Miscarriage is the loss of a fetus that is less than 20 weeks of gestation age based on the woman’s last menstrual period or a fetus weighing less than 500 grams.

There are several reasons why a woman may suffer a miscarriage during her pregnancy. She may have some medical issues like diabetes, chronic hypertensive problems, thyroid problems or autoimmune disorders that can increase her risk of miscarriage.

Acute infections during pregnancy such as rubella or bacterial infections can be transmitted to the fetus and affect fetal development, causing miscarriage. Or fetal development may be abnormal, including chromosomal or genetic problems, which may lead to miscarriage.

Types of miscarriage

“There are different types of miscarriage like spontaneous miscarriage, recurrent spontaneous miscarriage and induced abortion based on the patient’s history, clinical signs and symptoms, physical examination and confirmatory diagnostic procedures like ultrasonography,” said Dr Allyn Zamora, an obstetric and gynecological specialist at Shanghai East International Medical Center (SEIMC).

Spontaneous miscarriages usually occur in the first 12 weeks of pregnancy and half of these cases are caused by chromosomal abnormalities. They can be further classified clinically into threatened miscarriage, inevitable miscarriage, incomplete miscarriage, complete miscarriage and early pregnancy loss or missed miscarriage.

In a threatened miscarriage, the woman’s vital signs are generally stable unless there are signs of infection or vaginal bleeding that can cause a drop in blood pressure due to blood loss.

Threatened miscarriage may develop in 20 to 25 percent of pregnant women in early pregnancy and may persist for days or weeks and approximately half of these pregnancies may end. The risk of miscarriage becomes lower, however, if fetal cardiac activity is seen during an ultrasound examination. Even if miscarriage does not follow, these fetuses can be at increased risk for premature delivery, low birth weight and perinatal death.

Inevitable miscarriage means the cervix has opened and in most of the cases, evacuation is necessary to avoid infection and hemorrhage.

“In this type of miscarriage, the pregnant woman may experience a sudden gush of fluid accompanied with or followed by vaginal bleeding, and it is associated with abdominal pain or cramping. The pelvic examination reveals a dilated cervix,” Zamora said.

In incomplete miscarriages, not all products of conception (the baby, the sac or the placenta) are expelled naturally from the mother.

In the early pregnancy failure or the missed miscarriage, the woman’s pregnancy typically is normal until fetal death or embryonic demise are discovered, usually through ultrasound examination.

The recurrent pregnancy loss or recurrent spontaneous miscarriage means the woman had history of three or more consecutive pregnancy losses. These women should be evaluated and monitored closely because the risk of subsequent pregnancy loss is estimated to be 24 percent after two clinically recognized miscarriages, 30 percent after three losses and 40 to 50 percent after four losses.

“Recurrent spontaneous miscarriage takes place in every 400 couples,” said Dr Wang Ling from Obstetrics and Gynecology Hospital of Fudan University. “There are many causes for recurrent spontaneous miscarriage, while about 40 percent of such patients’ conditions are related with immune factors, including an insufficient maternal immune tolerance toward the fetus, an overactive maternal immunity toward the fetus and complicated maternal immunity toward the fetus. All can be treated by Western medicine and traditional Chinese medicine.”

Wang said she saw a 35-year-old woman, who got married eight years ago and had five consecutive miscarriages. Repeated checks didn’t find the cause of the recurrent miscarriages and infertility had started to damage the relationship between husband and wife.

“I conducted a reproductive immunology check on her and found that she had insufficient maternal pregnancy tolerance, which caused the miscarriage,” Wang said. “After two episodes of therapy, she successfully delivered a son.”

Dr Li Dajin, Wang’s tutor, led Wang and her colleagues to test how Cyclosporin A, a powerful immunosuppressive that has been widely used to prevent organ rejection and to treat certain autoimmune diseases since 1970s, also can be used to treat recurrent miscarriage.

The research has begun its phase II clinical trials.

An induced abortion is defined as the medical or surgical termination of pregnancy before the time of fetal viability and it is further classified into therapeutic or elective (voluntary) abortion. Therapeutic abortion can be due to several reasons — it may be because the maternal physical health cannot sustain the additional stress of pregnancy like in women with severe cardiac problems, or in cases of rape or incest. The most common indication for therapeutic abortion is to prevent the birth of a fetus with a significant anatomical or mental deformities, while elective abortion is the interruption of pregnancy before viability without medical reasons.

Q: What are the symptoms of miscarriage?

A: The most common symptoms are bleeding from the vagina and belly pain or cramping. However, these symptoms do not always mean a miscarriage. Small amount of bleeding in early pregnancy is relatively common. Bleeding often stops on its own without treatment. Your doctor can help figure out if anything is wrong.

Q: How is miscarriage treated?

A: You cannot stop a miscarriage that has already started. If you have had a miscarriage, the fetus and the extra fluid in your uterus need to leave your body. Your doctor might want you just to wait and let it exit through your vagina by itself. This usually takes up to two weeks, but it may take longer in some cases. If this is not an option, your doctor might treat you with medicine to help your uterus get rid of what was inside it, or surgery to remove the contents of your uterus left over from pregnancy. The option used depends on many factors, including how far along in the pregnancy you were.

Q: What do I do after a miscarriage?

A: After the miscarriage, the doctor will advise you not to put anything into your vagina (such as tampons or having sexual intercourse), usually for two weeks. This deters infection. Call your doctor right away if you have heavy bleeding, fever, chills or severe pain.

Q: What can I expect emotionally?

A: The loss of a pregnancy — no matter how early — can cause feelings of sadness and grief. After a miscarriage, you need to heal both physically and emotionally. For many, emotional healing takes a good deal longer than physical healing. Grief can involve a wide range of feelings. You may feel sad and depressed one day, and angry the next. You may find yourself searching for a reason your pregnancy ended. You may wrongly blame yourself. You may have headaches, lose your appetite, feel tired, or have trouble concentrating or sleeping. Your feelings of grief may differ from those of your partner. Your partner also may grieve but may not express feelings in the same way. This may create tension when you need each other the most. Partners also may feel that they need to be strong for you both and not show grief. If you think you might be depressed, mention it to your doctor. There are treatments and coping strategies that can help.

Q: Can I prevent a miscarriage?

A: There is no way to ensure you will not have a miscarriage. You can reduce your chances by avoiding cigarettes, alcohol and injury to your belly. Having a fever or some kinds of infections puts you at risk for miscarriage, so you should also talk to your doctor about how to avoid getting infections. Also, some medicines or other treatments can be harmful to a fetus. Before you take any medicine (herbal, over-the-counter or prescription) or have a medical treatment or X-ray, ask your doctor or nurse whether it could hurt your fetus.

Q: Will I be able to have a normal pregnancy after a miscarriage?

A: Probably. Most women who have a miscarriage go on to have healthy pregnancies. Your doctor might suggest that you wait two or three months before trying to become pregnant again. If you have three or more miscarriages, your doctor might want to run some tests.

The Article is contributed byMichelle Lu-Ferguson, vice president of Shanghai Redleaf International Women Hospital, an OB/GYN physician.