4.BASICETIOLOGIES OF MISCARRIAGEAge:When the woman isaround 35-40 years old the risk of miscarriage is higher.

(The American CollegeOf Obstetricians and Gynecologists, 2015)It is highly suggested by many doctors for women togive birth at an early age (18-30). Their opinions are based on the woman’sbody’s highest capability of providing best quantity of nutrients, goingthrough labor pain, and recovering from the procedure.  Chromosomeabnormalities:  50% of pregnancy loss is due to chromosomicanomalies of the fetus.

The 50% of these anomalies usually is autosomic and themost common is trisomy, monosomy X. (Stephenson & Awartani & Robinson, 2002)In the 21st century, now more than ever, theconsequences of vast population growth, and with 7 billion people inhabitingour 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 amiscarriage, in hope that the woman will not go through dangers during labor.Endocrinefactors: diabetes, thyroiddisease polycystic ovarian syndrome are endocrine disorders that may cause miscarriage.

(FORD& SCHUST, 2009)There are also cases in which miscarriage has to dodirectly with the woman’s health and nothing at all with the fetus. It is verycritical that the host is able to maintain her own well-being before providingfor another living organism. That is why it is very important that theappropriate examinations are done to ensure a normal pregnancy.Anatomicabnormalities: 10% to 15% ofcases of miscarriage. The most common is the anomaly of the uterus. Otherabnormalities are unicornuate, didelphic uteri. (Lin Pc, 2004)Once again, a thorough examination of the woman willshow if her anatomy (uterus) will outcome the pregnancy. Breastfeeding: The breastfeeding to the newborn of the pregnancymay cause a pregnancy loss due to the fact that the contraction of theendometrium is activated.

(Karpathios, 2001)More than one pregnancies during periods too close toeach other should be avoided, as the body still needs time to recover and takecare of  a newborn even after the labor(breastfeeding). Poisoning: A big part of motherhood has to do withresponsibility. Nutrition is of the utmost importance as it determines thefoundation on which the fetus’ body will be built.  Certain bacteria’s infections such assalmonella enterocolitis, listeriosis and toxoplasmosis are established aspossible 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 whichcan cause implications.

The mother should try and live in a peacefulenvironment and control herself during stressful situations. (Karpathios,2001)RiskFactors: Such as smoking,drugs, alcohol, and caffeine during the pregnancy The direct connection betweenthe aforementioned harmful substances and miscarriage has not been detected yetbut is sure to exist. Any of these, that are known to cause addiction, canresult to an addiction on the fetus itself if consumed during pregnancy (size,cervix insufficiency, endometrial polypus) is proper.    5. ETIOLOGIES OF RECURRENT PREGNANCY LOSSMany cases of recurrent pregnancy loss have verysimilar – if not identical – causes to individual ones. Geneticfactors (5%): Due to hereditythe fetus can develop chromosomic diseases. The possibility to detect thegenetic abnormality is higher in cases of childless couples.    Endocrinediseases (17%): Low or noproduction of hormones such as progesterone, estrogens, folliculitis, luteinand such.

Also disorders of the hypothalamic or the pituitary parts of theaxis, chronic diseases, ovarian insufficiency and hypothyroidism. It is alsobelieved but not yet diagnosed, that diabetes can be a cause.Anatomicabnormalities (12%): Theinsufficiency of internal cervix and also the anomalies of the uterus arerecognized causes for the recurrent pregnancy loss.Infections(5%): There is no diagnosed,but microorganisms such as chlamydia and mycoplasma are the factors which cancaused pregnancy loss.?mmunologicalfactors (50%): The fetus forthe woman’s body is no identical so there are immunological factors that areallow her to continue the pregnancy without rejection. During the pregnancy maybe abnormalities between these immunological mechanisms and end up inmiscarriage. Antiphospholipidantibody: Is a syndrome thatcan be related by the antibodies that are exist is because there is increasedquantity of thromboxane and decrease of prostacyclin and resulting in plateletaccumulation and ended up with the placental abruption. These antiphospholipidantibodies can caused early childbirth and endometrium death of the fetus.

Unexplainedetiologies (10%):There are and others causes for the recurrent pregnancy loss as chemical substances,medicines and radiation.(Karpathios, 2001) 6.THE ROLE OF MIDWIFEMidwifery offers professional care and support for thepregnant 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 malepartner. The midwife is also the key person in the physical andpsychological health of the pregnant. She is the one that can help with thefamily planning, that follows all prenatal and order tests, the one thatadvises even about diet, exercise, how to stay healthy, counsel about pregnancyand newborn care and finally delivers the baby.The role of midwife is not only supportive during thelabor.

The most important thing in case of pregnancy loss is the woman tounderstand that it is not her fault, so her midwife –or anyone midwife- shouldinform her with all the etiologies about miscarriage. They can inform thepregnant about the care that maybe need. Although, when they have to confront apregnancy loss she must be positive. The influence that has is importantbecause that period of her life the woman wants to be supported and she has tomove 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 lossis a devastating situation for the woman as well as the male partner midwifewill develop a trust relationship.

The emotional pain has to be deal at once sothat the woman shouldn’t feel guilty at all. Then midwife will communicateeffectively  the stage of denial, anger,and disbelief as most of the women experience these kinds of emotions. Thereunion of the couple, the grief, and the recovery are the next steps to befollowed by the midwife.  She will bethere to make all above steps are followed and make sure that women will try tobecome pregnant again, free of guilt and prejudice.Midwife according to the Bible means with women but themeaning of word midwife is also there for the male partner. She is responsiblefor the following up of the male partner as well. She will inform the male ofall 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 casesomething goes wrong also the unknown after the childbirth.

Most of them arewilling to attend the labor of the child but they must be first prepared thatthe procedure is somehow too personal and leaves mixed emotions. It seems fromdifferent cases that a childbirth can either bring closer a couple or drivenapart by it. She will be the calming influence and the male must fall with herplan in order to manage the stress or anxiety of watching the labor pain andalso the fact that he can’t help at all. She is the one to sense the parent’sfear and reassure that she is there for them. 7.SIGNS THAT INDICATE THE DANGER FOR PREGNANCY LOSSThe most common symptoms of a pregnancy loss arevaginal bleeding and pain.

The blood is red color and in big quantity and thepain 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 gynecologistand do a physical exam. ( Karpathios,2001)To confirm that the fetus is still growing in theuterus she should have an ultrasound exam to make sure that there is aheartbeat. Also, she has to measure the blood level of human chorionicgonadotropin, this is a hormone that is produced during pregnancy.

If the testshows low or decreasing level of this hormone maybe there is pregnancy loss. (The American College OfObstetricians and Gynecologists, 2015).There are also cases, where no signs of all aboveoccur and miscarriage is diagnosed only during a routine scan.          8.

EXAMSFOR INVESTIGATION OF PREGNANCY LOSS·        History·        Gynecologicalexamination·        Laboratoriesexams·        Differentseroantibodies (toxoplasma·         Urea cultivation and vaginal secretion·        Controlof cervix during the pregnancy. (Karpathios,2001) 9. DIAGNOSTICEVALUATION OF RECURRENT PREGNANCY LOSS BASED ON ETIOLOGY Genetical: After genetic counseling most common therapyincludes in vitro fertilization with preimplantation genetic diagnosis.

In caseof genetics anomalies the use of donor gametes may be suggested.( FORD & SCHUST, 2009)Anatomical: The anatomic anomalies are often confrontedsurgically. The woman undergoes in hysteroscopic septum resection andmyomectomy (in cases of any type fibroids larger than 5cm). The myomectomy canbe executed through open laparotomy, laparoscopy or hysteroscopy. (Bajekal, 2000 ;Grimbizis, 2001)Endocrinal: Thyroid-stimulating hormone level should be regularlymeasurement. Other testing such as insulin, ovarian, serum prolactin,antithyroid antibody testing should be done as well. Common treatment withinsulin-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-Antiphospholipidsyndrome: Once diagnosed,treatment includes low dose aspirin plus prophylactin heparin. (Derksen,2009)Unexplained:  In such casesthere is no definitive diagnosis.

The progesterone seems to decrease therecurrent pregnancy loss rate. LDA is recommended as a potential therapy. (Haas&Ramsey,2008;Rai&Backos&Baxter&Chillcott&Regan,2000)10. PROGNOSISThe prognosis of the causes of all previous recurrentlosses help the patient to carry the next pregnancy to term with success.Correction of all endocrine disorders and anatomic anomalies encourage thepatient for the next try.(Stephenson& Sierra,2006; Sugiura-Ogasawara et al. 2004).

11. STEPSTO BE FOLLOWED AFTER RECURRENT PREGNANCY LOSSBy the time, doctor informs the woman for the miscarriage or lossthere  are certain steps to  be followed. An ultrasound scan or scans willconfirm that the pregnancy  is stopped.Also draw blood to check HCG levels is an alternative choice to verify theloss.There are several ways that a pregnancy loss should be faced : ·        Complete miscarriage: in this case a heavy bleeding in the very few weeksof pregnancy is a sign that the fetus is completely removed from the uterus(TheAmerican College Of Obstetricians and Gynecologists, 2015). Nature takes careof the loss and waits few weeks until the fetus is completely expelled from thebody.

·        Medical treatment : in this case the fetus remains ,no blood signsappears and pills must be taken so that the body begins to expel the fetus -usually mifepristone or misoprostol(Mentula et al, 2011). This kind oftreatment usually  causes nausea ,vomiting and diarrhea but it is the only way to avoidthe surgery. (The American College Of Obstetricians andGynecologists, 2015)·        Surgical treatment : a minor vacuum aspiration will remove the fetus andplacenta from the uterus, using  asuction devise attached to the a slender tube called a cannula. Anothersurgical option is Dilation & Curettage (D&C) where the cervix isopened and the fetus is gently scraped from the inside of the uterus(TheAmerican College Of Obstetricians and Gynecologists, 2015).   Based to all above the gynecologist will recommend recovery for 1-2 weeks and advice the woman to avoidhaving sexual intercourse or also  not toinsert anything into vagina such as tampons.In case of the following symptomssuch as heavily bleeding, fever, severe pain and chills she must get in contactwith her gynecologist immediately. (The American College Of Obstetricians andGynecologists, 2015).

   12.DISCUSSION Will be refereed to advantages and disadvantages between medical andsurgical treatment after miscarriage. Also patient preferences based to studieswill be taken in consideration in order to evaluate the best solution for thewoman’s health and quick recovery.Both options are acceptable as common treatment after the diagnosis ofpregnancy loss.

According to stage progress of the labor medical or surgicaltreatment are standard therapies. Medical treatment is usually based to the dosage of misoprostol which isplaced vaginally. The fetus should be expelled within the 3 day.

If not, then asecond dose placed vaginally again and within 8 day there is complete abortion.The risks of bleeding and infection are the same with those of surgicalmanagement. ( Zhang & Gilles& Barnhart & Creinin & Westhoff& Frederick 2005). The advantages of medical therapy is that no surgicalprocedures are needed specifically general anesthesia and surgery .

The patient is ready to continuenormal activities within a few days. The disadvantages is that in some casesthis procedure is not successful and then surgical approach has to befollowed.  The risks includes bleeding,infection, cramping and diarrhea. (The AmericanCollege 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 othermedical condition. The fetal is removed with Dilation & Curettage (D)from the uterus.

The advantages is that the procedure is scheduled andperformed at a certain time. The patient can be prepared physically andemotionally and even get helped from a specialist. This is a certain successtherapy excluding the risk of possible incomplete abortion. The risks of a Dinvolve bleeding, infection, perforation of the uterus and possible Ashermansyndrome after the procedure.

( Zhang & Barnhart & Creinin & Westhoff& Frederick, The AmericanCollege Of Obstetricians and Gynecologists, 2005-2015)Based to studies, in incomplete abortion among patients that had to choosebetween medical or surgical treatment shown their preference in medical treatmentat 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 soprotective and no exception can be made for the conceptus.

No tolerance isaccepted that is why rejection often causes miscarriage.    Reccurent pregnancy loss is a personal tragedy for people willingparenthood. But is a fact that has to empower the couple to find the reasonsand the answers for it.

Knowledge will help them to regain strength for thenext try. Suffer, grief and despair and pain are normal emotions that mostlywoman experiences.An obstetrician gynecologist, a family medicine doctor, a midwife can helpto manage a miscarriage. They are specialists, well-educated professionals thatwill advise how to overcome the loss, arrange all necessary exams, instructmedications if required. They offer physically as well as emotionally supportand guidance.In our days there are also helplines, support groups and organizationsfor pregnancy loss ( stillbirth, miscarriage) to offer information and alistening ear. Most of people participate in such groups experience similarcircumstances, share same feelings and thoughts. Sometimes it is difficult to seek answers for the irrelevant.

Each caseis different especially to recurrent loss but treatment is offered as a hopefor any future effort. Parenthood worth’s every try, it is long and difficultjourney which continues also after giving birth to a new human life.   

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