Pregnancy Loss

A Guide to What Complementary and Alternative Medicine Can Offer

Janetta Bensouilah

• Editorial: Routledge
• Año: 2021
• ISBN:
  9781315346564
• Edición: 1
• Categoría: Médecine
• Categoría: Théorie, pratique et référence de la médecine

Growing numbers of women who experience pregnancy loss of all kinds - from early spontaneous miscarriage to stillbirth - seek help from practitioners of complementary and alternative medicine (CAM) in their recovery and preparation for future pregnancy. However, CAM is largely unregulated, and can be an unfamiliar and confusing area for mainstream health professionals. Many of these also have questions about the efficacy and safety of complementary or alternative treatments, and what they may be able to offer. Meanwhile, CAM practitioners may be unaware of the medical investigations and treatments available for conditions such as miscarriage, ectopics, gestational trophoblastic disease, preterm labour, foetal reduction, intrauterine death and stillbirth, and other less common complications. This book, written by an experienced CAM practitioner, aims primarily to provide medical professionals with the knowledge and confidence to advise women seeking complementary or alternative treatments. The author draws on her experience as a CAM practitioner to illustrate key areas where integrating sound and professional CAM into standard practice can offer women benefits, including improved psychological recovery from pregnancy loss. It also gives CAM practitioners greater insight into conventional medicine, and aids them to better understand, respect and care for women experiencing pregnancy loss. This book will be essential reading for all those who work with women who have experienced pregnancy loss, including health visitors, midwives, GPs, practice nurses, counsellors, psychotherapists, and CAM practitioners of all kinds.

CHAPTER 1

Pregnancy loss defined

INTRODUCTION

An early miscarriage may be a normal, natural way to end an unhealthy pregnancy, or it may not. It might be an event which indicates disorder that can be corrected or at least managed, thus reducing any threat to future pregnancies. No one knows for certain the exact prevalence of miscarriage. However, it is estimated that around 15% of clinically recognised pregnancies will end in miscarriage, with a further 15–25% of subclinical pregnancies miscarrying before any signs or symptoms of pregnancy develop.^1–3 Nowadays, with advances in pregnancy detection technology, pregnancies can routinely be detected that would have gone unnoticed in earlier times, leading to an apparent increase in the number of miscarriages, with researchers now viewing recurrent miscarriage as far more common than was once assumed to be the case.⁴ In addition to loss through miscarriage, pregnancies can be doomed by their very nature, as in the case of ectopic or lethal abnormality of the baby, or in the later stages they may result in stillbirth.

DEFINITIONS AND TERMINOLOGY

The World Health Organization (WHO) has defined miscarriage as the loss of an embryo or fetus weighing 500 grams or less, which corresponds to 20 to 22 weeks’ gestation, whereas the legal definition in the UK is the loss of a baby with a gestational age of 24 weeks or less, and in North America it is 20 weeks.⁵ After 24 weeks’ gestation, spontaneous loss of a baby is termed a stillbirth, but if the baby dies in the womb and is not miscarried it is referred to as an intrauterine death. Although ‘abortion’ is the correct medical term for any loss of a pregnancy before viability, and ‘spontaneous abortion’ is sometimes used to refer to miscarriage, there has been a move away from the use of these terms among health professionals. The Royal College of Obstetricians and Gynaecologists suggests that, when talking with parents, the word ‘miscarriage’ is used, and it is reported that after 14 weeks parents prefer the term ‘stillbirth’, as this shows an understanding of the meaning of the loss that has been experienced.⁶

Miscarriage

Early, late, missed and spontaneous miscarriages

Spontaneous miscarriage is the most common complication of early pregnancy. Loss of a baby before week 13 of gestation is called an early miscarriage, and the majority of pregnancy losses occur during this period, in fact in the first 8 weeks of pregnancy. If the physical process of miscarriage has not occurred – that is, the uterus has not expelled the failed pregnancy – it is termed a ‘missed miscarriage’, and it can be particularly distressing for couples to discover at the 12-week scan that the baby had died some time beforehand. Mid-trimester or late miscarriages occur after week 13 of gestation and are relatively rare, affecting less than 3% of all pregnancies.¹ The causes of early and late miscarriage differ considerably, and late miscarriages in particular should always be medically investigated in order to find the underlying cause.

Recurrent miscarriage

Defined as the loss of three or more consecutive pregnancies, recurrent miscarriage (RM) affects around 1–2% of conceptions, and in 50% of these cases no cause can be identified despite major advances in understanding in recent years.^1,5 Some clinicians argue that two miscarriages justify investigation, because the likelihood of finding a cause is more or less the same as after two or three miscarriages. However, although it can be hard for women who have experienced two miscarriages to accept this, undergoing investigations which can be stressful and expensive may not be their best option, as 70–80% of couples who experience RM eventually achieve a successful pregnancy without any medical intervention.^4,5

Threatened miscarriage

Vaginal bleeding with or without pain in the first 24 weeks of pregnancy is relatively common, with the estimated incidence ranging from 20% to 50% of clinically recognised pregnancies.^3,5 There are several possible causes of bleeding and abdominal pain in pregnancy, including those coincidental to the pregnancy (see Box 1.1). As well as bleeding, a diagnosis of threatened miscarriage is reached with the help of an ultrasound scan and an examination showing a closed cervix. Although threatened miscarriages are always alarming, the probability of the pregnancy continuing successfully is high, as 50% of all pregnancies involving bleeding continue. If bleeding occurs at 10 weeks, more than 90% of pregnancies continue, and if it occurs at 13 weeks, more than 99% continue.⁵ Furthermore, studies have shown that there is no damage to the baby as a result of the bleeding.²

Inevitable miscarriage

If the cervix starts to open, a threatened miscarriage becomes an inevitable one as the cervix cannot close again. The opening of the cervix usually causes cramping pain as the uterus attempts to expel the fetus and the bleeding becomes more severe. If any of the pregnancy tissue remains in the uterus, the miscarriage is termed ‘incomplete’ and an evacuation of retained products of conception (ERPC) procedure is usually performed, although expectant management may be offered if deemed appropriate by the medical team.

BOX 1.1: Common causes of vaginal bleeding and abdominal pain in pregnancy

Pregnancy-related causes

• Ectopic pregnancy
• Hydatidiform mole
• Miscarriage

Coincidental to pregnancy: gynaecological causes

• Ruptured corpus luteum
• Rupture or torsion of ovarian cyst
• Torsion or degeneration of fibroid

Causes unrelated to pregnancy

• Appendicitis
• Cholecystitis
• Dysfunctional uterine bleeding
• Endometriosis
• Intestinal obstruction
• Pelvic inflammatory disease
• Renal colic

Missed miscarriage

In some cases, when the fetus dies there are no clinical signs of miscarriage as the uterus fails to expel the fetus. This is termed a missed miscarriage, or early fetal demise. In some cases, women can recall a stage in the pregnancy when they noticed changes, usually a lessening or disappearance of nausea or breast tenderness, but this is not always the case, and the shock of discovering that the pregnancy has ended with no apparent warning can be immense. Although the body will usually expel the pregnancy eventually, many women prefer an ERPC to be performed as it formally ends the pregnancy.

Ectopic pregnancy

A pregnancy that occurs outside the uterine cavity is described as ectopic, and most ectopic pregnancies (98%) occur in the Fallopian tube, with the remainder sited on the ovary, in the cervix or in the abdominal cavity. Ectopic pregnancies are fairly common and their incidence is increasing, now affecting approximately one in every 200 pregnancies in the general maternal population. Although the maternal mortality rate associated with ectopic pregnancy has decreased significantly in the last quarter of a century, it remains the leading cause of first-trimester maternal death in western countries.⁵ The increase in the numbers of ectopic pregnancies may be due to a number of factors, including higher rates of assisted conception, and greater sensitivity of diagnostic tests leading to earlier detection, whereas in previous times spontaneous resolution might have occurred prior to detection. Another factor accounting for the increase is the higher number of older women who are conceiving. Women aged 35–44 years are three times more likely to have an ectopic pregnancy than women aged 15–24 years.¹ The presentation of ectopic pregnancy varies considerably, but one of the most common early symptoms is lower abdominal pain with or without bleeding, and a brown vaginal discharge, sometimes developing into heavier bleeding. Severe abdominal pain is a later feature and localisation is not specific. Abdominal pain associated with rupture tends to be much more intense, and there will be accompanying signs of peritonism on abdominal palpation. It is essential that medical care is sought if an ectopic pregnancy is suspected.

Gestational trophoblastic disease and hydatidiform moles

Gestational trophoblastic disease (GTD) is an uncommon cause of first-trimester vaginal bleeding, and encompasses a range of conditions involving abnormal proliferation of gestational trophoblast tissue, the most common one being the usually benign partial hydatidiform mole. Complete and partial moles can occur, the difference being that complete moles may develop into an invasive cancer. Essentially, moles develop from an accident at fertilisation, resulting in either no developing embryo in the case of complete moles, or one with three sets of chromosomes in partial moles, but in both cases the result is rapidly developing placental tissue. Persistent bleeding, nausea and a larger than expected uterus for gestational age accompany the moles, which are detected by ultrasound scan and removed surgically. If pregnancy is more advanced, medical termination may be used instead, and in all cases careful medical follow-up should be arranged.

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