4.BASIC
ETIOLOGIES OF MISCARRIAGE

Age:
When the woman is
around 35-40 years old the risk of miscarriage is higher. (The American College
Of Obstetricians and Gynecologists, 2015)

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It is highly suggested by many doctors for women to
give birth at an early age (18-30). Their opinions are based on the woman’s
body’s highest capability of providing best quantity of nutrients, going
through labor pain, and recovering from the procedure. 

Chromosome
abnormalities:  50% of pregnancy loss is due to chromosomic
anomalies of the fetus. The 50% of these anomalies usually is autosomic and the
most common is trisomy, monosomy X. (Stephenson & 
Awartani & Robinson, 2002)

In the 21st century, now more than ever, the
consequences of vast population growth, and with 7 billion people inhabiting
our planet, chromosomic abnormalities are at their highest chance of occurring.
The average woman’s body is able to detect most of these and force into a
miscarriage, in hope that the woman will not go through dangers during labor.

Endocrine
factors: diabetes, thyroid
disease polycystic ovarian syndrome are endocrine disorders that may cause miscarriage.(FORD
& SCHUST, 2009)

There are also cases in which miscarriage has to do
directly with the woman’s health and nothing at all with the fetus. It is very
critical that the host is able to maintain her own well-being before providing
for another living organism. That is why it is very important that the
appropriate examinations are done to ensure a normal pregnancy.

Anatomic
abnormalities: 10% to 15% of
cases of miscarriage. The most common is the anomaly of the uterus. Other
abnormalities are unicornuate, didelphic uteri. (Lin Pc, 2004)

Once again, a thorough examination of the woman will
show if her anatomy (uterus) will outcome the pregnancy.

 Breastfeeding: The breastfeeding to the newborn of the pregnancy
may cause a pregnancy loss due to the fact that the contraction of the
endometrium is activated.(Karpathios, 2001)

More than one pregnancies during periods too close to
each other should be avoided, as the body still needs time to recover and take
care of  a newborn even after the labor
(breastfeeding).

Poisoning: A big part of motherhood has to do with
responsibility. Nutrition is of the utmost importance as it determines the
foundation on which the fetus’ body will be built.  Certain bacteria’s infections such as
salmonella enterocolitis, listeriosis and toxoplasmosis are established as
possible as pregnancy loss causes. (Pejcic-Karapetrovi,
2007 ; Gurnani& Russell, 2008; Finlay et al, 2005)

Psychology: Intense psychological trauma can be harmful to the pregnancy.
Emotions have to do with the production of hormones, a big gathering of which
can cause implications. The mother should try and live in a peaceful
environment and control herself during stressful situations. (Karpathios,
2001)

Risk
Factors: Such as smoking,
drugs, alcohol, and caffeine during the pregnancy The direct connection between
the aforementioned harmful substances and miscarriage has not been detected yet
but is sure to exist. Any of these, that are known to cause addiction, can
result to an addiction on the fetus itself if consumed during pregnancy (size,
cervix insufficiency, endometrial polypus) is proper.

 

 

 

 

5. ETIOLOGIES OF RECURRENT PREGNANCY LOSS

Many cases of recurrent pregnancy loss have very
similar – if not identical – causes to individual ones.

Genetic
factors (5%): Due to heredity
the fetus can develop chromosomic diseases. The possibility to detect the
genetic abnormality is higher in cases of childless couples.   

Endocrine
diseases (17%): Low or no
production of hormones such as progesterone, estrogens, folliculitis, lutein
and such. Also disorders of the hypothalamic or the pituitary parts of the
axis, chronic diseases, ovarian insufficiency and hypothyroidism. It is also
believed but not yet diagnosed, that diabetes can be a cause.

Anatomic
abnormalities (12%): The
insufficiency of internal cervix and also the anomalies of the uterus are
recognized causes for the recurrent pregnancy loss.

Infections
(5%): There is no diagnosed,
but microorganisms such as chlamydia and mycoplasma are the factors which can
caused pregnancy loss.

?mmunological
factors (50%): The fetus for
the woman’s body is no identical so there are immunological factors that are
allow her to continue the pregnancy without rejection. During the pregnancy may
be abnormalities between these immunological mechanisms and end up in
miscarriage.

Antiphospholipid
antibody: Is a syndrome that
can be related by the antibodies that are exist is because there is increased
quantity of thromboxane and decrease of prostacyclin and resulting in platelet
accumulation and ended up with the placental abruption. These antiphospholipid
antibodies can caused early childbirth and endometrium death of the fetus.

Unexplained
etiologies (10%):
There are and others causes for the recurrent pregnancy loss as chemical substances,
medicines and radiation.(Karpathios, 2001)

 

6.
THE ROLE OF MIDWIFE

Midwifery offers professional care and support for the
pregnant during and after pregnancy. The midwife provided health care services,
advice and counseling, prescriptions during pregnancy, labor and newborn care.
Midwife is a birth partner that often equals the importance of the male
partner.

The midwife is also the key person in the physical and
psychological health of the pregnant. She is the one that can help with the
family planning, that follows all prenatal and order tests, the one that
advises even about diet, exercise, how to stay healthy, counsel about pregnancy
and newborn care and finally delivers the baby.

The role of midwife is not only supportive during the
labor. The most important thing in case of pregnancy loss is the woman to
understand that it is not her fault, so her midwife –or anyone midwife- should
inform her with all the etiologies about miscarriage. They can inform the
pregnant about the care that maybe need. Although, when they have to confront a
pregnancy loss she must be positive. The influence that has is important
because that period of her life the woman wants to be supported and she has to
move on because she feels guilty and emptiness.

The midwife is also the provider of emotional,
practical and social support. In case of pregnancy loss where such kind of loss
is a devastating situation for the woman as well as the male partner midwife
will develop a trust relationship. The emotional pain has to be deal at once so
that the woman shouldn’t feel guilty at all. Then midwife will communicate
effectively  the stage of denial, anger,
and disbelief as most of the women experience these kinds of emotions. The
reunion of the couple, the grief, and the recovery are the next steps to be
followed by the midwife.  She will be
there to make all above steps are followed and make sure that women will try to
become pregnant again, free of guilt and prejudice.

Midwife according to the Bible means with women but the
meaning of word midwife is also there for the male partner. She is responsible
for the following up of the male partner as well. She will inform the male of
all changes that will be affected during the process of pregnancy and birth.
Most of the male partners have feared not only for the pregnant in case
something goes wrong also the unknown after the childbirth. Most of them are
willing to attend the labor of the child but they must be first prepared that
the procedure is somehow too personal and leaves mixed emotions. It seems from
different cases that a childbirth can either bring closer a couple or driven
apart by it. She will be the calming influence and the male must fall with her
plan in order to manage the stress or anxiety of watching the labor pain and
also the fact that he can’t help at all. She is the one to sense the parent’s
fear and reassure that she is there for them.

 

7.
SIGNS THAT INDICATE THE DANGER FOR PREGNANCY LOSS

The most common symptoms of a pregnancy loss are
vaginal bleeding and pain. The blood is red color and in big quantity and the
pain usually is located in the hypogastric and reflected in the lumbar spine.
If the woman has any signs that may indicate miscarriage she must contact her gynecologist
and do a physical exam. ( Karpathios,2001)

To confirm that the fetus is still growing in the
uterus she should have an ultrasound exam to make sure that there is a
heartbeat. Also, she has to measure the blood level of human chorionic
gonadotropin, this is a hormone that is produced during pregnancy. If the test
shows low or decreasing level of this hormone maybe there is pregnancy loss. (The American College Of
Obstetricians and Gynecologists, 2015).

There are also cases, where no signs of all above
occur and miscarriage is diagnosed only during a routine scan.    

 

 

 

 

 

 

8. EXAMS
FOR INVESTIGATION OF PREGNANCY LOSS

·        
History

·        
Gynecological
examination

·        
Laboratories
exams

·        
Different
seroantibodies (toxoplasma

·        
 Urea cultivation and vaginal secretion

·        
Control
of cervix during the pregnancy. (Karpathios,2001)

 

9. DIAGNOSTIC
EVALUATION OF RECURRENT PREGNANCY LOSS BASED ON ETIOLOGY

Genetical: After genetic counseling most common therapy
includes in vitro fertilization with preimplantation genetic diagnosis. In case
of genetics anomalies the use of donor gametes may be suggested.( FORD & SCHUST, 2009)

Anatomical: The anatomic anomalies are often confronted
surgically. The woman undergoes in hysteroscopic septum resection and
myomectomy (in cases of any type fibroids larger than 5cm). The myomectomy can
be executed through open laparotomy, laparoscopy or hysteroscopy. (Bajekal, 2000 ;Grimbizis, 2001)

Endocrinal: Thyroid-stimulating hormone level should be regularly
measurement. Other testing such as insulin, ovarian, serum prolactin,
antithyroid antibody testing should be done as well. Common treatment with
insulin-sensitizing present sufficient results. (Vaquero & Lazzarin& De Carolis, 2000;FORD & SCHUST, 2009)

Infectious: Routine, underlying 
or endometritis infections are treated with antibiotics. (FORD & SCHUST, 2000-2009)

Immunological-Antiphospholipid
syndrome: Once diagnosed,
treatment includes low dose aspirin plus prophylactin heparin. (Derksen,2009)

Unexplained:  In such cases
there is no definitive diagnosis. The progesterone seems to decrease the
recurrent pregnancy loss rate. LDA is recommended as a potential therapy. (Haas&Ramsey,2008;Rai&Backos&Baxter&Chillcott&Regan,
2000)

10. PROGNOSIS

The prognosis of the causes of all previous recurrent
losses help the patient to carry the next pregnancy to term with success.
Correction of all endocrine disorders and anatomic anomalies encourage the
patient for the next try.
(Stephenson& Sierra,2006; Sugiura-Ogasawara et al. 2004).

11. STEPS
TO BE FOLLOWED AFTER RECURRENT PREGNANCY LOSS

By the time, doctor informs the woman for the miscarriage or loss
there  are certain steps to  be followed. An ultrasound scan or scans will
confirm that the pregnancy  is stopped.
Also draw blood to check HCG levels is an alternative choice to verify the
loss.

There are several ways that a pregnancy loss should be faced :

·        
Complete miscarriage: in this case a heavy bleeding in the very few weeks
of pregnancy is a sign that the fetus is completely removed from the uterus(The
American College Of Obstetricians and Gynecologists, 2015). Nature takes care
of the loss and waits few weeks until the fetus is completely expelled from the
body.

·        
Medical treatment : in this case the fetus remains ,no blood signs
appears and pills must be taken so that the body begins to expel the fetus –
usually mifepristone or misoprostol(Mentula et al, 2011). This kind of
treatment usually  causes nausea ,vomiting and diarrhea but it is the only way to avoid
the surgery. (The American College Of Obstetricians and
Gynecologists, 2015)

·        
Surgical treatment : a minor vacuum aspiration will remove the fetus and
placenta from the uterus, using  a
suction devise attached to the a slender tube called a cannula. Another
surgical option is Dilation & Curettage (D&C) where the cervix is
opened and the fetus is gently scraped from the inside of the uterus(The
American College Of Obstetricians and Gynecologists, 2015).  

Based to all above the gynecologist 
will recommend recovery for 1-2 weeks and advice the woman to avoid
having sexual intercourse or also  not to
insert anything into vagina such as tampons.In case of the following symptoms
such as heavily bleeding, fever, severe pain and chills she must get in contact
with her gynecologist immediately. (The American College Of Obstetricians and
Gynecologists, 2015).

 

 

 

12.DISCUSSION

Will be refereed to advantages and disadvantages between medical and
surgical treatment after miscarriage. Also patient preferences based to studies
will be taken in consideration in order to evaluate the best solution for the
woman’s health and quick recovery.

Both options are acceptable as common treatment after the diagnosis of
pregnancy loss. According to stage progress of the labor medical or surgical
treatment are standard therapies.

Medical treatment is usually based to the dosage of misoprostol which is
placed vaginally. The fetus should be expelled within the 3 day. If not, then a
second dose placed vaginally again and within 8 day there is complete abortion.
The risks of bleeding and infection are the same with those of surgical
management. ( Zhang & Gilles
& Barnhart & Creinin & Westhoff& Frederick 2005). The advantages of medical therapy is that no surgical
procedures are needed specifically general anesthesia and surgery .The patient is ready to continue
normal activities within a few days. The disadvantages is that in some cases
this procedure is not successful and then surgical approach has to be
followed.  The risks includes bleeding,
infection, cramping and diarrhea. (The American
College Of Obstetricians and Gynecologists, 2015)

Surgical treatment is the only solution in case of progressive gestation.
It is highly recommended at the sight of infection, heavily bleeding or other
medical condition. The fetal is removed with Dilation & Curettage (D)
from the uterus. The advantages is that the procedure is scheduled and
performed at a certain time. The patient can be prepared physically and
emotionally and even get helped from a specialist. This is a certain success
therapy excluding the risk of possible incomplete abortion. The risks of a D
involve bleeding, infection, perforation of the uterus and possible Asherman
syndrome after the procedure.( Zhang &
Gilles & Barnhart & Creinin & Westhoff& Frederick, The American
College Of Obstetricians and Gynecologists, 2005-2015)

Based to studies, in incomplete abortion among patients that had to choose
between medical or surgical treatment shown their preference in medical treatment
at 96.3% to 91.5% (Weeks & Alia
& Blum, 2005)

 

13.CONCLUSION

Reproductive system is the most inefficient system for any living being.
An entire specialized system which is able to block and reject the failure. This  is 
the  explanation  that 
should be given to a failure, miscarriage. The system itself is so
protective and no exception can be made for the conceptus. No tolerance is
accepted that is why rejection often causes miscarriage.   

Reccurent pregnancy loss is a personal tragedy for people willing
parenthood. But is a fact that has to empower the couple to find the reasons
and the answers for it. Knowledge will help them to regain strength for the
next try. Suffer, grief and despair and pain are normal emotions that mostly
woman experiences.

An obstetrician gynecologist, a family medicine doctor, a midwife can help
to manage a miscarriage. They are specialists, well-educated professionals that
will advise how to overcome the loss, arrange all necessary exams, instruct
medications if required. They offer physically as well as emotionally support
and guidance.

In our days there are also helplines, support groups and organizations
for pregnancy loss ( stillbirth, miscarriage) to offer information and a
listening ear. Most of people participate in such groups experience similar
circumstances, share same feelings and thoughts.

Sometimes it is difficult to seek answers for the irrelevant. Each case
is different especially to recurrent loss but treatment is offered as a hope
for any future effort. Parenthood worth’s every try, it is long and difficult
journey which continues also after giving birth to a new human life.

  

 

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