A Mother’s Guide to Miscarriage and Moving On

Miscarriages are relatively common in Singapore, with about 20% of pregnancies ending this way. This can be cold comfort when you are still coming to terms with a recent loss. But, one can gather strength from the knowledge of what just happened. Having that can help you grasp the situation, understand the underlying reasons with objectiveness, and move forward. 

We cannot tell you how to grieve over the loss, but we can help you make sense of it. We have gathered easily digestible information to understand the physical aspect behind pregnancy loss. Besides being of help to women who dealt with miscarriage, this information can also benefit those who are still planning to start a family.

What is a miscarriage? 

Miscarriage, also known as spontaneous abortion, refers to pregnancy loss before the 24th week of gestation. If a pregnancy ends after, it’s no longer called a miscarriage even though it’s a pregnancy loss but termed a stillbirth.

The American College of Obstetricians and Gynecologists (ACOG) estimates that about 15-20% of clinically recognised pregnancies end up in miscarriages. Some women may even miscarry even before they are aware that they’re pregnant, or before it was confirmed by their doctor. Compared to that in the first trimester, the risk decreases in the second trimester. That is why it’s a common practice for couples to make their baby announcement after the first three months. 

Why do some women have a tendency to miscarry? 

There are indeed women who are more likely to miscarry than others. Sometimes, they may even blame themselves, but miscarriages usually happen for reasons that are beyond one’s control.

Causes like chromosomal abnormalities, abnormal placenta development, a weakened cervix, an abnormally shaped womb, and umbilical cord issues are causes that can be difficult to control, especially without professional help. A glitch in genetics accounts for more than 50% of miscarriages in the first trimester. Meanwhile, anatomical anomalies in the reproductive system also heighten the risk of recurrent miscarriages. Furthermore, complications involving the placental development or the umbilical cord can also compromise a pregnancy because it affects proper blood circulation between the mother and her baby. 

Fortunately, some of these potential causes are controllable, such as a poor diet  (e.g. high levels of caffeine and alcohol intake), medications, stress, and underlying health conditions (e.g. obesity, high blood pressure, severe uncontrolled diabetes, kidney disease, HIV, Malaria, Gonorrhea, Syphilis). Infections like german measles, listeriosis or chickenpox can also complicate and even terminate a pregnancy, especially if you contract it in the first trimester. 

All these causes strengthen the importance of getting preconception screening and regular prenatal check-ups. 

What are the factors that put me at risk of having a miscarriage?

Several risk factors can lead to miscarriage. If you’re planning to get pregnant or trying to make sense of a past miscarriage, you will benefit in knowing the contributing circumstances.

Here are the following risk factors that may lead to pregnancy loss:

Obesity

Based on data by the World Health Organization (WHO), Singapore ranked second in overweight prevalence in the Association of Southeast Asian Nations (ASEAN) at 32.8 per cent in 2014. A study conducted by Singapore’s Health Promotion Board (HPB) also revealed that Singaporeans are 3 kilograms heavier than they were 15 years ago. 

Source: Food Industry Asia

Research also revealed that obesity is associated with increased risk of the first trimester and recurrent miscarriage. This lifestyle disease can also compound any risk factors that are associated with pregnancy loss. For instance, linked to high blood pressure, and it can also make diabetes difficult to manage.

Underweight

On the other end of the scale, women who are underweight before they get pregnant have a higher chance to miscarry in the first trimester. 

Older maternal age

In terms of age, conceiving quite late may be successful for some, but it doesn’t mean that it comes without any risks. Women under 35 have a 20 per cent or less risk of miscarrying, while those over 40 have more than a 40 per cent chance. 

Previous history of miscarriage

A previous miscarriage can also increase your risk by up to 20 per cent. After two consecutive pregnancy losses, the risk increases by up to about 28 per cent, and 43 percent for three or more consecutive miscarriages.

Illicit drug use

Anything that is established to be harmful in regular individuals can have severe consequences to vulnerable populations like pregnant women and her unborn child. Illegal substances can cause miscarriage and preterm birth.

Alcohol intake

You don’t have to abuse alcohol to introduce risks to your pregnancy or the baby. One study showed that any amount increases the odds of a miscarriage by 19 per cent. In particular, binge drinking also comes with severe risks to the baby like fetal alcohol syndrome.

Smoking

Cigarette smoke is also another habit that can put significant harm to your pregnancy. Research found that women who smoked heavily while pregnant (at least 20 sticks a day) have beyond twice as much risk as non-smokers to have a miscarriage. E-cigarettes are no safer option either because on top of nicotine it also contains a mix of other aerosolised chemicals.

Caffeine

Skipping coffee may not be an easy compromise, especially if your day jumpstarts with it. A 2016 study by the National Institutes of Health examined 344 pregnancies and found that the rate of miscarriage was higher if either one or both partners drank two or more caffeinated beverages a day in the weeks leading up to conception. The general advice is to keep to one cup of coffee a day in pregnancy. 

Exposure to workplace hazards 

Long work hours, psychosocial stress, physical efforts, and environmental exposure (e.g. chemicals or radiation) are just some of the dangers that a pregnant woman can potentially encounter in the workplace. Fortunately, these are preventable factors. Expectant moms should be mindful of what she is exposed to because while some are harmful at high doses, other factors can already do damage at low doses. 

What are the symptoms of a miscarriage? 

As mentioned earlier, some miscarriages go unnoticed, but for those that do, some women may experience the following symptoms:

What are the diagnostic tests used to check if you had a miscarriage?

Besides red flags that signal a miscarriage, some measures can confirm if there was indeed a miscarriage. Diagnosis is essential because any treatment done before a confirmed diagnosis can have harmful consequences such as interruption of a pregnancy, pregnancy complications, and birth defects. 

Diagnosing early pregnancy loss is relatively straightforward, requiring limited testing or imaging. For other cases, the doctor may use a combination of these diagnostic exams to confirm a suspected miscarriage, and these procedures include:

1. Transvaginal ultrasound

If you’ve had an ultrasound during the early stages of pregnancy, you may be familiar with a transvaginal ultrasound since it’s the usual device used to assess the baby before you reach 8 weeks of pregnancy. It’s a wand-like probe inserted into the vagina, to check a suspected miscarriage. It can also help reveal any abnormalities in the structure of your womb, which may have led to pregnancy loss. It may not be as comfortable as a trans-abdominal scan, but a transvaginal ultrasound provides an accurate image and details problematic areas. 

2. Blood Test

A blood test can also be ordered by your doctor to check the levels of pregnancy hormones in the blood and compare it previous measurements. Abnormal levels may indicate a problem, especially if a decrease in other pregnancy symptoms accompanies it. However, a conclusive diagnosis of pregnancy loss may require an ultrasound to check your baby’s heartbeat, followed by a confirmatory process involving scans conducted on multiple days.

3. Pelvic exam

A pelvic exam, on the other hand, can check if your cervix is thinning or opening, since this is a strong indication that you could be miscarrying. If you experienced spotting or light vaginal bleeding, but the cervix has not opened, this may suggest a threatened miscarriage, which is a relatively common condition. However, it means that the pregnancy is still viable. 

Furthermore, an ectopic pregnancy, a condition where the fertilised egg implants outside the uterus, may be suggested on a pelvic exam usually manifested in unilateral lower abdominal pain. Sadly, this pregnancy is nonviable, and it may turn into a medical emergency if left untreated. 

4. Fetal heart rate monitors

These fetal heart rate monitors, also called fetal dopplers, are handheld ultrasound devices which solely detect the sound of your baby’s heart through your belly. This device is routinely used during prenatal visits although occasionally some women purchase one for use at home. 

In the early stage of pregnancy, the lack of a heartbeat doesn’t mean that you had a miscarriage. A baby’s heartbeat doesn’t develop until 6th week in the womb, and it becomes audible using fetal heart rate monitors somewhere between the tenth and twelfth week of pregnancy. However, the exact time may vary based on the position of your uterus, the position of the placenta, and other factors. 

A lack of heartbeat after 12 weeks of pregnancy is a strong indication of pregnancy loss. Your doctor may conduct a full ultrasound scan to check for any heartbeat. 

What can I do to reduce my risk of a miscarriage?

Almost 80-90% of miscarriages happen in the first trimester (before week 14). After that, your chance of miscarrying drops. While most cases of pregnancy loss can’t be prevented, some precautions can help increase your chances of a healthy pregnancy. But, here’s how to lower your risk:

Watch what you eat

To avoid a recurrent miscarriage, it’s also essential that you watch what you eat. Ensure a well-balanced diet that is rich in folic and calcium. You can also supplement this with prenatal vitamins which you must take daily to ensure that your baby gets the key nutrients for development. On the other hand, there are also food options that pregnant women must avoid because they pose serious risks to a pregnancy, such as raw meat, unpasteurised dairy or fishes with elevated concentrations of mercury.

Run ALL your medications by your doctor

On top of choosing your meals carefully, you must also be mindful of the medications you take. We are aware that as much as clinical drugs are therapeutic, they also come with side effects or adverse reactions that may be harmful to pregnant women and unborn babies.

Check with your doctor first before taking any medications, including over-the-counter drugs. For instance, what may seem as a regular headache medication can already pose serious risks to a pregnancy which could lead to complications or pregnancy loss.

Maintain a healthy weight before pregnancy

Controlling your intake not only provides you with essential nutritional requirements, but it’s consequential to your weight. The ACOG currently recommends that doctors offer nutritional counselling to obese women who plan to start a family, so you can always approach your doctor for weight management. Professional guidance is helpful when you struggle to shed the extra pounds when trying for a baby, and it’s also beneficial during pregnancy to check whether you’re putting in too much or too little.

Source: Health Hub

Limit caffeine intake

With most of us dependent on coffee to start our day, pregnancy doesn’t have to push you to go cold turkey on caffeine. Current guidelines from the ACOG and other experts say that it’s safe for pregnant women to consume up to 200 milligrams of caffeine a day, or around one 12-ounce cup of coffee daily.

Ditch bad habits

Alcohol, recreational drugs, and cigarettes all bear adverse effects that can compromise a pregnancy. Remember that you pass much of what you eat, drink, and breathe into your baby. Besides the risk of pregnancy loss, the substances involved also pose certain risks to your baby’s development in the womb.

Attend all scheduled prenatal appointments

Prenatal care is an essential part of staying safe and healthy during pregnancy, and you must start it as early as possible. Doing so can help prevent problems for you and the baby. These visits are scheduled regularly for a reason, and you must come in for each one of them for the doctor to:

✔ track the progress of your pregnancy

✔ detect any problems along the way

✔ check your health and that of your baby’s

✔ clarify any concerns you might have about the pregnancy

✔ provide immunisation against infectious diseases

Beside prenatal appointments, pre-pregnancy care is just as important because it involves preconception health screening which can help detect any risk factor that may predispose you to have a miscarriage. 

Lighter regular exercise 

Physical activity doesn’t necessarily increase the risk of miscarriage, but it’s also an important point to discuss with your obstetrician during your prenatal appointments. If your doctor gives you the green light, you can consider which activities you can do safely. 

However, there are certain conditions or complications where this type of physical exertion may prove to be risky. These include the following: 

• Certain types of heart and lung diseases  
• Cervical insufficiency (the inability of the uterine cervix to retain a pregnancy in the second trimester) 
• Being pregnant with twins or triplets (or more) with risk factors for preterm labour 
• Placenta previa after 26 weeks of pregnancy (a problem where the placenta grows in the lowest part of the womb and covers all or a portion of the opening to the birth canal)
• Preterm labour or ruptured membranes (your water has broken) 
• Preeclampsia or pregnancy-induced high blood pressure 
• Severe anaemia

Avoid environmental hazards

Besides what you introduce to your body, you must also be mindful of the hazards you are exposed to everyday, because a lot of these risks may just be right under your nose. For instance, cleaning products, cellphone radiation, and cosmetics may have compounding toxicity when used daily. Mom Junction provides easy tips on how to protect yourself, here.

What are the accepted management options for early miscarriage? 

Preferred treatment options for early pregnancy loss include expectant management, medical treatment, and surgical evacuation. The interventions may vary based on the unique presenting factors in a miscarriage. To know which among these is suitable for you means discussing it extensively with your OB.

Expectant Management

This approach involves watchful waiting for the miscarriage to happen by itself naturally without any treatment. With adequate time (up to 8 weeks), expectant management has been successful in achieving complete expulsion of pregnancy tissues in approximately 80% of women. Women with incomplete miscarriages ( already bleeding and passed out some pregnancy tissue) have a higher rate of complete expulsion then those with missed miscarriages or blighted ovums.

What to expect:

• It may sometimes take a few weeks for the body to respond to a missed miscarriage. During a miscarriage, you may experience moderate to heavy bleeding and cramping. In general, the larger the gestation, the heavier or more painful symptoms are felt. Pain or bleeding should lessen or stop completely within 7-21 days.
• You will be instructed on what to expect during this time and how to respond to it (e.g. tracking the severity of bleeding by counting soaked pads and reporting it to your OB).
• You will learn when and who to call in case of excessive bleeding.
• Prescription medications will be provided.
• There may be a chance that miscarriage is incomplete, which means that there is a possibility that surgery might be needed.

Medical Management

This approach is suitable for women who have not encountered infection, haemorrhage, severe anaemia, or bleeding disorders and who want to shorten the time until complete expulsion but wish to avoid surgery. It increases the likelihood of complete expulsion compared to expectant management.  

What to expect: 

• Medications will be prescribed to trigger expulsion of the pregnancy tissues. The most common side effects of the medicines are nausea, vomiting and diarrhea. 
• You will be provided with pain medications.
• Similar to expectant management, you may experience moderate to heavy bleeding and cramping during the miscarriage. Pain or bleeding should lessen or stop completely within 7-21 days.
• Follow-up visits to document if there is a complete passage of tissue within 7-14 days using ultrasound.
• If this approach fails, the treatment may shift to expectant management for a time agreed by you and your OB-GYN, repeated medication or consider surgery via a suction curettage.

Surgical Management

Surgical uterine evacuation has been the traditional approach for women who experience early pregnancy loss and retained tissue especially in women who need urgent care due to haemorrhage or signs of infection. It is also advised for those with medical conditions like cardiovascular disease, bleeding disorders, or severe anaemia. Many women opt for this type of treatment because it provides immediate completion of the process with fewer follow-up visits. Suction aspiration of the pregnancy tissue is performed under sedation as a day surgery procedure. 

Studies have demonstrated that either method used ,expectant, medical or surgical management of early pregnancy loss, all result in complete evacuation in most patients with rare serious complications. As a primary approach, surgical evacuation results in faster and more predictable complete evacuation. Intrauterine adhesions (scar tissue formation within the uterus) is a rare complication of surgical evacuation. Hemorrhage and infection can occur in all treatment approaches but rates are generally low. 

Support group in Singapore after pregnancy loss

So you had a miscarriage, and your reproductive system is in the clear. However, moving on after pregnancy loss can be a long and difficult process – but it’s not without help. There are support groups and helplines available in Singapore to help you cope. You can check out any of these: 

• KK Hospital Women’s Mental Wellness Service
• Child Bereavement Support (Singapore)
• Pregnancy and Infant Loss Support Group Singapore

If you want to get help to minimize chances of a miscarriage, improve your chances of having a healthy pregnancy, or plan your next one, it helps to have professional help close by. You may talk to Dr Pamela Tan to help you through this process.