Fertility and Obesity
November 14, 2019
If you’re reading this you may have suffered a loss of your pregnancy, or a miscarriage. First, let us offer you our deepest sympathies. As physicians, nurses and staff who strive daily to create families, we become attached to you, and are profoundly saddened by your loss and want you to know that we respect and understand your grief. We want you to know, we are here for you, medically, physically and emotionally.

When an individual or a couple suffer a pregnancy loss, there are so many questions to be answered. We try to take the time to answer these in person, but the news of a loss can be deafening, and sometimes it’s helpful to have a resource to turn to. Please accept this information as a brief summary of frequently asked questions regarding pregnancy loss. For more information, let us know and we will make adequate time to answer all your questions.

What is a miscarriage? A pregnancy loss occurs when either a pregnancy never fully forms, such as a blighted ovum which has a sac, but no fetus, or a fetus develops but does not continue to grow or loses fetal cardiac activity. In some cases patients will have a chemical pregnancy, where the beta hcg level rises and then falls before anything is ever seen on ultrasound.

What types of pregnancy loss are there? There are several types:
Missed abortion: the fetus is no longer alive or viable, but there has been no significant bleeding, or passage of tissue.
Incomplete abortion: the fetus is not alive, and some of the tissue has begun to pass out of the uterus.
Inevitable abortion: the cervix is open and the fetus is delivering or will deliver
Septic abortion: an infection has occurred and there is intrauterine infection. This is dangerous and uterine evacuation is mandatory.

Why did I lose the pregnancy? There can be numerous reasons for pregnancy loss, but by far the most common is genetic abnormality. Between 60-80% of pregnancy losses occur because of a genetic abnormality in the fetus itself. Other factors that can be associated include abnormal uterine contour (septate uterus, bicornuate uterus etc.), intrauterine infection, maternal immunological abnormalities, excess blood clotting (thrombophilias such as Factor V Leiden mutations, Protein S and C deficiency, etc), trauma, and chemical or environmental exposures. Modifiable risk factors include smoking (up to a 400% increase in miscarriage risk), alcohol intake, drug and marijuana use, and extremes of weight (eg. BMI > 25 kg/m2). No one should ever feel blame or guilt for a miscarriage. This isn’t your fault. But there are things we can do to help prevent it from happening again.

What is my risk of having another miscarriage? The risk of miscarriage in general is between 15-20%. This is very dependent on age, with younger women having a low risk, while women over 40 years of age can have risks in excess of 50%. Your risk does not significantly increase above the normal rate, unless you’ve had more than 3 losses in a row. At that point, evaluation is indicated to make sure you’re not at risk for recurrent pregnancy loss. There are tests and treatments available to deal with this.

How do I deal physically with my pregnancy loss? There are three choices for managing pregnancy loss.
1. No therapy: patients who choose to have no therapy can wait up to four weeks post miscarriage to see if it will pass naturally. The success rate is anywhere from 25-75% and is highly variable. Risks include failure, cramping, bleeding, need for intervention and a small risk of serious bleeding problems if the tissue stays in utero for more than 4 weeks.
2. Misoprostol: this is a medication that will cause your uterus to cramp and to try to expel the contents. This is successful in 71% of patients with one dose (four pills taken orally, vaginally or rectally) and requires a follow up ultrasound 3 days later to confirm that all tissue is out of the uterus. If not complete, a second dose can be given and this bring success up to 84%. A follow up ultrasound is needed in 5 days. If there is still tissue present in the uterus, a dilation and curettage procedure is needed. Risks include heavy bleeding and cramping, failure and need for additional therapy.
3. Dilation and Curettage: this is a surgical evacuation of the uterus most often using a suction device to remove the contents from the uterus. It is usually done under general anaesthetic, takes less than 5 minutes, and has very low risks. Success is over 99% and usually post operatively recovery in within a few hours. Risks include anaesthesia, bleeding, infection and injury to all internal organs, though these risks are substantially less than 1%.

What happens after the pregnancy loss? It is normal to experience moderate to heavy bleeding for up to two weeks after a pregnancy loss regardless of how it is managed. Factors that would be considered concerning would be prolonged heavy bleeding, fever and severe pain. If you have any of these you should present to your emergency department immediately.

How long should I wait to try conceiving again? Although in the past patients were frequently advised to wait three months, this is no longer considered necessary. Conception can be attempted after the resumption of your normal menstrual period. Just make sure you have adequate vitamin levels, including folic acid at least one month prior to conception, and Vitamin D.

How do I deal with the emotional loss? No matter how short or long you continued in your pregnancy, the sense of loss and grief can be overwhelming. No one should have to go through this process alone and we are here to support you emotionally as much as we are here for you medically. We have created a diverse and strong support system to meet all of your emotional and psychological needs. Please check our website for specifics, but we have on staff a psychologist, a social worker, a family physician that specializes in counselling, and we pay for our patients to get three months of free access to the online program called Organic Conceptions. As always, you can meet in person with our nurses and physicians if you want one on one contact.

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