Dr Warner Huh (Host): Hello, everyone. It's Dr. Warner Huh again, the Chair of the Department of Obstetrics and Gynecology here at the University of Alabama at Birmingham. And I'd like to welcome you to this month's episode of Women's Health with Dr. Huh. So today, I have an excellent colleague who's going to talk about something that I think is a lot more common than the public realizes, and I'm going to let her get into that in a second.

Host: But today, we're going to talk about first trimester pregnancy loss, what this is, why does it happen; what should patients who are trying to get pregnant, what should they expect. This is a difficult thing to deal with, and I think because it's somewhat common, I wanted to have our guests talk about this today and share some fundamental facts and management issues with our listeners. So with me today is Dr. Shweta Patel. Shweta Patel is an Assistant Professor in the Division of Women's Reproductive Health in the Department of OB-GYN here at UAB. She has been very actively involved with education of our medical students and leads a major what we call reproductive module course for our medical students. So, we're deeply indebted to her for her dedication in this area. So, we're going to just dive right into it. So, welcome to this monthly podcast, Dr. Patel.

Dr Shweta Patel: Thank you. I'm glad to be here and thank you for the invitation.

Host: So, let's just start off, and I'm going to ask you to define for our listeners what exactly do we mean by first trimester pregnancy loss. Some of our listeners may not quite understand that terminology. And if you could just go ahead and just talk about how common this is, what are the symptoms. And then, perhaps in general terms, why does this happen?

Dr Shweta Patel: Okay. Great. So, first trimester pregnancy losses are more commonly referred to as miscarriages, and that's how patients typically understand first trimester pregnancy losses to be. And it's by definition, a non-viable pregnancy that's intrauterine in the first trimester. It's more common than people realize. It can occur in 10-15% of pregnancies and overwhelming number, about 80% of these occur in the first trimester. There are some risk factors that can lead to first trimester losses. Those are things like age and a prior history of a miscarriage. And throughout this discussion, you'll hear me interchangeably use first trimester pregnancy loss and miscarriages, and just wanted to clarify that. But yeah, it is more common than people realize. And those risk factors like age and prior history of miscarriages, they're not modifiable, meaning it's not something that we can change in our history of how old we are or what our past medical histories are. And so, it can make going forward with future pregnancies a little difficult.

To give an example of how age affects your risk for miscarriages, about average risk for miscarriage is 10-15% in the first trimester. For example, at age 35, that risk can increase to 20%. And then furthermore, that risk for first trimester pregnancy loss can increase up to 40% up to age 40. And so, it's a pretty steep increase in risk for miscarriage as age progresses. There are some other risk factors that lead to first trimester pregnancy losses, and these are things that I consider modifiable risk factors, so things that patients can modify, whether in their health or medical conditions, so things like smoking history, obesity, uncontrolled diabetes. These are risk factors that can be modifiable and help prevent future miscarriages from a medical condition standpoint.

Some symptoms you asked about what are some symptoms related to first trimester pregnancy losses? The most common symptoms are vaginal bleeding and uterine cramping. Typically, uterine cramping alone is very common in the first trimester and not solely associated with miscarriages. But when there's a combination of both uterine cramping and vaginal bleeding, it does pique our interest and worry as that there could be a risk for miscarriage. But it's really important to realize that first trimester bleeding can also be seen in normal pregnancies. And so just because a patient may have vaginal bleeding, it is not always correlated to a miscarriage. It's something that needs evaluation or discussion with providers. But it doesn't always mean that there is a miscarriage. Sometimes patients may have vaginal bleeding or pelvic pain or uterine cramping that's associated with a whole different type of pregnancy or abnormal pregnancy, like an ectopic pregnancy, which is a pregnancy outside of the uterus. So, this isn't typically considered a first trimester pregnancy loss, but there are more than just miscarriage related to vaginal bleeding.

A lot of patients ask what causes miscarriages to happen. And the cause of miscarriages may be multifactorial, but about half of the miscarriages in the first trimester are due to fetal chromosomal abnormalities. So, the way I describe it to patients is that when the egg and sperm meets and the cells are rapidly dividing, there's a abnormal chromosomal abnormality that occurs that leads to first trimester miscarriages. A lot of times when I mention chromosome abnormalities, the first thing patients think about, "Oh no, is there something I passed on to the pregnancy that led to this?" And very rarely that's the case. It's something that occurs spontaneously and not preventable.

Host: That was great. I mean, I like how you define this and categorize them as modifiable and non-modifiable. So, I think for our listeners it's actually really important to hear that. And the other point that you made that I think is really important to stress is not all bleeding is associated with pregnancy loss or miscarriage. And in fact, there are many pregnancies that have a little bit of bleeding, I don't want to use the word normal, but it's sometimes anticipated and expected. And so, I'm glad that you brought that up for our listeners because I think that's a really important take home point. So, can you comment on how we manage these miscarriages or first trimester losses? And also, maybe briefly comment on like how you do manage those women that have bleeding in the first trimester. What do you do when you see them in the office, et cetera?

Dr Shweta Patel: Sure. So just like we mentioned in the first trimester, sometimes small amount of vaginal bleeding can be expected. And so, since sometimes that is seen in a normal pregnancy, it's very important to have a thorough evaluation to make a definitive diagnosis of a miscarriage or early pregnancy loss prior to management is discussed. And so, besides evaluating the patient, taking a history and physical exam, oftentimes doing blood work to trend a pregnancy hormone called hCG can help us understand that this is either a normal pregnancy or not a normal pregnancy, and ultrasound can help us determine if a patient is having an early pregnancy loss or not. So, these are things that can be done to provide definitive diagnosis prior to undergoing management.

Unfortunately, there is no treatment to stop or prevent a miscarriage that's in progress. And often, patients ask about activity restrictions. If they're having bleeding, they ask about bedrest or pelvic rest or activity restrictions. And none of these have been shown to prevent a miscarriage from occurring. And so, once an early pregnancy loss diagnosis has been diagnosed, there are some main categories of management options that we discuss with our patients and those, I kind of categorize them into the three different ones. And those are expectant management, medical management and procedural management.

Expectant management, which is basically watch and wait, essentially means allowing the body time to take care of the miscarriage on its own. Let the pregnancy tissue naturally pass. It's hard to know how long it will take the body to recognize the miscarriage and have a completion of the miscarriage. For some patients, it's two to four weeks. Sometimes, it can be up to eight weeks before the body recognizes it. And that's a long time for patients to wait for their body to recognize it, especially all the emotional component with a diagnosis of miscarriage.

So, sometimes patients may not want to wait that full amount of time. And so, a lot of times, we talk about medical management options. And those medical management options allow for a shorter time span from a diagnosis of a miscarriage to full completion, but also avoiding a procedure if a patient doesn't desire to have a procedure. And these medical management options are tablets either placed orally or vaginally that help the uterus allow more cramping to happen to expel the pregnancy tissue. And it can be done through a prescription that's provided and the patients can do it in the comfort of their home or in a place that's not public.

The third option we talk about are procedural management of a first trimester pregnancy loss. This is something that most patients have heard about. It's called a D&C. Specifically, we use instrumentation called suction D&C, and it's done in the operating room. You could do it under regional anesthesia, so patients do not have to be fully asleep, or it can be done under general anesthesia when patients are fully asleep when the procedure is being done. But there's also a non-OR operating room option. The clinic option is something called a manual vacuum aspiration that is done in the clinic under local anesthesia. But both of these procedures, they allow for timely and definitive management of an early pregnancy loss. Sometimes if patients have signs of infection, hemorrhage, which is excessive bleeding, that's not controlled or they're unstable, then often a surgical intervention is required for urgent treatment.

Host: Yeah. So again, that's the one of the most thorough answers I've heard on this topic. And I think a lot of this, I hope you would agree, is dependent on the wishes of the individual patient. Some women want just to be expectantly managed and some women just want to be done and have, like you said, a suction D&C. I think it's just important to recognize that with expectant management, a lot of women do fine, but they do have issues related to bleeding or complications related to bleeding. So, they have to have the D&C. But it's important for our listeners who are in this scenario to ask these questions, because there is definitely more than one way to manage this.

So, I know one scenario that you have dealt with with your patients, and it's pretty common in women's health is, what happens after the first trimester loss or miscarriage? What can women expect? I know that you were talking a little bit earlier about physical activity, but my understanding, one question that comes up quite a bit is when can women start trying to conceive again and become pregnant? And it'd be great for you to provide some guidance to our listeners on that. But further also, just to talk about the term recurrent first trimester losses or miscarriages and why that's important. So first, if you could just talk about what should patients expect, particularly when trying to get pregnant. And also, lastly, talk about just recurrent first trimester losses.

Dr Shweta Patel: Dr. Huh, you're right. Those are the very common questions we get after we tell patients that they have had a miscarriage. Their questions are, "What does this mean for my future pregnancies? When can I start conceiving again? Am I at risk for this happening again?" So, those are very common questions. But typically after a first trimester loss, it takes time for the uterus to heal and the body to heal from that miscarriage. And often, we see bleeding continue. Bleeding can be expected for one to two weeks after a miscarriage, and there's no quality data that supports delaying conception after a miscarriage, meaning that immediately after a miscarriage, if patients want to try to conceive again, they can. Oftentimes, however, many providers recommend waiting to conceive after they've had one cycle. It's difficult to know when that next menstrual cycle will resume, but typically it takes about four to six weeks after a pregnancy loss.

If patients do not desire to conceive immediately or in the new future, it's also important to talk to patients about their contraceptive options if they desire to discuss it, because they may want to take some time before conceiving again or don't desire a future pregnancy immediately. And so, contraception is also really important to discuss if that's something that they want to talk about.

As we talked about in the beginning, early pregnancy loss itself is a risk factor for having another miscarriage or another pregnancy loss. And so, according to the American Society of Reproductive Medicine, recurrent pregnancy loss is defined by having two or more consecutive miscarriages. And so, oftentimes after one miscarriage, we do not recommend additional testing or evaluation to determine why a miscarriage occurred, especially since overwhelming number are due to chromosomal abnormalities that are spontaneous. But after two consecutive miscarriages, we do recommend evaluation to determine why these miscarriages have occurred. That miscarriage evaluation is in the form of blood work and ultrasound. However, despite a thorough evaluation, more than half of recurrent miscarriages are unexplained. So, it still can be a very devastating process for patients because they've gone through not only one, but now two miscarriages, let's say, sometimes even three miscarriages before they do testing, and we still don't have answers for why miscarriages occur. And that's why this can be a very emotional rollercoaster for patients not having answers. And it's even more difficult because in general, there are no effective treatments or interventions to prevent early pregnancy losses.

Host: So, I appreciate that response. And I have lots of patients who ask about this question. But again, stress that that first miscarriage is not that unusual. And like you said, we don't dive deep into this extensive workup. But when you have two or more, that definitely requires further evaluation to understand why that's occurring. And it goes into some of these modifiable risk factors that you were talking about earlier.

So, one additional question, I think that's really important. I would argue that how we counsel patients in the bereavement process and the resources that we provide are somewhat inconsistent with the first trimester pregnancy loss. And I just don't know if you have any thoughts about what those resources look like. I think that we underestimate how hard this is for women to go through and it's not like you have the pregnancy loss and you go right back to your normal self and life and work. But I would just love to know your thoughts on this.

Dr Shweta Patel: Yeah, I agree. Like we talked about earlier, going through a miscarriage process, it's a very emotional process for our patients. And a lot of times when patients have pregnancy losses later on in the pregnancy, let's say in the third trimester, or have stillbirths, sometimes patients feel like there are more support for patients who have had pregnancy losses later on in the pregnancy, but not as many options when they have first trimester pregnancy losses. I think we as providers are really good at discussing objective and clinical information, talking about treatment options and what to expect for recovery, but I think we could all do better at discussing emotional recovery, which can take a lot longer for patients to recover from than their physical recovery.

It doesn't matter how early in the pregnancy patients found out about their miscarriage, whether it's four weeks after their positive pregnancy test or eight weeks after their positive pregnancy test, or even 20 weeks, whether this was a planned pregnancy or a unplanned pregnancy, patients have strong feelings of loss and grief associated with early first trimester pregnancy losses. And so, it's just as critical to provide the emotional support compared to the medical support we are used to providing and helping patients navigate their feelings, their support around them and the treatment decisions. And it can be very overwhelming when they first hear about their diagnosis of a miscarriage. And sometimes patients need time to process their diagnosis before making any decisions about management options, because that in itself can be overwhelming.

Also, I've realized it's really important to explain to patients that they did not do anything to cause the miscarriage to happen. A lot of times we have patients, or it's not uncommon for patients to blame themselves for having a miscarriage. They go back in time. They think about, "What did I do? What did I eat? What caused this miscarriage to happen? Is it because I lifted this box that was 20 pounds or I went on a two-mile hike?" They go through their lives in the last four or eight weeks and try to figure out what could have led to this miscarriage, and it's really important to say it out loud and say it to the patients clearly that there's nothing that they particularly did that caused the miscarriage to happen.

However, it's also important to discuss if they do have those modifiable risk factors that we talked about earlier. Things like smoking cessation, weight loss and obese patients, or blood glucose control in patients who have uncontrolled diabetes, because this can be empowering for patients and things that they can help improve their medical conditions to help prevent future miscarriages from happening.

But pregnancy loss affects not just the patient having the miscarriage, but it affects the entire family or the support system that they have. And oftentimes as providers, we forget about their support system and the other family members or friends that are going through the miscarriage with them. And so, it's important to involve them in a conversation asking patients who is their support system, and so that we are not treating just the patient but their entire support system as well.

And then, one last thing I'll say about bereavement and some resources that are available, there are some support groups that are available nationally and usually locally as well. But here at UAB, we're working on providing a broader bereavement counseling and resources for our patients because that is much needed.

Host: That was a fantastic answer. And to your last point, as the chair of the department, I fully recognize that we can do a better job. And the first step is recognition that we can do a better job. And I think the department is very much committed to providing those resources to our patients because it is hard, and I love it that you brought up that it's not just about the patient. It's about their partner, their spouse, their family. This is all really, really hard and I just think that we all could just do a better job at recognizing it and helping women work through this process and to return to some level of normalcy. I don't know if you have any further closing thoughts or comments, Dr. Patel?

Dr Shweta Patel: Yeah, I think there's a few things I want to close with. When we talk to patients about their first miscarriage that they've had, that next pregnancy that they try to conceive for or planning to conceive, that next pregnancy, there's high anxiety around it. It's almost like a goal that they're trying to meet. Let's say they have an eight-week miscarriage. They're trying to get to nine weeks, they're trying to get to 10 weeks. And so even if they have emotionally and physically healed well from their first pregnancy loss, it's important when they come back for their second pregnancy to still continue to provide that support and help them through their early trimester, because they're always going to have that fear and anxiety of another miscarriage.

And I think as providers, telling a patient about an early pregnancy loss is a difficult conversation to have. And each individual patient processes it differently. So, no matter how many times we have this conversation throughout our careers, diagnosing patients with miscarriages and explaining it to them each encounter, each patient makes it a little bit different and doesn't necessarily get easier every time. And it's important for patients especially to understand that, despite having a first trimester pregnancy loss, overwhelming number of patients will continue and have a successful next pregnancy and have the family that they hope for.

Host: And thank you for ending that on a very positive note, Dr. Patel, because I know this is a little bit of a sober topic to discuss. I want to thank, again, Dr. Patel for talking about first trimester pregnancy losses or miscarriages. I do want you to know, Dr. Patel, this is probably one of the very best high-level discussions on this topic that I've heard. So, deeply indebted to you, and thank you for doing this with me. As always, please rate this podcast and we welcome any comments, particularly in topics that you're interested in. And for more information on our obstetrical services and all clinical services that UAB provides, please check out uabmedicine.org. And until next time, thank you. Have a great day. Hope you all are enjoying your summer. Take care. Peace out. Bye-bye.