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Miscarriage: The Hardest Loss

Miscarriage was the last thing on the mind of Suzanne, a Boston executive, when she got pregnant for the second time three years ago. Her first pregnancy had gone smoothly, she had no trouble conceiving, and she felt great. When she was 10 weeks pregnant, Suzanne had her first prenatal appointment. She looked forward to hearing the thrilling whoosh-whoosh-whoosh of her baby’s heart.

But when the nurse practitioner listened, she heard nothing. “At that point there should have been a strong heartbeat,” says Suzanne. “When I looked at her face, I knew.” An ultrasound confirmed it: Suzanne had experienced a miscarriage.

Suzanne, now 35, was shocked—she thought miscarriage was something that happened to other people. “I had given very little thought to the possibility of something going wrong. It really pulled the rug out from under me.”

Like many women, Suzanne had no idea how common miscarriages are. In the United States, 15 percent to 25 percent of recognized pregnancies—more than a million a year—end in miscarriage. “It’s an astoundingly large number—one that most women do not learn until they are sitting in a paper gown in their obstetrician’s office, hearing the heartbreaking news about their pregnancy loss for the first time,” says Bruce K. Young, MD, professor of ob/gyn at New York University Langone Medical Center and author of the book, Miscarriage, Medicine & Miracles: Everything You Need to Know About Miscarriage (Dell, 2008).

The number of miscarriages is even higher if you take into account the “unrecognized” pregnancies that occur when a fertilized egg fails to implant in the uterus. These pregnancies are considered unrecognized because they usually happen before a woman realizes she’s pregnant and result in bleeding around the time of her next period. According to the March of Dimes, adding in those early losses pushes the miscarriage rate to 50 percent of pregnancies.

The good news is that although first miscarriages are common, second, third, and fourth miscarriages are not. “The likelihood of having two successive miscarriages is less than 5 percent, and the majority of women who have had a miscarriage go on to have healthy pregnancies,” says Christine C. Skiadas, MD, a clinical fellow in reproductive endocrinology and infertility at Brigham and Women’s Hospital in Boston.

Among those couples who do have repeated miscarriages, medical treatment can often correct the physiological or genetic problems that stand in the way of a successful pregnancy. “Even after three miscarriages, there is still a 72 percent likelihood of a term pregnancy and a healthy baby the next time you try,” Dr. Young says.

Why Do Miscarriages Happen?
One of the first questions couples ask themselves after a miscarriage is “why?” Usually, the answer is “genetics.” Up to 70 percent of miscarriages are caused by genetic error in the fetus. These abnormalities occur when the sperm or egg is defective, when cells don't divide normally, or when a gene contains the wrong number of chromosomes. Genetic defects occur more often in aging sperm and eggs, which is why the risk of miscarriage increases with age. After age 40, more than one-third of recognized pregnancies end in miscarriage, according to the American Society for Reproductive Medicine.

Some other, less common causes of miscarriages include bacteria (listeria or brucella) or viruses (chicken pox, rubella, parvovirus B19). For example, one study found that bacterial vaginosis, a common vaginal infection, makes a woman nine times more likely to miscarry. A woman may also have a hormone imbalance, such as too little progesterone or thyroid hormone, or an immune system disorder, such as antibodies that cause blood clots in the placenta. Anatomical abnormalies in the uterus, fallopian tubes, or cervix can also lead to miscarriage, as can dangerous lifestyle factors, including cigarette smoking, heavy alcohol and illegal drug use, and exposure to toxic chemicals such as industrial solvents. Major trauma from a serious car accident, physical abuse, or a fall can cause a miscarriage, and prenatal tests such as amniocentesis and chorionic villus sampling (CVS) raise miscarriage risk slightly, to 1 in 370 procedures for amnio and 1 in 360 for CVS.

Despite what you may hear from your mother-in-law or read online, miscarriage in healthy women is not caused by exercise, having sex, climbing ladders, flying on airplanes, seeing something frightening, lifting heavy objects, being in a bad mood, or working. Researchers are studying whether there is a connection between stress and miscarriage, but most doctors see no link. “The reality is, during World War II, when people were being starved and brutalized, they still had babies,” Dr. Young says. “Women in prisons get pregnant and have babies. And after 9/11, studies showed no increase in miscarriages.”

After the second trimester begins, miscarriage risk drops sharply—95 percent of miscarriages occur during the first 13 weeks of pregnancy.

Anatomy of a Miscarriage
Vaginal bleeding is the most common miscarriage symptom, although many women also experience menstrual-like pain, cramping in the abdomen, or low backache. Some women, like Suzanne, have no bleeding. “I didn’t know you could have a miscarriage without bleeding,” Suzanne says. Likewise, some women who have light spotting do not miscarry—but any vaginal bleeding merits a call to your healthcare provider.

After a miscarriage, the placenta and fetal tissue must come out of your body. “You can let nature take its course and let it pass on its own, but some women can’t emotionally deal with that,” says Barbara O’Brien, MD, a maternal-fetal medicine specialist and director of perinatal genetics at Women and Infants Hospital of Rhode Island in Providence. If the woman doesn’t want to wait for it to pass, if it’s been more than a week, or if there is heavy bleeding or signs of infection, she must have a D&C (dilation and curettage)

A D&C is a surgical procedure that takes place in a doctor’s office, health clinic, or hospital. A woman receives anesthesia (general, epidural, or IV, depending on the situation), and then her doctor opens the cervix and removes the fetal and placental tissue from the lining of the uterus.

If it’s your first miscarriage, your doctor may not have the tissue analyzed—the assumption is that it’s a genetic fluke that has a very low likelihood of occurring again. If it happens a second time, however, testing makes sense. “Many doctors would evaluate someone after having two miscarriages to determine the cause,” though the definition of recurrent pregnancy loss is technically three miscarriages, Dr. Skiadas says. “The goal is to identify if there are factors that, if treated, will decrease her miscarriage rate for future pregnancies.

Some of the tests done after multiple miscarriages include bloodwork, analysis of fetal chromosomes, ultrasound, hysteroscopy (a test in which a scope is inserted through the cervix to examine the uterus), and biopsy of the uterine lining.

There are several other conditions that, while not technically considered miscarriages, also bring about the end of a pregnancy: Blighted ovum is a condition in which the gestational sac grows, but the fetus doesn’t. An ectopic pregnancy occurs when a fertilized egg becomes lodged in a place other than the uterus, usually the fallopian tubes. A molar pregnancy is a condition in which an abnormal mass forms in the uterus instead of a baby. And a stillbirth is a pregnancy that ends after the 20th week. All of these are far less common than miscarriage.

Coping with a Miscarriage
Miscarriage can trigger powerful emotions
. It’s normal to feel grief, anger, self-blame, depression, and shame. “Women tend to blame themselves, even though nothing they did caused the miscarriage,” Dr. O’Brien says.

Many women keep their miscarriage secret, but Dr. Young says opening up can be cathartic. “Like all things that are associated with a feeling of grief, it is better to talk about it. Once you do, you may find that it’s as if you’re a member of a secret club—you’ll find that there are lots of women who have had the same experience, but they never told you about it.”

If friends and family can’t offer you the support you need, consider seeing a therapist or attending a support group meeting. “People may tell you that you should just get over it, it’s just a miscarriage,” Dr. O’Brien says. “But those kinds of comments belittle it and are very unhelpful. It’s a normal response to grieve.” Suzanne found comfort in writing a letter to her lost baby. “I attached the positive pregnancy test stick to it and saved it,” she says. “It was a way for me to mourn.”

Although they may not show it, fathers also may feel grief after a miscarriage. “We tend to ignore the man, and I think that’s unfair,” Dr. O’Brien says. “He’s feeling it, too.”

Starting Over after a Miscarriage
Medically, it’s okay for most women to start trying to conceive again one or two months after a miscarriage—doctors suggest waiting until after you’ve had one normal menstrual cycle—but for others, that’s too soon. “You really should wait until you’re emotionally ready,” Dr. O’Brien says. “That could be right away, or it could be a year.”

Suzanne and her husband decided to try to conceive again as soon as possible. Shortly after, she got pregnant—but this time, she and her husband kept the pregnancy a secret until they heard the heartbeat. “When we heard a heartbeat at seven weeks it was a blessing,” she recalls. “But even five months into the pregnancy, I was still getting high anxiety.” Suzanne’s doctor referred her to a psychologist who helped her use mind/body techniques to feel less anxious. Several months later, Suzanne gave birth to a healthy son.


A version of this article originally appeared in the Fall 2008 issue of Conceive Magazine.

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