Pregnancy loss, miscarriage, immune infertility, and ectopic pregnancy

Miscarriage

Healthy fertility does not mean just the ability to conceive. Good fertility means establishing and then nurturing a pregnancy for 9 months to full term. Thus, doctors specializing in the treatment of infertility need to hold clearly in their mind the goal of the birth of a healthy baby and not focus only on the first hurdle, the positive pregnancy test: some of the modern technologies used in assisted reproduction place so much emphasis on achieving that first prize that the integrity of the rest of the pregnancy can be compromised. The quality of that small bundle of just a few cells, the pre-embryo, determines (to a significant extent) the development of the rest of the pregnancy. And the biological integrity of the embryo is directly related to the quality of the gametes that fuse to form it and, of course, the quality of the gametes depends on the health and circumstance of the men and women who make them. Equally, the integrity of the uterine lining and the uterine environment is crucial for successful implantation, development of the placenta and establishment of a viable pregnancy.

So, if we are to approach fertility in the broad view, all aspects of the health of both partners and their gametes must be considered, which means examining all aspects of lifestyle and life stresses before conceiving. It might mean avoiding exposure to certain environmental factors or changing eating patterns or addressing chronic diseases. Many different parts of our lives can have a big impact on fertility and can be reflected not only in ease of conception but also in miscarriage rates (see Ch. 12).

Miscarriage is a common event causing large numbers of women (e.g., a quarter of a million each year in the UK) to experience grief and distress The term miscarriage refers to pregnancy loss after a conception has produced viable quantities of the pregnancy hormone (human chorionic gonadotrophin (hCG) in the blood and urine, or the fetus has developed to the point where either a gestational sac (1 week after a missed menstrual period) or a heart beat is visible on ultrasound (2–3 weeks after a missed period). In its broadest definition, pregnancy loss refers to any fetal loss from conception until the time of fetal viability at 23 weeks’ gestation.

In the first part of this chapter, we shall examine pregnancy loss by miscarriage. We shall also look at all the steps that occur between fertilization and a well-established and viable pregnancy and how loss of embryos can happen at any of these stages, even before pregnancy is suspected. After examining all the options for treatment or prevention of miscarriage, the second part of this chapter examines pregnancy loss caused by implantation of the embryo in the wrong place – ectopic pregnancy.

When it comes to treatment, the focus is primarily on the female of the couple, as she is the stage on which the pregnancy is enacted. However, just because the sperm has left the male partner’s body and successfully made contact with an egg does not mean that we can ignore its role in the future survival of the fetus. There are many factors affecting both male and female gametes that can influence the future of the fetus and which will be examined in more detail below. Historically, however, in both Western medicine texts and in Chinese medicine texts, the miscarriage spotlight has fallen on the mother-to-be.

Pre- and post-implantation loss

Clinical rates of miscarriage are often reported to be between 10 and 25% – or higher depending on age. However, the loss of embryos after fertilization but before implantation is much higher than that.

Of the potential pregnancies which are lost, 75% are due to implantation failure and are not clinically recognized as miscarriages. If a small (unviable) amount of hCG is measured on an early pregnancy test, it is called a biochemical pregnancy; it has reached implantation stage but gotten no further. In these days of IVF, what used to be occult pregnancy losses are not so occult anymore.

Conceptions, therefore, occur much more frequently than we think but embryos can be lost before the woman even knows she is pregnant, maybe even before the trophoblast (which forms a week or so after fertilization) has started producing hCG to tell the corpus luteum to keep producing progesterone.

Defective embryos reflect faults in the egg (especially if it is older); faults in the sperm (especially if they have been exposed to radiation or toxic chemicals); faults in the fertilization process itself (polyspermia or fertilization by more than one sperm), or may be just a random strike of destiny in the way the embryo itself develops. The technical term for the reason for these failures of implantation or development is chromosomal embryopathy, i.e., a genetic fault exists in the embryo such as to make it unviable, and cell division and development cease. Because the genetic blueprint of each embryo is brand new, it has never been tested and so fatal mistakes are commonplace.

There are some chromosomal embryopathies which unfortunately do not make the embryo unviable enough and these are the chromosomal patterns which produce Down syndrome babies and other genetic syndromes. Ultrasound measurements of the fetus at week 11 or 12 will alert the mother to risk of abnormality. Where there is suspicion of increased risk of genetic abnormalities, tests may be ordered to determine the genetic make-up of the embryo. These tests are done by collecting cells from the newly forming placenta (CVS or chorionic villus sampling) or from the amniotic fluid (amniocentesis); from these cells the chromosomes of the embryo are analyzed.

Once a pregnancy is confirmed by an ultrasound which measures a healthy heartbeat, and there are no symptoms of back or abdomen pain or bleeding, then the risk of miscarriage falls to a low level (approx. 2%).¹

Advanced age is the primary risk factor for miscarriage. The risk rises sharply and exponentially from age 35 (see Fig. 8.1). While the effect of maternal age on miscarriage is marked, the male partner’s age also can impact miscarriage risk. Several studies have looked at the effect of the male partner’s age on miscarriage risk, noting that more advanced age (>35–40 years) is associated with more miscarriages.^2–4 This increased risk is especially apparent where the female partner is under 35. The miscarriage rate in younger women with male partners aged ≥35 is double that of women with younger husbands.⁵

Figure 8.1 Miscarriage risk increases with female age.

What does Chinese medicine say causes miscarriages?

Kidney Jing and Yin deficiency not only mean difficulty in producing gametes in the first place but also difficulty in producing healthy effective gametes (i.e., ones with intact chromosomes and undamaged DNA). Yin deficiency, which exerts its effects more noticeably with age, is a common factor affecting the viability of the gametes. In the case of ova, this viability is measured not only in the integrity of the chromosomes in the nucleus of the egg but also in the mitochondria (the organelles which produce the energy currency the cell needs to carry out all its activities), which have their own DNA. The DNA in a baby’s mitochondria is inherited only from the mother.

Although environment and lifestyle can affect the Kidney Jing and Yin (see Ch. 12), it is aging which is the main drain on Kidney reserves, evidenced by the fact that many women who become pregnant in their 40s miscarry (Fig. 8.1). As mentioned above, although the effect of age is not quite so marked in men, presumably because sperm are made afresh constantly, there are nevertheless more miscarriages when the male partner is older. Thus, the Jing-depleting effects of age affect men’s fertility too. The difficulty older women and men experience in trying to have children is a control provided by nature to discourage the production of offspring who do not have a strong Jing Qi inheritance. The offspring of parents who pass on poor-quality Jing may suffer the consequences. If the Jing that the new fetus inherits is too deficient, however, nature will ensure it will not survive and miscarriage will follow.

Interestingly, women who have taken the oral contraceptive pill for an extended period of time (≥8 years) have a reduced risk of miscarriage when they are older. In fact, the rate of miscarriage and infertility is half that of other women (≥35 years) who have not taken the pill.⁶ Because they have conserved rather than spent the thousands of eggs which years of menstrual cycles consume, they have a larger store of good-quality eggs and a larger store of Jing later in their reproductive years.

As practitioners of TCM, we can try to apply preventative treatment or measures for the gametes so that they do not develop abnormalities (see Prevention of future miscarriage, later). This might be easier to achieve with sperm than with eggs. Although stem cell science tells us there is a possibility that new oocytes can be produced by ovarian tissue, the fact is that the eggs in a woman’s ovaries available for ovulation have been present since before her birth; hence, their genetic integrity has much to do with their age and past history (of radiation, etc.). Certainly no influence can be exerted on the DNA in the chromosomes of these egg cells, but influence can be exerted on the nourishment and development of the follicle (see Ch. 11). Herbal and acupuncture treatment of men diagnosed with Yin deficiency and internal Heat (who often have a high percentage of abnormal sperm forms) can achieve a positive influence on the sperm quality.

Mechanism of embryo loss before implantation

As mentioned before, at least half of the embryos which fall by the wayside before they even implant in the uterus are those that show abnormal development, i.e., there is something wrong with the genetic programing.

For those embryos that do not have a genetic problem, other factors may arrest further development. This may be a lack of energy (ATP) required for cell division in the early embryo (discussed in Ch. 11). In some of these cases, the problem is not so much with the gametes or the embryo itself but with the reproductive tract of the mother; the fallopian tubes or the uterus.

Tubes – Qi stagnation/Damp: There may be a problem with the tubes such that the pre-embryo does not receive the necessary care and nourishment to take it through the first few cell divisions that occur after fertilization. A fault in the tubes may also mean that the embryo traverses them too rapidly or too slowly, thus it arrives in the uterus at a time when the stage of development of the endometrium does not match its own and implantation is not favored.

The TCM doctor gives treatment around ovulation time and immediately afterwards to regulate the Liver Qi and therefore the passage of the embryo in the tubes. If mucus secretions are suspected to be obstructing or slowing passage in the tubes, treatment to clear Damp will be added. (This has already been discussed in Chapters 4 and 6.)

Endometrium – Damp or Blood stagnation/Yin, Yang or Blood deficiency: Alternatively, or in addition, there may be a problem with the endometrium. Excess fluid or mucus on the surface can interfere with implantation. In TCM, such a situation represents excess Damp. The aim of treatment will be to clear Damp and Fluids with herbs and acupuncture.

In another situation, the endometrium does not provide a well formed surface with appropriate sites for attachment and implantation. In TCM terms, this may reflect Blood stagnation, deficient Yin or Blood, or a ‘Cold womb’. Blood stagnation is best treated during the period to ensure a thorough discharge of the endometrium and smooth remodeling of endometrial tissue to provide a more favorable surface for implantation later on. Blood and Yin deficiency, which lead to a thin or dry uterine lining, is best treated straight after the period with Blood and Yin tonic herbs and foods. A ‘Cold womb’ is how TCM doctors describe the uterus of a woman who is Yang deficient. Yang deficiency is often manifest in low progesterone levels, which means the lining of the uterus does not secrete sufficient nutrients in the luteal phase to nourish the embryo; thus, it fails to implant or develop.

TCM approach to the treatment of miscarriage

A miscarriage from the Chinese medicine point of view can be nearly as demanding on the body’s resources as childbirth, i.e., the physiologic changes experienced by a pregnant body which then suddenly becomes not pregnant are significant and require great adjustments. The hormone levels drop very rapidly after a miscarriage and if there has been significant blood loss, this will leave the body very weak. The recovery is not just physical; in the case of a miscarriage, there is usually emotional distress and this can be considerable if the miscarriage follows a period of infertility.

Chinese medicine texts describe several different clinical approaches to miscarriage, depending on the circumstances.

• Threatened miscarriage: trying to save a pregnancy at risk. If a woman who is pregnant starts bleeding, this is called a threatened miscarriage and treatment is employed to ‘pacify the fetus’ in an attempt to stabilize and save the pregnancy if possible. Since a large percentage of miscarriages are the result of genetic defects in the embryo, such treatment will in many cases, have very limited useful effects. Often, no matter what treatment is given, the miscarriage still occurs. Ideally, the TCM doctor needs to discover whether the fetus is doomed by chromosomal abnormality or whether it is quite healthy and it is the mother’s condition which needs to be improved. A master pulse-taker may be able to make such a diagnosis but for many less experienced practitioners, it may be signs of healthy development of the fetus (or not) on the ultrasound that can give us more precise information. In the end, many practitioners will choose to give treatment on a ‘lets give it a try, we’ve got nothing to lose’ basis.

• Inevitable miscarriage and sequelae. In the event the pregnancy is inevitably doomed, the doctor of Chinese medicine can contribute in quite a different way. Once the fetus has died and has been expelled, or still needs to be expelled, then Chinese medicine can be used to expedite the complete removal of all the contents of the uterus. Subsequently, recuperative treatment will address weakness in the mother due to blood loss and physiologic and psychological stress. When such weakness is made good, treatment to regulate the menstrual cycle again will be appropriate. In most cases, it is only after 2 or 3 healthy cycles that attempting pregnancy again is advised. This is an area in which skillfully applied TCM treatment brings great benefit and may, in the long term, be a sounder approach than the prevailing medical attitude which advises getting back on your feet and trying to conceive again as soon as possible.

• Recurrent miscarriage: preventing future miscarriages. If a woman has had two or three or more miscarriages, then it is more likely that a problem exists in one of the would-be parents. The aim of treatment will be to prevent future miscarriages and, in this case, the couple is asked to refrain from attempts to conceive for at least 3–6 months while the male or female partner is being treated.

Chinese medicine can realistically be expected to have a very useful impact on the treatment of recurrent miscarriage because it is the constitution of the would-be parent that is being treated, not the pregnancy or the fetus.

Threatened Miscarriage

The first signs of a miscarriage are some bleeding and cramping in the abdomen or lower back pain. If the pregnancy is in the very early stages (i.e., the period is late by only 1 week or less), then the woman may just experience what feels like a heavy period. Since the only evidence of pregnancy is the positive blood test for hCG, these are called subclinical miscarriages of biochemical pregnancies. As a rule, the flow of blood will carry all the products of conception out and a surgical procedure like a dilatation and curettage (D&C) to clear out the uterus is not necessary.

Later-stage miscarriages, called clinical miscarriages, occur after the pregnancy has already been well established, i.e., if there has been an ultrasound it reveals the gestational sac and maybe a heart beat. This sort of miscarriage can involve heavy clotty bleeding, pain and cramping, and shock. Where the pregnancy is more advanced, a D&C will often be recommended to resolve the miscarriage and ensure no pregnancy products remain.

If bleeding during pregnancy occurs without pain and examination by a doctor shows the cervix to be firmly closed, then a miscarriage is not inevitable. The bleed may just be reflecting some process in the endometrium as the new placenta starts to form and exchange blood vessel surfaces with those of the mother. A transvaginal ultrasound will usually reveal all; if the gestational sac and the embryo are the normal size for their age and the heart beat is obvious, then there is every likelihood that the pregnancy will develop normally despite some early bleeding. If, however, the gestational sac is too small or the heart beat is absent or too slow at a time when it should be well developed, then a miscarriage will likely follow the bleeding. Most fetuses which miscarry in the 1st trimester (first 3 months) show abnormal development. For the remaining miscarriages in which there is normal development and normal chromosomes, there is likely to be a hormonal, immunological, or emotional cause. Miscarriages occurring for one of these latter reasons are more common among couples who have recurrent miscarriage (described below).

Other causes of a threatened miscarriage (which is not part of a recurrent miscarriage pattern) include isolated events such as a high fever or drug or alcohol abuse, which can cause fetal death.

Causes of threatened miscarriage

Infections, fevers, and accidents

Fever at the time of ovulation can disturb cell division and lead to chromosomal abnormalities, which means, if that particular egg is fertilized the fetus will probably not be viable and miscarriage will follow. Fever during the 1st trimester of the pregnancy can also cause abnormalities in the baby, followed by miscarriage (or in rare cases, a baby with a malformation like a short or absent limb). High fever during pregnancy is usually managed effectively with paracetamol and lots of fluids and bed rest. Chinese herbs to reduce Heat and resolve the causative factor (usually a virus or in TCM terms a Wind-Heat or Wind-Cold attack) can also be useful if applied quickly.

Sometimes, infections are already present in the endometrium before conception and the inflammation they cause (endometritis) can irritate the fetal membranes and cause premature contractions of the uterus. If we are aware of a history of pelvic inflammation or diagnose it from the signs and symptoms the Chinese medicine doctor recognizes as Heat or Damp-Heat, then treatment can be applied to remove the Heat and inflammation and an attempt made to save the pregnancy. Of course it is always preferable to deal with endometritis before conception if possible (see Ch. 5). Sometimes, infections reach the fetus from the outside through the cervix, causing fetal death and a miscarriage. Rapid diagnosis and treatment may be helpful, but often the harm is done before the diagnosis is made.

Other infections which can damage a fetus directly – i.e., by crossing the placenta from the mother’s bloodstream – include German measles virus (rubella), the chickenpox virus (herpes zoster), the genital herpes virus (herpes simplex), cytomegalovirus, bacteria such as those causing syphilis and tuberculosis and parasites such as those causing toxoplasmosis and malaria. If the damage to the fetus is serious, then it will miscarry. Sadly, in some cases of rubella and syphilis infection, the baby will survive but be born with serious abnormalities. These infections are not the cause of recurrent miscarriages, because the woman usually develops an immunity to them after the first infection.

Infections in the genitourinary tract which are active at the time of pregnancy increase the risk of 2nd trimester miscarriage about three times over normal.⁷

A history of sexually transmitted disease often causes problems with becoming pregnant rather than with staying pregnant (see Ch. 6).

Accidents such as serious falls or shocks are sometimes blamed for miscarriages. From a TCM point of view, falls and injuries can cause Blood stagnation, which may manifest as a disorder of blood flow in the placenta or endometrium. In addition, the TCM doctor recognizes that shock can affect the Heart and obstruct the Bao vessel, an important channel for controlling Blood to the Uterus and therefore for nourishment of the fetus.

Strain of the lower back associated with lifting heavy loads can also cause a miscarriage. Studies with physiotherapists, kitchen workers, and cleaners show that work which involves lifting and bending can increase the risk of miscarriage more than three times above normal.⁸

Strain and overuse of the lower back damages the Kidney energy which, you may recall from Chapter 4, is a crucial factor from a TCM point of view for a healthy pregnancy.

Alcohol and drugs

Alcohol or drug abuse, if extreme, can create such toxic conditions for the fetus that it cannot survive. Or they damage the mother’s health sufficiently that her body is unable to sustain the pregnancy (see also Recurrent miscarriage, below).

In TCM, such agents are usually said to create internal Heat, which at a certain level damages the endometrium. Long-term alcohol or drug abuse is usually accompanied by malnutrition; in TCM terms, this implies insufficient Qi and Blood to nourish a fetus.

Prescription drugs taken in early pregnancy can in some cases present a risk, e.g., there is some evidence that even commonly used drugs such as non-steroidal anti-inflammatory drugs (NSAIDs) can contribute to miscarriage.⁹ One study found that the use of NSAIDs (ibuprofen, naproxen, or aspirin) during early pregnancy increased the risk of miscarriage by 80%. The risk was much higher when NSAIDs were taken around conception or were used for longer than a week. It is thought that prostaglandin inhibition by NSAIDs might interfere with implantation.¹⁰ Paracetamol use is not associated with any increased risk of miscarriage.

Other drugs such as Roaccutane (isotretinoin) used to treat resistant acne are well known for their ability to cause defects in the embryo; when these are lethal enough, miscarriage will follow.

There is much more research to be done in this area; meanwhile, drugs should be avoided in early pregnancy if possible.

Hot baths

The use of hot tubs is also a risk factor for miscarriage, especially in the first few weeks of pregnancy. Women who use hot tubs or Jacuzzis (which keep the water temperature high) in early pregnancy are twice as likely to miscarry as those women who do not use them. The use of regular bathtubs does not seem to be a risk factor, but sustained elevation of core body temperature is best avoided, not only because of the risk of miscarriage but also the increase in neural tube defects associated with hyperthermia.¹¹

Exposure to chemical agents (e.g., during the preparation of synthetic drugs or use of industrial or domestic cleaners) as either discrete events or on an ongoing basis, can also contribute to miscarriage (such agents are discussed in the Causes of recurrent miscarriage, below).

There has been some debate about the effects of the oral contraceptive pill on pregnancies which closely follow its use. Not all specialists are in agreement about the persisting effects of the pill and, indeed, most claim there is no lingering effect.¹² However, some manufacturers of the pill have advised that it be stopped for 3 or 4 months before attempting pregnancy, claiming an increased risk of miscarriage immediately after using contraceptive hormones.¹³ Other surveys have noted that taking the pill for more than 2 years is associated with an increased risk of miscarriage.¹⁴ This may be due to persistent disruption of endometrial function caused by the pill, which can result in implantation difficulties for the embryo, or it may be because oral contraceptive use depletes folic acid stores, which puts at risk the development of the fetus in its first few weeks.

There is much Chinese medicine can contribute to preparing the endometrium and the cervix for a healthy and stable pregnancy after stopping the pill. Following the treatment regimens described in Chapter 4, with a special emphasis on building the Yin (to promote cervical mucus production) and regulating and then building the Blood and boosting Kidney Yang (to promote a healthy endometrium) should facilitate rapid reversal of any undesired effects of the pill.

We will discuss more causes of miscarriage below when we discuss recurrent miscarriages.

TCM treatment of threatened miscarriage

In the event of a threatened miscarriage, TCM intervention can sometimes play a useful role. It is one of those times when Chinese medicine doctors like to be more proactive than their Western medicine counterparts, who view early miscarriages as relatively trivial events from a physiologic point of view (though not from a psychological point of view). If the pregnancy can be saved, the TCM doctor will have something up his sleeve rather than just adopting a fatalistic attitude of wait and see. Obviously in many cases, there is little that can be done and the miscarriage is necessary to expel a defective embryo. But in cases where the problem lies with the mother or the way in which the pregnancy is being established, then timely treatment may save a pregnancy. If there is no lower back pain or bleeding, the pulse is slippery, the tongue is not purple and the abdomen feels warm, then the threatening miscarriage has more chance of being rescued.

Chinese medicine texts describe a threatened miscarriage as ‘fetal restlessness’ or ‘fetal bleeding’. The symptoms are spotting or bleeding in early pregnancy sometimes accompanied by lower back pain and abdomen cramping. If the pregnancy is threatened for reasons other than chromosomal embryopathy, then it is ideal if treatment is administered before bleeding starts. However, this may be difficult to assess. Doctors working in infertility clinics in China will closely supervise the first few weeks of an at-risk pregnancy. ‘At risk’ in this context means the pregnancy follows a period of infertility, or there has been a history of previous miscarriage. In these clinics, women may be encouraged to continue taking basal body temperature (BBT) readings for the first few weeks after the pregnancy is confirmed; that way, the doctor can determine the vigor of the Kidney Yang by the temperature readings. If the temperature starts to drop at all, Kidney Yang tonics (and Qi tonics) will be administered, or increased if they are already being taken. Similarly, blood levels of hCG and progesterone can be monitored and vaginal ultrasounds can be taken. However, although these tests can give accurate assessments of the progress of the pregnancy, to do them on a frequent basis may be prohibitively costly.

Categories of threatened miscarriage are:

• Kidney deficiency

• Qi deficiency (Blood deficiency)

• Heat in the Blood

• Blood stagnation.

Kidney deficiency

When we constructed treatment protocols for encouraging conception, in Chapter 4, we emphasized Kidney Yin. Once conception has occurred, then treatment of Kidney Yang is emphasized, i.e., the Uterus must be kept ‘warm’. It is Kidney Yang deficiency which is the most common cause of early-stage (subclinical) miscarriage and also pre-implantation loss (where there is no chromosomal embryopathy). In the case where a diagnosed pregnancy is threatening to miscarry there will be spotting or bleeding, which may be accompanied by lower back pain, sore legs and frequent urination.

The pulse will be weak and soft. This will be especially notable in the Kidney position, which in a healthy pregnancy should quickly develop a firm, solid and slippery feel. The tongue will be pale or unremarkable.

Herbal formula: The guiding formula in this situation is:

Shou Tai Wan (Fetus Longevity pill)

Tu Si Zi	20 g	Semen Cuscatae
Du Zhong	9 g	Cortex Eucommiae Ulmoidis
Sang Ji Sheng	9 g	Ramulus Sangjisheng
E Jiao	9 g	Gelatinum Asini

Tu Si Zi is the most important herb to prevent miscarriage due to Kidney deficiency. It has a strong supplementing effect on the Kidney, combined with an astringent effect; consequently, the dose used is often much larger than usual. However, doses above the level given above are not advised.

Xu Duan can be used instead of Du Zhong in this formula, as they both have the effect of strengthening the Kidney and preventing miscarriage. Sang Ji Sheng supports the Kidneys and with E Jiao nourishes Blood and prevents miscarriage; E Jiao also has the action of stopping bleeding.

More herbs can be added to stop bleeding if necessary, e.g.

Ai Ye tan	9 g	Folium Artemisiae
Zhu Ma Gen	15 g	Radix Boehmeria Nivea

It is common for Kidney deficiency miscarriage to also show signs of Qi deficiency. In that case, some of the herbs mentioned in the next category (Qi deficiency) will be added to the above guiding formula, e.g.

Huang Qi	20 g	Radix Astragali
Bai Zhu	9 g	Rhizoma Atractylodis Macrocephalae
Dang Shen	9 g	Radix Codonopsis Pilulosae

If there is a history of chronic miscarriage, these Qi tonic herbs will always be used before and after conception to encourage the Spleen Qi to hold the fetus in.

Acupuncture points: Choose from the following points (and see Table 8.1):

Table 8.1

Acupuncture points ^a used in treatment of threatened miscarriage due to Kidney deficiency

Treatment goal	Acupuncture points
To strengthen Kidneys, especially Kidney Yang	KI-6, KI-3, BL-23 (cautious shallow needling or moxa), Ren-4 (light moxa only)
To reinforce and lift Spleen Qi	Ren-6 (shallow needling or moxa), Ren-12, DU-20

^a Reinforcing method is used; moxa can be applied on trunk and head points.

Ren-4	Guanyuan
BL-23	Shenshu
Ren-6	Qihai
KI-3	Taixi
KI-6	Zhaohai
Ren-12	Zhongwan
DU-20	Baihui

CASE HISTORY – MORGAN

Morgan’s pregnancy was a long time coming – 5 years (between the age of 33 and 38) of trying hard, the last 6 months taking Chinese herbs and having acupuncture. She had almost given up and when she finally conceived, she planned a celebration overseas trip. But by 5½ weeks, she was in trouble. Severe back pain and weakness caused her great discomfort and set off my alarm bells. Everything she did except rest made it worse. In addition, she started spotting a brownish bloody discharge accompanied by aching pain in the abdomen. She felt very irritable. She had no morning sickness. Her Kidney pulse was very weak as was her Stomach and Spleen pulse; the Liver pulse was wiry. Her tongue had a red tip and a yellow coating.

It was all stops out to save this pregnancy and, fortunately, the treatment could be started early. Although we would have felt more reassured had she been experiencing pregnancy-related nausea, at least her strong stomach meant she was able to swallow good doses of herbs regularly.

The diagnosis of her threatened miscarriage was Kidney Yang deficiency with Qi deficiency. Morgan also had a constitutional tendency to Damp-Heat affecting the Liver. Acupuncture at 5–7 weeks of pregnancy:

KI-3, KI-9, DU-20, LIV-3, BL-28, BL-23, DU-4 – all back points with moxa only

Herbal formula

Xu Duan	12 g	Radix Dipsaci
Du Zhong	12 g	Cortex Eucommiae Ulmoidis
Tu Si Zi	15 g	Semen Cuscatae
Bai Zhu	9 g	Rhizoma Atractylodis Macrocephalae
Huang Qi	9 g	Radix Astragali
Sang Ji Sheng	15 g	Ramulus Sangjisheng
Ai Ye tan	9 g	Folium Artemisiae
Huang Qin	9 g	Radix Scutellariae Baicalensis
E Jiao	6 g	Gelatinum Asini

At 7 weeks, the bleeding had stopped, abdomen pain was better and she felt less irritable. However, the most troubling symptom, her lower back pain, was still bad. She had developed mild nausea.

We repeated the acupuncture and moxa, adding PC-6 and ST-36, deleting KI-3. The herbal prescription was also repeated, deleting Ai Ye tan and E Jiao, and increasing Tu Si Zi to 20 g.

At 8 weeks, her lower back weakness and pain were much better, there was no spotting and her nausea became marked. Her right Kidney pulse strengthened, although the left was still weak. The Liver pulse was thin and wiry. At 9 weeks, she experienced vomiting of bile and a chemical taste in the mouth and could no longer tolerate herbs. Her lower back pain returned for 2 days. She was anxious, depressed, and irritable.

We had to rely on acupuncture now: GB-34, LIV-14, Ren-12, PC-6, TB-6, ST-36, KI-21

This was repeated several times over the next 2 weeks.

By 11 weeks, she felt much better. The nausea was mild and manageable and the lower back pain was all but gone. She set off on her overseas trip with confidence (but with lots of warnings about avoiding lifting heavy suitcases). A healthy baby girl was born at term.

Qi deficiency

Qi dropping is another cause of clinical or subclinical (usually the former) miscarriage. The woman will experience abdomen distension, with a bearing down sensation that may spread to the lower back. She will probably feel fatigue and may notice spotting of blood. If the cervix is examined, it may appear to be slightly open. The pulse will be thready and the tongue swollen or pale.

Herbal formula: The formula of choice is:

Bu Zhong Yi Qi Tang (Reinforce the Center and Benefit the Qi decoction)

Huang Qi	30 g	Radix Astragali
Dang Shen	15 g	Radix Codonopsis Pilulosae
Bai Zhu	12 g	Rhizoma Atractylodis Macrocephalae
Dang Gui	9 g	Radix Angelicae Sinensis
Chen Pi	6 g	Pericarpium Citri Reticulate
Sheng Ma	6 g	Rhizoma Cimicifugae
Chai Hu	6 g	Radix Bupleuri
Gan Cao	6 g	Radix Glycyrrhizae Uralensis