Pregnancy Loss

An ectopic pregnancy (or tubal pregnancy) occurs when the fertilized egg attaches itself outside the cavity of the uterus (womb). The majority of ectopic pregnancies are found in the Fallopian tubes. In rare cases, the egg attaches itself in one of the ovaries, the cervix (neck of the womb) or another organ within the pelvis. An ectopic pregnancy is not usually capable of surviving and in most instances an embryo is not developed. An ectopic pregnancy will spontaneously miscarry the majority of cases diagnosed will have to be operated on or treated with medication.

The most common signs and symptoms of an ectopic pregnancy are:

An overdue period (suggesting pregnancy)

Bleeding from the vagina

Positive pregnancy test

Lower abdominal pain

Fainting

At first an ectopic pregnancy develops like a normal pregnancy and the same symptoms such as nausea and tender breasts will be present. However, some women do not have these symptoms and do not suspect that they might be pregnant.

The vaginal bleeding can vary from being slight or brown vaginal discharge to being like a normal period. If you are pregnant and have a long-lasting throbbing in one side of your lower abdomen or if you experience sudden pain you should contact your doctor. This is important as an ectopic pregnancy can be life-threatening if it ruptures and causes internal bleeding.

In a normal pregnancy, the egg is fertilized by the man's sperm in the Fallopian tube and is then transported into the cavity of the womb where it attaches itself. This is called implantation. This transportation is made possible by the tiny cilia (finger like projections) in the delicate inner lining of the Fallopian tubes which push the fertilized egg along.

Risk factors may be present which increase the likelihood of a woman experiencing an ectopic pregnancy. These are:

Previous surgery to the Fallopian tubes or previous inflammation of the Fallopian tubes (pelvic inflammatory disease). Because the lining of the Fallopian tubes is so delicate, inflammation or trauma can cause the cilia to beat in an abnormal fashion so that the pregnancy implants in the wrong place.

Previous ectopic pregnancy. If you have previously had an ectopic pregnancy, the chances of another one in the same Fallopian tube and in the other tube are increased.

Becoming pregnant whilst using a contraceptive coil or the progestogen only contraceptive pill (mini-pill)

Becoming pregnant with in-vitro fertilization (test-tube methods). When using the test-tube method to overcome infertility one or more eggs are inserted into the woman's uterus. Despite being placed within the womb, the fertilized egg may still attach itself to the wrong area outside the cavity of the uterus.

However, many women experiencing an ectopic pregnancy do not have any of these risk factors.

An ectopic pregnancy is usually diagnosed with a urine test for pregnancy and will nearly always be positive but it might be only weakly positive. In cases of doubt, a blood pregnancy test may be performed which is always positive in ectopic pregnancy.

In the case of ectopic pregnancy, the uterus will often be smaller than expected for the number of weeks since the woman's last period and this can be checked by an internal pelvic examination. The doctor might feel a tender swelling corresponding to an ectopic pregnancy.

An ultrasound scan will help the doctor differentiate between a possible miscarriage, a continuing pregnancy inside the womb and an ectopic pregnancy.

Further investigation depends on the woman's symptoms, the scan findings and

the level of pregnancy hormone (HCG) in the woman's blood. If there is uncertainty about the diagnosis then waiting 48 hours and measuring the level of HCG again is often appropriate.

If an ectopic pregnancy is strongly suspected then the gynaecologist may perform a laparoscopy to confirm the diagnosis. Laparoscopy is performed through small incisions on the abdomen and the ectopic pregnacy can usually be removed in this manner.

The Fallopian tube in which the ectopic pregnancy occurred may be removed at the same time. However, in some instances, open surgery becomes necessary in which the pregnancy is removed through a larger incision above the pubic hair line. This option is usually chosen if technical problems occur during the laparoscopy or if the internal bleeding in the abdominal cavity is difficult to control.

An alternative treatment to surgery is the drug methotrexate which decreases the growth of cells in the ectopic pregnancy. As a result the pregnancy shrinks and eventually disappears. The advantage of methotrexate is that it avoids the need for surgery but success rates with methotrexate tend to be slightly lower than with surgery. Occasionally both surgery and methotrexate will be necessary.

The outlook for future pregnancies depends on several factors especially whether the other Fallopian tube appeared normal or not. As a general guide, after one ectopic pregnancy, 20 percent of women will experience another ectopic pregnancy, 30 percent will not become pregnant again and 50 percent will have a successful pregnancy inside the womb.

What is stillbirth?

Stillbirth and miscarriage both define a pregnancy loss. Stillbirth is the death of a baby after the 20th week of pregnancy but prior to delivery. Most often it is detected while the baby is in the mother's uterus, sometimes not until labor is underway. Miscarriage (sometimes called spontaneous abortion) is a loss that occurs before the 20th week of pregnancy.

There is a great sense of disappointment and loss whenever parents suffer the death of their baby, whether it be an early pregnancy loss, a late pregnancy loss, or a loss occurring sometime after birth. Stillbirth and miscarriage are separately defined, not because one is an easier or more difficult loss with which to deal, but because they differ in many ways. Stillbirth and miscarriage have different causes, need different evaluations, and differ medically and in the ways that parents and families can best be helped.

Why Should You Know About Stillbirth?

Stillbirth is common. It may affect anyone. There is no way to predict when stillbirth will happen or who will experience it. Stillbirth occurs in families of all races, religions, and income levels. Each year in the United States about 25,000 babies, or 68 babies every day, are born still. This is about 1 stillbirth in every 115 births. Something as common as this will, at some point, directly or indirectly touch the lives of many people. A friend, a relative, or you, yourself, may experience stillbirth.

What are the signs and symptoms of the condition?

Certain signs and symptoms make a healthcare provider suspect a possible stillbirth. These include:

-a mother who notices the baby has stopped moving for a long period of time

-a uterus or womb that fails to get bigger over time

an inability to hear the baby's heartbeat with a special heart monitor

-lack of movement of the baby or no heartbeat during a pregnancy ultrasound, a special test that uses sound waves to show the baby

-an abnormal blood level of the hormone of pregnancy, known as a quantitative HCG test

What are the causes and risks of the condition?

Some of the known causes of stillbirth include:

infections in the mother or baby, such as fifth disease or the TORCH infections. These include toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes.

placenta or umbilical cord problems. The placenta and umbilical cord connect the baby to the mother's womb. The placenta may separate from the womb too early or bleeding from the cord or placenta may occur.

trauma or injury, usually to the mother's abdomen

high blood pressure in the mother, which may or may not be related to the pregnancy

diabetes in the mother

birth defects in the child affecting the lungs, heart, brain, or kidneys

Rh incompatibility, which may occur when the mother and baby have different blood types

an autoimmune disorder in the mother, a condition in which a person's immune system attacks his or her own body

Other causes are also possible. In at least 50% of the cases, the cause is not known.

What can be done to prevent Stillbirth?

Prevention is sometimes possible, by avoiding certain pregnancy risk factors.

Women can avoid rubella by making sure that they receive the rubella vaccine, part of an MMR immunization.

Avoiding raw meat and not working with cats may prevent toxoplasmosis.

Frequent hand washing can keep a pregnant woman from getting certain infections.

Not using cocaine and not smoking during pregnancy can help prevent cases of stillbirth that are caused by the placenta separating from the womb too early.

Controlling diabetes in the mother can reduce the risk of stillbirth from diabetes.

Why Do Stillbirths Happen?

One of the most common questions following a stillbirth is, "Why did my baby die?" Answering this question is not always easy or possible. Extensive and careful examination of the baby and placenta is needed following delivery. This includes an internal autopsy and several other studies. Often these evaluations will provide helpful information and eventually bring peace of mind. With extensive evaluation, a cause for stillbirth can be identified in 40%-50% of all stillbirths. Even when a cause is not specifically identified, at least potential high risks for recurrence may be ruled out. Parents who experience stillbirth will be asked to consider extensive evaluations for their baby. Many will want everything done to try to discover why their baby died. Others may think that such assessment violates their baby. The decision should be theirs. They will need to choose what is best for them.

Types Of Causes Of Stillbirth

Information about cause can be very important for parents and families. It may help parents in planning future pregnancies by providing insight to the frequently asked question, "Will stillbirth happen again?" The information may also help parents and families to deal emotionally with their loss. Knowledge, in general, can be empowering, and it may provide a sense of comfort by helping to alleviate uncertainty or guilt.

Identifiable causes of stillbirth generally fall into one of three different categories: birth defects in the baby, problems with the placenta or umbilical cord, or maternal illnesses or conditions which may sometimes affect pregnancy.

Birth defects are common but often overlooked causes for stillbirth. About one-fourth of babies who are stillborn have one or more birth defects that are responsible for their death.

The placenta and umbilical cord are the baby's "lifeline" for oxygen and nutrients. Problems in either one may completely cut off or severely interfere with the needed flow of blood, oxygen, and nutrients to the baby. Although commonly pointed to as the likely cause for the death of a baby, problems with the placenta or umbilical cord actually account for only a moderate number of stillbirths.

Although uncommon, maternal conditions may be responsible for stillbirth. Certain illnesses in the mother, such as diabetes or hypertension, and their treatments, sometimes cause stillbirths. An increased risk for stillbirth is also associated with the use of certain recreational drugs, particularly cocaine.

In addition, there are many other rare causes of stillbirth. Stillbirths are usually not caused by something parents or family members did or did not do

If Stillbirth Happens Once Will It Happen Again?

Extensive evaluation of the baby and placenta may help determine the chance that stillbirth could happen again. On average, there is approximately a 3% chance for stillbirth to recur in a next pregnancyor approximately a 97% chance that a future pregnancy would not end in stillbirth. Finding a specific cause may imply a much higher or lower risk than this average one. In almost all circumstances, healthy pregnancies are possible.

Some Common Responses To Stillbirth

In the natural course of life events, babies are least of all expected to die. The loss of a baby through stillbirth can be overwhelming and devastating for parents as well as for family members and friends. Although such feelings are surprising to some, the stillbirth of a baby is a great loss, as great as that of an older child or any loved one.

When stillbirth occurs, parents who were anxiously awaiting a baby suddenly are not. It is natural for them to grieve deeply for the baby who has died and for the hopes, dreams, and wishes that will never be; hopes, dreams, and wishes that, for parents, are real long before the birth of their baby. They may feel a strong sense of sadness, or anger, or bitterness at the unfairness of this tragedy. There is usually nothing anyone did to cause, or could have done to prevent, a stillbirth. Yet, parents especially may feel guilt and blame themselves for the death of their baby. Parents may also experience feelings of loneliness and longing, helplessness, or, because of the intensity of their emotions, confusion.

These emotions are real and a normal part of grieving. Grieving is a process of making meaning out of the loss and of life without their baby. Grieving is not easy. It is long, unpredictable, and requires a lot of energy. Parents and family members need time to grieve since grieving is necessary to work through pain toward healing.

What Can You Do To Help?

Naturally, there is an urge to ease parents' sorrow. Realistically, there is nothing anyone can say or do to take away their pain. You can provide love, hope, understanding, and the same support you would offer to anyone who has experienced the death of a loved one.

Ignoring the subject does not make it go away nor does it make parents feel less pain. Acknowledge the stillborn baby. Most parents and family members need to talk about the death and about their baby. Use the baby's name or refer to "the baby" and let parents know that you are willing and interested in hearing about their experience if they wish to share it with you.

Acknowledge and validate the grief parents and family members may feel following stillbirth. Help them by allowing and encouraging them to express their feelings and concerns.

Don't be silent just because finding the "right" words to say is sometimes difficult. A simple "I've been thinking about you," "I'm sorry", or "I'm here if you would like to talk" can be comforting and reassuring.

Sometimes presence is more powerful than words. Be there to provide a shoulder to lean on or a hand to hold. Be there to listen.

Let parents make their own decisions. Encourage them to do what is best for them and support them in whatever they choose.

Your patience, love, and understanding are important immediately following the stillbirth and are also needed as time passes. Grieving takes time. Parents and family members will not be "done thinking about the baby" after a month or even a year. Their baby will never be forgotten. Continual love and support will help parents to work through their tragedy and cope with this painful experience. You can make a difference.

When a baby is born alive, but dies soon after birth, parents are devastated. Most had been happily anticipating the birth of a healthy baby. Then their dreams are abruptly shattered when they learn that their baby was born very sick and is not expected to survive.

Sadly, in 1998, about 19,000 babies died in their first month of life. Death in the first 28 days of life is referred to as neonatal death. During this difficult time, parents may feel helpless, frightened, angry and emotionally overwhelmed. After their baby dies, parents need time to grieve. As parents attempt to cope with their loss, they may have many questions about why this happened to their baby. The following may begin to answer some of these questions.

What are the most common causes of neonatal death?

Neonatal deaths often occur because a baby was born with birth defects or because he or she was born prematurely (before 37 completed weeks of pregnancy; a full-term pregnancy is 38 to 40 weeks). Some premature babies also may have birth defects, which may cause or contribute to their death.

The most common cause of neonatal death is birth defects. These cause about 25 percent of neonatal deaths. Sometimes parents learn about their baby’s birth defects before birth, through prenatal diagnosis (using tests such as ultrasound, amniocentesis and chorionic villus sampling). Ultrasound can help diagnose structural birth defects, such as spina bifida (open spine), anencephaly (brain and skull defect), heart or kidney defects. Amniocentesis and chorionic villus sampling are used to diagnose chromosomal abnormalities, such as Down syndrome, and numerous genetic birth defects. Prenatal diagnosis of life-threatening birth defects may help parents begin to cope with their grief over their baby’s expected death.

Prematurity is another important cause of neonatal deaths. About 11 percent of babies are born prematurely. A minority of premature babies have birth defects, which may cause their death. Many more face life-threatening health problems that result from being born too small and too soon.

Prematurity and its complications cause about 20 percent of neonatal deaths. The earlier a baby is born, the more likely he or she is to die. Only 5 to 10 percent of babies born at 23 weeks of pregnancy survive, while about 50 percent of babies born at 24 weeks and 80 percent born at 26 weeks survive.

The causes of premature delivery are not thoroughly understood. In some cases, a pregnant woman may have health problems (such as high blood pressure) or pregnancy complications (such as placental problems) that increase her risk of delivering prematurely. Women who are pregnant with twins (or other multiples) also are at increased risk. More often, preterm labor develops unexpectedly in a pregnancy that had been problem-free, sometimes leading to the birth of a tiny, sick infant.

Less common causes of neonatal death include problems related to complications of pregnancy; complications involving the placenta, cord and membranes; infections; and asphyxia (lack of oxygen before or during birth).

Which birth defects most commonly cause neonatal deaths?

Heart defects are the most common birth defect-related cause of infant deaths (neonatal deaths as well as deaths in the first year of life). Heart defects cause nearly one-third of these deaths.

About one in every 125 babies is born with a heart defect. Because of improvements in the surgical treatment and medical management of these defects, most affected babies survive and do well. However, some babies with severe heart defects may not survive until surgery, or may not survive the procedure. Many babies who die of heart defects in the first month of life have a specific heart defect called hypoplastic left heart syndrome, in which the main pumping chamber of the heart is too small to supply blood to the body. An experimental surgical procedure has saved a small number of affected babies, but the outlook remains grim. In most cases, doctors do not know why a baby is born with a heart defect, although both genetic and environmental factors are believed to play a role.

Small, underdeveloped lungs that lack sufficient lung tissue and/or airways are another common cause of death. Sometimes, one or both lungs does not develop at all or is underdeveloped for reasons that are not known. In most cases, underdeveloped lungs occur because other birth defects interfered with lung development, or due to pregnancy complications (such as premature rupture of the membranes) that result in insufficient amniotic fluid (which is crucial for lung development). Sadly, about 70 percent of babies with underdeveloped lungs die, usually in the neonatal period.

Chromosomal abnormalities are a common cause of neonatal death. Humans normally have 46 chromosomes, the tiny thread-like structures in our cells that carry our genes (the basic units of heredity that dictate all traits from eye color to workings of internal organs). However, sometimes a baby is born with one (or occasionally more) too many or one too few chromosomes. In most cases, when an embryo has a chromosomal abnormality, it will not survive, and the pregnancy will end in miscarriage. Sometimes the fetus does survive until birth, only to die in the early weeks of life. For example, babies with an extra copy of chromosome 18 or chromosome 13 (called trisomy 18 or trisomy 13) have multiple birth defects and generally die in the first weeks or months of life. Babies with less severe chromosomal abnormalities, such as Down syndrome (trisomy 21) often survive, although affected children have mental retardation and other serious problems.

Birth defects involving the brain and central nervous system are another important cause of neonatal death. One example is anencephaly, in which most of the brain and skull are absent. Affected babies may be stillborn or die in the first days of life. This birth defect often can be detected before birth with a blood test, ultrasound or amniocentesis. It often can be prevented in subsequent pregnancies when the woman takes the B vitamin folic acid prior to and in the first months of pregnancy. A woman who has had a baby with anencephaly should consult her doctor prior to another pregnancy to find out how much folic acid to take before she attempts to conceive. Generally, a higher-than-normal dose is recommended (usually 4 milligrams).

What causes death in premature babies who don’t have birth defects?

Premature babies, especially those born at less than 32 weeks of pregnancy and weighing less than 3-1/3 pounds, often develop respiratory distress syndrome (RDS). About 40,000 babies develop RDS each year.

Babies with RDS have immature lungs that lack a chemical mixture called surfactant, which keeps the small air sacs in the lungs from collapsing during breathing. They do not get enough air in and out of their lungs. Since 1990, widespread use of surfactant treatment has greatly reduced the number of babies who die from RDS and has greatly decreased the severity of RDS in survivors. However, about 1,200 babies a year still die in the neonatal period due to RDS.

About 25 percent of very premature babies develop bleeding in the brain that can result in death. These tiny babies also may develop life-threatening intestinal and heart problems. Couples with a family history of inherited diseases can discuss the possibility of prenatal diagnosis with their doctor or genetic counselor.

While tragic deaths due to prematurity are still too common, the outlook for these babies is improving. Surfactant and other treatments are saving more of these babies after birth. And treatment before birth can sometimes prevent or lessen the complications of prematurity. Women who are likely to deliver between 24 and 34 weeks of pregnancy should be treated with drugs called corticosteroids, which speed maturation of fetal organs. Studies show this treatment reduces infant deaths by about 30 percent, and reduces the incidence of RDS by 50 percent and brain bleeds by 70 percent.

Parents of critically ill babies in the intensive care nursery need support from family, friends and health care professionals during this sad and anxious time. They should never hesitate to ask their baby’s doctors and nurses about their baby’s comfort and the care he or she is receiving. Parents also may want to ask how they can share in their baby’s care so they can feel that they are helping their baby, as well as creating memories of their baby for the difficult days ahead. Some hospitals have support groups where parents of very sick newborns can share their feelings, as well as support groups for parents whose babies have died. Parents who are having trouble coping with their grief, before or after the baby’s death, should ask their health care provider for a referral to a counselor who is experienced in dealing with infant death.

Parents whose baby had a birth defect also should consider consulting a genetic counselor. These health professionals help families understand what is known about the causes of a birth defect, and the chances of the birth defect recurring in another pregnancy. Genetic counselors also can provide referrals to medical experts as well as to appropriate support groups in the community.

Genrally described at a fetus or embryo that dies before 20 weeks gestation. It is estimated that some 50% of fertilized ova do not result in a viable pregnancy. This means that though the sperm does fertilize the egg, it never implants on the uterine wall. In one study this percentage is as high as 70%. Most clinicians agree that the percentage of fertilized ova that become viable pregnancies is much less than 50%. There is fair agreement that the percentage of known pregnancies which miscarry is somewhere between 15% and 40%. It has been estimated that if a woman achieves certain pregnancy 3 times, the chance that one of these pregnancies will miscarry is greater than 50%.

Basically that means that miscarriage is quite common in sexually active women of reproductive age.

Your clinician may use the term "abortion" when s/he refers to early pregnancy loss. Clinicians learn about miscarriage in clinical settings where how things are labelled is crucial to be able to express exactly what is meant. They usually learn more about science than sensitivity. Thus, if you are unfortunate enough to suffer a miscarriage, you may hear your loss described as some type of "abortion". Most of the time, this word is hurtful to hear at such a difficult time. If it offends you, ask the clinician(s) not to use the term........ask them to be sensitive...... Here are some of the clinical terms used frequently when clinicians discuss miscarriage:

Blighted ovum- A Pregnancy that has implants but has failed to develop past the point where the embryo can be identified on ultrasound scan. Although evidence of a gestation is seen by ultrasound, the lack of fetal parts is often called and empty sac. These pregnancies are uniformly believed to have a genetic or endocrine reason for their poor outcome. May or may not require intervention with dilation and curettage (D&C).

Complete(d) abortion- Expulsion of the entire pregnancy: the embryo's fetal parts and membranes/placenta. The cervix is left closed. Usually completed abortion requires no intervention.

First-trimester miscarriage- Pregnancy loss within the first twelve weeks after last period. Often hormonal and or genetic in origin, expecially before six to eight weeks.

Incomplete abortion- a miscarriage that has only partially been expelled. The cervix is usually left open. Bleeding and pain are common. Usually requires surgical removal of the retained portion of pregnanct with D&C.

Inevitable abortion- Bleeding and pain, usually with the cervix dialating.

Missed abortion- Embryo or fetal death at any stage, without expulsion of the pregnancy.

Recurrent (habitual) miscarriage- At least two, some define as three, consecutive undesired pregnancy losses.

Second-trimester miscarriage- Loss before twenty weeks. Less often genetic and more often anatomic (abnormal uterus), immunologic, or due to maternal disease.

Septic abortion- Pregnancy loss due to infection.Also used to describe infection associated with abortion without direct cause and effect. In the past, a common complication of elective terminations performed under nonsterile conditions.

Spontaneous abortion- an early pregnancy loss; a miscarriage.

Therapeutic abortion- known commonly, simply as "an abortion"; an elective abortion. Also used to describe elective or voluntary interruption of pregnancy (VIP) for any reason.

Threatened abortion- Bleeding with or without crampin, cervix is closed. Outcome is uncertain.

What causes miscarriage?......... many things, probably. Chromosomal abnormalities, genetic mutations, and developmental mishaps probably account for the majority of miscarriages. These are simply genetic or developmental accidents that were not able to survive. Some public health studies have implicated environmental toxins in some isolated cases and communities.

Less often, there are problems with a mother's health. However, some rare and poorly understood "maternal factors" may play a role. Some "autoimmune" diseases have been associated with early and late pregnancy loss. Clinicians use the term "autoimmune" to describe disease which is caused by the body reacting harmfully in someway to itself. In these cases, the body makes antibodies against itself. Antibodies are supposed to be good things, which we produce to fight off illness caused by outside forces (for example, bacteria and viruses). Sometimes, however, they turn against us. Our own antibodies are capable of attacking our own tissue, organs and even components of our blood. If your clinician suspects autoimmune disease or if you have had recurrent miscarriages in the past, your blood can be examined to look for some of these antibodies. If they are found, you will need some specialized care prior to and during pregnancy. In addition, it may be advisable to check the chromosomes (via a blood sample) of both mother and father, if a couple experiences recurrent miscarriages.