Miscarriage and Pregnancy Loss with Dr. Swapna Kollikonda

Podcast Transcript

Cassandra Holloway:

My name is Cassandra Holloway, and I'll be your host for this episode. Today, we're discussing the once taboo topic of miscarriage. We're joined by OB-GYN, Dr. Swapna Kollikonda. Thanks for being here, and welcome to the podcast.

              Miscarriages are scary to think about, especially if you're trying to conceive or if you're already pregnant. But we also know that miscarriages are common, affecting nearly one in three pregnancies. Yet there is a lot of blame, guilt and questions when it comes to this sensitive topic. Our goal of this episode is to provide our listeners with the information about how miscarriages occur, the warning signs to watch for, and who is most at risk.

              Before we dive into this full episode, we just want to take one moment and remind listeners that this is for informational purposes only, and is not intended to replace your own doctor's advice.

              Dr. Kollikonda, I want to first start off by asking if you'll tell us a little bit about your practice at Cleveland Clinic, and the types of patients that you see.

Dr. Swapna Kollikonda:

I'm a general obstetrician and gynecologist. I see pregnant patients and related problems. And I also see patients who have gynecological problems, and I perform surgeries related to obstetrics and gynecology.

Cassandra Holloway:

So I want to dive right into our topic here. What exactly is a miscarriage? What's happening when someone experiences this?

Dr. Swapna Kollikonda:

Any pregnancy loss before 20 weeks is called a miscarriage. And having said that, the miscarriages are more common before 13 weeks of pregnancy, which we call them as early pregnancy loss. And they account for 80% of the miscarriages of the documented overall 10% of pregnancies. And only 5% of miscarriages happen in later part of the pregnancy, that's between 13 weeks and 20 weeks of pregnancy. So not necessarily every woman, when they have a miscarriage, they'll experience symptoms. Half of them, they do not experience any symptoms. Half of them experience symptoms such as vaginal bleeding, or lower abdominal cramps, or back pain.

Cassandra Holloway:

Does your body react the same way as having a miscarriage, you said before 13 weeks or having it after 20 weeks? Is it all the same symptoms that you were mentioning?

Dr. Swapna Kollikonda:

After 20 weeks, most of the pregnant patients stop feeling the baby movements, and a lot of pregnancy systemic changes happen in the body. And as well as by the time, they have got all the preliminary genetic testing, ultrasounds, reassuring them that the pregnancy is going normal. So they build a lot of emotional bonding, and it's psychologically and physically hard for them to take it or to cope with that after 20 weeks.

              Before 20 weeks, they do not experience the baby movements and not much changes happen. So the impact is slightly less. But again, any pregnancy loss is a huge emotional, personal loss.

Cassandra Holloway:

Can you talk a little bit about the psychological effects of having a miscarriage? How do you treat the emotional side of it?

Dr. Swapna Kollikonda:

Miscarriage is a huge personal loss, and it is not very well spoken out, and they tend not to grieve with the family members or with the close friends. It's very common for them to feel guilt, sadness and anxious, and feeling jealous of when they see pregnant patients or patients who have babies. It's very common. They have to reach out to family and they have to talk to the close friends. If they are going into extreme depressive symptoms, then they have to reach out to the doctors. Some women tend to grieve this process with other women who are going through the miscarriage, then they can connect to the support groups.

Cassandra Holloway:

Yeah. I think finding that support in a support group, like you mentioned. Would you also recommend maybe speaking to a therapist, to work through that loss as well?

Dr. Swapna Kollikonda:

Yeah, if the symptoms are extreme, leading to depression, then we do offer them counseling sessions. Depending upon how the couple is taking it, we also offer them the counseling sessions.

Cassandra Holloway:

You always hear about pregnant patients who are pregnant, getting to that, quote, safe zone. I think it's when you reach the second trimester. Is there any truth to that?

Dr. Swapna Kollikonda:

Generally, we say that when we see the baby's heart booms by week seven, the rate of miscarriage goes down to five to 10%, and that's the first safe zone. After 13 weeks, the rate of miscarriage is five in 100. So it's again, it's very rare after 13 weeks.

Cassandra Holloway:

What about you hear people going in for their week 17, monthly, normal appointment, and they find out that the baby doesn't have a heartbeat anymore, or maybe the baby stopped growing two weeks ago, how common is that type of miscarriage?

Dr. Swapna Kollikonda:

It is not that common. As I said, it happens only in five in 100. Yes, it is very hard, because they have gone through the pregnancy changes already, and it's going to hit them hard.

Cassandra Holloway:

I want to talk a little bit about some of the causes of a miscarriage. What are some of those reasons that this would happen to a woman?

Dr. Swapna Kollikonda:

There are many causes, but the most important is the genetic causes, which are the chromosomal abnormalities, what we call. Usually, the egg contributes 23 chromosomes and the sperms contribute 23 chromosomes. And if there is any misplacement, decrease or increase in the number of the chromosomes, that can result in miscarriage. Or any imbalance in the chromosomes, even though the number is normal, then also the miscarriage can happen.

              And there are other causes of miscarriage, such as infections. To name a few, toxoplasma, cytomegalovirus, listeria, parvovirus, and history of any fibroids, or any abnormal shape of the uterus. Or any uncontrolled medical problems, such as thyroid problems, hypertension, and diabetes. And sometimes blood disorders or lupus. These are some of the most common causes of miscarriage.

Cassandra Holloway:

What about trauma to the stomach area, or lifting something heavy, or even like a strenuous workout? Does that typically cause a miscarriage, or not so much?

Dr. Swapna Kollikonda:

It's unlikely with the exercise or any strenuous exercise for a miscarriage to happen. But if the strenuous exercise lead to any huge trauma, especially in the later part of the pregnancy, it can cause separation of the placenta and can lead to miscarriage. And the low impact traumas are very rare to lead to miscarriages. The high impact trauma, such as motor vehicle accidents, can cause miscarriage, can lead to miscarriage, especially in the later part of the pregnancy.

Cassandra Holloway:

You always hear about pregnant women having to limit their caffeine intake, along with obviously alcohol. But I'm wondering if the reason why you have to limit caffeine, does that play into effect with a miscarriage, or how does caffeine affect your pregnancy in that aspect?

Dr. Swapna Kollikonda:

Anything in excess is not good, so caffeine, smoking, alcohol. They do not have the direct relationship with miscarriage, but we tend to restrict caffeine at least 200 milligrams per day, which is equivalent to two cups of coffee a day. And the same thing with alcohol too, limited alcohol. Most of the time, we tell them not to have any alcohol, and patients are aware of not doing that. And smoking, either in a personal history of smoking or a secondhand smoking, we tell them to avoid.

Cassandra Holloway:

What about hot tubs and saunas? I know pregnant women should be aware of increasing their internal temperature. Should we avoid hot tubs and being in hot environments when we are pregnant?

Dr. Swapna Kollikonda:

There is no direct scientific evidence to say that this can lead to miscarriage. A few things can happen if you are regularly exposed to hot tubs, especially the sauna, hot saunas. It can lead to a spinal cord defect, neurological defects such as spina bifida. And the same sometimes if you're for a long time in the hot tub, you can feel your blood pressure can go down and that can affect your pregnancy.

Cassandra Holloway:

So basically, the underlying theme here, as we said, that it's genetic reasons for a miscarriage, correct?

Dr. Swapna Kollikonda:

Most of the time, 80% of the time, it's a genetic reason for the miscarriage.

Cassandra Holloway:

80%. That's right. Okay. I want to talk a little bit about whose most at risk for a miscarriage. Does the percentage ever go up and down for certain age groups? Talk to me about the risk factors involved.

Dr. Swapna Kollikonda:

Below 30 years, the risk is 20%. About 35, the risk increases. And when we hit 40 years, the risk increases by 40%. And at 45, the risk increases by 80%.

Cassandra Holloway:

Is there anything advice-wise that women listening to this podcast, who might be over that 35 threshold, or into their 40s or even 45, like you mentioned, is there anything they can do to help decrease their risk of miscarriage, even though they are a little bit older in age?

Dr. Swapna Kollikonda:

Not in particular, apart from the general measures, such as regular exercise, healthy eating, avoiding alcohol, smoking, and going through extreme stress. So these are some of the things they can try to avoid, and making sure that they take prenatal vitamins every day, which has 400 micrograms of folic acid.

Cassandra Holloway:

Speaking of prenatal vitamins, is skipping several days in a row or even a couple of weeks when you're pregnant, is that ever a culprit for having a miscarriage?

Dr. Swapna Kollikonda:

Not at all. If they eat a healthy, regular diet, most of the time, it should supplement in their diet.

Cassandra Holloway:

I want to talk about multiple miscarriages now. For someone who has suffered two, three, four miscarriages in a row, what's that red flag number that something might be wrong, or there's something wrong with their body? What could that mean, if they're suffering from multiple miscarriages like that?

Dr. Swapna Kollikonda:

Sometimes if you find a cause for the miscarriage, we can try to treat it, such as uncontrolled medical conditions. Or sometimes if they have cervical surgeries leading to short cervix, we can put a stitch around the cervix, which can prevent a miscarriage. Or if we can find that have any blood disorders, we can give aspirin or blood thinners to prevent a miscarriage to happen.

              But less than 50% of the time, we find a reason why they're having a recurrent miscarriage. We also try to do a lot of testing on them, to find out what could be the reason so that we can help them out. And more than two thirds of these patients can have a normal, healthy pregnancy after undergoing recurrent miscarriages. And the rate of miscarriage, recurrent miscarriages can happen one in 100. It's not that common.

Cassandra Holloway:

And I assume it has to do with the diagnosis of multiple miscarriages. But if someone keeps experiencing these miscarriages, does that affect them? Can they have a miscarriage and then be completely fine for multiple other pregnancies? Or does it increase the risks of keep having to have more miscarriages?

Dr. Swapna Kollikonda:

The risk of having a recurrent miscarriage is one in 100, so it's very less for them having one after the others.

Cassandra Holloway:

I want to talk a little bit more about the symptoms and warning signs. I know you had mentioned some symptoms include bleeding, and cramping, and pain in the stomach area. What are other warning signs that might signal or cue you into a miscarriage that might be happening right then and there, or might be happening in the near future?

Dr. Swapna Kollikonda:

Most of the patients do not experience any symptoms, and they do not know that they're having a miscarriage until they get an ultrasound, or they have an abnormally increasing or decreasing pregnancy hormone, which we call as hCG. And only some patients experience symptoms such as vaginal bleeding, abdominal cramping, and these are the most common ones. And some people experience back pain and abnormal vaginal discharge, but these are pretty uncommon.

Cassandra Holloway:

Wow, so it's common to not even know that you're having a miscarriage, it sounds like what you're saying.

Dr. Swapna Kollikonda:

Yes, exactly.

Cassandra Holloway:

If a woman thinks that she is, in fact, having a miscarriage, if she is having some of those more symptoms like bleeding and cramps, what should she do? Should she call her doctor? Should she go to the ER? Walk me through her next steps.

Dr. Swapna Kollikonda:

When a patient get diagnosed to have a miscarriage, if she is asymptomatic or if she has minimal symptoms of vaginal bleeding or an abdominal cramping, the best thing is to contact her doctor, so that they can walk them through the options available. But if they experience severe bleeding, changing maxi pads, two pads an hour, or severe abdominal cramping, then the best thing is to go to the emergency department.

Cassandra Holloway:

I want to talk a little bit now about the types of miscarriages. I know there is such a thing as an ectopic pregnancy. Can you talk to me a little bit about what that entails?

Dr. Swapna Kollikonda:

Ectopic pregnancy is when a fertilized sperm is attached outside the uterus and growing outside the uterus. And the most common sign for the ectopic pregnancy is in the fallopian tubes. And it can lead to a fatal disaster if it ruptures and bleeds inside the abdomen. So the ectopic pregnancy can happen in one in 50 pregnancies. And if it's not treated, as I said, it can be fatal.

Cassandra Holloway:

What are some of the symptoms that you should watch out for? And I assume it happens pretty early then, in the pregnancy, is that correct?

Dr. Swapna Kollikonda:

Yeah. It happens anywhere from four weeks of pregnancy, to 12 weeks of pregnancy. And they may not experience any symptoms, and they'll come to know that they have an ectopic when they have their first ultrasound. And they may experience a similar symptoms as other generalized miscarriages, such as abdominal cramping and the vaginal bleeding. And 15% of the patients who come with these symptoms of miscarriage to the emergency department are ectopic pregnancies.

Cassandra Holloway:

Are there any risk factors that puts you at high risk for having an ectopic pregnancy?

Dr. Swapna Kollikonda:

Patients who have a history of an ectopic pregnancy, or who conceive with an IUD in place, or who had tubal sterilization before, or any kind of tubal surgeries or any abdominal surgeries, which can lead to scar tissue around the tubes. Or age above 35 in general, a history of smoking, a history of endometriosis, pelvic inflammatory diseases, or sexually transmitted diseases are one of the main reasons for ectopic pregnancy.

Cassandra Holloway:

When someone has an ectopic pregnancy, can you ever save the pregnancy?

Dr. Swapna Kollikonda:

Unfortunately, no. The baby cannot grow outside the uterus.

Cassandra Holloway:

And I want to move to a chemical pregnancy. You often hear people talking about that. What is a chemical pregnancy, and why does that happen?

Dr. Swapna Kollikonda:

Chemical pregnancy is a very early pregnancy, which happens immediately after the embryo implants in the uterus. And it happens between four to six weeks, before we can even diagnose the pregnancy on the ultrasound. But they do have the pregnancy hormone in the blood, because the implanted embryo secretes a pregnancy hormone, which is in the blood. And that's how we diagnose it to be a chemical pregnancy. And it's very common, and 80% of the miscarriages are chemical pregnancies. And some of them, they do not recognize that they were pregnant and they miscarried it. And the only way they describe is they had a delayed period with heavy bleeding, or a heavy menstrual period. And by the time they come to see their doctors, the pregnancy test is already negative.

Cassandra Holloway:

So it sounds like it's quick and it happens earlier on, for sure, when you're in that testing phase.

Dr. Swapna Kollikonda:

Yes. It's pretty common too.

Cassandra Holloway:

I want to talk a little bit about how miscarriages are diagnosed or treated. I know we talked about if a woman is experiencing bleeding and going to her doctor, or contacting her doctor's office, if she comes in for an exam and evaluation, what tests or exams are typically done to officially say that she is going to have miscarriage, or she currently is miscarrying?

Dr. Swapna Kollikonda:

Sometimes we can diagnose them to have a miscarriage just by one ultrasound, and one pregnancy hormone level. And sometimes we may have to do multiple ultrasounds, or multiple pregnancy hormone levels to see the trend of them, and to diagnose them to have the miscarriage.

Cassandra Holloway:

You often hear about the D&C. Can you talk to me about what that is? What does it entail? And do you always need one when you have a miscarriage?

Dr. Swapna Kollikonda:

Not necessarily. When they have a miscarriage, if it's an early miscarriage, before 13 weeks, they do have options of expectant management, where we don't do anything. And we let the miscarriage happens spontaneously, but it takes long time. The success rate of it is 80%, if we can wait for two months. That's pretty long time. And we counsel them to report us, if they experience any excessive bleeding, and we provide them the pain medications.

              And the second option they have is the medical management, where we can insert the misoprostol tablets in the vagina, and to expedite the process of miscarriage. And these tablets can be repeated again within seven days, but no later than three years. And again, we counsel them to report, if they have excessive bleeding, and give them pain medications.

              If any of these managements fail, then we can give the option of the suction dilation and curettage, the surgical options. And we also give the option of suction dilation and curettage, when the patient is unstable with excessive bleeding, or having severe abdominal cramping or any signs of infection, such as fever or abnormal discharge, vaginal discharge, indicating that it could be an infectious miscarriage. Then we will offer them. And of course, patient's preferences, always. If patient prefers to have a suction D&C, they can have it.

Cassandra Holloway:

Yeah. It sounds like a really personal decision that you make alongside your healthcare provider, what you want to do. If you do want to wait it out a little bit, or if you want to go the medication route, like you were saying, or have a D&C, if that makes sense, it sounds like a very personal decision to make.

Dr. Swapna Kollikonda:

Yes. It's a personal and informed decision.

Cassandra Holloway:

You talked a little bit about the procedures for what happens during an early stage miscarriage. Can you talk about what procedures are available, or what happens when you have a later stage miscarriage, after 13 weeks?

Dr. Swapna Kollikonda:

After 13 weeks, we don't give them expectant management. They have either a medical management, or a surgical option. For the medical management, we most of the time, bring them to the labor and delivery, so that they'll get good pain relief while they're going through this miscarriage, because they experience this as a mini labor process. So we have to make sure that they're going through this process pain-free, because they're already going through a lot of psychological pain.

              And the second option is the surgical option, where we have to dilate the cervix, and we have to evacuate all the pregnancy parts and clean the uterus. That's done in the operating room. And after the procedure, we usually give them precautions not to have any sex for a couple of weeks, or not to put any tampons or anything inside the vagina for a couple of weeks, because they still experience some minimal bleeding for almost one to two weeks.

Cassandra Holloway:

How soon can you try again to get pregnant after a miscarriage? When can you start trying again?

Dr. Swapna Kollikonda:

Early miscarriages, they can get pregnant within two to four weeks. Whereas miscarriages between 13 to 20 weeks, they can get pregnant after three months. It's up to them. Every couple is different. Some couple get over with this miscarriage pretty fast, but some couple take time. So I always tell them that when they're emotionally and physically ready, then they can go ahead and try to get pregnant.

Cassandra Holloway:

Yeah. Going through a miscarriage obviously takes a toll on your body, physically, mentally, emotionally. One of the last things I wanted to ask you about today is what advice do you have for women preparing for future pregnancies, after going through this emotional and physical rollercoaster? How do they move past this experience?

Dr. Swapna Kollikonda:

This experience is always going to be there, and they always think about it, but we just have to go with the flow sometimes. And the regular exercises and a regular healthy diet, with prenatal vitamins. They have to go with the general measures. And they have to remember that a miscarriage is a random thing, and the recurrence rate of miscarriage is also only one in 100. So they should always be positive that this is going to be a normal, healthy pregnancy.

Cassandra Holloway:

But why is it important to still seek care, or reach out to your doctor if you think you're having a miscarriage, even during a global pandemic?

Dr. Swapna Kollikonda:

Pandemic is something different, but this is again, a medical emergency. So when you're having a miscarriage, first, you have to get treatment. Either it is an expected or a medical or surgical option. If it's not treated at the right time, this can lead to some complications, such as infection or heavy bleeding. At which point, you have to go to the emergency department, and where your risk of exposing to pandemic COVID infection is high.

              And also, going through a pandemic, you're already psychologically affected. And adding to that, if you're going through this process of miscarriage, that psychological impact is going to be high on you. So you have to reach out to the family doctors in order to get treated.

Cassandra Holloway:

Absolutely. Thank you, Dr. Kollikonda, for joining us and sharing all of your insight. We really appreciate you being here.

Dr. Swapna Kollikonda:

Thank you for having me here.

Cassandra Holloway:

For the latest news about women's health, or to schedule an appointment, visit clevelandclinic.org/obgyn, or call 216-444-601. Thanks for listening.