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 After the diagnosis has been set up the patients would like to know what to do both in the given case and for avoiding further similarmedical cases. Early miscarriage is a collective term including complete, incomplete and started spontaneous abortion, blighted ovum as well as missed abortion of the previously living embryo.

OUR MATERNITY PRIVATE DEPARTMENT PROVIDES CARE AFTER „UNSUCCESSFUL PREGNANCIES (MISCARRIAGES)”

Pregnancy loss before 24th week of gestation is called spontaneous abortion, if the embryo does not show life functions when coming to world, its weight is below 500 grams and the abortion took place without any noticeable external influence.

Approximetly 15-20 % of clinically diagnosed pregnancies end with early pregnancy loss. A significant part of death happens before the clinical diagnosis of pregnancy, and patients experience it as a delayed menstruation. Early losses can be up to 60 % of total conceptions according to estimates

As request of a pregnant the abortion can be under operational conditions and with permission, which is called artificial abortion (legal abortion, interruption). This can be done on the basis of medical recommendation, mainly due to genetic disease of the embryo, or at the request of the pregnant woman, according to the actual laws. Abortion induced under non-appropriate conditions and without permission is called illegal or criminal abortion („prohibited abortion”)

CAUSES OF SPONTANEOUS ABORTION

Spontaneous miscarriage is actually not „spontaneous” so it always has a reason. The causative factors can be listed in six groups:

  1. Luteal insufficiency: In case the luteum does not produce enough progesterone (luteal hormone) during the cycle the endometrium cannot prepare for receiving the fertilized ovum. Progesterone is produced until the end of the 6th week only in the ovum and mainly in the placenta after the 10th week. In case of luteal insufficiency between 6th and 10th week, typically around 9th week the ovum already and the placenta still does not produce enough luteal hormones. The consequence can be death of the embryo. In this case the next pregnancy may only be undertaken with well-prepared medical treatment and regular cycles.
  2. Vaginal infection: : Certain pathogens are capable of reaching the lower surface of the amniotic sac after 16th week of pregnancy and they induce inflammation there and as a result the sac ruptures and the embryo is expulsed. The cause can be infection of the husband, e.g. in the form of chronic prostatitis.
  3. Chromosomal abnormalities: Most of the embryos started to develop with chromosomal abnormalities does not come to light. One third of those with Down syndrome and 2 per cent with Turner syndrome are characteristic exceptions. Chromosomal abnormality can be developed as a new mutation or as the unlucky consequence of a balanced abnormality carried by one of the parents. If one parent’s chromosome’s piece and it sticks to the other chromosome (translocation) the person remains healthy because neither lack nor excess of the genes exist. It can happen, however, the child df or excess gene in addition to the healthy one, thus translocation becomes unbalanced and spontaneous abortion will prevent multiple and severe congenital abnormalities by natural selection. In case of abnormalities due to genetic defects or environmental influences spontaneous miscarriage depends on the seriousness of the anomalies. The more severe the abnormality the more probable that natural selection will develop earlier.
  4. Gynaecological abnormalities: Malformations of the uterus (e.g. duplicate defects) decay of the endometrium (e.g. due to tuberculosis), uterine wall adhesion (Asherman syndrome), extremely large, many myomas in unfavourable positions etc. all can be the causes of spontaneous miscarriage.
  5. Cervical insufficiency: Cervical insufficiency can be primary (originated from underdeveloped uterus or malformations) when the cervix opens without any symptom during the first pregnancy, typically around 20th week. Secondary cervical insufficiency means that damage of the cervical sphincters is the consequence of a previous delivery or abortion.
  6. Immunological incompatibility: If the antigens of the husband and the wife are very similar, then the production of the embryo’s protective antibody can be delayed so the embryo may become the victim of lymphocytes („killer cells”) showing aggressivity against the foreign tissues.

CLINICAL COURSE

Miscarriage occuring before 16th week of pregnancy takes place mainly in one stage, this is the embryo and the auxiliaries (sacs and placenta) leave together. From 16th week on, miscarriage occurs in two stages, similarly to the delivery. First the embryo leaves and later comes the placenta in the next stage. In both cases the symptoms of abortus imminent refer to miscarriage. Bleeding is experienced and the pregnant has abdominal pains. This time the cervical canal is still closed.

In case of open cervical canal, if the embryo and/or the auxiliaries have not left yet, we speak about abortus incipient

When the embryo and/or the auxiliaries have already left but the uterus has not been completely evacuated, the abortus is incomplete (abortus incompletus). Complete miscarriage means that the uterus has been fully evacuated (abortus completus)

We speak about missed abortion (delayed abortion) when the embryo has died but expulsion does not begin spontaneously.

Miscarriage before 6th week of pregnancy takes place in one stage and often completely

THE SYMPTOMS OF SPONTANEOUS MISCARRIAGE

Should any (or all) of the signs referring to miscarriage experienced at the same time, it is worth of visiting the gynaecologist, who will be able to determine what is going on inside the body. The following symptoms may develop in case of miscarriage:

  • milder or stronger back pain, being often more unpleasant than the pain accompanying menstrual spasms
  • weight loss
  • white-pink mucous discharge
  • uterine contraction accompanied with repeatative strong pain in every 5-20 minutes
  • brownish or live red vaginal bleeding with spasms or without them (it should be noted that bleeding occurs in the early stage in 20-30 % of pregnancies, but in half of the cases it will go on developing undisturbed)
  • tissue pieces with clots leave from the vagina
  • sudden disappearance of the well-known signs of pregnancy

TREATMENT

Abortus imminent can be often cured. Strict bed rest, mild sedatives, uterus relaxants and exclusively natural progesterone preparations (in the form of capsules and vaginal tablets) can often result in reversing the process.

In case of already started miscarriage, spontaneous process is ensured under sterile conditions. In case of suspected inflammation antibiotics are used. After the cervical canal has fully opened the dead embryo is sucked from the uterine with a vacuum aspirator, and uterine revision is performed with a sharp curette spoon for the purpose of removing any embryonic or auxiliary part and hematoma from the uterine.

During specific treatments it is reasonable to cure the main diseases predisposing miscarriage before undertaking the next pregnancy. For example infection of the patient or of the husband should be cured, if required. In case of cervical insufficiency cervix closing surgery is recommended. Repeated miscarriages give reason for examining the chromosomes of both the husband and the wife.

PREVENTION AND DIAGNOSIS

We have the chance of efficient prevention if the conditions mentioned in section „Causes” have already been diagnosed and targeted before conception.

  • A Luteal insufficiency kcan be reported by measurement and careful analysis of wake-up temperature. Evaluation of the curve needs a specialist! Luteal insufficiency can be short, if it lasts 11 days or shorter, and insufficient luteal phase is determined if progesterone is produced in insufficient quantity. Luteal insufficiency diagnosed before conception can be cured.
  • In case of suspicious infection both the vaginal discharge and the husband’s sperm must be subjected to microbiological examinations to determine possible infections.
  • Chromosomal defects are usually examined when there has already been chromosomal abnormality in the family, or when the older age of the pregnant woman gives reason for the examination, since the risk of chromosomal defects is getting higher because of the increasing age of the parents. While the frequency of congenital Down syndrome is 1/1000 of the total childbirths, it is already 2 % at the age of 40 and it is increasing by one per cent every year. In case of repeated miscarriages chromosomal examination of the wife and the husband may be required for excluding balanced chromosomal defects.
  • The most severe gynaecologic diseases can be screened out with simple routine tests. X-ray examination of the uterine and oviducts with contrast agents (hysterosalpingography), or ultrasound examination can be performed for revealing developmental abnormalities, but it is also possible to survey the uterus and the pelvic organs with optical devices (hysteroscopy, or laparoscopy). In case of duplicate uterus metroplastic surgery is indicated.
  • Cervical insufficiency can be diagnosed by gynaecological examination in middle time, when closing operation can still be performed. Cervical insufficiency can be proved with cervicography before conception. Cervix closing operation can also be performed before conception
  • • Immunological examination is performed in case of repeated miscarriages, when immunological incompatibility is suspected. The suspicion is reasonable when more and more miscarriages occur before the new pregnancy

Stages of miscarriage can be diagnosed by gynaecological examination.Anamnesis, abdominal pain, bleeding and palpation of the cervical canal can help in setting up the diagnosis. Missed abortion can be recognised mainly by ultrasonic examination, this way dead embryo can be seen and lacking life functions can be presented (e.g. heart function). Abdominoscopy – laparoscopy – may be needed if extrauterine pregnancy is suspected.

CHANCES OF RECOVERY

Repetition depends on the basic disease. Luteal insufficiency, inflammations of the genital channels and insufficiency of the cervical canal can be best cared and cured. In case of larger and/or unfavourably located and/or multiple tumours and more severe abnormalities of the uterine development surgery can reach results, namely prevention of miscarriage. In case of Asherman syndrome or severe developmental abnormalities of non-sexual organs operation can be the good solution

Spontaneous miscarriage is not a sole disease, but it is the similar manifestation of the several diseases and conditions. One must strive for recognition of the basic disease. Recovery with high probability can be reached especially in case of luteal insufficiency presenting in the form of missed abortion, which make up at least two-third of the total cases of spontaneous miscarriages

If you lost your embryo, do not give up. Contact us so we could give worthy reply to your problem and do not be satisfied with the wave of the doctor’s hand doing curettage and saying that „next time you will succeed.”

CARE FOR PARENTS WHO HAVE GONE THROUGH MISCARRIAGE 

Our relation to our child differs from our connection with our parents, sisters, brothers and spouse. The special nature of loss and mourning following miscarriage stems also from this difference.

When this loss occurs in the first trimester of the pregnancy the typical reaction of the women, hallucination related to the embryo/child and strong motivation for replacement of pregnancy, can be more originated from the interruption of the desired development process than from the loss of a real person. Not only a child but also a mother is born during the pregnancy. The special element of this relationship is the internal image of the woman of herself, as a mother, and the image of her own child. Due to these fantasies of the embryos most of the women experience their embryos as an independent individual by the end of the 2nd trimester. The important role of fantasies about the embryo is proved by the fact that they determine more strongly the image of the infant’s personality than the actual behaviour of the child after birth. Women living in marriage survive loosing of their child with much less depression. The age, sex and general health condition, religious beliefs and struggling strategies of the parents in problematic situations have crucial importance.

Prof. Dr. Papp Zoltán

Prof. Dr. Papp Zoltán
A szerző A Maternity Magánklinika igazgatója.

 

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