It's not only safe to continue taking your medication, it's vital to both your baby's well-being and your own. One reason is that women with untreated hypothyroidism (a condition in which the thyroid gland does not produce adequate amounts of the hormone thyroxine) are more likely to miscarry. Another reason is that maternal thyroid hormones are necessary for early fetal brain development; babies who don't get enough of these hormones in the first trimester can be born with neurological development problems and, possibly, deafness. (After the first trimester, the fetus makes its own thyroid hormones and is protected even if mom's levels are low.) Low thyroid levels are also linked to maternal depression during pregnancy and postpartum-another compelling reason to continue your treatment.

Your dose, however, may need to be adjusted, since the body requires more thyroid hormone when it's in baby-making mode. Check with your endocrinologist and your obstetrician to be sure your dose is appropriate now, but keep in mind that your levels will probably be monitored periodically during pregnancy and postpartum to see if your dose needs further adjustment. Be on the lookout, too, for signs that your thyroid level is too low or too high and report these to your practitioner (though many of those probably familiar symptoms of hypothyroidism, such as fatigue, constipation, and dry skin, are so similar to those of pregnancy that it's often tough to tell which have you down, report them anyway).

Iodine deficiency, which is becoming more common among women of childbearing age in the United States because of reduced iodized salt consumption, can interfere with the production of thyroid hormone, so be sure you are getting adequate amounts of this trace mineral. It's most commonly found in iodized salt and seafood.

"I have Graves disease. Is this a problem for my pregnancy?"

Graves disease is the most common form of hyperthyroidism, a condition in which the thyroid gland produces excessive amounts of thyroid hormones. Mild cases of hyperthyroidism sometimes improve during pregnancy because the pregnant body requires more thyroid hormone than usual. But moderate to severe hyperthyroidism is a different story. Left untreated, these conditions could lead to serious complications for both you and your baby, including miscarriage and preterm birth, so appropriate treatment is necessary. Happily, when the disease is treated properly during pregnancy, the outcome is likely to be good for both mother and baby.

During pregnancy, the treatment of choice is the antithyroid medication propylthiouracil (PTU) in the lowest effective dose. If a woman is allergic to PTU, methimazole (Tapazole) may be used. If neither drug can be used, then surgery to remove the thyroid gland may be needed, but it should be performed early in the second trimester to avoid the risk of miscarriage (in the first trimester) or preterm birth (in the late second and third trimester). Radioactive iodine is not safe to use during pregnancy, so it won't be part of your treatment plan.

If you had surgery or radioactive iodine treatment for Graves before you became pregnant, you'll need to continue your thyroid replacement therapy during pregnancy (which is not only safe but essential for your baby's development).

Getting the Support You Need Though it's true that every expectant woman needs plenty of support, it's also true that moms-to-be with a chronic condition could use even more. Even if you've had your condition for years, you know everything there is to know about it, and you're an old pro at handling it, you'll probably find that pregnancy changes the rules (including the ones you had memorized).

Enter, that extra support. No pregnant woman should ever have to go it alone, but as a pregnant woman with a chronic condition, you may want and need even more company. Among the kinds of support you'll benefit from: Medical support. Just like every expectant mom, you'll need to find (if you don't already have one) a prenatal practitioner who can consult with you before you conceive (if possible), care for you during your pregnancy, and make that special delivery when the time comes. Unlike with a lot of other expectant moms, that practitioner won't be the only member of your obstetrical team. You'll also need to bring the doctor or doctors who care for your chronic condition on board. Your team of doctors will work together to ensure that you and baby are both well taken care of-that your baby's best interests are represented in the care of your chronic condition, and your best interests are represented in the care of your baby. Communication will be a vital part of that teamwork-so make sure your doctors are all kept in the loop about tests, medications, and other care components. Just like every expectant mom, you'll need to find (if you don't already have one) a prenatal practitioner who can consult with you before you conceive (if possible), care for you during your pregnancy, and make that special delivery when the time comes. Unlike with a lot of other expectant moms, that practitioner won't be the only member of your obstetrical team. You'll also need to bring the doctor or doctors who care for your chronic condition on board. Your team of doctors will work together to ensure that you and baby are both well taken care of-that your baby's best interests are represented in the care of your chronic condition, and your best interests are represented in the care of your baby. Communication will be a vital part of that teamwork-so make sure your doctors are all kept in the loop about tests, medications, and other care components.

All your doctors have lots of other patients, so it's best not to assume that communication's always taking place. If your chronic-care specialist prescribes a new medication, ask if it's been okayed by your prenatal practitioner, and vice versa.

Emotional support. Everyone needs somebody to lean on, but you may find you need plenty of somebodies. Somebody to vent to when you're feeling resentful over your special diet (Easter eggs instead of chocolate bunnies?). To complain to about being stuck in a revolving door of medical procedures (six tests in three days?). To cry to when you're feeling particularly anxious. To confide in, share with, unload on. To give you the emotional support every expectant mom craves-since you might crave a little more. Everyone needs somebody to lean on, but you may find you need plenty of somebodies. Somebody to vent to when you're feeling resentful over your special diet (Easter eggs instead of chocolate bunnies?). To complain to about being stuck in a revolving door of medical procedures (six tests in three days?). To cry to when you're feeling particularly anxious. To confide in, share with, unload on. To give you the emotional support every expectant mom craves-since you might crave a little more.

Your partner is a perfect source of this support, of course, especially because he sees what you're going through and would do anything to help you. Your friends and relatives may lend a sympathetic ear when you need one, too, even if their own pregnancies were more "normal" and they can't always relate. But you'll probably find that no one quite gets it like another mom in the same situation-and that no one else gives you as much comfort, empathy, and satisfying support.

Depending on your chronic condition and where you live, you may be able to find a support group geared to expectant moms or new moms who are in the same or a similar boat as you. Or with a little help from your medical team, you might even be able to start one (even if it's just a group of two-another mom you can have lunch with or chat with on the phone). Or reach out online, either on pregnancy message boards or chat rooms for those who have the same chronic condition. Not only will you find the emotional hand-holding you're in the market for, but you'll find practical support, too-advice, treatment tips, strategies, diet ideas, and other resources to help you cope with your important dual mission: caring for your chronic condition and nurturing your baby-to-be.

Physical support. Again, there isn't an expectant mom who doesn't need it at some point in her pregnancy (probably at many points): someone to do the shopping when she's too tired to move, to scrub the toilet so she doesn't have to breathe in those fumes, to cook dinner when coming face-to-breast with uncooked chicken makes her heave. But for moms who are juggling the physical demands of pregnancy with the physical challenges of a chronic condition, there's no such thing as too much help. Get it wherever you can, and don't be shy about asking for it. Enlist your partner to pick up the slack (and the dry cleaning and groceries) that you don't have the energy to pick up, but also look to friends, relatives, and, if you can afford it, paid household help. Again, there isn't an expectant mom who doesn't need it at some point in her pregnancy (probably at many points): someone to do the shopping when she's too tired to move, to scrub the toilet so she doesn't have to breathe in those fumes, to cook dinner when coming face-to-breast with uncooked chicken makes her heave. But for moms who are juggling the physical demands of pregnancy with the physical challenges of a chronic condition, there's no such thing as too much help. Get it wherever you can, and don't be shy about asking for it. Enlist your partner to pick up the slack (and the dry cleaning and groceries) that you don't have the energy to pick up, but also look to friends, relatives, and, if you can afford it, paid household help.

PART 7.

The Complicated Pregnancy

CHAPTER 22.

Managing a Complicated Pregnancy.

IF YOU'VE BEEN DIAGNOSED WITH A complication or suspect that you're having one, you'll find symptoms and treatments in this chapter. If you've had a problem-free pregnancy so far, though, this need-to-know chapter is not for you (you don't need to know any of it). Most women sail through pregnancy and childbirth without any complications. While information is definitely empowering when you need it, reading about all the things that could go wrong when they're not going wrong is only going to stress you out-and for no good reason. Skip it, and save yourself some unneeded worry. complication or suspect that you're having one, you'll find symptoms and treatments in this chapter. If you've had a problem-free pregnancy so far, though, this need-to-know chapter is not for you (you don't need to know any of it). Most women sail through pregnancy and childbirth without any complications. While information is definitely empowering when you need it, reading about all the things that could go wrong when they're not going wrong is only going to stress you out-and for no good reason. Skip it, and save yourself some unneeded worry.

Pregnancy Complications The following complications, though more common than some pregnancy complications, are still unlikely to be experienced by the average pregnant woman. So read this section only if you've been diagnosed with a complication or you're experiencing symptoms that might indicate a complication. If you are diagnosed with one, use the discussion of the condition in this section as a general overview-so you have an idea of what you're dealing with-but expect to receive more specific (and possibly different) advice from your practitioner.

Early Miscarriage What is it? A miscarriage-known in medical speak as a spontaneous abortion-is the spontaneous expulsion of an embryo or fetus from the uterus before the fetus is able to live on the outside (in other words, the unplanned end of a pregnancy). Such a loss in the first trimester is referred to as an early miscarriage. Eighty percent of miscarriages occur in the first trimester. (A miscarriage that occurs between the end of the first trimester and week 20 is considered a late miscarriage; see A miscarriage-known in medical speak as a spontaneous abortion-is the spontaneous expulsion of an embryo or fetus from the uterus before the fetus is able to live on the outside (in other words, the unplanned end of a pregnancy). Such a loss in the first trimester is referred to as an early miscarriage. Eighty percent of miscarriages occur in the first trimester. (A miscarriage that occurs between the end of the first trimester and week 20 is considered a late miscarriage; see page 540 page 540).

Types of Miscarriage If you've experienced an early pregnancy loss, the sadness you'll feel is the same no matter the cause or the official medical name. Still, it's helpful to know about the different types of miscarriage so you're familiar with the terms your practitioner might be using.

Chemical pregnancy. A chemical pregnancy occurs when an egg is fertilized but fails to develop successfully or implant fully in the uterus. A woman may miss her period and suspect she is pregnant; she may even have a positive pregnancy test because her body has produced some low-but detectable-levels of the pregnancy hormone hCG, but in a chemical pregnancy, there will be no gestational sac or placenta on ultrasound examination. A chemical pregnancy occurs when an egg is fertilized but fails to develop successfully or implant fully in the uterus. A woman may miss her period and suspect she is pregnant; she may even have a positive pregnancy test because her body has produced some low-but detectable-levels of the pregnancy hormone hCG, but in a chemical pregnancy, there will be no gestational sac or placenta on ultrasound examination.

Blighted ovum. A blighted ovum (or anembryonic pregnancy) refers to a fertilized egg that attaches to the wall of the uterus, begins to develop a placenta (which produces hCG), but then fails to develop into an embryo. What is left behind is an empty gestational sac (which can be visualized on an ultrasound). A blighted ovum (or anembryonic pregnancy) refers to a fertilized egg that attaches to the wall of the uterus, begins to develop a placenta (which produces hCG), but then fails to develop into an embryo. What is left behind is an empty gestational sac (which can be visualized on an ultrasound).

Missed miscarriage. A missed miscarriage, which is very rare, is when the embryo or fetus dies but continues to stay in the uterus. Often, the only signs of a missed miscarriage are the loss of all pregnancy symptoms, and less commonly, a brownish discharge. Confirmation of the miscarriage occurs when an ultrasound shows no fetal heartbeat. A missed miscarriage, which is very rare, is when the embryo or fetus dies but continues to stay in the uterus. Often, the only signs of a missed miscarriage are the loss of all pregnancy symptoms, and less commonly, a brownish discharge. Confirmation of the miscarriage occurs when an ultrasound shows no fetal heartbeat.

Incomplete miscarriage. An incomplete miscarriage is when some of the tissue from the placenta stays inside the uterus and some is passed through the vagina via bleeding. With an incomplete miscarriage, a woman continues to cramp and bleed (sometimes heavily), her cervix remains dilated, pregnancy tests still come back positive (or blood hCG levels are still detectable and don't fall as expected), and parts of the pregnancy are still visible on an ultrasound. An incomplete miscarriage is when some of the tissue from the placenta stays inside the uterus and some is passed through the vagina via bleeding. With an incomplete miscarriage, a woman continues to cramp and bleed (sometimes heavily), her cervix remains dilated, pregnancy tests still come back positive (or blood hCG levels are still detectable and don't fall as expected), and parts of the pregnancy are still visible on an ultrasound.

Threatened miscarriage. When there is some vaginal bleeding but the cervix remains closed and the fetal heartbeat (as seen on ultrasound) is still detectable, it is considered a threatened miscarriage. Roughly half of those women with a threatened miscarriage go on to have a perfectly healthy pregnancy. When there is some vaginal bleeding but the cervix remains closed and the fetal heartbeat (as seen on ultrasound) is still detectable, it is considered a threatened miscarriage. Roughly half of those women with a threatened miscarriage go on to have a perfectly healthy pregnancy.

Early miscarriage is usually related to a chromosomal or other genetic defect in the embryo, but it can also be caused by hormonal and other factors. Most often, the cause can't be identified.

How common is it? Miscarriage is one of the most common complications of early pregnancy. It's hard to know for sure, but researchers have estimated that over 40 percent of conceptions end in miscarriages. And well over half of those occur so early that pregnancy is not even suspected yet-meaning these miscarriages often go unnoticed, passing for a normal or sometimes heavier period. See the box above for more on the different types of early miscarriage. Miscarriage is one of the most common complications of early pregnancy. It's hard to know for sure, but researchers have estimated that over 40 percent of conceptions end in miscarriages. And well over half of those occur so early that pregnancy is not even suspected yet-meaning these miscarriages often go unnoticed, passing for a normal or sometimes heavier period. See the box above for more on the different types of early miscarriage.

Miscarriage can happen to any woman, and in fact, most women who have one have no known risk factors. Still, some factors somewhat increase the risk of miscarriage. One is age; the older eggs of older mothers (and possibly their older partner's sperm) are more likely to contain a genetic defect (a 40-year-old has a 33 percent chance of miscarrying, while a 20-year-old's odds of losing a pregnancy are 15 percent). Other risk factors include vitamin deficiencies (especially of folic acid); being very overweight or underweight; smoking; possibly hormonal insufficiency or imbalance, including an untreated thyroid condition; certain sexually transmitted diseases (STDs); and certain chronic conditions.

You'll Want to Know ...

In a normal pregnancy, miscarriage is not not caused by exercise, sex, working hard, lifting heavy objects, a sudden scare, emotional stress, a fall, or a blow to the abdomen. The nausea and vomiting of morning sickness, even when it's severe, will not cause a miscarriage. In fact, morning sickness has been linked with a lower risk of miscarriage. Happily, the vast majority of women who experience miscarriage go on to have a normal pregnancy in the future. caused by exercise, sex, working hard, lifting heavy objects, a sudden scare, emotional stress, a fall, or a blow to the abdomen. The nausea and vomiting of morning sickness, even when it's severe, will not cause a miscarriage. In fact, morning sickness has been linked with a lower risk of miscarriage. Happily, the vast majority of women who experience miscarriage go on to have a normal pregnancy in the future.

What are the signs and symptoms? The symptoms of a miscarriage can include some or all of the following: The symptoms of a miscarriage can include some or all of the following: [image] Cramping or pain (sometimes severe) in the center of the lower abdomen or back Cramping or pain (sometimes severe) in the center of the lower abdomen or back[image] Heavy vaginal bleeding (possibly with clots and/or tissue) similar to a period Heavy vaginal bleeding (possibly with clots and/or tissue) similar to a period[image] Light staining continuing for more than three days Light staining continuing for more than three days[image] A pronounced decrease in or loss of the usual signs of early pregnancy, such as breast tenderness and nausea A pronounced decrease in or loss of the usual signs of early pregnancy, such as breast tenderness and nausea What can you and your practitioner do? Not all bleeding or spotting means you're having a miscarriage. In fact, many situations (other than miscarriage) could account for bleeding (see Not all bleeding or spotting means you're having a miscarriage. In fact, many situations (other than miscarriage) could account for bleeding (see page 139 page 139).

If you do notice some bleeding or spotting, call your practitioner. He or she will assess the bleeding and probably perform an ultrasound. If the pregnancy still appears to be viable (in other words, a heartbeat is detected on the ultrasound), your practitioner may put you on some sort of temporary bed rest, your hormone levels will be monitored if you're still very early in your pregnancy (rising hCG levels are a good sign), and the bleeding will most likely stop on its own.

If your practitioner finds that your cervix is dilated and/or no fetal heartbeat is detected on ultrasound (and your dates are correct), it is assumed a miscarriage has occurred or is in progress. In such a case, unfortunately, nothing can be done to prevent the loss.

You'll Want to Know ...

Sometimes it's too early to see a fetal heartbeat or visualize the fetal sac on ultrasound, even in a healthy pregnancy. Dates could be off or the ultrasound equipment not sophisticated enough. If your cervix is still closed, you are spotting only lightly, and the ultrasound is ambiguous, a repeat sonogram will be performed in a week or so to let you know what's really going on. Your hCG levels will also be followed.

If You've Had a Miscarriage Though it is hard for parents to accept it at the time, when an early miscarriage occurs, it's usually because the condition of the embryo or fetus is incompatible with normal life. Early miscarriage is generally a natural selection process in which a defective embryo or fetus (defective because of genetic abnormality; or damaged by environmental factors, such as radiation or drugs; or because of poor implantation in the uterus, maternal infection, random accident, or other, unknown reasons) is lost because it is incapable of survival.

All that said, losing a baby, even this early, is tragic and traumatic. But don't let guilt compound your misery. A miscarriage is not your fault. Do allow yourself to grieve, a necessary step in the healing process. Expect to be sad, even depressed, for a while. Sharing your feelings with your spouse, your practitioner, a relative, or a friend will help. So will joining or forming a support group for couples or singles who have experienced pregnancy loss or reaching out to others online. This sharing with others who truly know how you feel may be especially important if you've experienced more than one pregnancy loss. For more suggestions on coping with your loss, see Chapter 23.

For some women, the best therapy is getting pregnant again as soon as it is safe. But before you do, discuss possible causes of the miscarriage with your doctor. Most often, miscarriage is simply a random one-time occurrence caused by chromosomal abnormality, infection, chemical or other teratogenic (birth defectcausing) exposure, or chance, and it is not likely to recur.

Whatever the cause of your miscarriage, some practitioners suggest waiting two to three months before trying to conceive again, though intercourse can often be resumed as soon as you feel up to it. Other practitioners let nature take over; they tell their patients that their bodies will know when it's time to conceive again. Some studies have shown that women actually have a higher than normal fertility rate in the first three cycles following a first-trimester loss. If your practitioner does recommend a waiting period, however, use reliable contraception, preferably of the barrier type-condom, diaphragm-until the waiting time is up. Take advantage of this waiting period by getting your body into the best baby-making shape possible (see Chapter 1).

Happily, the chances are excellent that next time around you'll have a normal pregnancy and a healthy baby. Most women who have had one miscarriage do not miscarry again. In fact, a miscarriage is an assurance that you're capable of conceiving, and the great majority of women who lose a pregnancy this way go on to complete a normal one.

If you're in a lot of pain from the cramping, your practitioner may recommend or prescribe a pain reliever. Don't hesitate to ask for relief if you need it.

Can it be prevented? Most miscarriages are a result of a defect in the embryo or fetus and can't be prevented. There are steps you can take, however, to reduce the risk of preventable miscarriage: Most miscarriages are a result of a defect in the embryo or fetus and can't be prevented. There are steps you can take, however, to reduce the risk of preventable miscarriage: [image] Get chronic conditions under control before conception. Get chronic conditions under control before conception.[image] Be sure to take a daily prenatal supplement that includes folic acid and other B vitamins. New research has shown that some women have trouble conceiving and/or sustaining a pregnancy because of a folic acid or vitamin B Be sure to take a daily prenatal supplement that includes folic acid and other B vitamins. New research has shown that some women have trouble conceiving and/or sustaining a pregnancy because of a folic acid or vitamin B12 deficiency. Once these women begin the appropriate supplementation, they may be able to conceive and carry to term. deficiency. Once these women begin the appropriate supplementation, they may be able to conceive and carry to term.

Management of a Miscarriage Most miscarriages are complete, meaning all the contents of the uterus are expelled via the vagina (that's why there is often so much bleeding). But sometimes-especially the later in the first trimester you are-a miscarriage isn't complete, and parts of the pregnancy remain in the uterus (known as an incomplete miscarriage). Or a heartbeat is no longer detected on ultrasound, which means the embryo or fetus has died, but no bleeding has occurred (this is called a missed miscarriage). In both cases, your uterus will eventually be-or need to be-emptied so your normal menstrual cycle can resume (and you can try to get pregnant again, if you choose to). There are a number of ways this can be accomplished: Expectant management. You may choose to let nature take its course and wait until the pregnancy is naturally expelled. Waiting out a missed or incomplete miscarriage can take anywhere from a few days to, in some cases, three to four weeks. You may choose to let nature take its course and wait until the pregnancy is naturally expelled. Waiting out a missed or incomplete miscarriage can take anywhere from a few days to, in some cases, three to four weeks.

Medication. Medication-usually a misoprostol pill taken orally, or vaginally as a suppository-can prompt your body to expel the fetal tissue and placenta. Just how long this takes varies from one woman to another, but, typically, it's only a matter of days at the most before the bleeding begins. Side effects of the medication can include nausea, vomiting, cramping, and diarrhea. Medication-usually a misoprostol pill taken orally, or vaginally as a suppository-can prompt your body to expel the fetal tissue and placenta. Just how long this takes varies from one woman to another, but, typically, it's only a matter of days at the most before the bleeding begins. Side effects of the medication can include nausea, vomiting, cramping, and diarrhea.

Surgery. Another option is to undergo a minor surgical procedure called dilation and curettage (D and C). During this procedure, the doctor dilates your cervix and gently removes (either by suction, scraping, or both) the fetal tissue and placenta from your uterus. Bleeding following the procedure usually lasts no more than a week. Though side effects are rare, there is a slight risk of infection following a D and C. Another option is to undergo a minor surgical procedure called dilation and curettage (D and C). During this procedure, the doctor dilates your cervix and gently removes (either by suction, scraping, or both) the fetal tissue and placenta from your uterus. Bleeding following the procedure usually lasts no more than a week. Though side effects are rare, there is a slight risk of infection following a D and C.

How should you decide which route to take? Some factors you and your practitioner will take into account include: [image] How far along the miscarriage is. If bleeding and cramping are already heavy, the miscarriage is probably already well under way. In that case, allowing it to progress naturally may be preferable to a D and C. But if there is no bleeding (as in a missed miscarriage), misoprostol or a D and C might be better alternatives. How far along the miscarriage is. If bleeding and cramping are already heavy, the miscarriage is probably already well under way. In that case, allowing it to progress naturally may be preferable to a D and C. But if there is no bleeding (as in a missed miscarriage), misoprostol or a D and C might be better alternatives.[image] How far along the pregnancy is. The more fetal tissue there is, the more likely a D and C will be necessary to clean the uterus out completely. How far along the pregnancy is. The more fetal tissue there is, the more likely a D and C will be necessary to clean the uterus out completely.[image] Your emotional and physical state. Waiting for a natural miscarriage to occur after a fetus has died in utero can be psychologically debilitating for a woman, as well as for her spouse. It's likely that you won't be able to begin coming to terms with-and grieving for-your loss while the pregnancy is still inside you. Completing theprocess faster will also allow you to resume your menstrual cycles soon, and when and if the time is right, to try to conceive again. Your emotional and physical state. Waiting for a natural miscarriage to occur after a fetus has died in utero can be psychologically debilitating for a woman, as well as for her spouse. It's likely that you won't be able to begin coming to terms with-and grieving for-your loss while the pregnancy is still inside you. Completing theprocess faster will also allow you to resume your menstrual cycles soon, and when and if the time is right, to try to conceive again.[image] Risks and benefits. Because a D and C is invasive, it carries a slightly higher (though still very low) risk of infection. The benefit of having the miscarriage complete sooner, however, may greatly outweigh that small risk for most women. With a naturally occurring miscarriage, there is also the risk that it won't completely empty the uterus, in which case a D and C may be necessary to finish what nature has started. Risks and benefits. Because a D and C is invasive, it carries a slightly higher (though still very low) risk of infection. The benefit of having the miscarriage complete sooner, however, may greatly outweigh that small risk for most women. With a naturally occurring miscarriage, there is also the risk that it won't completely empty the uterus, in which case a D and C may be necessary to finish what nature has started.[image] Evaluation of the miscarriage. When a D and C is performed, evaluating the cause of the miscarriage through an examination of the fetal tissue will be easier. Evaluation of the miscarriage. When a D and C is performed, evaluating the cause of the miscarriage through an examination of the fetal tissue will be easier.

No matter what course is taken, and whether the ordeal is over sooner or later, the loss will likely be difficult for you. See Chapter 23 for help in coping.

[image]Try to get your weight as close to ideal as possible before conceiving: Being extremely overweight or extremely underweight puts a pregnancy at higher risk.[image] Avoid lifestyle practices that increase the risk of miscarriage, such as alcohol use and smoking. Avoid lifestyle practices that increase the risk of miscarriage, such as alcohol use and smoking.[image] Use caution when taking medications. Take only those that are okayed by a doctor who knows you are pregnant and avoid those that are known to be risky during pregnancy. Use caution when taking medications. Take only those that are okayed by a doctor who knows you are pregnant and avoid those that are known to be risky during pregnancy.[image] Take steps to avoid infections, such as STDs. Take steps to avoid infections, such as STDs.

If you've had two or more miscarriages, you can have tests to try to determine the possible cause so future pregnancy losses might be prevented (see box, page 542 page 542, for more).

Late Miscarriage What is it? Any spontaneous expulsion of a fetus between the end of the first trimester and the 20th week is termed a late miscarriage. After the 20th week, the loss of the baby in utero is called a stillbirth. Any spontaneous expulsion of a fetus between the end of the first trimester and the 20th week is termed a late miscarriage. After the 20th week, the loss of the baby in utero is called a stillbirth.

The cause of late miscarriage is usually related to the mother's health, the condition of her cervix or uterus, her exposure to certain drugs or other toxic substances, or to problems of the placenta.

How common is it? Late miscarriages occur in about 1 in 1,000 pregnancies. Late miscarriages occur in about 1 in 1,000 pregnancies.

What are the signs and symptoms? After the first trimester, a pink discharge for several days or a scant brown discharge for several weeks may indicate a threatened late miscarriage. Heavier bleeding, especially when accompanied by cramping, often means a miscarriage is inevitable, especially if the cervix is dilated. (There may be other causes of heavy bleeding, such as placenta previa, After the first trimester, a pink discharge for several days or a scant brown discharge for several weeks may indicate a threatened late miscarriage. Heavier bleeding, especially when accompanied by cramping, often means a miscarriage is inevitable, especially if the cervix is dilated. (There may be other causes of heavy bleeding, such as placenta previa, page 551 page 551; placental abruption, page 553 page 553; a tear in the uterine lining; or premature labor, page 556 page 556).

What can you and your practitioner do? If you're spotting light pink or brown, call your practitioner. He or she will evaluate the bleeding, possibly do an ultrasound and check your cervix, and probably prescribe bed rest. If the spotting stops, it's likely it wasn't related to miscarriage (sometimes it's triggered by sexual intercourse or an internal exam), which means normal activity can usually be resumed. If your cervix has started to dilate and you have had no bleeding or pain, a diagnosis of incompetent cervix may be made and cerclage (stitching the cervix closed; see If you're spotting light pink or brown, call your practitioner. He or she will evaluate the bleeding, possibly do an ultrasound and check your cervix, and probably prescribe bed rest. If the spotting stops, it's likely it wasn't related to miscarriage (sometimes it's triggered by sexual intercourse or an internal exam), which means normal activity can usually be resumed. If your cervix has started to dilate and you have had no bleeding or pain, a diagnosis of incompetent cervix may be made and cerclage (stitching the cervix closed; see page 47 page 47) may prevent a late miscarriage.

Repeat Miscarriages Though having one miscarriage definitely doesn't mean that you're likely to miscarry again, some women do suffer recurring miscarriages (defined as two or three in a row). If you've had several, you may wonder whether you'll ever be able to have a healthy pregnancy. First, know that there's a good chance you will, although you may need to manage future pregnancies differently. The causes of repeated miscarriages are sometimes unknown, but there are tests that may shed light on why the miscarriages took place-even if they each had a different cause.

Trying to determine the cause of a single loss usually isn't worthwhile, but a medical evaluation might be recommended if you have two or more miscarriages in a row. Some factors that might be related to recurrent miscarriage include a thyroid problem, autoimmune problems (in which the mother's immune system attacks the embryo), a vitamin deficiency, or a misshapen uterus. There are now many tests that may pick up risk factors for pregnancy loss and suggest possible ways of preventing it, in some cases very easily. Both parents might also have blood tests to screen for chromosomal problems that can be passed on to a fetus. You may be tested, too, for blood-clotting disorders (some women produce antibodies that attack their own tissues, causing blood clots that can clog the maternal blood vessels that feed the placenta). An ultrasound, MRI, or CT scan may be performed on your uterus, your uterine cavity may be assessed with hysteroscopy, and the miscarried fetus itself can be tested for chromosomal abnormalities.

Once you know the cause, or causes, you can talk to your practitioner about treatment options, as well as how best to care for the next pregnancy. Surgery may correct some uterine and cervical issues; thyroid medication can easily treat a thyroid condition, and medically supervised supplementation can just as easily resolve a vitamin deficiency; hormone treatments may also help, as can tests for antibodies and treatment to prevent blood clots (low-dose aspirin and/or heparin). In some instances, patients with a history of early miscarriages who appear to be producing too little progesterone may benefit from taking the hormone, though this treatment is controversial. Or, if excess prolactin is the cause, medication to reduce prolactin levels in the mother's blood may allow a pregnancy to proceed to term.

Even if you've had repeated miscarriages, you still have a good chance of sustaining a successful pregnancy in the future. But that may be hard for you to believe or even to hope for. It will be important to find ways of managing your understandable fear that becoming pregnant again will mean you'll miscarry again. Yoga, visualization techniques, and deep-breathing exercises can help with the anxiety, and support can come from other women who've suffered similar losses. Sharing your feelings openly with your partner may also help. Remember, you're in this together.

If you're experiencing the type of heavy bleeding and painful cramping that signal a miscarriage, there's usually nothing, unfortunately, that can be done to stop the inevitable. The further along your pregnancy, the more likely your practitioner might bring you into the hospital. Performing a D and C may be necessary to remove any remnants of the pregnancy.

Can it be prevented? Once a late miscarriage is under way, it isn't preventable. But if the cause of a late miscarriage can be determined, it may be possible to prevent a repeat of the tragedy. If a previously undiagnosed incompetent cervix was responsible, future miscarriages can be prevented by cerclage early in pregnancy, before the cervix begins to dilate. If chronic disease, such as diabetes, hypertension, or a thyroid condition, is responsible, the condition can be brought under control prior to any future pregnancy. Acute infection can be prevented or treated. And an abnormally shaped uterus or one that is distorted by the growth of fibroids or other benign tumors in some instances can be corrected by surgery. The presence of antibodies that trigger placental inflammation and/or clotting may be treated with low-dose aspirin and heparin injections in a subsequent pregnancy. Once a late miscarriage is under way, it isn't preventable. But if the cause of a late miscarriage can be determined, it may be possible to prevent a repeat of the tragedy. If a previously undiagnosed incompetent cervix was responsible, future miscarriages can be prevented by cerclage early in pregnancy, before the cervix begins to dilate. If chronic disease, such as diabetes, hypertension, or a thyroid condition, is responsible, the condition can be brought under control prior to any future pregnancy. Acute infection can be prevented or treated. And an abnormally shaped uterus or one that is distorted by the growth of fibroids or other benign tumors in some instances can be corrected by surgery. The presence of antibodies that trigger placental inflammation and/or clotting may be treated with low-dose aspirin and heparin injections in a subsequent pregnancy.

Ectopic Pregnancy What is it? An ectopic pregnancy (also known as a tubal pregnancy) is one that implants outside the uterus, most commonly in a fallopian tube, usually because something (such as scarring in the fallopian tube) obstructs or slows the movement of the fertilized egg into the uterus. An ectopic pregnancy can also occur in the cervix, on the ovary, or in the abdomen. Unfortunately, there is no way for an ectopic pregnancy to continue normally. An ectopic pregnancy (also known as a tubal pregnancy) is one that implants outside the uterus, most commonly in a fallopian tube, usually because something (such as scarring in the fallopian tube) obstructs or slows the movement of the fertilized egg into the uterus. An ectopic pregnancy can also occur in the cervix, on the ovary, or in the abdomen. Unfortunately, there is no way for an ectopic pregnancy to continue normally.

Ultrasound can detect an ectopic pregnancy, often as early as five weeks. But without early diagnosis and treatment of an ectopic pregnancy, the fertilized egg might continue to grow in the fallopian tube, leading to a rupture of the tube. If the tube bursts, its ability in the future to carry a fertilized egg to the uterus is destroyed, and if the rupture is not cared for, it can result in severe, even life-threatening, internal bleeding and shock. Luckily, quick treatment (usually surgery or medication) can help avoid such a rupture and removes most of the risk for the mother while greatly improving the chances of preserving her fertility.

How common is it? About 2 percent of all pregnancies are ectopic. Women at risk of having an ectopic pregnancy include those with a history of endometriosis, pelvic inflammatory disease, a prior ectopic pregnancy, or tubal surgery (conceiving after getting your tubes tied carries a 60 percent chance of an ectopic pregnancy). Also included in the at-risk group are those who became pregnant while using progesterone-only birth control pills; women who became pregnant with an IUD in place (though with today's newer IUDs, especially the hormonal kinds, the chance of an ectopic pregnancy is significantly lower); women with STDs; and women who smoke. About 2 percent of all pregnancies are ectopic. Women at risk of having an ectopic pregnancy include those with a history of endometriosis, pelvic inflammatory disease, a prior ectopic pregnancy, or tubal surgery (conceiving after getting your tubes tied carries a 60 percent chance of an ectopic pregnancy). Also included in the at-risk group are those who became pregnant while using progesterone-only birth control pills; women who became pregnant with an IUD in place (though with today's newer IUDs, especially the hormonal kinds, the chance of an ectopic pregnancy is significantly lower); women with STDs; and women who smoke.

You'll Want to Know ...

More than half of the women who are treated for ectopic pregnancies conceive and have a normal pregnancy within a year.

Ectopic Pregnancy In an ectopic pregnancy, the fertilized egg implants in an area other than the uterus. Here, the egg has implanted in the fallopian tube.

What are the signs and symptoms? Early symptoms of an ectopic pregnancy include: Early symptoms of an ectopic pregnancy include: [image] Sharp, crampy pain with tenderness, usually in the lower abdomen (it often begins as a dull ache that progresses to spasms and cramps); pain may worsen on straining of bowels, coughing, or moving Sharp, crampy pain with tenderness, usually in the lower abdomen (it often begins as a dull ache that progresses to spasms and cramps); pain may worsen on straining of bowels, coughing, or moving[image] Abnormal bleeding (brown spotting or light bleeding that precedes the pain) Abnormal bleeding (brown spotting or light bleeding that precedes the pain) If the ectopic pregnancy goes unnoticed and your fallopian tube ruptures, you may experience: [image] Nausea and vomiting Nausea and vomiting[image] Weakness Weakness[image] Dizziness and/or fainting Dizziness and/or fainting[image] Severe sharp abdominal pain Severe sharp abdominal pain[image] Rectal pressure Rectal pressure[image] Shoulder pain (due to blood accumulating under the diaphragm) Shoulder pain (due to blood accumulating under the diaphragm)[image] Heavier vaginal bleeding Heavier vaginal bleeding What can you and your practitioner do? Occasional cramping and even slight spotting early in pregnancy is not cause for alarm, but do let your practitioner know if you experience any type of pain, spotting, or bleeding. Call right away if you experience sharp, crampy pain in the lower abdomen, heavy bleeding, or any of the other symptoms of a ruptured ectopic pregnancy just listed. If it is determined that you have an ectopic pregnancy (usually diagnosed through ultrasound and blood tests), there is, unfortunately, no way to save the pregnancy. You'll most likely have to undergo surgery (laparoscopically) to remove the tubal pregnancy or be given drugs (methotrexate), which will end the abnormally occurring pregnancy. In some cases, it can be determined that the ectopic pregnancy is no longer developing and can be expected to disappear over time on its own, which would also eliminate the need for surgery. Occasional cramping and even slight spotting early in pregnancy is not cause for alarm, but do let your practitioner know if you experience any type of pain, spotting, or bleeding. Call right away if you experience sharp, crampy pain in the lower abdomen, heavy bleeding, or any of the other symptoms of a ruptured ectopic pregnancy just listed. If it is determined that you have an ectopic pregnancy (usually diagnosed through ultrasound and blood tests), there is, unfortunately, no way to save the pregnancy. You'll most likely have to undergo surgery (laparoscopically) to remove the tubal pregnancy or be given drugs (methotrexate), which will end the abnormally occurring pregnancy. In some cases, it can be determined that the ectopic pregnancy is no longer developing and can be expected to disappear over time on its own, which would also eliminate the need for surgery.

You'll Want to Know ...

Occasional cramping in your lower abdomen early in pregnancy is probably the result of implantation, normally increased blood flow, or ligaments stretching as the uterus grows, not a sign of an ectopic pregnancy.

Because residual material from a pregnancy left in the tube could damage it, a follow-up test of hCG levels is performed to be sure the entire tubal pregnancy was removed or has reabsorbed.

Can it be prevented? Getting treated for sexually transmitted diseases (STDs), and the prevention of STDs (through the practice of safe sex) can help reduce the risk of an ectopic pregnancy, as can quitting smoking. Getting treated for sexually transmitted diseases (STDs), and the prevention of STDs (through the practice of safe sex) can help reduce the risk of an ectopic pregnancy, as can quitting smoking.

Subchorionic Bleed What is it? A subchorionic bleed (also called a subchorionic hematoma) is the accumulation of blood between the uterine lining and the chorion (the outer fetal membrane, next to the uterus) or under the placenta itself, often (but not always) causing noticeable spotting or bleeding. A subchorionic bleed (also called a subchorionic hematoma) is the accumulation of blood between the uterine lining and the chorion (the outer fetal membrane, next to the uterus) or under the placenta itself, often (but not always) causing noticeable spotting or bleeding.

In the vast majority of cases, women who have a subchorionic bleed go on to have perfectly healthy pregnancies. But because (in rare cases) bleeds or clots that occur under the placenta can cause problems if they get too large, all subchorionic bleeds are monitored.

How common is it? Around 1 percent of all pregnancies have a subchorionic bleed. Of those women who experience first-trimester bleeding, 20 percent of them are diagnosed with a subchorionic bleed as the cause of the spotting. Around 1 percent of all pregnancies have a subchorionic bleed. Of those women who experience first-trimester bleeding, 20 percent of them are diagnosed with a subchorionic bleed as the cause of the spotting.