your doctor will make sure there is no remain in the uterus with a curette before the surgery is completed.

3. Dilation and curettage
Similar to the above procedure, dilation and evacuation (D&E) is a method associated with the dilation of the cervix with the insertion of either a curette or forceps and surgical evacuation of the fetus from the uterus. Your doctor will make sure there is no remain in the uterus with a curette before the surgery is completed.

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