MISCARRIAGE / PREGNANCY LOSS

I sit here writing this while waiting for a poor woman who is here getting medication trying to get her uterus to expel (push out) a baby who died at 17 weeks of pregnancy.   Time to write about pregnancy loss and miscarriage.

First off, we have such sensitive early pregnancy testing now that women know–even before they miss a period–that they are pregnant.  This can be perceived as good —  or not so good.   I always tell my infertility patients to wait until day 40 of a cycle before doing a test.  Too many times they are doing a test at day 29, and phone –all excited, naturally–“I’ve got a positive test!!!”

Many times they call a few days later to say  “I’m bleeding and cramping!”   It’s like we don’t give Mother Nature a chance to check things out.  Of course, a woman can do any test she wants, but I do tend to advise CAUTIOUS OPTIMISM.   I wouldn’t post the pregnancy stick on Facebook.   You tell a bunch of people you’re pregnant–then you have to tell a bunch of people you’re not going to have this baby.

So let’s say you are pregnant and you have made it to 6 weeks.  Hate to tell you, but you really need to make it to 12 weeks before you are unlikely to miscarry.

Some studies suggest that 70% of fertilized eggs end up as a miscarriage before the women even realizes she is pregnant.  Once she knows she is pregnant, you are looking at about 20% chance of a miscarriage before 12 weeks–so it is REALLY common.  It is just not discussed over lunch .  You will find that when you tell people you have had a miscarriage, that you will hear many women say they, too, have had a miscarriage, or two.

I don’t know what to tell you all about telling people.   It’s like “Keep it a secret”–all hush hush–if you don’t tell anyone you’re pregnant, then you don’t have to tell anybody you miscarried–and basically, deal with it all by yourself!  We are an odd society when it comes to miscarriage.  You are told quietly, and go home–nothing is said—it’s like we don’t want you to acknowledge it, and then you won’t feel grief?  What horse puckey—you can be totally devastated when told you do not have a live baby in your womb.

I have had women get an ultrasound at 9 weeks–all looks good–baby kicking, and then WHAM—the phone call–“I’m bleeding–and cramping”

You can have some bleeding during the first 12 weeks, and carry a perfectly healthy baby, but when I hear “cramping”–I am not too optimistic in general.  I also don’t like hearing that your breasts are not tender anymore, or that you are not having ‘morning sickness’ anymore–that you just don’t “feel” pregnant anymore.

So –if you are under 12 weeks, the most common reason for the miscarriage is that the chromosomes did not line up right.  You get 23 chromosomes from the father, and 23 chromosomes from the mother, and they have to line up–like a zipper.   Before you pull up on the zipper, the “teeth” have to be lined up perfectly, otherwise when you pull up, the zipper will get stuck half way up, and you can tug and pull and twist until the cows come home—that zipper is NOT going to zip up. Same with pregnancy–if the chromosomes didn’t line up, then Mother Nature is going to say “WHOA!!–this isn’t working–STOP RIGHT NOW!”

So– you come in with spotting or cramping–and it doesn’t  have to be a lot of bleeding.  An ultrasound is done, and there is no easy way to tell you that there is no heartbeat in your baby.   Your world just collapses–you don’t hear much else–it is a shock!   Hopefully you will have someone with you to support you–but often times, you are alone with the doctor when you hear the news.   You may have had a little spotting, and friends/family may have said that you can spot while you are pregnant and everything is fine–so you are not expecting the baby to die.   It is perfectly natural and human to try and comfort someone with “It’s probably nothing–I bled during MY pregnancy, and everything was OK”.   We all crave hope!

The other thing MANY women feel is anger.  They get mad just thinking about all the girls who get pregnant as teenagers in the back of the car, the drug addicts who get pregnant, the women who decided to abort their baby.  When they see women being short-tempered with their child, they feel that the mom they perceive as “not a good mom” gets to BE a mom, and even though THEY may not smoke, or drink, or do drugs, and do everything “right”, that THEY don’t get to carry a pregnancy.   I would say MOST women I talk with about their miscarriage feel this way–and so does the father.   We tend to forget that the FATHER has the miscarriage too—and many men take it way harder than the woman!   This may be the first time that life has not gone “according to plan”.  It can test one’s religious faith, lead to depression, trouble with a marriage/relationship….

So—what else can cause a miscarriage.  Well–there are things that can cause an increase in the rate of miscarriage, but it does not mean that this was the cause of YOUR miscarriage.

SMOKING (I have never smoked and had two miscarriages), alcohol (meanwhile–millions of babies are conceived as a result of alcohol consumption), drug use–particularly cocaine, diabetes or other chronic health condition, viral illness, kidney infections–or any infection, some blood clotting disorders-(‘sticky blood’)….

Once you get to 12 weeks your chance of miscarriage is less than 2 %.

So–the other thing is not to go blaming yourself!   It is not because you lifted a hamper of laundry, or because you had sex the night before, or because you put your arms over your head, or you didn’t conceive while facing north—IT IS NOT YOUR FAULT!!!   IT HAPPENS!  It happens to the rich, the poor, the good, the honest, the dishonest, the police officer, the criminal………it happens because you are HUMAN.

WHAT ARE YOUR OPTIONS?

If you are under 12 weeks, and have a baby with no heart beat, you have, in my opinion, the following options:   medical termination using drugs that make you cramp and miscarry, a surgical D&C  (go to the OR, and under anesthesia we empty the uterus), or waiting (not many choose this, and we can’t let it go on beyond 3 weeks as that can cause other problems.  I find NOBODY wants to wait past a few days, and some studies show that if you wait past 3 days that there are more problems with depression, and negative feelings.

If you live close to the hospital, I will often have you take medication to start the process, and then tell you to come to the hospital when cramping/bleeding gets worse.  It is unusual to need a blood transfusion with a miscarriage–but the bleeding can often be way more than a regular period.

If you opt for surgical procedure it is generally booked within 1-3 days if you are not actually bleeding–for instance, if you came in on a Friday –then you may not get surgery until the Monday.  Some women will try the medical approach, and the surgical approach is back up.  The medical approach works about 80% of the time— not 100%.

If you are over 12 weeks this is not as common, and I tell you, it can be difficult to get these babies out!  Some obstetricians have a lot of experience with doing a surgical emptying of the uterus in a 16 weeker, but most of us may only see one or two a year in our practice–so not an easy surgical procedure to do –and for some women, they don’t like the idea of the fetus being pulled out–so may will opt for the medical approach.  The medical approach can take 1-3 days.

I will often put a balloon in to the cervix to start the cervix opening up–the catheters that we put in the bladder that most of you know about–we can put those tubes into the cervix.

My preferred drug to use is CYTOTEC (misoprostel).   There are some women who cannot use this drug–such as asthmatics.  The other drug is PITOCIN–but we have to give MUCH higher doses when you are not full term–as it is not easy to make a uterus contract early in the pregnancy.   We can be pretty generous with pain medication in this case–whatever it takes to get you comfortable.  It is a cruel thing of life  that you have to go through a labor for a dead baby—life is just not nice sometimes!!

TO SEE OR NOT SEE THE BABY/FETUS

I have to say that I think society puts a LOT of pressure on us to “bond” or “get closure”–but this is NOT a case where a woman is ‘supposed’ to do anything!  It is 100% HER decision whether she wants to see the fetus or not.  I can tell you that, sometimes, it is a really horrible thing to see–it is not what you may imagine–a sleeping baby–it is often a baby that has gone soft because it has been dead for a few days, and everything has collapsed.  I don’t encourage women to look as they deliver.  We will often wrap the fetus in a blanket and then we will take a look at the fetus and describe to the mother briefly what is looks like, and THEN she can decide if she wants to see the baby –or not!   You are NOT a “better mother” because you looked at your dead baby.  Let me tell you that once an image is in your head—it doesn’t leave your head.

I wouldn’t want to see my son or daughter if they were totally crushed in a car wreck—I would want to remember then as they WERE–not as some horrible dead version on a hospital table.   Should we make the mother of a man beheaded by ISIS look at her dead son??   Is she a bad mother if she doesn’t???   OF COURSE NOT!!!

I also question some parents who want to have their elementary aged children–or any child see the dead fetus.  Might be different if a formed baby who looks like a baby who is asleep–but the fetus can be a thing of nightmares–and I do have to ask “Who’s needs are you meeting?”    Let the child be a child—how do we know what impact this image will have on them.  In the end though, I have had some children see 16-18 week fetus and seem to take it all in stride.

It is kind of a relief when we see the REASON why the baby died–sometimes we will see that the baby is totally tangled up in the umbilical cord, or that the cord is twisted too tightly or that there is a know in the cord.  Not knowing the reason is, I believe, harder to deal with.   Most times, you don’t see the reason!

SIDETRACK

I once did a tubal ligation on a 31 year old (old enough to make that decision).  WHY?   Because when she was in grade 6, the school thought it would be educational to have the children bussed to the big city for a science exposition at the museum.   Part of the exhibition was a film showing childbirth.   In 6th grade, she was so traumatized by seeing this film, that she was afraid to have sex until she was 25–and then she made sure that her partner never wanted children.  She had gone through counseling, but remained adamant that she never wanted children, and wanted her tubes tied.  A reversible IUD was not for her–she had given it much thought.  PTSD from a birth film!!!—think about if you want to have your child see this ADULT thing  very carefully.   Are you meeting THEIR needs??  or YOURS?

AFTER THE LOSS

Oh–and here’s another thing to prepare for.   If you lose a baby–even a full term baby–there are no balloons, no flowers, no cards.   People don’t know what to do –and do nothing.  You may, yourself, have done nothing when you heard about an acquaintance with a miscarriage, or a fetal death.   Your friends are all probably very uncomfortable with the whole things too–it’s not like our parents cover this with our child rearing.   You will often find that YOU will end up comforting your friends, who will burst into tears when they see you.  It just makes the whole thing so much more sad—you go home to no happy notes, no flowers, no balloons, and often–you have to look at things you may have already bought, in anticipation of bringing home a baby.

You need–both of you–to take time to talk and grieve.    Counseling may be a good idea if you are having trouble coping with it.

Also–you have to think about birth control–you need to have a period, ideally, before you try again–and something nobody will tell you–but I will—you may want to think about not getting pregnant at the same time of the year–so you don’t have that whole “deja vu” thing that you are going to be pregnant, and due at the same time–I find it makes people even MORE anxious!   It is going to be tough getting up the courage to try again–but there is no other way.   You tend to almost “detach” yourself–afraid to hope too much, or say too much for fear you will somehow “jinx” things.

It is not uncommon, unfortunately, for women to have two miscarriages a row–but to have three in a row is about 1% chance.

PREGNANCY LOSS –when you are CLOSE to survival time….but not close enough

One of the things I find sad to do is meet with a couple in the ER–she may be say 16 weeks and has had a damn good bit of bleeding—not needing a blood transfusion, but a significant amount.  This is not typically a good scenario.   It usually means that the placenta tore off the wall of the uterus—not enough to kill the baby–but enough that now we have to worry about if the rest will tear off–or is there enough placenta left to grow the baby normally.  I tell the couple that we will hope for the best but they need to prepare (how the heck does one do that), for the worst.

Quite often, the placenta is not able to keep up with the baby, and the fluid level starts to drop.  When the fluid (water bag), around the bay is low, then the baby is not able to stretch out, and can get too cramped.  This can lead to abnormal growth of the arms and the legs—clubbed feet, curved legs.

It also means that the baby cannot practice breathing—yes–the baby actually breathes in the uterus.  You can see this on ultrasound.  If there is no fluid, then the lungs do not develop, and the baby will not be able to breathe when born.

NORMAL FLUID AROUND BABY

 

 

 

 

LOW FLUID(virtually none)

 

 

 

 

 

 

So–this is the saddest part.  You really need to get to 25 weeks to get a GLIMMER of hope of survival–but what kind of survival.  Over 80% of babies at 25 weeks will have significant impairment.  Every day after 25 weeks is gold!

So—let’s say you may it to 23 weeks 1 days (just an example).

Let’s say your dates are dead right based on the period, and early ultrasound.

This is when you are CLOSE—but not close enough!  You have to make really tough decisions.

You have two options:

  1. You decide to try and keep you baby alive–so you choose aggressive resuscitation, knowing that survival means a very high chance of significant health issues (cerebral palsy, blindness, bowel digestion issues that may require tube feeding, …)    It is a tough road, but if this is what you want to do, then every effort will be made.    You do have the right to stop at any time if things are not going well.

2   DO NOTHING—this is certainly a very reasonable option–chosen by many in this situation.

If you choose this option, we do not monitor the baby during labour, and the baby may be born alive or already has died.   This may sound a little heartless–but the watching a heartbeat hour after hour and see the moment that your baby actually dies is really hard on women–and their partner–WE need to remember that this is a loss for BOTH of you!

When the baby is born you may see signs of life for a short while–but we have you hold and cuddle your baby for the short time your child is on this earth.  I typically tell women that their child will be loved form the moment of birth, to the moment of death—something we all hope will happen in our lives.

We often are able to put together a little box of mementoes–the bracelet, foot and hand prints, sometimes a picture, the hat that the baby wore.  It is hoped that these will help —knowing that your child did exist, wore these things, and will always be remembered.

Many funeral homes actually provide free cremation services for pregnancy loss –  these things will all be discussed with you.

Let’s hope you never have to suffer through the loss of a baby.

 

 

 

 

 

 

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