Let us first explain the different types of miscarriage because considerable differences exist depending on whether we want to save the pregnancy or whether we can no longer do so:

Over 50% of all incidents of bleeding in early pregnancy (i. e., in the first 12 weeks of pregnancy or the first trimester) are a matter of abnormal pregnancies. The risk of miscarriage drops with increasing length of pregnancy. Ninety percent of all miscarriages fall in the time up to the 12th week of pregnancy.

In the majority of miscarriages in the first trimester, we find chromosomal changes and also deformations like neural tube defects or lip-jaw-palate clefts. Metabolic disorders of the pregnant woman (e. g., diabetes mellitus, hypo- or hyperthyroidism) or infections can trigger a miscarriage as well. Lastly, malformation of the uterus and myomas can lead to miscarriage, but only after the 12th week of pregnancy due to the fetus’s increasing need for space.

Threatened abortion refers to bleeding in early pregnancy, possibly accompanied by labor-like pain in the lower abdomen; in this case, the possibility of an intact pregnancy still exists. We see scant bleeding, sometimes—not always—accompanied also by mild abdominal pain, but with an intact pregnancy under ultrasound. If a local infection is found in the vagina or cervix, the patient receives antibiotic treatment. There is no specific therapy for this form of miscarriage, except for rest or even bedrest if necessary. Nevertheless, the risk of a miscarriage later on in the pregnancy is higher than in pregnancies without any bleeding.

The embryo shows no heartbeat in the ultrasound, and sometimes we see brown spotting. If there is no evidence of any embryonic tissue in the amniotic sac, we can speak of a “wind egg.” Biomedicine responds swiftly with surgical evacuation, to avoid severe bleeding and a rising infection, as well as by giving anti-D immunoglobulin to rhesus-negative women to avoid rhesus incompatibility in subsequent pregnancies.

Spontaneous miscarriage is most common between the eighth and 12th week of pregnancy, but also often occurs only after the 12th week. Parts of the placenta remain in the uterus, as a result of which a follow-up curettage and possibly anti-D injection are necessary. Most often, the underlying reason is a developmental disorder in the child.

This refers to an impending miscarriage with bleeding, contractions, and cervical dilation. This will be treated in the same way as an incomplete abortion.

This is the most critical form of miscarriage, requiring both surgery and high doses of antibiotics.

In a patient with a history of three or more miscarriages, biomedicine speaks of habitual abortion. Two percent of all couples are affected by this. In up to 50% of these couples, it is impossible to furnish evidence of the specific cause of miscarriage.

Causes of habitual abortion include:

• Chromosomal changes in one parent in the form of numerical changes in the chromosome set or a rearrangement of genes within chromosome pairs (translocation).
  
• Polycystic ovary syndrome, often combined with overweight and insulin resistance, which also represent risk factors for recurrent miscarriage.
  
• Thyroid disorders, especially hypothyroidism and autoimmune thyroid diseases.
  
• Diabetes mellitus with impaired metabolism.
  
• Uterine deformities and, related to this, failure to nourish the implanted egg sufficiently (in 50–60% of habitual abortions).
  
• Myomas or polyps can present a mechanical obstacle.
  
• Infections: especially chronic endometrial infections from chlamydia, mycoplasma, and ureaplasma urealyticum (rising cervical infections are more likely to cause spontaneous abortion).
  
• Coagulation factors: factor V Leiden mutation, protein C, protein S, or protein Z deficiency, defects in the antithrombin system, prothrombin mutations, hyperhomocysteinemia. In all these cases, hypercoagulability of the blood is present. In addition to a higher risk of miscarriage, we also see a higher risk of thrombosis, as well as in the more advanced stages of the pregnancy a higher risk of retarded intrauterine growth and HELLP syndrome. The formation of microthrombi leads to impaired vascularization in the area of implantation and in the later stages to impaired supply. Treat with heparin injections; but if bleeding occurs, heparin must be stopped immediately!
  
• Immunological factors: at the site of implantation, the body reacts with both rejection and assistance. In this reaction, the rejection involves primarily natural killer cells while the assistance involves primarily cytokines and growth factors that are produced and secreted by immunocompetitive cells. Implantation can be disturbed by both an excessive rejection or an insufficient presence of cytokines and growth factors, but also by the production of irregular autoantibodies in the context of a false activation of the immune system.
  
• In women with habitual miscarriages, irregular autoantibodies that can also cause thrombophilia are much more common than in normal women. Thrombophilia causes the formation of local blood clots in the area of nidation; the result is faulty implantation, which ultimately causes the death of the embryo. In terms of therapy, we can consider giving small doses of heparin in combination with small doses of acetylsalicylic acid (ASS).
  
• Environmental toxins: continuous exposure can cause habitual miscarriages, but not a single contact. Most noteworthy are especially lead, copper, mercury, vinyl chloride, pesticides, sulfur dioxide, cadmium, and organic solvents. Some substances can also affect male fertility.
  
• Psychological factors: here we find two groups of women: those who originally reject motherhood, and those who do not feel adequate to the responsibility.
  
• Male sub- or infertility is of lesser significance.

From the TCM perspective, the four key signs for a threatened miscarriage are:

• disquieted fetus with a downward-pulling, sinking feeling
  
• back pain
  
• lower abdominal pain
  
• vaginal bleeding

The key treatment strategy in threatened abortion is to avoid the miscarriage by swift treatment with Chinese medicinals.

We distinguish between vaginal bleeding in pregnancy and disquieted fetus, which manifests with abdominal and back pain and a downward-pulling feeling in addition to bleeding. Back pain is one of the key symptoms in threatened abortion, in which case there is a relationship between the intensity of the pain and the severity of the imminent miscarriage.

In the Jing Yue Quan Shu (Complete Works of Jing Yue) published in 1624, we read:

The pathology of threatened abortion basically consists of a disharmony of the ren mai and chong mai (conception and thorough fare vessels), as a result of which nourishment of the fetus with qi and blood is insufficient. This disharmony of the ren mai and chong mai is very often compounded by weakness in the kidneys. Additional disease patterns are blood deficiency, qi deficiency, and sinking qi, as well as blood heat and blood stasis.

Possible causes for threatened abortion are a weak constitution, overwork, excessive physical and psychological strain, chronic illness, and traumas. As a result, kidney qi is not secure and cannot hold the fetus. In this context, heavy lifting damages kidney yang; chronic diseases exhaust qi, blood, and essence. Anger, rage, and frustration can lead to liver qi constraint, which transforms into liver fire and produces heat in the blood. Falls and other traumas can injure the ren mai and chong mai.

The most important treatment principle in threatened miscarriage is to quiet the fetus and to supplement the ren mai and chong mai, thereby also strengthening kidney qi. Additional important treatment principles are:

• nourish the blood
  
• supplement and upbear qi
  
• cool the blood
  
• stanch bleeding.

• huang qin (Scutellariae radix)

For Bleeding

• ai ye (Artemisiae argyi folium)
  
• e jiao (Corii asini colla)
  
• di yu (Sanguisorbae radix)
  
• duan long gu (Mastodi ossis fossilia calcinata)
  
• duan mu li (Ostreae concha calcinata)
  
• sang ye (Mori folium)

To Warm the Uterus

• ai ye (Artemisiae argyi folium)
  
• bu gu zhi (Psoraleae fructus)

To Astringe, Secure, and Strengthen Kidney Essence

• fu pen zi (Rubi fructus)
  
• wu wei zi (Schisandrae fructus)
  
• jin ying zi (Rosae laevigatae fructus)
  
• lian zi (Nelumbinis fructus)
  
• ma huang gen (Ephedrae radix)

The most important disease patterns in threatened abortion include:

• kidney qi vacuity
  
• spleen and kidney qi vacuity
  
• blood deficiency
  
• blood heat
  
• blood stasis

Threatened abortion, most commonly in early pregnancy; with back pain, a feeling of collapse in the lower abdomen, minor vaginal bleeding, exhaustion, weak legs, frequent urination, a pale tongue, and a deep weak pulse.

Supplement kidney yin and kidney yang and quiet the fetus.

The main formula is Shou Tai Wan (Fetal Longevity Pill), which supplements kidney qi and secures and holds the fetus. We achieve this effect with the medicinals tu si zi, sang ji sheng, xu duan, and e jiao; many current modifications additionally contain du zhong to increase the effect of the formula. All in all, this is an excellent formula for consolidating the kidneys and stabilizing the pregnancy. By means of supplementing the kidneys, kidney qi can hold the fetus, and fetal qi can itself become strong.

Threatened abortion, especially towards the end of the first trimester; with back pain, downwardpulling pain in the lower abdomen, a dull pale face, fatigue, lack of appetite, heart palpitations, thin and pale red blood, increased bleeding after physical exertion, a pale tongue, and a deep weak pulse.

Persistent chronic illness as well as inadequate nutrition can lead to qi and blood vacuity, as a result of which the woman is unable to provide enough nourishment for the fetus, and a miscarriage threatens.

Supplement and upbear qi, strengthen the spleen, nourish the blood, and quiet the fetus.

The future mother develops anemia with symptoms like fatigue, heart palpitations, and paleness.

Blood deficiency is rarely the direct cause of a threatened miscarriage, but can contribute to delayed fetal development.

Nourish the blood.

Some authors recommend Dang Gui Shao Yao San to treat lower abdominal pain during pregnancy. This formula should be used in the initial stage of a threatened miscarriage with lower abdominal pain and vaginal bleeding. It relaxes the muscles, relieves pain, regulates the liver, nourishes the blood, and stabilizes the fetus.

Threatened miscarriage with back and abdominal pain, vaginal bleeding with bright red blood, heat sensations, thirst, disquietude and disturbed sleep, a red tongue with yellow fur, and a replete rapid pulse.

This pattern tends to develop out of yin vacuity, which favors the formation of heat in the blood. The heat pushes the blood out of the uterine vessels. Additional causes of blood heat are anger, liver fire, or the consumption of excessively spicy foods and coffee and alcohol abuse.

As soon as the heat reaches the heart, the risk of miscarriage is high because the connection from the heart to the uterus via the bao mai (the uterine vessel) is disturbed. Lyttleton comments on this pattern:

Quiet the fetus, cool the blood, and discharge heat.

To discharge heat from the heart and liver, Xia Guicheng, a famous gynecologist from the Jiangsu Provincial Hospital in Nanjing, recommends gou teng (Uncariae ramulus cum uncis), chao huang lian (Coptidis rhizoma frictum) and lian zi xin (Nelumbinis plumula). In cases of disquieted sleep or insomnia, she recommends chao suan zao ren (Ziziphi spinosi semen frictum), wu wei zi, he huan pi (Albizziae cortex), fu shen (Poria cum pini radice), bai zi ren (Platycladi semen), long chi, mu li (Mastodi dentis fossilia calcinata), and gui ban (Testudinis plastrum), to restore communication between the heart and the kidneys.

We can also use modifications of Gu Jing Wan (menses-securing pill) with medicinals like gui ban, bai shao yao, huang qin, huang bai (Phellodendri cortex), or di gu pi (Lycii cortex).

The main symptom is abdominal pain, but we also find scant vaginal bleeding. The tongue and pulse are inconspicuous.

Blood stasis is often triggered by trauma to the uterus, for example, as the result of a fall; but it can also arise from medical interventions during in vitro fertilization.

Move the blood, quiet the fetus, supplement and upbear qi.

Possible choices are Tao Hong Si Wu Tang (Peach Kernel and Carthamus Four Agents Decoction) or Shao Fu Zhu Yu Tang (Lesser Abdomen Stasis-Expelling Decoction).

There are certainly authors who warn against neglecting moving blood as a treatment option during pregnancy. Li Guangrong, for example, believes that:

The Chinese term for habitual abortion is hua tai (“slippery fetus”). Treatment occurs while the woman is not pregnant. This means that a woman with known habitual abortions should not pursue another pregnancy for 6–12 months and receive treatment during this time. It is important to plan this treatment in detail with the woman and convince her that the therapy has priority over a new pregnancy. In contrast to a threatened miscarriage, the main emphasis of treatment is not on quieting the fetus but on the underlying constitutional cause in the woman. The time frame of 6–12 months is necessary to effectively stabilize the constitution. Clinical practice has shown that many of these women show a constitutional deficiency of kidney qi and blood. Kidney qi here loses its holding power and its ability to preserve and secure. Frequent miscarriage can damage the chong mai and ren mai and further aggravate a pre-existing kidney vacuity; therefore kidney vacuity has shown to be the most common cause of habitual miscarriages in TCM. This can be compounded by a spleen vacuity, disharmony of the ren mai and chong mai, as well as qi descent.

In addition to the patterns of blood stasis and blood heat, the clinically most important therapy in habitual abortion consists of:

• supplementing, consolidating, and strengthening the kidney and spleen
  
• upbearing spleen qi
  
• nourishing the blood
  
• harmonizing the ren mai and chong mai

There is a saying in TCM, “to treat the illness, search out the root.” The energetic imbalances and disharmonies that trigger habitual miscarriages often resemble those that are responsible for infertility.

In most women, you should balance kidney yin and kidney yang before attempting another pregnancy. To achieve this, strengthen kidney yin after menstruation and supplement kidney yang after ovulation, in accordance with the menstrual cycle.

The most important disease patterns in habitual abortion include:

• kidney yang vacuity
  
• kidney yin vacuity
  
• qi vacuity
  
• blood vacuity

The patient’s history reports past miscarriages; back pain and cold symptoms, that is, cold feet, pale urine, and a pale tongue.

In addition to miscarriages, kidney essence is also consumed by aging. Pregnant women over 40 are therefore more likely to suffer from frequent miscarriages. In the West, we see more and more pregnant women in this age group.

It is important to warm the uterus and kidneys and also to supplement the kidneys.

Here we find miscarriages in the patient’s past history as well, combined with back pain, tinnitus, and night sweating. The tongue is reddened and without any fur.

Women around the age of 40 are more likely to suffer from kidney yin vacuity than younger women. This causes a dilemma because building up yin for a good development of the egg and endometrium requires a long time; at the same time, though, these women often feel that they have no time left. Nevertheless, they must be convinced under any circumstances to wait for a minimum of 4 months before another pregnancy, to strengthen yin sufficiently and to prepare the body for another pregnancy.

Nourish yin and blood, strengthen the kidneys, secure the ren mai and chong mai.

It is typical that the cervix opens from the third month of pregnancy on as the fetus increases in size, resulting in the threat of a miscarriage.

A serious state of spleen qi vacuity can cause the uterus to drop; the cervix is no longer closed tightly to hold the pregnancy.

Supplement and upbear the qi of the center burner.

We see scant menstrual bleeding, disturbed sleep, problems with visual acuity, dry skin, and dizziness.

In this disease pattern, we often find a thin endometrium; this results in a failure of the egg to implant or in insufficient nourishment to the egg.

Nourish the blood and kidneys, secure the ren mai.

__________

How safe is the use of Chinese medicinals during pregnancy? Where are the limits of its applications? According to US studies, roughly 25% of all women experience miscarriages as part of a natural process, for example, to sort out genetic defects. Miscarriages are particularly common in couples with fertility problems, late pregnancies, infectious sexually transmitted diseases, and excessive stress.

A number of babies are born with physical or mental problems. A certain percentage of these can be attributed to the consumption of medications and recreational drugs like crack, alcohol, tobacco, and coffee during pregnancy. Most women are quite aware of these connections. Many medications are not recommended during pregnancy because there is not enough proof of their safety.

The Chinese people contemplated the question of which medicinals were safe for pregnant women as early as 1800 years ago in the Jin Gui Yao Lüe. In the West, Chinese medicinals have only been in use for a few years. In contemporary China, pregnant women receive prescriptions for Chinese medicinals as a matter of course for many complaints. As far as we can judge without relevant statistics, there appear to be few problems.

The typical patient in the West, however, will not be prepared to accept even the smallest risk to treat a condition like a cold during pregnancy. Assuming that problems arose after the use of Chinese medicinals, these medicinals could very easily be held responsible. In mild illness or when you are unsure, it is therefore better to do without any treatment.

On the other hand, though, if the condition is so critical that the only alternative are biomedical medications that might have incalculable risks for the fetus or if the pregnancy itself is endangered by the illness, for example in threatened miscarriage, Chinese medicinal therapy is often the safer method, with fewer side-effects for mother and fetus. It is nevertheless wise to limit both the dosage and the length of usage to what is absolutely necessary.

Unfortunately, there is not enough statistical information and significant data on the safety of Chinese medicinal therapy. The experience of innumerable generations of physicians certainly counts: many Chinese medicinals and formulas are so well-tested in their application during pregnancy that they can be regarded as safe.

Medicinals like bai zhu, huang qin, tu si zi, or du zhong and formulas like Shou Tai Wan have a stabilizing and calming effect on the fetus in the dominant disease patterns of kidney and spleen vacuity.