What To Do After a Miscarriage
Seeing those two pink lines can be one of the most exciting moments in your life. Unfortunately, for 10-30% of women, those two pink lines can lead to one of the most traumatic moments in their life.
Miscarriage, otherwise known as spontaneous abortion, is generally defined as a pregnancy lost occurring up to 20 weeks into your pregnancy. For some the lost is sudden and occurs within days of a positive pregnancy test, whereas for others, it may happen weeks after hearing that strong heartbeat. No matter when you experience a miscarriage, the loss is still the same. Total devastation. Many of the early symptoms of a miscarriage can also be seen in a full-term pregnancy, light vaginal bleeding and cramping. However, unlike a full term pregnancy, these symptoms often persist and worsen.
Some of the most common risk factors associated with a miscarriage include increased maternal age, prior medical conditions (diabetes, thyroid disease), certain medication and/or substance use as well as environmental exposures.
Although we may have thought that advanced maternal age would start between 40-45 years ago, the reality is researchers have found that advanced maternal age actually begins at 35 years ago. In fact, researchers have found the most significant risk factor for miscarriages is maternal age due to its strong association with fetal chromosomal abnormalities. This does not mean that if you are over 35 years old, you will never have a successful pregnancy. It does however mean there are more risks associated with getting pregnant after 35 and of the 10-30% of pregnancies seen to end in miscarriages, more of them will be seen in patients over 35 years old. Now before you think there is nothing you can do to reduce your risk of miscarriages because you are 35 years old, I encourage you continue reading because there are absolutely things we should be doing to reduce your risk of experiencing another miscarriage and important proactive measure, we at NMD Wellness of Scottsdale, believe have helped our patients reduce their risk of a miscarriage. Age is not something we can control and genetic abnormalities will happen and this does account for a large portion of miscarriage, however, there are a few important steps we should be taking before assuming a miscarriage was just caused by a genetic abnormality and maternal age.
Prior Pregnancy Loss
It appears that prior pregnancy loss increases the risk of subsequent pregnancy loss and interestingly enough appears to be independent of maternal age. Prospective cohort studies have also found that patients who experienced pregnancy loss were more likely to have a mother who also had a history of pregnancy loss. This suggests there is a potentially inheritable component to miscarriage. This is also the reason we review a detailed personal and family history when evaluating anyone who would like to conceive, whether they have experienced a miscarriage or not. For patients who have a family history of miscarriages, we may order additional genetic testing, monitor early pregnancies more closely and provide additional support and coordination with their OBGYNs. At NMD Wellness of Scottsdale, we believe preconception counseling and care should be provided to all patients desiring to start/add to their family, not only those that have experienced a loss or are struggling to conceive.
Studies have found a variety of maternal comorbidities associated with pregnancy loss including endocrine disorders, cardiovascular disease as well as metabolic disorders, many of which are considered as modifiable risk factors. Modifiable risk factors are health conditions that can be managed or reversed and can reduce the risk of pregnancy loss. At NMD Wellness of Scottsdale, this is where detailed intakes and visits allows us to evaluate and monitor for modifiable risk factors.
The effects of type 1 and type 2 diabetes mellitus on early pregnancy can be extreme and can lead to pregnancy loss. This is why all of our preconception patients will undergo testing including, but not limited to, fasting glucose, hemoglobin A1C and fasting insulin. Evaluating all three biomarkers provides us more information on how to manage and maintain your sugar levels. This is particularly important in patients with Polycystic Ovarian Syndrome (PCOS) who are more predisposed to experience insulin resistance and Type II diabetes. If you have PCOS, making sure to evaluate all three biomarkers, at least annually, can help us make modifiable changes prior to your next pregnancy. If you have experienced gestational diabetes in a previous pregnancy, we also will need to make sure to address all three biomarkers. Unfortunately, although a fasting glucose is usually part of your annual screening with your PCP or OBGYN, a hemoglobin A1C and fasting insulin are usually not. This is important to know because if your doctor says “everything looks normal” but didn’t order a fasting insulin or hemoglobin A1C, you are only getting a part of the puzzle. I also encourage you to ask for the cash-pay price, if you doctor says that your insurance company won’t cover these types of “additional tests”. You may be shocked at the cash-pay price. For example, in our clinic, we have been able to negotiate dramatic price options for our cash-pay labs to the point that a hemoglobin A1c is $8.00 and a fasting insulin is $10.00! Knowing your options is important.
This is a topic we have to discuss. A 2008 meta-analysis of 16 different studies demonstrated that a BMI greater than 25 was associated with nearly a 70% increase risk of experiencing a miscarriage. Unfortunately, if you are struggling with your weight, a doctor telling you “eat less, exercise more”, is far from helpful. At NMD Wellness of Scottsdale, we know that calories in and calories out is NOT the answer and it is important that we tackle mindset, food relationships, education and accountability in order to help our patients get the success they need. We also know that many women desperate to lose weight will often skip meals or begin dangerous food behaviors that can impact their hormones and interfere with their menstrual cycle, making it even harder to get pregnant. We also know for women with PCOS, that weight loss can be an uphill battle especially if they also experience insulin resistance or are prediabetic/diabetic. Addressing weight management must have multi-factorial approach.
Both hyper (high thyroid function) and hypo (low thyroid function) have been associated with an increased risk of pregnancy loss. One study even indicated that uncontrolled thyroid disease could double your risk of experiencing a miscarriage. Evaluating your thyroid function before as well as after a miscarriage is extremely important. Since your baby does not have a fully developed thyroid in the first trimester of pregnancy, your thyroid often has to compensate for that which can lead to thyroid dysfunction shortly after experiencing a miscarriage. Evaluating your thyroid should include Thyroid stimulating hormone (TSH), Free T3, Free T4 as well as thyroid antibodies. Some women will experience “normal” TSH levels with extremely elevated thyroid antibodies which may be impacting their ability to have a successful pregnancy.
Stress is definitely multi-factorial and can be difficulty to separate from other risk factors, however chronic stress (like that seen with modern life, a stress job, a sedentary life or experiencing a miscarriage), leads to an increase in our stress hormone, cortisol. This risk in cortisol can decrease your immune function and may make us more susceptible to infections and other maternal conditions, risking the risk of pregnancy loss.
Although pregnancy with an IUD in place is relatively rare, patients who choose to continue their pregnancies, the risk of pregnancy loss appears to be higher in women who choose to have the IUD removed vs. those that elect to leave the IUD in place.
During pregnancy, iron requirements increase in order to support both maternal blood supply and fetal and placental growth and development. Without adequate iron supply, this increases the risk of pregnancy loss. This is particular important because many women who have experienced a history of heavy periods (menorrhagia) or other bleeding related disorders, may not know they are iron deficiency, even if they have regular labs drawn with their PCP or OBGYN. A routine CBC is ordered annually to evaluate for anemia (low red blood cell count), however it is not always routine to order an iron and ferritin (storage form of iron). If you experience unexplained fatigue, hair thinning, decreased tolerance for exercise, irritability or depression, evaluating not only your thyroid is recommended. Again, ask for the cash-pay pricing options as an iron panel (including Iron, Ferritin and TIBC) can be as low as $12.00!
It Takes Two to Tango
Don’t forget that your partner's health matters too. I know society puts additional pressure on women to have and maintain a healthy pregnancy, however your partner's health is important as well. According to a retrospective cohort study of an insurance database covering 958,804 pregnancies in the United States, compared with men with no components of metabolic syndrome, there was an increase in pregnancy loss associated with men who had at least 1 risk factor for metabolic disease. Again, there is limited data on paternal health on miscarriage rate partially because there is often less follow up and monitoring done on men during preconception and pregnancy.
Some drugs are known teratogens. Teratogens are substances that can cause abnormalities or birth defects in a developing fetus. Some of the most common teratogens include acne medication isotretinoin (Accutane, Retin-A), androgens (like testosterone),tetracycline antibiotics (Achromycin) and doxycycline (Vibramycin) and streptomycin.
There are also certain medications, like NSAIDs, that although they are not considered teratogenic, they may interfere with pregnancy. This is a rather complicated scenario because of the nature of NSAIDs and their risk of pregnancy loss because nonsteroidal anti-inflammatory drugs (NSAIDS) like aspirin and indomethacin are commonly used for obstetric conditions including preeclampsia prevention and treatment of acute preterm labor, however other NSAID, including ibuprofen and diclofenac, may increase the risk of pregnancy and should be avoided for most patients.
Exposure to toxins and pollutants has long been associated with the increase of pregnancy loss due to the fact that it can cause cell death, altering growth of normal tissues and can interfere with normal cellular differentiation important for fetal development. Exposure to ionizing radiation is definitely associated with pregnancy loss however excessive exposure to lead, arsenic and certain air pollutants have also been associated with an increased risk. Endocrine disrupting chemicals known as EDC, have been found to affect a variety of factors associated with fertility including affecting sperm, egg and embryo quality. Some of the most common endocrine disrupting chemicals include:
DDT, Chlorpyrifos, Atrazine, 2, 4-D, Glyphosate (Used in: Pesticides)
Lead, Phthalates, Cadmium (Used in: Children’s Products/Toys, Cosmetics and Fragrances)
Polychlorinated biphenyls (PCBs) and Dioxins (Used in: Industrial Solvents or Lubricants and their Byproducts)
Bisphenol A (BPA), Phthalates, Phenol (Used in: Plastics and Food Storage Materials)
Parabens, UV filters (Used in: Cosmetics, sunscreens)
Triclosan (Used in: Antibacterial soaps, Colgate Total)
Perfluorocheicals (Used in: Textiles, Clothes, Non-stick food wrappers, Microwave Popcorn bags, old Teflon cookware)
About the Author: Meet Dr. ZenAlissia Zenhausern- Pfeiffer, NMD, FABNE, (commonly known by her patients as Dr. Zen), is a licensed naturopathic doctor board certified in naturopathic endocrinology and the founder of NMD Wellness of Scottsdale, a premier naturopathic medical practice that focuses on helping women to take a proactive approach to their hormone and fertility health. Dr. Zen has been featured as a lead expert in Forbes, Shape Magazine, and Instyle and is deeply passionate about bridging the gap between traditional and natural medicine in the world of fertility. She works with a variety of hormone related issues including PCOS, endometriosis and unexplained infertility. Her goal is to help more women get back into the driver’s seat of their own health to make lasting transformational changes to their health to bring more cute and adorable babies into this world. Read More About Dr. Zen...