The Role Of Herbs In The Prevention And Treatment Of Miscarriage
Miscarriage, medically referred to as spontaneous abortion, is the spontaneous, unexpected, and often unexplained loss of a pregnancy before 20 weeks gestation. Miscarriage is the most common pregnancy complication; however, the exact incidence is unknown because the actual incidence of conception in the population is uncertain. One in seven clinically recognized pregnancies will miscarry, and in studies of women attempting to conceive, spontaneous abortion occurs in 10% to 15% of conceptions. Based on studies of pregnancies achieved through assisted reproductive technologies, 50% of conceptions result in miscarriage. Miscarriage rate is related to maternal age, with rates under 2% for women under 30 years of age, and between 5% and 10% for women more than 40 years old. Miscarriage rates decline to less than 3% if there is a healthy fetus present at 8 weeks gestation (as visible upon ultrasonogram) in healthy women. Note: The term fetus is used throughout this chapter; however, the term embryo is the technically correct developmental term for any baby less than or equal to 8 weeks of gestation.
Although miscarriage may occasionally be welcome in the case of an undesired pregnancy, it is generally accompanied by a sense of loss, grief, or sadness, and a woman may experience self-doubt or self-reproach (e.g., “Maybe I miscarried because of that glass of wine I had last week, or maybe it was because I was ambiguous about being pregnant.”). In addition to supportive physical care, women need emotionally sensitive care providers who can understand and empathize that the loss of a pregnancy may matter a great deal to the mother.
Causes Of Miscarriage
Numerous factors contribute to miscarriage; however, the etiology of most individual miscarriages is never determined. Causes of miscarriage can originate with either parent or the conceptus. Investigation into specific causes of miscarriage in individual women is generally not pursued unless the woman miscarries recurrently. Causes include:
• Fetal Factors
• Maternal Factors
• Environmental Exposure
• Physical and Congenital Abnormalities
• Endocrine Disorders
• Immunologic Factors
• Coagulation Disorders
• Nutritional Deficiencies
• Psychological Factors
• Paternal Factors
Signs And Symptoms Of Miscarriage
Signs and symptoms of miscarriage include:
• Vaginal bleeding (brown or bright red “spotting” or bleeding)
• Abdominal cramping, pain, or contractions that becomes increasingly regular
• Passing of clots, tissue, or a gush of fluid
• Diminished subjective signs of pregnancy (e.g., nausea and vomiting of pregnancy, breast tenderness)
• Cervical dilatation
Diagnosis and staging of miscarriage is made primarily upon ultrasound findings and the presence of cervical dilatation. Ultrasonography is considered the most important and useful diagnostic tool for spontaneous abortion. Passage of complete embryonic or fetal tissue, cessation of pregnancy symptoms, and negative hCG levels for pregnancy are indicative of miscarriage; however, self-diagnosis on the basis of passage of large amounts of “tissue,” abatement of pregnancy symptoms, and a negative home pregnancy test are not proof of miscarriage. What appears to be embryonic or fetal tissue can actually be clots, pregnancy symptoms can fluctuate, and home pregnancy tests can give false-negative results.
Bleeding in early pregnancy can be a sign of serious problems. Major causes of early pregnancy bleeding, other than miscarriage, that must be ruled out include ectopic pregnancy and cervical, vaginal, or uterine pathology (e.g., trauma, polyp, cervicitis, or neoplasia). Molar pregnancy (hydatidiform mole) also should be ruled out. Some women experience a small amount of bleeding on implantation, known as physiologic bleeding, which typically is not of concern.
Conventional Treatment Approaches
Initially, an ultrasound should be performed to determine whether a live fetus is present. A live baby is born in 94% of pregnancies in which there was a threatened miscarriage. Conventional treatment of threatened miscarriage ranges from a “wait and watch” (expectant) approach with reassurance to the use of bed rest, administration of progesterone, use of uterine muscle relaxant drugs (tocolytics), or other therapies when appropriate, such as specific treatments for SLE or APS:
• Expectant approach
• Bed rest
• Progesterone therapy
• Uterine muscle relaxants (tocolytics)
Conventional treatment of inevitable miscarriage includes hospital admission for pain medication if needed, and ultrasound to determine whether the fetus is alive or whether miscarriage is incomplete. In incomplete abortion where there has been substantial blood loss, appropriate emergency procedures are followed, including resuscitation if needed, administration of intravenous fluids, blood work, and treatment of shock and infection is present. A dilatation and evacuation is performed to empty the uterus of any remaining products of conception and medication for pain and infection prophylaxis is administered as appropriate. In cases of missed abortion, typically first identified during routine ultrasound examination, or attention to a discrepancy between maternal growth or subjective or objective pregnancy signs and time elapsed since the missed period, a wait and see attitude may be adopted for up to several days to 2 weeks (depending upon the time elapsed since the missed abortion first occurred) to see if completion of the abortion ensues spontaneously, or surgical removal of the conception products may be scheduled to prevent the risk of hemorrhage and infection.
Women presenting with a history of miscarriage should be evaluated for the presence of any of the factors named earlier that are associated with miscarriage. Diabetes mellitus, thyroid diseases, and immunologic factors should be ruled out. Chromosomal evaluation of both partners should be performed, and an evaluation of the woman’s reproductive anatomy should be performed. Presence of infection and infectious organisms should be ruled out, and if present, treated. Cervical incompetence often can be treated successfully with cervical cerclage, a suture placed in the cervical os in the first trimester of pregnancy.
RhoGAM should be administered within 72 hours of miscarriage to all women who are Rh — to prevent maternal sensitization and possible Rhesus isoimmunization of a fetus in a subsequent pregnancy.
Support and counseling should be provided, as miscarriage is frequently accompanied by feelings of guilt, shame, and grief. Practitioners should reassure couples that it is unlikely that anything either parent did caused pregnancy loss. Women with a history of repeated miscarriage may need significantly more counseling than women experiencing a first miscarriage.