Miscarriage - what one needs to know

Written by Dr Parul Chopra Buttan

As a passionate obstetrician and a woman myself, I'm pained by the unhappy & uncomfortable situations my patients sometimes find themselves in.

 

Early pregnancy bleeding is one such situation. It wreaks havoc in the mind of the patient and is of grave concern to the obstetrician. I've noticed in my consultations that giving the couple or family complete knowledge about what is going on, what we can expect and what can be done, helps them go through this challenging phase.

 

There are several causes of bleeding in early pregnancy. A sound obstetrician should be able to establish the exact circumstances of your situation by asking you a few questions, doing a gentle, thorough examination and some basic investigations.

 

One of the foremost worries on the mind of the woman and the family is MISCARRIAGE. It is one of the most important and common causes of early pregnancy bleeding, though the only one. The other causes such as ectopic pregnancy, gestational trophoblastic disease, cervical polyp etc merit a separate article and I shall not discuss them further here.

 

This post focuses on miscarriage. There are types and stages to it and most importantly, all is not lost the moment the doctor utters the dreaded word.

1.     THREATENED MISCARRIAGE

The pregnancy is very much alive and intact but is in a vulnerable state. The woman experiences bleeding, usually painless. The site of bleeding may be visible on an ultrasound or may be unknown. Physical exertion needs to be avoided, though bed rest has no role. Pregnancy supportive hormonal medication has an empirical role as per evidence in literature. Medications to control the bleeding may also be given if deemed fit by the gynecologist. At this stage, the pregnancy is salvageable and may continue without any further complications.

2.     INEVITABLE MISCARRIAGE

As the name suggests, miscarriage is unavoidable and usually imminent. The mouth of the uterus may be seen to be open on examination and bleeding is usually heavier than normal menses and often accompanied by pain. The process of expulsion of the pregnancy can be enhanced by medication or by a minor surgical procedure depending on the physical findings and the preference of the patient. Waiting for spontaneous resolution may also be a practical option.

3.     INCOMPLETE MISCARRIAGE

The pregnancy has been partially lost in the usually painful vaginal bleeding and is not salvageable. Again, the remaining part of the pregnancy may be removed with medicines or a surgical procedure depending on the time since bleeding, amount of tissue left behind, any other complications, physical condition of the patient and her preference. There is a risk of anaemia from prolonged heavy blood loss and of infection involving the uterus, converting it into a dangerous septic miscarriage (explained later).

4.     COMPLETE MISCARRIAGE

The whole pregnancy has passed in the bleeding. The bleeding usually reduces significantly and soon stops. Our focus is to provide emotional support and advice on recovery from the event, besides addressing the various questions that arise (why did it happen, when can the patient conceive again, does this episode put future pregnancies at risk… - these questions will be addressed in detail in a separate article.)

5.     MISSED MISCARRIAGE

This entity is usually diagnosed on an ultrasound or if the pregnancy is not seen to be growing clinically. The heart beat is absent and the pregnancy is not salvageable. The woman may have no problems or may experience reduction in the symptoms of pregnancy (such as morning sickness, fatigue etc). Bleeding may begin in some days and start the process of removal of pregnancy or it may remain silent for quite some time. Medicine or a surgical procedure is usually advised when the woman is ready for it. The pregnancy can be sent for testing to know the cause, though in about 40% of the cases, no cause can be found.

6.     SEPTIC MISCARRIAGE

 

It means any kind of miscarriage (spontaneous or voluntary) that has been complicated by infection. It is a serious condition that can quickly become life-threatening by complicating into septicaemia and multi-organ failure. It usually needs prompt management and hospital admission. It may take some time to recover and may even have long term consequences like infertility. Any woman who develops fever, foul smelling vaginal discharge, severe generalised pain in the abdomen while miscarrying should seek urgent medical help.

 

Miscarriage, though not desirable, is a reality. It is one of nature's ways of eliminating the not-so-healthy pregnancies early on. Emotional support and tender loving care from the caregiver and from the family go a long way in restoring the woman's health and long term well-being.

Feed, mother, feed!

Written by Dr Parul Chopra Buttan

Being a woman and a mother, breast feeding my baby has been THE most fulfilling experience of my life. It beats everything...cracking the toughest of exams, performing life-saving surgeries, surpassing the highest highs and overcoming the lowest lows of life… It's just incredible, the experience of being able to nourish a life... And that too, the life you hold dearer than your own!

Women nourish the baby inside of them with their blood every single minute of the nine months during pregnancy, but that is invisible and happening involuntarily. Breast feeding is voluntary, visible and purely magical! Doctors recommend 6 months of exclusive breastfeeding. So all the growth, and it is huge, that you see in your little wonder at this time is through you!

As an obstetrician and gynaecologist, I feel really strongly about this miracle of life. I would urge our community and every family to take utmost care of our women during this precious time.

1. Rest


Give a new mother ample rest. Physically, mentally, emotionally. Give her space and time so she's relaxed and comfortable and can perform this job that nobody else can do. Stress, whether physical, emotional or mental affects milk production and the health of the baby directly.


2. Nutrition

A nursing mother needs about 550 extra calories over and above her daily needs. She should have a balanced diet inclusive of whole grains, fruits, vegetables and plenty of fluids.
 

3. Water

Especially in India, there is a myth that gynaecologists come across often - that water is bad for a nursing mother. I have had so many families in my practice who argue that water dilutes milk and also contributes to a lax tummy post-delivery. It's as far from the truth as can be. Adequate hydration is absolutely essential for milk production, besides guarding against diseases like urinary infections which can be dangerous post delivery.


4. Start early

The baby needs to be put to the breast as soon after delivery as possible, preferably within 1 hour! The baby and the mum, both need to learn the art of breast feeding. This early suckling is what promotes milk production and  ensures the baby gets the all important 'colostrum'. The thick yellowish discharge in the first days after birth is supremely nutritious besides providing the baby protection from diseases such as diarrhoea. So much  so, it is hailed as the baby's first immunisation!! Don't deny this elixir to the baby. Yes, the whole family is excited to hold the newborn. Also, the doctors want to weigh the baby and do their numerous checks to ensure a healthy baby but as far as possible, the newborn baby should be close to the mother and she should be supported in this endeavour. The mother infant bonding at this time goes a long way in ensuring a healthy baby, physically and emotionally!

5. Seek help

If there is anything worrisome regarding the new mother like fever, persistent low mood or anxiety, inability to breastfeed despite trying, painful or swollen breasts, excessive blood loss, tiredness, breathing difficulty, swelling in legs etc., seek help urgently. She needs to see a gynaecologist as soon as possible.

Happy breastfeeding to you!

Letter to Parents-to-be!

Written by Dr Parul Chopra Buttan

Dear mommy and daddy-to-be,

Congratulations on making it this far! You are now about to embark on the final leg of this incredible journey which is also the most exciting and miraculous part of it. By now you would have had a detailed discussion with your doctor regarding the plan of delivery suitable for you according to how your pregnancy has been and your preferences.

Signs of onset of labour/ when to call your doctor?

If you experience any of the following, it's time to call your doctor

1. Pain abdomen - usually regular, rhythmic, intermittent, increasing in intensity& frequency
2. Breaking of waters - this will usually feel like a gush of urine-like fluid leaking out of the vagina. May even begin by small amounts leaking intermittently.
3. Show - a dirty, sticky mucoid discharge may precede pain.
4. Any other symptom you may be concerned about depending on your pregnancy.

Labour

Labour is a slow and exhausting process. The mouth of the uterus opens slowly from zero to ten centimetres (dilatation) and then the baby descends. Any deviation from the normal may necessitate some action on the part of the team caring for you. Your doctor will familiarise you with the various situations that can arise commonly so as to ease the communication and save time during those all important minutes, should an emergency arise. Discuss options for pain relief available and have a plan ready and documented.

Normal delivery

Your doctor will encourage you to push at the right time. You may feel the urge by yourself too. A small cut at the vaginal opening (called episiotomy) may be required to facilitate the delivery safely. The umbilical cord is cut and the baby is handed over to the baby receiving team. The after births are delivered. Some medicines may be administered to reduce blood loss. Your doctor will stitch up the cut under local anesthesia and apprise you of the care of the stitches.

Instrumental delivery

Sometimes, the delivery of the baby may need to be aided with a vacuum cup ( Aamir Khan's character in the Hindi film, 3 idiots does one!) or forceps. Discuss the pros and cons of both the instruments with your doctor beforehand and make an informed choice.

Elective Caesarean birth

In case your delivery is by a pre-planned Caesarean section, your doctor would have discussed the expected procedure and recovery. Usually a spinal anesthesia is used wherein you are awake and pain free and can hear your baby's cry! A different anesthesia may be needed depending on your particular case. Drinking and eating may commence 4-6 hours after the surgery. You will usually be able to get up and walk by the next day. Depending on your recovery and preferences, discharge from the hospital may be planned 1-3 days post surgery.

Newborn care

The baby will usually be cleaned, examined, weighed and covered by the receiving doctor and team. They will let you know about concerns, if any, and their plan of management. Most of the babies can be shifted immediately to the mother's side and you may begin breast feeding as soon as comfortable. If it is your first baby, do familiarise yourself with newborn care with the hospital staff who would be happy to help in all respects.

My best wishes for a safe delivery!

 

Dr Parul Chopra Buttan