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Early Pregnancy Loss
If you’ve been trying to conceive, a positive pregnancy test can make you feel on top of the world. Discovering later that you’re at risk for miscarrying can be devastating. Most of us have had no psychological preparation for this unfortunate circumstance; we may become overwhelmed by feelings of shock, disbelief, shame, guilt and grief. Yet at least 25% of women with new pregnancies will eventually miscarry, and higher rates are seen in older moms. Despite the fact that most women trying to conceive will experience a miscarriage at some time, pregnancy loss is a topic that few women speak about. Not uncommonly, miscarriage may occur before we have shared the news of the pregnancy with friends and coworkers. So when problems do occur in an early pregnancy, we may feel frightened, isolated and unsure how to reach out for support.

Common warning signs for a miscarriage include vaginal spotting, bleeding, low back pain or pelvic cramping. Other clues may be a noticeable loss of pregnancy symptoms; breast soreness and nausea diminish, and pregnancy fatigue may lift. However, many women with completely healthy pregnancies experience many of the same symptoms. Fifty percent of early pregnancies with light bleeding result in healthy pregnancies (for more information on this subject, see my article on this web site titled, “First Trimester Bleeding”). Bleeding accompanied by cramping and the passage of tissue (fibrous, meaty material) indicates a miscarriage is likely occurring. Contact your physician if you bleed during the first weeks of pregnancy, and head to an emergency room if your bleeding is severe or accompanied by abdominal pain or lightheadedness.

A health care provider will need to examine you to see if there is indeed a problem. First, a physical exam will reveal whether your uterus is an appropriate size for your gestational age and whether your cervix has opened or you’ve started to pass tissue. If your cervix is still closed and your pregnancy is under 10 weeks from your last normal menses, an ultrasound is the best exam to confirm a living pregnancy. In a normal pregnancy, an ultrasound will detect a small sac of fluid within the uterus by 5 weeks gestation and usually shows clear evidence of a fetus by 6 weeks. A fetal heartbeat can be detected by ultrasound by 7 weeks, and is an important sign that a pregnancy is progressing appropriately. If your pregnancy is earlier than 7 weeks along, or if ultrasound is not available, your health care provider may order a series of blood tests to measure the rise in pregnancy hormone (human chorionic gonadotropin) over several days. The level of HCG usually doubles every two or three days in a healthy pregnancy. A progesterone level can also provide useful information in some situations; this hormone is necessary to support the growth of an early pregnancy.

If blood tests or an ultrasound determine that your pregnancy is abnormal, you may be told you have a “missed abortion,” (the pregnancy stopped developing but has not been expelled), a “blighted ovum,” (no embryo ever developed), or that you had a “spontaneous abortion,” (the medical term for miscarriage). A miscarriage may be “complete” (no more pregnancy tissue is left in the uterus) or “incomplete” (some tissue still remains inside the uterus). Your bleeding will not resolve until all of the pregnancy tissue has been removed from the uterus.

If you are told that you are miscarrying, the news may be overwhelming. You’ll likely be told that nothing can be done to fix this pregnancy, and that miscarriage is nature’s way of ensuring that only the healthiest pregnancies survive until term. Your health care provider may go on to describe surgical options to remove any remaining tissue from the uterine cavity, and may discuss some of the causes of miscarriage.

It’s normal to wonder whether any past activities played a role in the miscarriage. The truth is, most miscarriages are caused by a problem in the pregnancy itself and have nothing to do with physical exertion, being sick, sexual relations, emotional difficulties, having ambivalent feelings about the pregnancy, fighting with your husband, or any of the hundreds of potential reasons most women wonder about. Healthy pregnancies can survive a lot of stresses. And while we may want to find a reason for our own miscarriage, the cause is almost never something we have control over.

The majority of miscarriages are caused by chromosomal problems within the embryo. There is nothing that can be done to prevent this or change what will happen. Some spontaneous abortions are related to lower than normal levels of progesterone. If a low progesterone level has been found to play a role in your pregnancy difficulties, you may be asked to use supplements of progesterone in a future pregnancy. Some miscarriages are related to problems in the shape or structure of the uterus. Immunologic problems can also interrupt some pregnancies; there are special blood tests that can detect these rare problems with the immune system, but usually they’re only done after two or three miscarriages occur.

If your doctor does detect a problem, you will have several choices. If your pregnancy is still very early and the fetus has not yet developed, you could wait for the miscarriage to occur (spontaneous abortion) which could take days or weeks. Or, you could have a surgical procedure called a dilation and curettage (D & C) which allows your doctor to remove the pregnancy material from your uterus. If you are already bleeding a moderate amount, your body may be in the process of miscarrying. Often an emergency D & C is advisable to help the uterus to completely empty, which will minimize any further bleeding.

While you are likely to physically heal from the miscarriage within a couple of weeks, it may be a much harder process to heal emotionally. It is completely normal to be flooded by emotion: sadness, guilt, frustration, shame, anger. If you have not yet shared news of your pregnancy with people around you, it can be hard to introduce the topic now. And, if you have already made announcements to friends and family, telling people that you have lost your pregnancy can be too painful to bear.

Here are some suggestions:

1) Take time to digest what happened. If you missed every word your doctor told you about the miscarriage, make another appointment. Write down your concerns and be sure to have your questions answered.

2) Make an appointment with a therapist to discuss your feelings about the loss. Write in a journal. Talk to your partner, who will be filled with a myriad of feelings, too. Take some time off of work if you need to.

3) Confide in a friend, and have him/her do the work of telling other friends and co-workers if you don’t want to relive what happened over and over again. Friends and colleagues will be sad, too, but unsure of how to be most helpful. They may be unsure if you want them to talk about what happened with you. If you have an idea of what you would find most helpful, let your friend convey that information, too.

4) It’s not a bad idea to talk to a few friends about what happened. Seventy percent of women have experienced a miscarriage at least once. It can be helpful to learn that you’re not alone, and to have a group of friends who know what you’ve just been through.

5) Be kind to yourself. Your body needs to heal, which requires good nutrition and adequate rest. Give yourself permission to indulge in a massage, buy yourself something special or go away for a weekend.

The fortunate reality is that most women who miscarry will be able to have a healthy pregnancy at some time in the future. Making the effort now to heal both physically and emotionally is your first step in that direction.
Laura E. Stachel M.D. Obstetrician & Gynecologist