Recurrent miscarriages is defined as having two or more miscarriages. 1% of women experience this. Current guidelines recommend that investigations are done after the third miscarriage, but this depends on each couple’s circumstances.
There can be a variety of causes; in many women, no cause can be found. The most common is that of abnormal chromosomes in the embryo – older mothers are at a higher risk of this. Most of the time, this happens due to a random error during embryo formation. Sometimes, this occurs because one or both partners have genetic translocations (a small piece of chromosome attached to another chromosome) which pass on to the embryo and result in abnormal chromosomes.
Other causes may include:
Your gynaecologist will need to take a detailed medical and reproductive history, and perform a physical examination. A transvaginal ultrasound will be done to check your uterus and ovaries. A hysteroscopy may be advised if uterine abnormalities are suspected. You will be advised for blood tests to check your immune system. If tissue from your miscarriage is available, karyotyping (checking if there is the correct number of chromosomes) is recommended. Depending on the results, you and your partner may need to do genetic tests and see a geneticist.
This depends on the cause – you should discuss with your gynaecologist about the options suitable for you.
For structural abnormalities related to the uterus, surgery is usually recommended for correction. Women with recurrent miscarriages diagnosed to have autoimmune conditions such as antiphospholipid syndrome can be treated with blood-thinning medications e.g. aspirin and heparin to reduce their risk of miscarriage. For genetic issues, there is an option of doing in-vitro fertilisation with pre-implantation genetic testing. For women with cervical weakness/short cervix, there are options of monitoring the cervical length during pregnancy, progesterone supplementation, and possible cerclage.
Regardless of whether or not there is treatment involved, pre-conception care remains important – remember that 65% of women with no cause found will go on to have a successful pregnancy subsequently, with no extra treatment needed.
It is now very common for women to get pregnant for the first time when they are 35 years and above – you are definitively not alone! While most women go on to have successful pregnancies and healthy children, there are certain risks that have been linked with mothers who are older. Here are some that you should know about:
As a mother gets older, there is a higher risk of error during cell division and baby ending up with an abnormal number of chromosomes. The most common one is Down syndrome. You can opt to do prenatal Down syndrome screening if you and your partner are keen.
This can be due to fetal chromosomal abnormalities or your pre-existing medical conditions.
Older mothers have a higher risk of twins (which is associated with risks on its own); multiple pregnancies are also linked with the use of in-vitro fertilisation.
Older mothers have a higher risk of GDM. If you have risk factors e.g. GDM in previous pregnancy, are overweight or 40 years and above, you may be asked to have a OGTT early in your pregnancy and again in your late second trimester. Poorly controlled GDM can result in big baby (macrosomia), polyhydramnios (excessive amount of water in water bag), low blood sugar in baby after delivery (hypoglycemia), jaundice in newborn.
Your blood pressure will be measured every antenatal visit, and a urine dipstick performed to look for protein in your urine as these are signs that you may be developing PIH/PE. PE can affect placenta function and result in a small baby. It can also affect your liver/kidney function and put you at an increased risk of seizures and stroke.
Older mothers have an increased risk of having babies that are growth restricted, and may need additional ultrasound scans during pregnancy for monitoring.
Premature babies can have problems with their brains, lungs, hearts, eyes and other organs. They can also have long-term health issues including intellectual and development delays.
Research has shown the rates of stillbirth (where baby’s heartbeat stops suddenly) is higher in first time mothers aged 35 year and above. The cause is not clear, hence the higher rates of induction of labour.
This is related to a higher rate of pregnancy complications that an older mother may encounter and due to the higher risk of stillbirth in older mothers. If you are aged 40 years and above, you will be offered IOL from 39 weeks.
This is related to a higher rate of pregnancy complications that an older mother may encounter, including low-lying placenta/ placenta previa and those listed above.
In some cases, you may require additional medications, procedures and blood transfusions.
A miscarriage refers to a pregnancy loss before 24 weeks. 85% of miscarriages are early.
An early miscarriage is when a pregnancy is lost at 12 weeks or earlier.
A late miscarriage is when a pregnancy is lost after 12 weeks to 24 weeks.
Often there can be no cause found.
For early miscarriages, it is thought to be a problem with the baby’s chromosomes or abnormal fetal development – the older the mother is, the higher this risk is. 20% of pregnancies end up in early miscarriages and it is usually not related to what you could have or did/did not do.
For late miscarriages, there can be many causes e.g. abnormally shaped uterus, incompetent/short cervix, antiphospholipid syndrome, polycystic ovary syndrome (PCOS), placenta failure, infections, poorly controlled medical conditions e.g. diabetes or thyroid disease, smoking or alcohol use.
Some women with a miscarriage may experience no symptoms at all. Some women with a miscarriage will experience abdominal cramps and/or vaginal bleeding (some may not have any symptoms) – however not all women with these symptoms are necessarily having a miscarriage. You should contact your gynaecologist if you have these symptoms.
Your gynaecologist will need to perform a vaginal examination and a ultrasound scan. In some cases, you may be required to do some blood tests.
That depends on whether you have an early or late miscarriage, and what symptoms you are currently having.
Early miscarriage
1.Wait and see
You may need to wait for some time before the bleeding starts. You should expect some cramps (these may be painful enough for you to need painkillers) and the bleeding to be heavier and longer than your usual periods (up to 2-3 weeks). Your gynaecologist will schedule a follow-up visit to check the process has been complete. If your uterus is not empty, you may need to go on to medical or surgical options.
2. Medicines
This has a success rate of 85%. Misoprostol is a tablet taken orally that induces abdominal cramps and bleeding in a few hours. You may need to take more than 1 tablet every few hours. You should have some painkillers on standby. The bleeding should reach a peak within a day or two and you may pass some tissue out, after which your bleeding and cramps should decrease significantly. Side effects include fever, nausea, diarrhea and vomiting. Your gynaecologist will schedule a follow-up visit to check the process has been complete. If your uterus is not empty, you may need to go on to surgery.
3. Surgery
This has a success rate of 95% and involves cleaning out the uterus under anaesthesia in day surgery. Surgery is typically done if that is your preference, if the above 2 options have failed, or in cases of heavy prolonged bleeding or infection. Oral or vaginal tablets will be needed before the operation to soften the cervix. This operation is safe and commonly done, with a low rate of complications which your gynaecologist will discuss with you.
Late miscarriage
As the pregnancy is now bigger, you will need to be admitted to the hospital, where vaginal tablets will be inserted every few hours. This will induces abdominal cramps and bleeding and may feel like a mini-labor, with before the pregnancy is passed out. You may experience fever, nausea, vomiting and diarrhea.
20% of women may need surgical evacuation of uterus if the process is not complete.
After your miscarriage process has finished, you may experience light bleeding for the next 1-2 weeks. You should expect your next period to come in a month’s time (depending on how regular your periods were before getting pregnant).
You can have sex and try for your next pregnancy as soon as you and your partner feel ready – the earliest will be after your next period – but do remember to give yourself some time to grieve as a going through a miscarriage can be difficult.
If you wish to wait for some time before you attempt another pregnancy, you should use a reliable birth control method.
Contact your gynaecologist early if you:
If you have had 1 or 2 early miscarriages, you are not at a higher risk of another miscarriage. You are more likely than not to have a successful pregnancy the next time. Do remember your pre-conception care. If you have had more than that, speak to your gynaecologist as you may require further checks.
If you have had 1 late miscarriage, you will need further checks to establish the reason behind your miscarriage – depending on the cause, there may be things you can do before or during your next pregnancy to reduce the chance of this happening again.
These are non-cancerous growths that come from the muscle layer of the uterus which are commonly found in women of reproductive age. Fibroids can be single or multiple. They have varying shapes and can be located inside the uterine cavity, within the walls of the uterus, or on the outer surface of the uterus. They are slow-growing (about 1-2cm a year) and will typically start to shrink once a woman reaches menopause.
Many women get pregnant naturally even when they have fibroids. Most pregnant women with fibroids go on to deliver healthy babies. Fibroids will grow in size (together with the uterus!) as your pregnancy progresses, and shrink after delivery. Some complications that fibroids can cause when you are pregnant include:
You do not have to do anything. Your gynaecologist will monitor both your baby and fibroids throughout the pregnancy via ultrasound scans. Do see your gynaecologist if you develop sudden pain especially over your fibroid – this may be a sign of red degeneration.
This is not advisable as fibroids tend to be large with lots of blood supply at the time of delivery. Removing your fibroids at the time of your caesarean section will put you at risk of losing too much blood. It is recommended to leave the fibroids alone unless they are blocking access to your baby. Re-assess them after your uterus has shrunk back to its normal size – the fibroids would have most likely shrunk in size as well.
An ectopic pregnancy is a pregnancy that occurs outside the uterus, most commonly in the fallopian tubes (90%). Rarely it can occur in the ovary, cervix or at the site of a previous caesarean section scar. An ectopic pregnancy is not a normal pregnancy and cannot be turned into one, as the only place that can sustain a pregnancy to term is the uterus.
1 in 50 pregnancies turn out to be ectopic pregnancies. Once you have had a history of an ectopic pregnancy, you will have a higher risk (10-15%) of having another ectopic pregnancy in the future.
Some women may have no symptoms. Some women may have mild lower abdominal pain or discomfort, or some vaginal bleeding.
The dangerous thing about an ectopic pregnancy is that it can rupture and cause massive, life-threatening internal bleeding. In the event of a ruptured ectopic pregnancy, one needs to be rushed to the Emergency Department as one may experience severe abdominal pain, shoulder-tip pain, giddiness/dizziness, vomiting, fainting or even collapse.
If you suspect that you may have an ectopic pregnancy, you should see your gynaecologist immediately.
Your gynaecologist will need to take a detailed menstrual history and perform an abdominal and pelvic examination to look for any tenderness. A transvaginal ultrasound will be done to look for the location of the pregnancy. If your uterus looks empty on the scan, it may be too early for your pregnancy to be seen on ultrasound scan and you will need to take a blood test to measure your pregnancy hormone (b-hcg). Depending on the b-hcg levels, you may need to have your b-hcg trended every 48 hours, with an ultrasound repeated to ascertain the diagnosis of an ectopic pregnancy. Until then, you will need to stay vigilant and watch for any symptoms that may suggest ruptured ectopic pregnancy (see above).
This depends on your symptoms, blood pressure, pulse rate, b-hcg levels, size of ectopic pregnancy and willingness for regular follow-up. There are 2 main options:
1. Methotrexate (MTX) injection
This is an intramuscular injection which stops division of pregnancy cells. It is also used in chemotherapy, but the dose given for an ectopic pregnancy is much lower. The ectopic pregnancy cells shrink and are absorbed by your body. The success rate is 90% (lower if your b-hcg level is higher). 15% of women may need a 2nd injection if their response to the 1st injection was insufficient. You will be required to return regularly to trend your b-hcg levels. You will need to stay vigilant and watch for any symptoms that may suggest ruptured ectopic pregnancy as it can still happen anytime until your b-hcg goes back to normal – this may take 4 to 6 weeks.
You are suitable for MTX if you are stable with no severe abdominal pain or bleeding, your b-hcg is <5000IU, your ectopic pregnancy measures less than 3.5cm on ultrasound scan with no evidence of internal bleeding, there is no fetal heartbeat seen and you are willing to return for regular monitoring blood tests. You should not have kidney, lung, liver or blood disease, be breastfeeding or have an active infection.
MTX is generally tolerated well. Common side effects include pain at injection site, mild lower abdominal discomfort, mild vaginal bleeding. You should not get pregnant for 3 months after MTX injection as it will take some time for MTX to be cleared.
2. Surgery
This is usually done laparoscopically (keyhole). The best surgery to treat an ectopic pregnancy is a salpingectomy(removal of ectopic pregnancy with fallopian tube). This is because the fallopian tube is usually damaged resulting in the formation of the ectopic pregnancy in the first place, and further damaged following implantation of the ectopic pregnancy there.
In very few select patients where their other tube is also damaged, a salpingostomy can be done. This involves making a cut on the affected fallopian tube and removing as much of the ectopic pregnancy as possible. Weekly b-hcg blood tests will be required due to risk of persistent ectopic pregnancy tissue, which may need further treatment. Leaving a damaged fallopian tube behind means you will be at a higher risk of having another ectopic pregnancy (on the same side) in future.
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