Miscarriage & pregnancy loss and working with a Naturopath
Pregnancy loss* is a heartbreaking experience.
And it happens a lot.
We're getting better at acknowledging it and talking about it, but we've got some way to go yet.
Prevalence of pregnancy loss
One in five women in Australia who know they are pregnant will miscarry by 20 weeks.
Maybe that's been you? It's definitely been someone you know and love, even if they haven't told you.
Pregnancy loss can occur at any time in a pregnancy (though it's more common in the first 12 weeks), and might be called...
biochemical / chemical pregnancy, anembryonic pregnancy, blighted ovum, early miscarriage, late miscarriage, missed miscarriage, ectopic pregnancy, molar pregnancy, stillbirth, tfmr, neonatal loss...
Babies lost in Australia each day
These losses can occur for a multitude of reasons...
…chromosomal abnormalities, hormonal imbalances including progesterone and thyroid, autoimmune disease, clotting disorders, immunological dysfunction, nutritional deficiency, infection, maternal and paternal age, endometrial and uterine issues...
...and sometimes, for no reason at all x
Whenever it happens, however it happens, it's not your fault.
Different types of loss
Biochemical / chemical pregnancy
✴︎ Implantation of the embryo occurs, and an initial pregnancy test is positive, but is followed by a miscarriage 2 - 3 weeks later (often when the period is due)
✴︎ Most biochemical pregnancies likely occur without detection, though they are being identified more frequently thanks to high-sensitivity pregnancy tests and post-embryo transfer blood tests in IVF cycles
✴︎ It is characterised by a low b-hCG level <100 mIU/mL and doesn't progress to a gestational sac that can be visualised by ultrasound (hence 'chemical' pregnancy - the pregnancy is only diagnosed by chemical - hCG - means)
✴︎ Historically known as a 'false-positive pregnancy test', which diminishes the grief experienced with this loss (it wasn't false - you were pregnant)
✴︎ They are thought to be very common. In IVF settings, a biochemical pregnancy occurs in 15-20% of transfers.
Miscarriage
☾ 'Miscarriage' is a pregnancy loss before 20 weeks gestation
☾ It encompasses all losses that occur before 20 weeks, including ectopic and molar pregnancies
☾ The risk of miscarriage is greatest in the first trimester, but most losses actually occur before a woman even knows she's pregnant (eg. as above - biochemical pregnancy)
☾ A complete miscarriage is where all the pregnancy has passed
☾ An incomplete miscarriage is where some pregnancy tissue remains in the uterus. It might be expelled on its own in time, or you may be prescribed medication or a D&C to assist.
☾ 'Recurrent miscarriage' is where a woman has experienced two or more miscarriages, and occurs in <5% of cases (it was previously defined as 3+ losses, representing 1% of couples). The losses do not need to be consecutive.
Missed miscarriage
✴︎ This is where baby has sadly died but is still in the uterus - the body hasn't recognised the loss yet. This kind of loss is usually discovered at the 7-8 week scan (dating / viability scan, if you required one), or 12-week scan.
✴︎ A D&C is used to assist in managing the miscarriage process.
✴︎ Sometimes it is a woman's preference to wait until the body miscarriages naturally. This can take some time, up to 4 weeks.
Anembryonic pregnancy
☾ Previously known as Blighted ovum
☾ Where an early embryo stops developing, is reabsorbed and the gestational sac and placenta are left behind and continue to grow
☾ It's not known why this occurs, but is thought to be due to chromosomal abnormalities of the embryo.
☾ An early pregnancy test might be positive, and you may experience pregnancy symptoms until a miscarriage occurs.
☾ The miscarriage process may occur naturally, or be assisted medically or surgically.
Ectopic pregnancy
✴︎ This is where a fertilised egg starts growing outside the uterus, usually in a fallopian tube
✴︎ The fallopian tube can't contain this growing embryo, the pregnancy is unable to continue and a woman will experience (severe) pain and her tube may rupture. It is urgent the embryo is removed to avoid internal bleeding.
✴︎ Depending on your presentation an ectopic pregnancy will be managed with surgery or medication to remove the embryo, or if it looks like you will miscarry naturally, a 'wait & see' approach.
✴︎ Occurs in 1-2% of pregnancies and is more prevalent in women with a history of damaged fallopian tubes or pelvic infection, women who conceive while using an IUD, and women who've had previous surgery in the area eg. c-sec, appendectomy
Molar pregnancy (hydatiform mole)
☾ A complete molar pregnancy is where an egg with no genetic material, is fertilised
☾ The cells that would usually form the placenta, form a mass of abnormal cells/cysts instead
☾ The foetus doesn't develop at all
☾ In a partial molar pregnancy, a normal egg is fertilised by two sperm cells. Any developing foetus will not be able to survive. It may at most survive three months.
☾ In each case, a woman's hCG will be rising (sometimes at a faster pace than expected), she will experience a range of normal pregnancy symptoms, and think all is well with her pregnancy - a subsequent diagnosis of molar pregnancy comes as a shock.
☾ Molar pregnancy is not common, and is little understood in the community, making it challenging for grieving women and couples to discuss their loss.
Stillbirth
✴︎ Pregnancy loss after 20 weeks is referred to as Stillbirth.
✴︎ Half of stillbirths occur close to full term
✴︎ Sadly, 1 in every 135 pregnancies that reach 20 weeks will end in a stillbirth
✴︎ TFMR losses (see below) are included in the stillbirth statistics
✴︎ Unfortunately in around 25% of cases, a cause can't be identified.
✴︎ In other cases major contributing factors are maternal health and infection, bleeding, premature labour, congenital abnormalities.
Termination for medical reasons (TFMR)
☾ This is a heartbreaking decision facing parents who, during the course of their pregnancy, find out their baby has serious and significant health abnormalities.
☾ When this loss occurs after 20 weeks, it is included as part of the 'stillbirth' statistics
☾ It is estimated that TFMR accounts for less than 5% of terminations in Australia
☾ Sadly for individuals and couples facing TFMR, it arouses conflicting feelings in the community, and makes it even more challenging to discuss their loss
☾ Depending on the stage of gestation, TFMR involves a D&C, or the induction and birth of baby
Are you beginning to feel it's a miracle any of us are here...?!
Why me? Why my pregnancy?
These are many potential contributing factors to pregnancy loss. Some of them exist mostly as hypotheses in a research setting, and others arouse various degrees of acknowledgement depending on your specialist. Most commonly pregnancy loss is due to a chromosomal abnormality of the embryo.
In many cases no causative factor can be isolated.
It's never your fault. x
Chromosomal abnormalities
✴︎ It's thought the majority of pregnancy losses are due to chromosomal abnormalities
✴︎ Chromosomal abnormalities happen by chance, though parental age is also a contributing factor
✴︎ Sometimes we are carriers for chromosomal anomalies that contribute to pregnancy loss or congenital abnormalities. This can be determined by a blood test that looks for any chromosomal irregularities, called 'karyotyping'. If this is the case, IVF and preimplantation genetic diagnosis of your embryos is an option.
Autoimmune disease
☾ 'Auto'-'immune' conditions are where the immune reactions our body creates, are sometimes to our own tissues. The immune system is amped up and has difficulty differentiating healthy normal cells from problematic ones - like bacteria or viruses. Examples are Hashimoto's disease, Coeliacs disease, Lupus.
☾ Depending on the autoimmune condition, it may affect how our organs work (thus affecting pregnancy) or it might even affect how the body reacts to an embryo (spoiler alert...not well)
Clotting disorders
✴︎ These increase the risk of pregnancy loss occurring, though mechanisms are still unknown, and the role in pregnancy loss of some thrombophilias is contentious.
✴︎ It is hypothesized that a clotting issue might negatively affect implantation, placentation and the circulation to the placenta
✴︎ You might be born with a genetic predisposition to clotting events eg. Factor V Leiden, Prothrombin gene mutation
✴︎ Or you might develop a clotting disorder, like Anti-phospholipid syndrome. Investigation for this is covered under Medicare once you've had two miscarriages, by blood tests Cardiolipin antibodies and Lupus anticoagulant. Treatment involves the prescription of blood thinners once pregnancy is confirmed.
Immunological dysfunction
☾ Namely, Natural Killer (NK) cells and Human Leucocycte Antigen (HLA) antibodies. This is another contentious area of reproductive health.
☾ Both NK cells and the HLA system play a part in how our immune system responds to foreign substances (remember, an embryo contains at least 50% foreign DNA...100% if using donor eggs)
☾ Maternal 'immune tolerance' needs to exist to support and maintain a pregnancy
☾ Natural Killer cells are found in our general blood stream (peripheral NK cells), and in uterine tissue (uterine NK cells - these are the important ones)
☾ When functioning correctly, uNK cells provide an important initial link between the embryo and the endometrium, assisting in proper implantation and placentation
☾ HLA are a family of genes that code for immune system molecules. These molecules play a role in
immune system identification (is this cell 'self' or ‘foreign’)
immune system decision-making (to attack a cell or not)
☾ It's thought that certain HLA genes might predispose a women to experience recurrent miscarriage, and is hypothesised that similarities between maternal and paternal HLA genes might contribute to pregnancy loss
☾ uNK cells can be detected via endometrial biopsy (though note, they're not evenly and uniformly distributed across the endometrium)
☾ HLA typing is done via a blood test.
☾ Depending on your results, treatment might begin prior to an embryo transfer (in and IVF setting), or upon the confirmation of a positive pregnancy test.
☾ Treatment involves a variety of medications including IV intralipids, blood thinners and steroids
Hormonal / endocrine issues
Particularly thyroid function, glucose balance, progesterone secretion and maintenance.
Thyroid
Overt hypo- and hyper- thyroidism, and 'subclinical' hypothyroidism are linked with pregnancy loss
It is recommended that TSH not exceed 2.5 mIU/L in the first trimester (which means keeping it <2 mIU/L prior to conception). As TSH increases, so does the miscarriage risk.
The presence of thyroid antibodies (an autoimmune dysregulation compromising thyroid gland function) increases the chance of developing hypo- or hyper- thyroidism, and is an independent risk factor for miscarriage.
Glucose
Diabetes mellitus is a risk factor for pregnancy loss, with greater risk occurring in women with poorly managed blood sugar
This risk is independent of PCOS or obesity.
Diabetes may increase miscarriage risk due to chronic inflammation or the effects of excess insulin in early placental cells
Poor blood sugar balance is associated with a higher prevalence of foetal congenital abnormalities
Progesterone
Adequate levels of progesterone ('pro-gestation') are vital for the development of a healthy endometrium for implantation, maintains the uterine gestational sac, and may assist with maternal immune modulation
Defining luteal phase defect / assessing progesterone levels in early pregnancy /supplementing women in their first trimester with progesterone, are all polarising issues in reproductive medicine...is low progesterone a cause or effect of miscarriage...?
Progesterone supplementation via pessaries or intramuscular injection are routinely administered after an IVF embryo transfer cycle
Recent studies have shown an increase in live births of 3 - 5% in women presenting with a history of miscarriage or bleeding during pregnancy, when prescribed progesterone. This increased to 15% for women who had experienced three or more miscarriages (400mg twice daily as a pessary).
While there may not be a great deal of robust evidence yet around progesterone, there is no demonstrated harm of using it in pregnancy.
Nutritional issues
✴︎ Elevated homocysteine levels are associated with an increased risk of pregnancy loss, placental abruption and neural tube defect. Homocysteine levels are brought into balance in our bodies by B6, B12 and folate, and with the assistance of an enzyme called MTHFR. Nutritional deficiencies in these nutrients, or an MTHFR genetic mutation may be problematic.
✴︎ Homocysteine and MTHFR can both be assessed by blood test, though this is seen as controversial by some specialists. MTHFR testing is not covered by Medicare.
✴︎ There is a link between reduced folate metabolism and recurrent pregnancy loss, seen in women with an MTHFR genetic mutation. This risk is overcome by taking correct and adequate folate supplementation during preconception and pregnancy. Depending on your MTHFR polymorphism, you may have a reduction in enzyme function for folate metabolism by up to 65%.
Maternal infection
☾ Taking adequate precautions against infection, supporting overall immunity, and accessing treatment for infection, in preconception and during pregnancy is important
☾ An increased risk of pregnancy loss is demonstrated with Zika virus, Cytomegalovirus (CMV), malaria, Influenza, Bacterial vaginosis (BV), Syphilis, Listeria
☾ Infections like Chlamydia, Toxoplasmosis, Parvovirus, HPV, Herpes, show mixed evidence around pregnancy loss
☾ With BV / vaginal infections, problematic organisms are Ureaplasma urealyticum and Mycoplasma hominis (not routinely assessed in Australia due to conflicting research), Group B Strep, and an overall lack of abundance of healthy Lactobacillus species in the vaginal flora is also a risk for pregnancy loss.
☾ It's not always known if the issue with pregnancy loss and infection is due to the maternal response to infection, or how the infection itself might affects foetal or placental tissue
Age (maternal and paternal)
✴︎ There is common acceptance that women of advanced maternal age (over 35 years) demonstrate reduced egg quality with a higher degree of chromosomal abnormalities. This is a risk factor for pregnancy loss.
✴︎ What is increasingly known is that paternal age has a role to play too. Men over the age of 40 have increased sperm DNA fragmentation - a known risk factor for pregnancy loss. This is essential for couples and GP's to recognise.
Pregnancy loss by maternal age
Lifestyle
There are a variety of modifiable lifestyle and environmental factors that are independent risks for pregnancy loss
☾ maternal and paternal smoking
☾ alcohol intake (during preconception and pregnancy)
☾ caffeine intake (dose dependant, one study suggesting a 7% increase in miscarriage risk per 100mg caffeine)
☾ maternal and paternal obesity
Endometrial / uterine factors
✴︎ Endometrial receptivity - every woman has a unique optimal window of implantation after ovulation. If implantation occurs outside this optimal window, it will compromise the implantation and placentation. If you’ve experienced recurrent miscarriage or recurrent implantation failure after your embryo transfers, your specialist might like to consider an Endometrial Receptivity Analysis (ERA). An endometrial biopsy is taken to determine your best window for implantation. This will help to pinpoint the best time for an embryo transfer.
✴︎ Fibroids - submucosal fibroids (growing just beneath the inner lining of the uterus) and intramural fibroids (growing in the uterine muscle wall) that distort the uterine cavity may increase pregnancy loss risk
✴︎ Endometriosis - it’s hypothesised that endometriosis may affect egg quality, make immune-dependant changes to the endometrium, and subsequent altered placentation
✴︎Adenomyosis - as above, but also with uterine contractility and endometrial peristalsis that might reduce proper placentation
Male factor
☾ Sperm DNA fragmentation is a measure of how well the DNA in the head of the sperm cell holds together, or fragments apart. Higher rates of sperm fragmentation are associated with pregnancy loss. Sperm DNA fragmentation (sometimes called SCIT or SCSA) is not routinely tested in semen analyses and needs to be requested, and is usually tested at an andrology lab compared to a regular pathology lab. Higher degrees of sperm fragmentation are found as men age.
☾ Age - as mentioned above, as men age, sperm cells show higher degrees of abnormalities. Paternal age (>45 years) is an independent risk factor for pregnancy loss.
☾ Obesity
☾ Smoking status
☾ Alcohol intake
How can a naturopath help?
Naturopaths have a role to play in the health system to support women and couples experiencing loss, and to prevent it from happening again.
This work is meaningful to me. I have experienced the pain of baby loss. As a naturopath working to help couples conceive for so many years, when I experienced my own loss I felt huge shame. I felt guilt. I felt that had I done more this wouldn't have happened.
It took me years to accept I did nothing wrong and could have done nothing more.
In part, my experience has helped shape the practitioner I am. I don't want you to feel the pain of another baby loss, and I work pretty hard to support you in the very best way I can.
A naturopath experienced in fertility support and miscarriage management will delve deeply into trying to identify any underlying reasons for your pregnancy loss, to ultimately reduce the risk of it happening again.
Listening
No matter how or when it occurred - your loss is real
Even if this is a biochemical pregnancy (often dismissed by GP's)
Even when you've ‘only had one' miscarriage
Even though you had an 'early' miscarriage (these are all things women hear...!)
I want to hear your story.
Further testing
For you and partner.
In order to fully identify any underlying risk factors, we may need to do further comprehensive testing. This can be done collaboratively with your GP, or independently. Your specialist may have already done some tests - I want to see them!
Sometimes you will have been told your results are 'normal', but from a naturopathic perspective they might not be 'optimal' - there are shades of grey in the reference ranges. Depending on your case, I might send you off for semen analyses, ultrasound, hormonal tests, thyroid, glucose / insulin, thyroid antibodies, clotting antibodies, vaginal swab and more.
Preconception care
If you've experienced a pregnancy loss, I will very likely suggest a 12 week period of preconception care.
This 12-week period encompasses the whole maturation period of an egg and sperm cell, in order to optimise their quality. We'll focus on making specific and individualised dietary and lifestyle changes to support your fertility. We'll also do some further testing, and start treatment with tailored herbal and nutritional medicine.
Optimising egg and sperm quality
The health of every embryo we make depends on the health of your egg and sperm cell.
Spending time nourishing the quality of these cells is important. We tackle this by address dietary and lifestyle factors that may be impacting on cell quality, and by prescribing specific nutrients to make these cells as healthy as possible. Antioxidants, antioxidants, antioxidants.
Stress
Pregnancy is stressful.
Loss is stressful.
Trying to conceive can be stressful.
Once you’ve experienced a pregnancy loss, the anxiety of having another can be all consuming. Part of my role is to support your nervous system through this time. To support stress adaptation and reduce the effects of stress on your body systems (sleep, energy, ovulation, digestion, musculature, headaches...). I might use herbal or nutritional medicine, or I might suggest stress management techniques, or acupuncture, or tapping (EFT), or counselling.
Herbal and nutritional medicine
As a naturopath I am fortunate enough to have access to a huge array of exceptional quality nutritional and herbal medicines to prescribe and to individualise my treatment. In the case of pregnancy loss I will always prescribe nutrients and antioxidants that create the building blocks of healthy egg and sperm cells throughout their maturation period, aiming to optimise the quality of these cells.
I might also use herbs and supplements to balance hormone levels, support thyroid function, balance immunity / autoimmunity, support uterine tone and circulation and to reduce uterine spasm / inflammation, treat infection, balance blood sugar, calm and soothe.
We can work safely alongside prescribed medications (eg. thyroxine or prednisolone) or an IVF cycle.
In addition, if you’re coming to me after a pregnancy loss, remember that pregnancy is nutritionally depleting for mama - baby will preferentially get all your nutrients. This can leave you in need of specific nutritional support.
Diet & lifestyle
As you've seen earlier in this article, there are modifiable lifestyle factors that can reduce your risk of pregnancy loss. I can help with those!
We can work on making dietary changes around coffee and alcohol. I can support your weight loss goals. Together we can bring cravings and blood sugar levels into balance. There are even herbs and supplements with clinical evidence around addiction support for those that need it to QUIT smoking (St John's Wort and NAC...seriously special stuff).
Putting it all together
No two stories of loss are the same.
It's important to individualise treatment and advice and always aim where possible at getting to the root cause. This means putting seemingly disparate things in place. Looking at things with a holistic lens.
Unique support
Get ready, because a naturopathic approach might be a little different to what you've experienced with other practitioners - for starters, our consultations are longer.
A naturopath wants to know more, ask more and explore beneath the surface more. We will ask you questions about more than just your reproductive health, because your fertility is a reflection of your overall health as well as your environment and dietary exposures.
Collaboration
No practitioner is an island. I welcome being able to work alongside your GP or IVF specialist, and there are so many ways our approaches to your fertility complement each other!
More to explore & examine around pregnancy loss
Pregnancy loss brings up so many questions! For parents, for health-care professionals, for researchers.
Here's more very juicy food for thought..
Foetal microchimerism
Microchimerism is the presence of cells from one individual in another genetically distinct individual (Shrivastava et.al)
In Greek mythology the Chimera was a creature made from part lion, goat and snake.
When a woman is pregnant, cells from her baby pass over into her own bloodstream and cells. In fact, this is what the NIPT (non-invasive-prenatal test) is based on.
The thing is though, after baby is born or lost, those foetal cells persist in her for decades - this occurs as a natural feto-maternal ecxhange and is a phenomenon known as a microchimerism. A 'biological legacy' of pregnancy (Peterson et. al). From as early as 5 weeks gestation.
Baby's cells are found in yours at a ratio of around 1 in 1000 cells, and in your brain, heart, kidneys and other organs.
I can't help but think this is magical. And of course it isn't, and there'd be a fabulous and terribly clever evolutionary reason for this to occur (there are LOTS of hypotheses), but I still think...downright magic. Your baby is still with you.
i carry your heart with me (i carry it in my heart) ~ ee cummings
Matresence
Matresence, a term coined in the 1970's by anthropologst Dana Raphael means: the transition of woman to mother.
The concept has been pushed further more recently, exploring this transition to motherhood within physical, psychological, social and spiritual shifts / contexts.
The concept of 'motherhood' becomes a genuine existential question after pregnancy loss.
Am I a mother if my baby isn't here?
Am I a real mother?
I feel like a mother...but does anyone else see me as one?
What will I say if someone asks if I have children?
Pretty confronting stuff.
The mothers of babies who have died are as unseen as their babies.
This wonderful article about Matrescence could equally apply to the concept of motherhood post-loss. As with motherhood in general, the experience of pregnancy loss is a redefining transition for a women biologically, psychologically, socially and spiritually. I invite you to read it and think about how this applies to your own experience of pregnancy loss, or that of someone you know. And how we as a society really need to better acknowledge, support and understand what pregnancy loss looks like, and reframe & readjust the boundaries of motherhood.
🌸 💫 💞
*Note: forgive the terminology of 'loss'. I hate expressions like 'losing' or having 'lost' your baby. I remember taking huge offence to these terms - I wouldn't be so careless to LOSE my child! Until I can think of a better expression, I humbly ask you to forgive my use of 'loss' x
If you have any questions about your fertility or pregnancy loss, make an appointment with Jacintha to discuss.
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Additional references
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