Miscarriage: medical and psychological aspects in the approach to the patient

By Cristiano Antonino On Feb 22, 2023

Early miscarriage occurs within the first three months of gestation and is unfortunately a frequent occurrence, affecting about 15-20% of clinically recognised pregnancies

What we are seeing, however, is only the tip of the iceberg of this phenomenon, as it is estimated that 2 out of 3 conceptions go unrecognised and pass for late menses.

Nowadays, these so-called biochemical pregnancies are more easily recognised thanks to ultra-early pregnancy tests and must be reported to the doctor, since especially if they recur, this is an indication for further investigation.

It is very difficult for the woman to realise that there has been a miscarriage

In fact, the symptoms of pregnancy are not indicative (nausea, breast pain) they may not even be there or may change over time.

The woman may realise that she has had a miscarriage by the presence of even the slightest spots of blood (in such cases it is always a good idea to see a doctor) or by a routine ultrasound scan.

The first ultrasound check in pregnancy should be done from the seventh week of gestation (i.e. from 6+0), or earlier in the presence of abnormal symptoms (blood loss, severe pelvic pain).

Cause of miscarriage: not always easy to discover

In 65% of cases, the cause of miscarriage is chromosomal, which occurs when the oocyte carries an extra chromosome and the embryo that forms has an abnormality that is incompatible with life.

This is the main reason why the probability of miscarriage increases with maternal age.

In the other 35% of cases we think of mother-related factors such as progesterone deficiency, alterations in thyroid hormones, abnormalities of the uterus, e.g. malformations such as septum uteri, endometritis (inflammation of the uterus wall), immune factors, such as antiphospholipid antibodies, celiac disease, antithyroid antibodies.

Miscarriage a symptom of a problem?

It is said that a miscarriage is a common occurrence, but when it recurs it can be a symptom of underlying health problems.

International scientific societies recommend investigations from the second early miscarriage or even from the first miscarriage if it occurs during the period of foetal development, i.e. after the third month.

Tests in cases of polyabortion include hormonal tests and others concerning the coagulation system and autoantibodies.

Further examinations that are assessed on a case-by-case basis are the couple’s karyotype and hysteroscopy, a test used to assess the uterine cavity and exclude e.g. uterine septum, endometritis.

When can a pregnancy be sought after an abortion?

After an early miscarriage a new pregnancy can be sought after one or two months.

In all cases it is useful to consult with one’s doctor.

However, the timing also varies depending on how the couple feels.

Some decide to seek a new pregnancy quickly, others prefer to give themselves more time to grieve.

The risk of miscarriage can be reduced

A woman seeking a pregnancy is first advised to visit a gynaecologist with an examination and pelvic ultrasound.

The doctor will take stock of your health and assess the presence of risk factors, such as smoking and excessive alcohol consumption, that have an impact on fertility.

So-called pre-conception tests will be prescribed to see if vaccinations are required (e.g. against rubella, chickenpox and influenza for those seeking pregnancy in the winter months), if the thyroid gland is functioning properly, if there is a vitamin D deficiency.

The doctor will administer folic acid, which is a vitamin that helps prevent certain malformations of the unborn child and improves female fertility.

Psychological aspects of miscarriage

Loss in pregnancy, particularly within the first trimester, is a common occurrence and as such tends to be normalised in culture and healthcare practice, and its emotional impact is often downplayed.

As a sudden and unexpected event that threatens one’s sense of control and predictability over such an important aspect of one’s life, abortion is a high source of stress.

From the very beginning of pregnancy, women often imagine their future with a child; the child is represented early in their fantasies, gaining mental representation, internal dialogue and preparation for its arrival.

When women learn the news of the loss, it is not a blood clot, a set of cells, an embryo they have lost, it is their child, they fear they have caused their death, they feel the abandonment and are truly mourning this profound loss.

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Although it proceeds in a similar way to a conventional bereavement, its processing can be more difficult because the loss is easily underestimated by many people significant to the woman, such as family members, friends, medical personnel and also the wider socio-cultural context.

There is no visible and recognisable child to mourn for, there are no shared memories and there is little recognition of attachment to the lost child.

As a result, grief reactions, instead of being seen as appropriate responses to loss, are denied or misunderstood and, when noticed, improperly identified as pathological.

The loss is minimised, with the expectation that it will be resolved in a short time, ignoring its potential traumatic consequences. Painful experiences are sometimes accentuated by negative judgements about the quality of care, lack of information and support, and attitudes on the part of carers.

On a social and cultural level, the event is surrounded by silence

Miscarriage, like any other bereavement, takes time to process and varies from person to person, but if this does not happen naturally, it is advisable to consult a psychologist or psychotherapist.

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