You have probably watched this scene unfold in a TV drama.
A heavily pregnant woman hits her belly against something hard, blood trails down her legs and she passes out. Later, at the hospital, a doctor sombrely breaks the news that the unborn baby has been lost.
This is not to make light of the tragedy of miscarriages, which occur in an estimated one in four to six pregnancies. But this common mainstream portrayal may have presented a limited view of it.
For instance, many miscarriages are not that dramatic.
Most would happen before the woman reaches the 12-week mark in her pregnancy - before the baby bump begins to show.
"Such pregnancies are probably genetically abnormal from the beginning," said Associate Professor Tan Thiam Chye, who heads the inpatient service at the obstetrics and gynaecology department at KK Women's and Children's Hospital (KKH).
About half of all miscarriages stem from genetic or chromosomal disorders, he added. Other possible causes are womb abnormalities and a deficiency in the hormone, progesterone.
While bleeding does not always indicate a miscarriage, it remains a key danger sign.
A 2011 study on 139 pregnant women here found that complete miscarriages occur in 25 per cent of women who experienced bleeding in the early part of their pregnancies.
The study, conducted by KKH and Duke-NUS Graduate Medical School, also showed that older expectant parents, and mothers with a previous history of miscarriages and a low blood progesterone level during pregnancy, were at a higher risk of losing their unborn child as well.
Women are therefore encouraged to seek medical help if they notice bleeding, especially in their first trimester, advised Prof Tan.
Such cases, where a pregnant woman suffers from bleeding while her foetus remains alive, are termed "threatened" miscarriages. Many women will go on to give birth, but others may end up passing out some or all of their pregnancy sac.
That is, however, one of several ways a miscarriage can take place.
In another scenario, a woman could have a positive pregnancy test, although it does not show up in an ultrasound examination. She then suffers from bleeding.
This is referred to as a "chemical" pregnancy (a very early miscarriage where the egg was fertilised but did not survive), said Dr Anita Kale, a consultant at National University Hospital Women's Centre.
Meanwhile, early pregnancy failure or a blighted ovum refers to a pregnancy that is observed on an ultrasound scan only as an empty gestational sac in the womb.
Or, the scan may show a foetus, but no heartbeat could be detected. In some cases, a heartbeat could be detected initially, but was later "lost", said Dr Kale.
Regardless of how a miscarriage happens, there is often no specific reason for why it happened, said Dr Loh Seong Feei, medical director of Thomson Fertility Centre.
"Many women who have miscarriages are healthy," said Dr Loh. "Nothing that they have done caused the miscarriage. Nothing that they could have done more could have saved the pregnancy."
REPEATED LOSS IS RARE
In fact, a miscarriage does not mean that the next pregnancy will fail too, said Prof Tan.
Dr Kale pointed out that only about 2 per cent of women suffer from repeated miscarriages.
Sometimes, women who suffer from excessive bleeding from a miscarriage will need to undergo cleaning of the womb. Infections are rare. Therefore, most women will not suffer any long-term damage after a miscarriage, she added.
"Before the days of home pregnancy tests and ultrasound technology, it was not uncommon for a woman to mistake an early miscarriage for delayed menstruation," she said.
"The bleeding in early miscarriages is hardly any different from the usual menstrual loss. So, it is unlikely to harm the woman."
But women who have suffered three or more miscarriages in a row should get themselves checked, said Prof Tan. "The doctor may need to do some extra blood tests and scans to exclude certain antibodies that can 'attack' the foetus," he said.
"Some may have weakness of the neck of their wombs, called cervical incompetence, that can lead to mid-trimester losses."
While most miscarriages occur in the first trimester, some women lose their unborn baby after 14 weeks. This is referred to as a late miscarriage.
"It is not any more dangerous for the woman than an early miscarriage," said Dr Kale.
Doctors will have to use medicine, called prostaglandin, to induce the woman's womb to contract.
During this process, the woman will experience a "mini labour" after taking the medication and passes out the foetus and pregnancy tissue naturally, she added.
GET CHECKED FOR INFECTION
Even if the miscarriage happens spontaneously outside of medical facilities, it is a good idea to get checked to minimise infection risk from tissue that did not get expelled from the womb, said Dr Loh.
Observe if there is bleeding, pain or abnormal vaginal discharge.
"These symptoms may indicate that some pregnancy tissue may be left behind in the uterus," he said.
A detailed ultrasound exam will then be necessary to check if any tissue has remained inside the womb.
If there is, the doctor can remove it without much injury to the uterus in a hysteroscopy-guided removal.
A thin tool, the hysteroscope, is inserted into the vagina. It has a light and camera attached to its tip to assist the doctor in viewing the interior of the womb.
Ultimately, couples should not blame themselves for a miscarriage.
Work together to overcome the emotional distress and depression, said Prof Tan.
"Maintain a healthy lifestyle together and plan for the next pregnancy, ideally after three months from the last miscarriage."
This article was first published on June 11, 2015.
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