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Myths surrounding miscarriages?

by Dr.Vijith Vidyavibushana, Consultant Obstetrician and Gynaecologist, Colombo South Teaching Hospital, Kalubowila.

Miscarriage is a loss of a pregnancy (after confirmation following a urine test) before first 23 weeks or if gestation is not known, birth weight of lost foetus being less than 500 grams.

Why 23 weeks? That is the edge of viability. i.e. before that the foetus is not viable or cannot survive if born, with or without medical help. A loss after this time is called a stillbirth. Most occur before 12 weeks of pregnancy, but some occur later.

How common is this?

It is said to be around 15 - 20 per cent i.e. among 100 pregnant women 15 to 20 would have miscarriages. This is the incidence after confirmation of pregnancy. But the incidence of it before a pregnancy test (Usually the pregnancy test is done after missing a period and at that time the embryo is usually about 2 weeks old) may be around 50 per cent according to research.

This is because in many cases a very early pregnancy ends before you miss a period, and before you are aware that you are pregnant.

What are the causes?

Most occur spontaneously as 'nature's selection. Most of these foetuses are found to have some abnormality in their chromosomes arising by chance during cell division. Usually there are no abnormalities in parents in these cases. i.e. - It is thought that most early miscarriages are caused by a 'one-off' chromosome fault. This is usually an isolated genetic mistake, and rarely occurs again.

There are other less common causes of miscarriage including hormonal imbalance, abnormalities of the womb, weakness of the cervix, certain infections such as listeria and rubella.

Investigations into the cause of a miscarriage are not usually carried out unless you have three or more miscarriages in a row. This is because most women who miscarry will not miscarry again. Even two miscarriages are more likely to be due to chance than to some underlying cause.

If it happens once or twice, usually there is no specific cause it. But if this happens consecutively three times or more, one has to investigate to find the cause as there can be a cause.

Some wrong ideas about the cause of miscarriage

After a miscarriage, it is common to feel guilty and to blame the miscarriage on something you have done or failed to do.

This is almost always not the case. In particular, miscarriage is not caused by lifting, travelling in bus, on motor bicycle, straining or working, constipation or straining at the toilet, stress or worry, sex, eating spicy foods such as pineapple, papaw, or by doing normal exercise. There are many such myths about the cause of miscarriage.

What are the signs and symptoms?

Bleeding red or brown, heavy, with clots or light spotting, abdominal pain, backache, period like pain (NB- severe abdominal pain, faintness, slight bleeding with a positive pregnancy test can be the signs of an ectopic pregnancy, specially in early pregnancy. If you are high risk for ectopic pregnancy an ultrasound scan is needed to exclude that Loss of pregnancy symptoms (i.e.-feeling sick etc will vanish) What are the types and possible outcomes?

Threatened miscarriage - It is common to have light vaginal bleeding sometime in the first 12 weeks of pregnancy. This does not always mean that you are going to miscarry.

Often the bleeding settles and the growing baby is healthy. This is called a 'threatened' miscarriage. You do not usually have pain with a threatened miscarriage. If the pregnancy continues, there is no harm done to the baby.

In some cases, a threatened miscarriage progresses to a miscarriage. If the heartbeat is seen in the scan, there is more than 98 per cent chance of an uneventful pregnancy.

Delayed miscarriage (early fetal demise, missed miscarriage, silent miscarriage) - In some cases there are no symptoms and sometimes there may be very minimal symptoms. The baby dies, but remains in the womb.

You may have no pain or bleeding. Sometimes there may be a slight brown colour discharge. This may not be found until you have a routine ultrasound scan. Ultrasound can demonstrate heart beat in 95 per cent of pregnancies at six weeks when the embryo (the growing baby) is as small as five millimetres!. Therefore a competent doctor can make this diagnosis without repeating after a week.

Incomplete miscarriage - The usual symptoms are vaginal bleeding and lower abdominal cramps. You then pass some 'tissue' from the vagina. In many cases, the bleeding then gradually settles. The time it takes for bleeding to settle varies.

It is usually a few days, but can last two weeks or more. In most cases, the bleeding is heavy with clots, but not severe - more like a heavy period. However, it can be severe in some cases. In these cases there will be some pregnancy tissue left inside the womb and therefore is called an incomplete miscarriage.

Complete miscarriage - Symptoms may be similar to an incomplete miscarriage, but bleeding settles, neck of the womb closes and an ultrasound scan will show an empty cavity of the womb.

Do I need to go to hospital?

You should always report any bleeding in pregnancy to your doctor. It is important to get the correct diagnosis as miscarriage is not the only cause of vaginal bleeding. If you bleed heavily with clots, go to the hospital immediately.

Most women with bleeding in early pregnancy are seen by a doctor who specialises in pregnancy. It is usual to have an ultrasound scan. This helps to determine whether the bleeding is due to

* A 'threatened' miscarriage, (the baby will be seen to be alive).

* A miscarriage.

* Some other cause of bleeding (such as an ectopic pregnancy or bleeding from the neck of the womb).

What do the doctors do when I go to the hospital?

Complete history will be gone through before the examination. A general examination will be done to see if you are pale, Blood pressure will be checked, the abdomen will be examined and finally a speculum (an instrument inserted through the vagina to visualize the neck of the womb) examination may be done.

Speculum examination is usually uncomfortable but not painful and will not harm the pregnancy in any way. Speculum examination may be done after or before an ultrasound scan. Your blood group and haemoglobin level will also be checked.

How is the diagnosis made?

With the history, examination and an ultrasound scan usually a diagnosis can be made. For most patients an ultrasound scan is needed unless one can see pregnancy tissue in the neck of the womb during the speculum examination. Occasionally a repeat ultrasound scan will have to be done to arrive at a diagnosis.

Do I need any treatment?

Once the cause of bleeding is known, and the type of miscarriage is confirmed, your doctor will advise on options you have.

If it is a threatened miscarriage there is more than 98 per cent chance of a good outcome to have a normal pregnancy and a healthy baby. According to research bed rest will not improve the outcome. Some doctors give a medication orally or as an injection and it contains a hormone called Progesterone.

But there is no scientific evidence to suggest that it is effective and therefore one should not regret of not having this hormone injection as it is not proven to prevent a miscarriage.

For many years it was common to do a small operation (Surgical management) to 'clear the uterus' (commonly called in our country as a 'womb wash' and the correct word is evacuation or D & E) following a missed miscarriage or partial (incomplete) miscarriage and this is done under general anaesthesia.

The logic was that this would make sure all pregnancy tissue was gone, and may prevent infection or prolonged bleeding. However, if ultrasound reveals no or very minimal tissue, an evacuation is not needed as it is a complete miscarriage.

Many women in developed countries now opt to 'let nature take its course'. In most cases the pregnancy tissue is passed out naturally and the bleeding will stop within a few days. It is called expectant management. An operation to 'clear the uterus' can still be an option if the bleeding does not stop within a few days, or if bleeding is severe.

The other option is to have some medication to make the womb contract and expel the products which is called 'medical management of miscarriage'. Unfortunately we do not have this medication, as the termination of pregnancy in not legal in our country. The advantages in this method are its quick nature as, it does not involve any anaesthesia and therefore has minimal side effects.

How long can I have bleeding or discharge

After a miscarriage usually one can bleed for a week or two and occasionally for about for weeks. If the discharge or bleeding is increasing or if it is smelly or if you have fever and lower abdominal pain you should contact your doctor. Those may be a signs and symptoms of infection which is not common.

When can I plan a pregnancy again?

It is up to you and your husband. There is no hard and fast rule -not to get conceived for 3-6 months. Some consider a miscarriage as a loss to their family and need some time before planning a pregnancy again.

But they should understand that after a miscarriage, an ovulation can take place at any time and one can become pregnant even before missing a period. If you are planning for a pregnancy soon, it is always better to wait until you have your first period after miscarriage so that you can date the pregnancy.

When can I have sex again?

Usually when the discharge or bleeding stops. Otherwise it can give rise to infection.

If you are not planning a pregnancy very soon, it is always necessary that you use a reliable method of contraception as you can get pregnant even before missing a period. Feelings

It is only a couple who have had a miscarriage who feel how distressing it is. Although some take it lightly, feelings of shock, grief, depression, guilt, loss, and anger are common among these couples.

It is best not to 'bottle up' feelings. Talking and discussing with your husband, friends, or with a doctor or midwife, or with someone who can listen and understand will help them.

As time goes on, the sense of loss usually becomes less. However, the time this takes, varies greatly. Pangs of grief sometimes recur 'out of the blue'. The time when the baby was due to be born may be particularly sad especially if it is a late miscarriage after 12 weeks.

'Childhood cancers can be cured'

by Rosanne Koelmeyer Anderson

'Cancers in children are unique, with a different spectrum of pathologies compared with those of adults, but childhood cancers are now curable. Compared with adults; children have a much lower chance of contracting cancer.

Approximately, one in every 500 children will develop cancer during their childhood. Leukaemias and lymphomas account for more than 40 percent of childhood but the survival rate of children with cancer is almost 90 percent if timely diagnosed and advanced therapeutics is administrated, Dr. Anslem Lee, consultant paediatrics Haematologist Oncologist, Children's Haematology and Cancer Centre (CHCC) East Shore Hospital, Singapore explained addressing the Annual Scientific Session of the Sri Lanka College of Oncologists, in Colombo last week. Dr. Lee was in Sri Lanka to address the Sri Lanka College of Oncologists on the new trends in childhood cancer under the banner cures - the changing prognosis of childhood cancers.'

The medical sessions also included a comprehensive presentation on childhood cancers at the Lady Ridgeway Hospital, Borella.

It was revealed that the rate of children diagnosed with cancer is on the increase but with advanced therapeutics and timely diagnosis childhood cancers are curable.

The medical sessions was an insight and an opportunity for Sri Lankan oncologists to learn more about numerous childhood cancer related diseases such as leukaemias, Retinoblastoma, cancer of the eyeball, lymphomas and Hepatocellutar carcinoma which is relatively frequent in Asian regions where Hepatitis B infection is prevalent.

Children with down syndrome too are hundred times more vulnerable to get leukaemia taking the cancer risk as high as 60-70 per cent, thus, casting a heavy social responsibility on the family physicians and paediatricians, in the battle against cancer.

The diagnosis of cancer in the past Dr. Lee stated used to be a death sentence but today two out of three children newly diagnosed will now survive the disease with improvements in surgery, chemotherapy and radiotherapy.

'The answer as to why children get cancers is still not resolved for most cancers but cancers in children may be genetically related, chromosomal aberrations, immune deficiencies due to infections like Hepatitis B virus and human immonodefficiency virus infections, radiation mishaps or immunosuppressive treatments.

There is no evidence however to associate a mother's diet during pregnancy, vitamin K infection given to newborn infants, vaccinations or electromagnetic fields, Dr. Lee observed.

Investigations are needed to conform a diagnosis and classify the cancer type and define the extent of the disease.

Some children, it was revealed may even need a bone marrow biopsy too, and children need much supportive care to start cancer treatments, he explained.

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What are the cancers that affect children?

* Acute lymphoblastic leukaemia (ALL), is the commonest type of cancer seen in children. The affected child may show signs of fever, bruises, tiring easily and enlargement of glands in the neck. About 75-80 per cent of children can be cured after treatment.

* Acute myeloid leukaemia (AML) with similar symptoms where children need chemotherapy only. The cure rate after treatment being 45-60 per cent.

* Non-Hodgkin lymphoma (NHL), a cancer of the lymphatic glands. The child may develop fever, tiring and enlargement of the glands in the neck and inside the chest. Some children may complain of difficulty in breathing or abdominal pain. Over 80 per cent of children can be cured with chemotherapy alone. Only a small proportion of children will need surgery or radiation treatment.

* Brain tumors, the commonest form of solid cancer in children where children may complain of headache, vision problems, vomiting, weakness on one side of the body, unsteadiness in walking and epilepsy.

* Germ cell tumours, inside the brain, commonly seen in oriental children with a 60-70 per cent cure rate with chemotherapy and radiation without complicated surgery.

* Neuroblastoma, cancer in the adrenal glands inside the abdomen where the affected child may have fever and aches in the bones. If detected early cure rates are 90 per cent but if in an advanced stage treatment with surgery and chemotherapy followed by stem cell transplantation is needed and survival rates will be only 10-30 per cent.

* Wilms tumour, a cancer in the kidney where children show signs of distention of the abdomen. The standard treatment is surgery, chemotherapy and radiation with 80-90 per cent cure rates.

* Rhabdomyosarcoma, a cancer of the muscles, commonly present as a mass where any part of the body may be affected. If the disease hasn't spread cure rates are 70-80 per cent.

* Osteosarcoma, a cancer of the bones present with the swelling in the thigh or leg bones. Survival rate is 60-70 per cent with surgery, chemotherapy and radiation.

* Hepatoblastoma, a cancer of the liver, has a 90 per cent survival rate.

* Retinoblastoma, a caner of the eyeball is very common in children. If parents notice a white reflex in the affected eye especially when the child's face is photographed surgery or cryosurgery is available and survival rate is well above 90 per cent unless the disease has spread beyond the eyeball.