Making Sense Of Miscarriage

By Naturopath Kasey Willson

^{>> Resource for recommended testing post pregnancy loss found here <<}

^{Mentioned throughout episode:}

^{>> The Glutathione product I use for smoothing fine lines & wrinkles, is found here} 

^{>> The preconception health guide, Path To Conscious Conception}

Now a distant memory, I think back to the moment we discovered the two pink lines on the pregnancy test. I had waited all week for hubby to arrive home from working away so we could find out if this was ‘our time’. The nervous wait was replaced with joy when we discovered a positive reading. We were over the moon to be become parents to another little soul.

Fast forward to eleven weeks gestation, past the dreaded nausea, daily napping and ultra-sensitive nose. I had just started experiencing relief of my symptoms and we’d begun our camping adventure along the Gibb River Road from Darwin, to Broome. There was so much to be grateful for being out in nature, amongst the warming sunshine and spending quality time with good friends. We had just started sharing our exciting news with loved ones, so what happened next hit us for six.

We reached the NT & WA border and it was time for a toilet stop. Instead, what I discovered was the shocking first indications of a possible miscarriage. Staying positive, we gave it time and hoped for the best, but after each bathroom check-in, the symptoms became clearer and our concern grew.

We made the decision to turn around the next morning and head into the Karratha hospital. After nervously waiting for our names to be called, the heartbreaking news was shortly after confirmed- our precious baby was no longer with us. My heart sank as we both entered a space of shock.

The next few days were a blend of heightened emotions – trying to enjoy our time with loved ones in such a picturesque part of the world, mixed with absolute devastation, sadness and brief moments of anger . “Why us?!”

As I started to open up with friends and family about our loss, I soon became aware just how prevalent miscarriage is. I remember thinking at the time that this shouldn’t be such a taboo conversation and I still believe that more talk (sharing of experiences), education around miscarriage prevention and support post miscarriage is needed. If you have been through pregnancy loss, you may be comforted to know that you are certainly not alone.

After returning from our trip and getting the physical all-clear from my integrative GP, we consciously decided to take twelve months to focus on ourselves before trying again. In this time we did some detective work with testing to determine any imbalances, allow space for us both to emotionally heal and the time to follow specific dietary, lifestyle and supplementation phases, designed to detoxify and nourish our bodies, prior to trying again.

Miscarriage Stats

Did you know that 70% of conceptions fail prior to live birth? In most cases, these go unnoticed as the loss occurs prior to implantation or the missed period.¹ Out of confirmed pregnancies in Australia, up to 1 in 4 will end in miscarriage, before 20 weeks.

For affecting so many couples, miscarriage is just not spoken about enough.

Society teaches us to be hush about early pregnancy, so as an expecting mum you may go through the first trimester feeling confused about what is normal, suffering through morning sickness in silence and struggling with the ever-changing lifestyle adjustments a mum-to-be is advised to make.

There is often a constant worry and anxiety around the safety of the baby, especially in the event of past complications and in the devastating event of a pregnancy loss, the mum and dad are often left to suffer alone. Instead, I believe this is a time we should be sharing our joyous news, our fears and losses with close loved ones we trust, as being strong and suffering alone does not serve anyone.

Here my aim is to open up the conversation about pregnancy loss, and if you’ve been asking “why us”, I will talk through some potential causes of miscarriage and guidance of where to from here.

Types Of Miscarriage 

A miscarriage is the loss of a pregnancy before 20 weeks of gestation and includes post implantation failures in natural conception, also known as spontaneous miscarriage. This type of miscarriage effects 12-15% of pregnancies, with 30% occurring between implantation and the 6^th week of gestation.^2,3

Another type is a biochemical miscarriage, which shows a confirmed pregnancy through an increased reading of HCG hormone, but doesn’t progress further, either before or shortly after implantation. So you may have shown a positive pregnancy test reading but would then experience a bleed around the time of the expected period.  50-75% of all miscarriages are biochemical.⁴ 

Early miscarriage is a pregnancy loss that occurs in the first trimester, before 12 weeks gestation and a late miscarriage occurs in the second trimester, between 12-20 weeks gestation. Recurrent miscarriage affects 1% of couples trying for a baby and is when a couple miscarry for three or more consecutive pregnancies.⁵

All are incredibly heartbreaking for both parents and are physically and emotionally stressful events.

If you have been affected by pregnancy loss, or still birth, I am sending you the biggest of hugs right now. No matter what stage of your pregnancy, losing another soul is nothing short of devastating. As I talk on this subject, you may feel triggered by past events in your life and I encourage you to reach out to a close friend, family member or support line to encourage healing and closure. From a Mumma who has been through pregnancy loss, I know this helped me.

The good news is that the chances of a healthy pregnancy are high. Leah Hetchman explains in her text Advanced Clinical Naturopathic Medicine...

“Most women who have experienced miscarriage will more than likely go on to have a healthy pregnancy in the future. The prognosis is good. The predicted success rate, often confirmed in cohort trials, is 70% despite 2 or 3 prior losses.”⁴

So what are the risk factors for miscarriage?

Risk Factors Of Miscarriage

• Being early in the first trimester is a main risk factor. And this declines between 6-10 weeks gestation, in pregnancies with a confirmed heart beat.⁶ Miscarriage risk has shown through a large prospective study of 4070 pregnant women, to be 4-5% by week 6; 2.5% by week 7 dropping to 2% up until week 13 and decreased to less than 1% by 14 weeks gestation.⁷ 
• Maternal age over 35 years also increases the risk of miscarriage. If you are over 40 years the risk remains high even after 12 weeks gestation.
• Drinking alcohol⁴
• Smoking⁴
• Obesity can interfere with fertility, yet once pregnant, insulin resistance becomes more pronounced impacting the developing foetus, and causing higher rates of miscarriage, hypertension, gestational diabetes mellitus (GDM), preeclampsia and caesarean births.⁵

Causes of Miscarriage¹,² 

• Uterine anatomical abnormalities, causing issues with the formation of the placenta. This can be picked up on an ultrasound.
• During pregnancy the health and structure of the cervix is crucial for a pregnancy to develop and cervical insufficiency can also lead to miscarriage.

Genetics

• Chromosomal abnormalities accounts for 50% of clinically recognised miscarriages.⁸ Other genetic causes of miscarriage include karyotyping abnormalities and the MTHFR polymorphisms, which can lead to methylation defects.
• Heritable thrombophilia: Inherited maternal hypercoagulable states, including Prothrombin, Factor V leiden and MTHFR are associated with fetal losses in the second trimester. Association between inherited thrombophilias and early miscarriage is less evident.
• Research also indicates association between paternal Factor V Leiden and Prothrombin gene mutation, with pregnancy loss in their partner.⁵
• The MTHFR enzyme plays a key role in reproductive health and is required for the metabolism of folic acid into its active form. Variations in the gene that enable your body to produce the MTHFR enzyme (which up to 60% of the population have), have been associated with impaired fertility outcomes. It is for this reason, over the counter folic acid is not recommended for every woman pre and during pregnancy. Quality activated forms under the guidance of a functional health practitioner is recommended in order to utilise folate where it is needed for the health and development of your baby.

Immune

• Autoimmunity, including Hashimotos thyroiditis and diabetes mellitus.
• An autoimmune condition named Antiphospholipid Syndrome, which can follow a previous infection including Syphilis, Lyme disease, Epstein-Barr virus, Cytomegalovirus, HIV or hepatitis C virus,³ is a proven type of thrombophilia associated with adverse pregnancy outcomes.⁹ The antiphospholipid antibodies (aPLs) that are produced as a result, cause an issue with coagulation.
• Infections associated with miscarriage and stillbirths include: Cytomegalovirus, Chlamydia Trachomatis, Variola, Mycoplasma hominis, Listeria, Salmonella typhi, Vibrio fetus, Gardnerella vaginalis, Malaria, Parvovirus B19, Varicella (chicken pox).¹¹ Also Rubella, Uroplasma and Bacterial Vaginosis. 
• Alloimmune mediated miscarriages is where the mother’s immune system recognises the developing embryo and fetus as a threat and therefore rejected by her body. This happens when the couple has similar human leukocyte antigen (HLA), and the mother’s immune system recognises this as a threat, leading to issues with implantation or rejection of the developing embryo or fetus.
• Abnormal Natural killer (NK) cells (both peripheral and uterine) have been associated with miscarriage. Regular BPA exposure has been associated with natural killer cell activity.

Endocrine Imbalances

The following hormone disorders are implicated in approximately 17-20% of miscarriages, including recurrent miscarriage:

• 40% of women who experience recurrent miscarriages have Polycystic Ovarian Syndrome (PCOS)³
• High luteinising hormone production. Hypersecretion of LH (with or without a PCOS diagnosis), increases the risk of miscarriage.³
• A luteal phase defect, results from inadequate progesterone production by the corpus luteum and causes issues in the preparation of the endometrium for placenta development. If the fertilised egg is implanted into an environment, where it can’t thrive, miscarriage will occur. The luteal phase is the time from ovulation to your period and we want it optimally > 12 days, so if you’re tracking your cycle you will be aware of this as an issue prior to conceiving. Head back to episode 1 for more on this.

Along with being necessary for healthy ovulation, luteal phase, adequate progesterone production is required for an immune protective action such as inhibiting cell-mediated cytotoxicity and NK cells. It also plays a role in shifting proinflammatory Th-1 cytokines responses, to ani-inflammatory Th-2 responses.³

• A state of hyperprolactinaemia, where there is abnormally high circulating levels of the hormone prolactin with no apparent cause. The function of the ovaries is impacted by high prolactin and can contribute to a luteal phase defect and therefore miscarriage.¹²
• Insulin resistance (in PCOS patients and also independent of this syndrome), is a major cause of recurrent pregnancy loss, particularly of spontaneous miscarriage in naturally conceived pregnancies.^2,13 
• Poorly controlled diabetes mellitus also increases the chances of pregnancy loss.⁴ 
• Obesity is also a contributing factor for a higher miscarriage rate, with risk factor of 12-15% in women with a normal BMI (under 37 years), up to 31% in women with a BMI >35kg/m². For obese women, the rate of recurrent miscarriage also increases by four fold.¹⁴
• Thyroid issues contributing to miscarriage include hypothyroidism, Hashimotos thyroiditis, hyperthyroidism and Graves Disease.²
• Because of the close connection of adrenals with thyroid, adrenal stress / fatigue can be a contributing factor, yet likely won’t be recognised by your GP. Another reason to de-stress.
• In her book 'Natural Fertility' Franchesca Naish explains that there is also a higher incidence of stillbirths, miscarriages and congenital abnormalities in children conceived within a month of coming off of the pill. For this reason, allow at least 6 months break. 

Nutrition 

Vitamin A deficiency can lead to issues falling pregnant, but also miscarriage. It plays an important role in supporting your overall reproductive health, particularly for the health of both Mum and dad-to-be's sex organs, healthy hormone conversion (cholesterol to testosterone in the men and cholesterol to oestrogen in women) and is needed for healthy mucous membranes.¹⁵

Back in episode 1 I spoke about microscopic hairs along the fallopian tube lining which move an egg along the Fallopian tube and into the womb. Well these little guys need vitamin A to be healthy and do their bit to support a healthy conception.

After a miscarriage, Vitamin A (along with Vitamin E) are important for womb recovery.

You can find preformed vitamin A for superior absorption in foods such as cod liver oil, liver (get my liver pat recipe here), eggs and salmon roe. Vitamin E is rich in foods such as almonds, egg yolks, beef, hazelnuts and sesame seeds.

As I mentioned in episode 4, throughout pregnancy, sufficient maternal vitamin D levels have also shown to prevent miscarriage risks. In a study of 1,684 pregnant women, a twofold increase in miscarriage rates were shown during the first trimester in the women who were deficient in vitamin D (<50nmol/L).¹⁶

Other nutritional deficiencies that could impact egg, sperm and /or baby health and contribute to a miscarriage, include: Vitamin C, E, all B vitamins, especially Folate, B6 and B12; minerals Zinc, Magnesium, Manganese, Calcium, Selenium, Iron, Chromium, Copper, Iodine and Essential fats, omega 3 and 6. 

Pregnancy Spacing

Also discussed by Francesca Naish in her book 'Natural Fertility', the space of your pregnancies (between 2-3 years) can also play a role in preventing nutritional deficiencies, neural tube defects and the risk of miscarriage. This spacing also allows for adequate vitamin A replenishment, before your next conception.

Environmental Causes

“...links between sporadic and/or recurrent pregnancy loss and occupational and environmental exposures to organic solvents, medications, ionising radiation and toxins have been suggested, although the studies performed are difficult to draw strong conclusions from because they tend to be retrospective and confounded by alternative or additional environmental exposures.” Leah Hetchman 

Some examples that have the potential to impact your egg, sperm and pregnancy health outcomes, include:

• X-ray irradiation^2,4
• Chemotherapy drugs^2,4
• Other examples of both ionising, non-ionising radiation and electromagnetic fields can negatively impact reproductive health, contribute to a reduction in viable sperm, eggs, effect embryonic development and is linked to DNA fragmentation.¹⁶ Think regular use and storage of mobile phones near your body, flying and constant exposure to wi-fi. More info on that here. 
• Alcohol- the risk increasing with more than 3 drinks per week and during the first trimester. Or more than 5 drinks per week throughout the whole pregnancy.^2,4
• Nicotine has vasodilation effects that can reduce uterine and placental flow, therefore smoking is added to this list.
• Caffeine over 200mg per day.¹⁷
• Chemical exposure to anaesthetic gases, arsenic, aniline dyes, benzene, solvents, ethylene oxide, formaldehyde (which is an ingredient in some vaccines),¹⁸ herbicides and pesticides in agricultural areas and through conventionally farmed foods.¹⁹ 

As discussed across at gmwatch.org:

"People living in an Argentine town in the heart of the GM soy and maize growing area suffer miscarriages at three times and birth defects at twice the national average rate, a new study shows. In addition, the study found a correlation between a high environmental exposure to glyphosate and an increased frequency of reproductive disorders (miscarriage and birth defects)."

Head back to episode 5 for more information on the topic of the herbicide glyphosate.

• Exposure to heavy metals, such as lead, mercury and cadmium. They have shown to correlate with immune changes, such as increased NK cells and hormone changes,^{20, 21} which both as we’ve previously discussed can play a role in miscarriages.  These heavy metals can be exposed to a pregnant woman through foods, water, medications, vaccinations, amalgum fillings and personal care products. First and second-hand smoking is one source of cadmium. Excess copper can also be problematic for pregnancy health- exposure common through the use of the Copper IUD prior to conceiving. 

Male Factors

The fellas are also included within the investigation overhaul when it comes to detecting contributing factors to pregnancy loss. Along with a normal semen analysis, a Sperm Chromatin Structure Assay (SCSA) is recommended to determine the percentage of sperm with fragmented DNA (damaged sperm) and altered proteins in sperm cells. (54) This test therefore indicates issues with the sperm that lessen the chances of a successful embryo implantation and a pregnancy progressing full-term, either naturally or through IVF.  

Issues here can show up with the DNA damage of sperm, even if healthy parameters  have shown through a semen analysis, so its recommended to have both tests performed.

One study of couples experiencing recurrent miscarriages showed that 30% of the men, had sperm with high DNA fragmentation.²²  In this case the sperm may fertilise an egg, but further embryo development ceases prior to implantation. It may otherwise progress to a pregnancy but have a higher risk of miscarriage. The egg does have some ability to repair this damage, however over 30% DNA fragmentation is problematic.

Chemical and toxin exposure, heat (fever, excessive sitting, tight pants are some examples), infection, age, smoking, testicular cancer, radiation exposure and anything else that causes excessive oxidative stress and free radical levels in sperm, can cause DNA fragmentation. Alcohol, excessive caffeine, sugar intake, food sources of trans fats, all increase inflammation and oxidative stress.

Recommended Testing

As a cause can be identified in 50-60% of recurrent miscarriages, so thorough investigation is recommended to cover both maternal and paternal factors.³ This can provide you with important emotional support, and prevent you continually wondering why the loss occurred. More importantly, a road ahead to overcome any imbalances that show and set yourselves up for a healthy conception, when the time is right again.

I have included the full comprehensive list of tests in a download to take with you to your appointment with your health care providers. You can access it over here. Your GP will likely only want to do limited testing, unless you have experienced 2-3 miscarriages. In this case, I would seek the support of an Integrative GP, together with your Naturopath, Nutritionist or other functional medicine practitioner for additional natural medicine treatment options.

Here are some recommendations:

• See your GP for a screen for previous infection of those listed, along with a high vaginal swab for Bacterial Vaginosis, Uroplasma and Mycoplasma infections.
• If you hadn’t had this test performed prior to conception, a sperm analysis test will be helpful to determine any sperm health weaknesses
• Heavy metal testing, through a whole cell elements test, or hair tissue mineral analysis will rule out if heavy metals exposure and accumulation is a contributing factor for your pregnancy loss
• Antibodies for autoimmunity, such as ANA, thyroid antibodies (thyroid antibodies despite a normal TSH reading
• Thyroid function: TSH, T4, T3, RT3 (a TSH above 2.5 is showing to be outside the optimal range and contributes to more pregnancy loss)⁴
• Iron Studies
• Progesterone levels, once you’re cycling again test day 21 progesterone, along with LH and prolactin
• Cycle charting, to determine luteal phase length
• Investigation for the autoimmune condition of Antiphospholipid syndrome should be investigated, especially with recurrent miscarriages.
• MTHFR enzyme gene variant, to determine if you have a variant of either copies: C677T and/or A1298C and the importance of activated folate forms for you.

Healing 

First step is to share your struggles, with those nearest to you or that you trust. If you know others who have experienced pregnancy loss, reach out for a chat with them to share experiences. Talking about your loss can play a big role in your healing journey. If you feel it is needed, also seek support from a professional therapist, councillor, psychologist, hypnotherapist, or other holistic healers that resonate with you.

Herbal and nutrition medicine alongside emotional support, plays a powerful role in the recovery and healing post pregnancy loss. Once you’ve had testing, this can be very specific and effective for your individual needs.

Taking the time preconception to test and balance you hormones, promote a healthy weight range and stress levels, with nutritional and herbal medicine, healthy movement and mindset, all plays an important role in minimising pregnancy loss outcomes.

The Road Ahead 

If you’ve been through pregnancy loss, or have fears around your current pregnancy, be comforted to know you are not alone. Reach out for support and open up the pregnancy loss conversation- whether it’s through a friend, family member, someone you know who has been through the same heartbreak and/ or seek professional help for your healing journey. You don’t have to do this alone.

Be there for one another and check in regularly to see how your partner is. I personally found my emotions would cycle through waves of sadness, emptiness and anger. When I felt ok, my husband was feeling low so we were there for each other. Also utilise natural medicine to ease stress levels, enhance healing and prevent infection. 

Download the 'Recommended Testing Post Pregnancy Loss' resource and head to your GP to ask for thorough testing and gain referrals where needed for extra testing, work with a functional medicine practitioner to gain testing your GP won’t perform and utilise herbal and nutritional medicine through foods and supplements to build yourselves back up and replenish your fertility health nutrients. 

Further guidance on preconception nutrition is found in my Glowing Mumma Preconception Guide.

Lastly, don’t rush. Although your ovulation may return again from 10 days (up to 104 days) post miscarriage, take your time as a couple to be emotionally, mentally and physically ready before trying to conceive again. 

^References   

^{See links throughout}

^{4) Simpson J, Carson S. Genetic and causes of pregnancy loss. Glob Libr Women's Med 2013;3(3)}

^{9)  McNamee K, Dawood F, Farquharson R. Recurrent miscarriage and thrombophilia: an update. Curr Opin Obstet Gynecol 2012;24(4):229-34.}

^{13) Li ZL, Xiang HF, Cheng. LH et al. Association between recurrent miscarriages and insulin resistance: a meta analysis . Zhonghua Fu Can Ke Za Zhi 2012;47(12):915-19}

^{14) Hechtman L. Clinical naturopathic medicine. Chatswood, NSW. Elsevier Health Sciences; 2013}