Signs of new pregnancy after miscarriage

Use of Fertility Awareness (NFP) After Early Pregnancy Loss

December, 15, 2017

by Richard Fehring, RN

Early pregnancy loss can be defined as a loss of pregnancy within the first trimester of pregnancy or 13 weeks from the last menses (American Academy of Obstetrics and Gynecology 2015). Others define early pregnancy loss (also called miscarriage or spontaneous abortion) as a loss up to 20 weeks of pregnancy (Fritz and Speroff 2016). After 20 weeks, the loss of the baby is called stillbirth or a premature birth. When defined as loss of pregnancy within the first 12 weeks of pregnancy, the occurrence of early pregnancy loss (EPL) is from 30 – 60% of all pregnancies – with 30% being unrecognized clinical pregnancies happening before implantation. Most early pregnancy losses are due to chromosomal defects of the embryo, especially among older reproductive age women. There are, however, many other causes for EPL.

For the purpose of this review, EPL is defined as up to and including 12 weeks of pregnancy. It is within that time period, or soon after, that NFP providers will most likely be confronted in helping women cope with EPL. Charting or natural family planning (NFP) can be useful in providing predictors of EPL and for the diagnosis and treatment of EPL. The NFP provider, however, is most often challenged in how to help the couples use NFP post EPL. NFP users want to know when or how long it takes for fertility to return post EPL, when to resume intercourse to prevent or achieve pregnancy post EPL, and when to start observing and charting signs of fertility after they have experienced an EPL.

When Does Fertility Begin Post EPL?

An indication for a return to fertility after an EPL is when a woman’s human chorionic gonadotrophin (hCG) levels return to normal levels. hCG is the hormone that is produced by the human embryo after fertilization. It is the hormone that is measured in home urine pregnancy tests. And, hCG’s continued rise indicates a healthy pregnancy (Heffner and Schust 2014). If the levels of hCG in the urine are less than 5mIU/ml, it means the test is negative for pregnancy. Most women can expect their levels to return to a non-pregnant range in about four to six weeks after an EPL. Health care providers commonly will monitor hCG levels after an EPL to ensure they return back to <5.0 IU/mL. The highest levels of hCG occur from 8 to 10 weeks of gestation, and thus, when an EPL occurs during that time period it may take longer for hCG levels to return to level and for fertility to return.

Generally speaking, it takes one to two full months for a woman to have her menstrual cycle return after experiencing a miscarriage. One study found on the basis of the endocrine data (i.e., daily urine measures of estrogen, LH, and progesterone) that among 18 women following an EPL, ovulation occurred in all 18 women in the cycle prior to first menses at a mean of 29 days post-partum (range 13-103 days) (Donnet, Howie, Marnie, Cooper, and Lewis 1990). They also found that the mean luteal phase length of 12.9 days in the first cycle was shorter than the mean of 14.4 days in the second cycle. Another study found among 50 patients with pregnancy loss that the average time to the return of ovulation, as diagnosed by histological findings of the secretory endometrium, was 50 days (range 10 to 104 days) (Ratten 1970). These findings show that, although there is some disturbance of endocrine function in the first cycle after an EPL, the majority of women have a rapid return to ovulation and thus the early use of NFP or abstinence would be necessary for those wishing to avoid pregnancy.

NFP Charting Evidence for Return of Fertility Post EPL

Researchers at Marquette University are developing a data set of women with EPL and who chart their menstrual cycles in an online NFP charting system (Fehring and Schneider 2016; see example chart of an EPL in Figure 1). Chart data from 10 women with an EPL who used an electronic hormonal fertility monitor to observe their fertility, detect the LH surge, and the return of fertility, found that the average day of the first LH surge (and assumed ovulation) post EPL was 76.2 days (Range, 34 –119 days). The mean length of the first cycle post EPL was 33.9 days (Range, 28-42 days) with a luteal phase length of 11.9 days (Range, 4-19 days). The second menstrual cycle post EPL had an average length of 28.0 days (Range. 26-30 days) and with an average luteal phase of 12.3 days (Range, 9-14 days). It is obvious from this data that there is a lot of variability in the return of fertility post EPL. The data also shows that parameters of the menstrual cycle normalize quickly, i.e., by the second cycle post EPL. These parameters are similar to what Donnet, Howie, Marnie, Cooper, and Lewis (1990) found, in that the parameters of the menstrual cycle (i.e., length, and luteal phase length) normalize by the second cycle post EPL. Larger data sets of post EPL menstrual cycle charts however, need to be gathered and analyzed to have a clearer picture of this variable return to fertility and to determine what other factors affect this variability, such as how many weeks of pregnancy when the EPL occurred.

When to Start Achieving Pregnancy Post EPL

There is also the question as to when couples should try for pregnancy after an early pregnancy loss. There is a wide divergence of opinion concerning the interval a woman should wait after a miscarriage before attempting a new pregnancy. Waiting a full two months, or for a complete and normal menstrual cycle (which generally takes about two months), ensures that the pregnancy hormone hCG has dipped to levels so low that it’s undetectable. It also makes it more likely that the luteal phase will be long enough and the uterine lining has returned to normal, making it receptive to receive a future human embryo. There is a concern that women need to wait 3-4 months in order to reduce the risk of another miscarriage. One study found among 91 women post EPL that 19 women conceived within the first 12 weeks with no spontaneous abortions (miscarriages), and 18 pregnancies proceeded normally; 30 women conceived between 12 and 26 weeks, 29 pregnancies proceeded normally, and none miscarried; and 42 women conceived later than 26 weeks after the miscarriage, with 7 pregnancies terminated in miscarriage, and 30 proceeded normally (Rud and Klünder 1985). These authors found no reason to advise women to postpone a new conception after an EPL. Another study investigated whether a longer pregnancy interval lowers the risk of repeat miscarriage and/or prematurity (Wyss, Biedermann, and Huch 1994). Results showed that there was no evidence to recommend a waiting period between an EPL and a subsequent pregnancy. They found that the risk of another EPL was around 20% irrespective of interval duration. Prematurity too was not influenced by a waiting period after an EPL. Finally, Davanzo, Hale, and Rahman (2012) found that the shorter the time following a miscarriage, the more likely the subsequent pregnancy is to result in a live birth. Hence, it seems reasonable to attempt conception soon after an uncomplicated miscarriage in otherwise healthy women depending on their desire.

Use of NFP Post EPL

A common recommendation for use of NFP after miscarriage is to abstain from intercourse until the first menses, which will be in about four to six weeks after the miscarriage. Women NFP users may observe and chart signs of fertility until then. The body temperature most likely will be elevated for some time due to hCG levels but gradually return to baseline (Couple to Couple League 2007). Others recommend avoiding genital contact for four weeks while leaning to develop confidence in observing natural signs of fertility (i.e., cervical mucus changes) and to begin to have intercourse only at the end of the day on dry mucus days through the first menstrual cycle post miscarriage (Hilgers, Daly, Hilgers, and Prebil 1982). Another NFP text indicated to wait to have intercourse until the Symptom-Thermal rule has been met i.e., experiencing a significant temperature shift and waiting for three temps post the shift above the baseline (Fuller and Huetner 2000).There are no studies on the effectiveness of NFP methods in helping women/couples to avoid or achieve pregnancy post EPL.

A conservative approach to avoiding pregnancy after an EPL would be to wait until the woman has her first menses and then wait until they have established the end of the estimated fertile phase by use of the body temperature shift, the cervical mucus Peak day, or an LH surge. After the first menses they could also follow the instructions for using cervical mucus or urinary estrogen changes to estimate the beginning of the fertile phase and then follow normal instructions for avoiding pregnancy. Post EPL couples can be informed that it might take some time for the first ovulation and first menses to occur. They can also be instructed that the first menstrual cycle will most likely have a delay in ovulation and a shorter than normal luteal phase. The menstrual cycle should return to normal functioning by the second cycle post EPL.

For achieving pregnancy, the conservative approach would be to wait one full menstrual cycle before trying to achieve a pregnancy post EPL. This approach would help to begin achieving pregnancy when the menstrual cycle has normalized its hormonal patterns and the length of the luteal phase of the menstrual cycle. However, newer thinking and evidence is to advise the couple that they can decide when to achieve when they are ready psychologically and physically (Knight 2016).

In summary, the following represents current understanding about return of fertility post EPL and NFP use:

  • The return of fertility post EPL is variable and can be as early as 13 days post EPL but as long as 100 days or more.
  • The parameters of the menstrual cycle and in particular the luteal phase normalizes by the second menstrual cycle post EPL.
  • There is no evidence that achieving pregnancy soon after EPL will result in another EPL.
  • Couples who wish to achieve a pregnancy post EPL should try to achieve a pregnancy when they are physically and mentally ready.
  • Effectiveness of using NFP post EPL to avoid pregnancy or achieve pregnancy is unknown.

The biggest challenge with the use of NFP post EPL is coping with the unknown time of abstinence during the wait for the first menses post EPL. This time period could be very short but also 100 days or more. One approach could be to use periodic hCG home urine pregnancy tests, and as long as they are positive, the couple would not have to worry about pregnancy. The level of hCG detection in home pregnancy tests is around 20-25 IU/mL, a level that would ensure that pregnancy is not possible. Another option is to use postpartum NFP protocols that various NFP providers have developed; however, most of these protocols are not very effective with postpartum breastfeeding women (Bouchard, Schneider, and Fehring 2013). More research on the variability of the return to fertility and the effects on the menstrual cycle is needed. There is also the need to test the effectiveness of NFP protocols post EPL as well.

Republished from Current Medical Research [Winter/Spring 2017 Vol. 28 Nos 1 & 2] with permission from the USCCB.

What Are The Signs Of Spontaneous Abortion

The term spontaneous abortion refers to the loss of a baby within the womb, up to the gestational age of 20 weeks. However, the term has not been accepted by most women because in such cases, the loss of the baby is not intentional but spontaneously caused due to various factors. Hence, the term miscarriage is more commonly used to indicate such a loss.

In addition, overexertion, stress and trauma as well as maternal health can also lead to miscarriages.

Spontaneous Abortion or Miscarriage Signs

Miscarriage or spontaneous abortion signs include bleeding, passing of clots, abdominal cramps and lower back pain. The first sign of miscarriage is usually light bleeding or brownish colored discharge. However, this may also be seen at the time of implantation and could be mistaken for a miscarriage. Some women also experience a negligible amount of bleeding throughout the first trimester. However, since bleeding could indicate a threatened abortion, consulting a gynecologist at the earliest is recommended.

In the case of a miscarriage, the bleeding gradually becomes heavier than a normal period and is usually accompanied by the passing of clots. If miscarriage occurs in the initial weeks of pregnancy, a small sac containing the underdeveloped baby may also be passed with the clots. Abdominal cramping is another symptom of spontaneous abortions as the uterus starts contracting to expel the baby and the placenta through the vaginal opening.

At times, women do not experience any physical signs of spontaneous abortion but often realize that something is wrong when they cease to experience pregnancy symptoms like morning sickness and tender breasts. In such cases, a medical checkup and ultrasound help in confirming the unexpected.

Signs of miscarriage

How to know which symptoms are normal and which warrant a call to your caregiver.

By Teresa Pitman | Nov 12, 2017

When I was six weeks pregnant with my first baby, I went horseback riding. My little palomino mare was normally pretty calm, but on this day we were stalked by an annoying horsefly, and in her attempts to get rid of it she managed to buck me off. I wasn’t hurt, just bruised, and I trudged through the woods until I caught her.

The next morning, still sore from the fall, I noticed spots of blood in my underwear. My heart sank. Was I going to miscarry?

Wondering about the signs of miscarriage is a common worry, and in fact, about one in four pregnancies does end in miscarriage (sometimes called a “spontaneous abortion”). Obstetrician-Gynecologist Dr. Haim Abenhaim of McGill University explains that miscarriages seem even more common these days because new pregnancy tests now let us know we’re expecting very early on. In the past, he explains, a woman who miscarried early might not have known she was pregnant but simply assumed her period was late when she started bleeding.

“The first warning sign is usually bleeding,” adds Abenhaim. “But not all bleeding means that you are going to miscarry, because it’s very common in the first trimester.” In most cases, it’s simply a few spots of blood on your underwear. Miscarriage is more likely if the bleeding progresses from light spotting to something more like a normal period, if the colour is bright red rather than brownish, or if you are also feeling cramping.

That’s what happened to Jen Kowal. Her first pregnancy seemed to be going OK. “I had the normal pregnancy symptoms—nausea, sore boobs—but they were mild. I had the pregnancy confirmed by a blood test, and my doctor said I was pregnant, but barely.” Kowal thought perhaps she was just not as far along in the pregnancy as she’d thought. A few days later, though, she began bleeding.

“It was bright red, and it was a lot,” says Kowal. “I went to the doctor for confirmation, and there was no real question. It was over.”

What about cramps without bleeding—could that be a symptom of miscarriage? Sarah Dufton was pregnant for the fourth time. By five months, she was having “big contractions. I had to actually stop until they were gone, they were that strong.” But the contractions would peter out after a short time, only to start again another day. No miscarriage. Her son, Micah, was finally born 12 days after his due date. “With all those contractions, I really thought he might come earlier, but he didn’t,” Dufton says.

“That crampy feeling may just be the uterus expanding,” explains obstetrician Dr. Alison Barrett. As Dufton found, they may also be what are called Braxton-Hicks contractions, which tend to start earlier with each pregnancy.

However, cramps or contractions that become progressively stronger may indeed be a miscarriage sign. Kate Vanderwielen was about six weeks pregnant when she began having severe back pain. “I thought it was the chair I was sitting in that day,” she says. But as the back pain progressed to cramps, she decided to call her midwife. “I knew something was wrong. My midwife sent me for an ultrasound.”

Vanderwielen was told that the baby didn’t have a heartbeat, and she opted to take medication to end the pregnancy. “It was a relief, really,” she says. “I think I knew something was wrong from the start of the pregnancy. It just didn’t feel right.”

Sharp or persistent pains

There’s a lot going on inside your body during pregnancy, so it’s probably not surprising that you’ll experience occasional aches and pains, which might feel sharp and stabbing, or like a dull ache. Your growing uterus is pushing other organs out of the way and stretching the tendons that hold it in place, and that can be quite uncomfortable at times.

Another possible cause of persistent or intermittent pain is a bladder infection—something women are more prone to during pregnancy and which should be treated. “On the other hand, pain in the abdomen can also be a sign of a tubal pregnancy,” says Barrett. “So if you are experiencing persistent pain, you should see your doctor or midwife to rule out any problems.”

Sarah Johns had a healthy first pregnancy, but she was nauseous from beginning to end. When she conceived again, the nausea hit at around five weeks. “I was incredibly sick, and my doctor prescribed medication so that I could cope,” she says. She braced herself for eight more months of barfiness.

But at around 11 weeks, Johns started to feel less sick. She even cut back on her medication and still felt pretty good. “At first I said to my husband that maybe I was going to be like a normal person and feel better after the first three months,” she recalls. But somehow that dramatic decrease in nausea worried her.

Johns had earlier purchased a hand-held Doppler machine to hear the baby’s heartbeat, and had first listened to it when she was about nine weeks along. “I decided to try, thinking that if I could hear the heartbeat, it would reassure me,” she says. But this time she couldn’t find the heartbeat at all. “I tried for an hour, and then again the next morning, and there was nothing,” she says. An ultrasound confirmed that the baby had died.

Dr. Abenhaim stresses, though, that in most cases it’s quite normal for “morning sickness” to end at around twelve weeks and it doesn’t necessarily indicate a sign of miscarriage.

What about the other typical symptoms of pregnancy (tender breasts, tiredness, frequent urination, morning sickness)? Is it a bad sign if these symptoms disappear?

Not necessarily, says Barrett. Every pregnancy is different. For example, your breasts will be most uncomfortable during your first pregnancy because they are growing and developing the duct system that will produce milk for your baby. During a second or third pregnancy, especially if it’s soon after the first, there will be less growth and development—so less tenderness.

Some of the improvement can simply be the natural progression of the pregnancy. During the first trimester, the growing uterus puts a lot of pressure on your bladder, so you need to pee frequently. Once the uterus has grown a bit bigger, it comes out of your pelvis and the pressure on your bladder eases up. Similarly, many women feel much more energetic as they enter the second trimester.

However, Barrett adds, when a miscarriage is inevitable, women may notice an overall difference in how they feel. When the baby dies, the placenta stops producing the hormones that cause the familiar symptoms. Many women describe suddenly or gradually feeling their bodies change, and knowing that the pregnancy has ended.

Can miscarriages be prevented?

In some cases, perhaps. A new Danish study published in 2011 followed over 100,000 women from the beginning of their pregnancies. The study identified a number of risk factors that may increase the risk of miscarrying, including binge drinking, drinking large amounts of coffee, smoking (but not nicotine replacement treatments—good news for those trying to quit!), being overweight or underweight before conception, and lower education. Some of the results were a bit surprising: Working night shifts and intense exercise were also risk factors, and so was the age of the baby’s father if he was 45 or older.

So am I going to miscarry?

“I tell mothers, ‘It isn’t over until it’s over,’” Barrett says. “Sometimes you have symptoms that seem pretty scary, and yet the pregnancy continues.”

Abenhaim says that an ultrasound provides the best confirmation of whether a miscarriage is inevitable or not. He encourages women to see their doctors if they are concerned, as in certain situations prompt care may prevent a miscarriage. If you have had three or more miscarriages, or miscarry after the first 12 weeks, he recommends seeing a specialist who may be able to determine underlying causes and help reduce the risk with your next pregnancy.

He also stresses the need for emotional support. “A miscarriage is very difficult for most women,” he says. “Even though they are common, and even though they are usually not caused by anything the mother has done, a miscarriage can be devastating.”

Kowal understands that emotional challenge. She conceived again three years after her miscarriage, and says: “It was torture. I pored over every symptom. I felt terror whenever I felt better! I wanted to have morning sickness, like it would guarantee I was still pregnant.” This time, though, all went well and her daughter Lily was born—a little early, but healthy and strong.

Even though miscarriages are fairly common, the majority of pregnancies continue just fine despite worrying symptoms. When the baby and pregnancy are healthy, even a fall from a horse isn’t likely to cause a problem. Although I was pretty nervous when the spotting that I had after getting bucked off lasted for two or three days, a visit to the doctor confirmed everything was fine, and my nine-pound baby boy arrived safe and sound, two weeks after his due date.

Signs of Ovulation After Miscarriage


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One of the most common signs of early symptoms of miscarriage is vaginal bleeding. But keep it in mind that miscarriage without bleeding can happen or that is not sure that each vaginal bleeding is a miscarriage. So keep visiting your doctor. Some other symptoms of miscarriage are a pelvic cramp, the lake of morning sickness, decreasing breast tenderness and absence of the fetal heartbeat.

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When exactly is the best time to conceive? The answer is when you are psychologically and emotionally ready to welcome a new addition to the family. Give yourself enough time to grieve so that negative feelings associated from the previous pregnancy do not affect future attempts. Here’s how to conceive after a miscarriage. Waysandhow.

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Use of Fertility Awareness (NFP) After Early Pregnancy Loss

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