Even though a miscarriage is a relatively common occurrence, it is still a very traumatic experience to go through. By Xanet van Vuuren contributions by Joanna Kleovoulou Clinical Psychologist at PsychMatters Family Therapy Centre, Bedfordview

When a pregnancy ends without a baby, many women may feel that there is something wrong with them or that it is their fault for losing the baby. This is not the case at all. There are numerous reasons why a woman miscarries. Understanding the possible causes, risk factors and medical and psychological care associated with miscarriage may help parents overcome their ‘parental guilt’ after this traumatic event.

Clinical Psychologist Joanna Kleovoulou from the PsychMatters Family Therapy Centre, a facility that helps to empower families, explains that the psychological impact of a miscarriage is complex, as the loss of an unborn foetus involves a grieving process for a life that was not tangible.

The trauma can also be heightened if the mother had difficulty conceiving or if the baby was lost near the end of the mother’s reproductive lifespan. It can also influence a couple’s relationship, as it is a major life event that affects them on many levels – emotional, biological, social, mental and spiritual. In an open, honest and validating relationship with mutual respect and support, a miscarriage is likely to create a stronger bond and the loss might be less traumatic. If a relationship was already stressed and dysfunctional, a miscarriage may cause more strain and strife.

Kleovoulou adds that “men don’t always know how to communicate and connect with their partners about the loss of a child, which makes it difficult for them to support their partners in situations like these. However, there are support groups, couplescounselling, friends and family who can help them work through the distress caused by their loss.”

Lana Sykes shares her story

“After being married for three years, my husband Sean and I finally decided that we were ready to become parents. I fell pregnant at the end of 2003. I had stopped taking the pill three months before and when my cycle had not arrived, I did a pregnancy test and when two very clear lines appeared, I was over the moon. When I heard my husband arrive home, I rushed to the front door to tell him the good news. He was thrilled to say the least. We saw our gynaecologist who confirmed the pregnancy. We even got to see our ‘little bean’ on the monitor for the first time. Everything was perfect.

One Saturday afternoon, my mom, my husband and I were at a friend’s house for lunch. I was then seven weeks pregnant and was feeling a bit tired and had very light cramps. During lunch I felt something was not right and went to the bathroom. I noticed a bit of spotting. Naturally I panicked and called my mom, who had three miscarriages before my older brother was born. She suggested that I call my gynaecologist who said we should slowly make our way to his rooms. He did a scan and said that everything seemed to be in order. He could even detect our baby’s heartbeat, which was very exciting. He prescribed some medication to stop the bleeding and told me to get lots of bed rest. Everything was fine for the rest of the day.

On Sunday evening, I could feel something was wrong. This time the bleeding was much heavier. My gynae said that I should carry on taking the tablets and continue getting a lot of bed rest. I spent the following day in bed at my parents’ house. I just had a little cramping, but the bleeding had stopped. On our way home that evening, my husband and I stopped to get DVDs. While I was standing in the store, I felt the bleeding start again. I knew for certain then that things were more serious, as there was a lot of bleeding and clotting. It was terrifying. My poor husband was waiting outside for me and the minute he saw my face, he knew that something was horribly wrong. We called my gynaecologist and my parents. The scan showed that the little sac was broken and there was a lot of bleeding inside the womb. The gynae wanted me to have a scan the next day, and from there we would take the necessary steps.

The radiologist’s scan confirmed that we had lost our baby. It was the saddest day. My gynaecologist was also very emotional and kept telling us how sorry he was. I had a dilation and curettage (D and C) procedure done the same day. It was not painful, just a bit uncomfortable. Once it was all over, it was time for the emotional healing to begin. We tried for a year to fall pregnant again.

Today we are the proud parents of a beautiful, healthy and very bubbly 2-year-old girl named Morgan Ani-Mae. She is the light of our lives. My message to all those who have been through what we have and worse, is to “never give up hope!”

Miscarriage is the natural or spontaneous end of a pregnancy in the first 20 to 28 weeks of the gestation period. According to specialist obstetrician and gynaecologist Dr Patricia Okeyo, 12 to 15% of all recognised pregnancies end in miscarriage. “Only about 3% of pregnancies – which are viable at 8 weeks of gestation – subsequently result in miscarriage. Virtually all miscarriages occur by 14 to 16 weeks. If a woman has had one or two miscarriages before, the likelihood of a successful later pregnancy is still about 80%.” Studies have found that 30 to 50% of fertilised eggs are lost before a woman finds out that she is pregnant.

Possible causes of miscarriage

• Genetic and developmental abnormalities. These chromosomal imbalances account for about 50% of miscarriages in the first trimester and about 20% in the second trimester.

  • Placental problems. A placenta that does not function properly or an imperfectly formed one can cause malnourishment and death of the foetus.
  • Infection. Certain viral infections in the mother might cross the placenta and lead to miscarriage.
  • Anatomical disorders. Some women have an incompetent cervix, where the mouth of the womb does not stay firmly closed and cannot keep the growing baby secure in the uterus. Miscarriage in this case often occurs in the mid-trimester of pregnancy. If the womb is abnormally shaped, it can prevent the pregnancy from progressing normally. This abnormality may be as a result of a congenital defect of the uterus or may be due to the development of an acquired condition, such as fibroids.
  • Hormonal defects. Irregular hormonal levels may cause a miscarriage, as a delicate balance is required to sustain the growth of the baby and ensure that everything else functions normally. Low progesterone levels are the main imbalance. A diabetic mother with poorly controlled blood sugar is at a significantly increased risk of miscarriage.
  • Epidemiological factors. Maternal age may be a risk factor, for example, a teenage pregnancy or advanced maternal age above 35 years.
  • Other factors. A fall can cause a miscarriage, but only if the pregnancy is after 12 weeks and could have a direct impact on the abdomen. The uterus may also be compromised if the pelvis is fractured. Smoking and alcohol intake may have an adverse effect on a pregnancy and may play a role in recurrent miscarriages. These should therefore be avoided when planning a pregnancy, as well as during pregnancy.

Psychological factors associated with miscarriage

Kleovoulou says that some women who miscarry didn’t know that they were pregnant, and therefore destructive beliefs may start to surface: ‘Did I drink too much? Was I too active? What could I have done to do this to my child?’ Women who have suffered a miscarriage may experience a number of different emotions, ranging from shock to despair. Some may even feel jealous or envious of other mothers who have had healthy pregnancies. Women may often also feel that their friends are not being sensitive enough about their miscarriage and this may lead to them feeling alone. Some men blame their partners for losing the baby. “A partner may be very hurt, and because he may not know what to do with those feelings, he might externalise his pain by blaming his partner,” says Kleovoulou.

Medical Classifications of Miscarriages

A complete miscarriage is when all of the products of conception have been expelled from the uterus.

An incomplete miscarriage is when some of the products of conception are expelled from the uterus.

A missed miscarriage means that the foetus has died but is retained with the placenta in the uterus.

An inevitable miscarriage means that the foetus has died and is being expelled from the uterus. This may happen as a complete or incomplete miscarriage.

A threatened miscarriage is when the foetus is still alive and has not been expelled from the uterus, despite bleeding from the vagina.

Source: Complete Family Health Encyclopaedia by the British Medical Association, Dorling Kindersley, 1990

Signs of miscarriage

  • Vaginal bleeding
  • Lower abdominal cramps or pain
  • Fluid or blood clots and other pregnancy tissue passing from the vagina

Can a miscarriage be prevented?

Okeyo says that in the majority of cases there is nothing the woman or the doctor can do to prevent a miscarriage. “The doctor can try to save the baby, but it all depends on the underlying cause of the miscarriage. If the problems are treatable, the doctor will do as best as he or she can.” Women simply have to focus on taking good care of themselves and their babies.

Diagnosing miscarriage

Your doctor will do a pelvic exam to see if your cervix has begun to dilate. An ultrasound may also be used to check if your baby is still alive and to determine if the foetus is still developing normally.

Some treatment options for miscarriage

Expectant management

If a missed miscarriage is discovered through an ultrasound, a woman may choose to let the miscarriage progress naturally. This usually happens within a couple of weeks of determining that the embryo has died.

Medical treatment

In the case of an inevitable miscarriage, the process can be accelerated with medication that will cause the body to eject the pregnancy tissue and placenta.

Surgical treatment

If a woman had an incomplete miscarriage or some of the pregnancy tissue or placenta remains in the uterus, she may need a minor surgical procedure called dilation and curettage (D and C). The doctor dilates the cervix during this procedure and gently suctions the tissue out of the uterus. Okeyo adds that if a woman miscarries before eight weeks, she may well have a complete miscarriage and won’t need any treatment.

How long does it take to recover?

Okeyo says that physical recovery from miscarriage may take only a few hours or weeks, depending on how long a woman was pregnant. “She can expect her period to return within four to six weeks.” The emotional healing, however, may take much longer.

When can a woman try to conceive again?

While it is possible to fall pregnant during the menstrual cycle immediately after a miscarriage, Okeyo advises women who had a miscarriage to have a three-month break so that they can be fully psychologically and physically ready for their next pregnancy. Kleovoulou adds that it is important for a mother to grieve for her lost baby. “She needs to work through and process the psychological aspects like guilt and anger and accept that she has experienced a loss before trying to fall pregnant again.”

How to cope

Okeyo says that even though a lot of moms deal with the pain of a miscarriage on their own, some women may feel that they are not strong enough to do so. In these situations it may be helpful to get psychological counselling. Kleovoulou further explains: “The way a woman copes with a miscarriage depends on her personality and whether or not she has experienced a loss before.” Some women may feel that they can’t reach out for help, so they turn their pain inwards. Kleovoulou says that these women usually need the help of a support group or a psychologist. “Women who experience these emotions may also be more susceptible to depression and their prolonged grief may trigger other psychiatric conditions, such as anxiety or depression.” With a miscarriage, most of the sympathy often goes to the mother and the father may be excluded. Dads have to deal with the same pain as mothers as they’ve also lost a child. Kleovoulou recommends that couples go for counselling together. “The therapist will provide an open, warm space where partners can validate their feelings and create emotional intimacy. This will help them to facilitate each other’s healing.”

Debbie Flugel shares her story

My life officially began when my son Joshua was born. He has been such a wonderful child and I can’t imagine my life without him. About 18 months after we had Joshua, my husband and I decided to start trying for baby number two and we were ecstatic when I again fell pregnant.

My best friend phoned me about a week later to tell me that she was pregnant as well. We were so excited that we were going to be able to go out shopping for baby things together. The day after the phone call from my friend, I noticed that I was bleeding. I was incredibly shocked. I phoned my gynae’s rooms in panic. My gynae confirmed that we had lost our baby. It was the worst day of my life. I stayed at home for two days, crying myself to sleep, only to wake up and realise that it was not a nightmare but reality. After my check-up the following week, the gynae said that all was clear and that we could start trying to conceive again after my next period.

About a month later I went for a blood test and my beta count was not high enough to confirm a pregnancy. I just knew that I was pregnant, so I went back for another blood test a few days later and my beta count was somewhat higher, but the doctor was still not satisfied. After a few days, I went back for another blood test and my beta count was 240. I was pregnant! About a week later I started bleeding again. But this time it was just a little spotting, so I left it. The next day I was bleeding quite heavily and went to see my gynae. He said that the baby looked fine and that I was probably just having my period, which is not entirely unusual. He prescribed some medication for me and the bleeding stopped. I went for my check-up shortly afterwards and found that the baby had stopped developing. A blood test proved that my beta count had dropped and the pregnancy was lost.

After two miscarriages I was devastated and thought that I would never be able to have another baby. A few months later, another blood test came back positive with a high beta count. I have had two scans so far and I have seen my baby’s heartbeat. I believe that when the time is right, God will bless us with a baby. I only hope that this time is the right time.

Specialist obstetrician and gynaecologist Dr Patricia Okeyo can be contacted on 011 884 5556.

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