I saw a new patient Sonia, who was referred to me by her sister Sandra. Sandra has been my patient for 12 years and I have delivered all three of her daughters. Sandra insisted that I see her sister because she felt that I was the “best Ob ever” and I needed to take care of her baby sister. When Sandra came in with Sonia and her husband Trent for their first Obstetrics visit, they were all very excited to see the early 6 week pregnancy with a heartbeat. All three left the office beaming with delight.
Sonia and Trent returned two weeks later for a follow up visit. Sandra didn’t have any problems with cramping or bleeding. She felt very emotional but not nauseous. I did a follow up ultrasound hoping to see a healthy 8 week fetus, but instead I saw a very small fetal pole without a heartbeat. The fetus has not grown since the last ultrasound. Reluctantly I told both Sonia and Trent that the baby is no longer alive. Both look at me with disbelief and Sonia starts sobbing.
When asked what I love about my job, it is being there for my patients and helping to bring their baby into the world, or performing a surgery that will reduce their pain, stop abnormal bleeding or helping them live a healthy life by removing either a benign or cancerous tumor. What I hate the most is telling someone that they have lost their pregnancy, that their baby is not alive or they have cancer.
Miscarriages are caused by failure of the pregnancy to develop. They are very common. In women under age 35 the miscarriage rate is around 20 percent; in women over 35 it’s around 33 percent, and in women over 45 it is around 50 percent. People are not aware of how common they are so many times, just like Sonia’s story. They are not expecting this news. More than 90 percent of the time first trimester miscarriages are caused by a genetic abnormality in the fetus that prevents it from developing. Miscarriages are nature’s natural selection. If a fetus has multiple problems that are incompatible with life nature stops the growth of the fetus. There are other causes of miscarriage such as untreated thyroid disease, poorly controlled diabetes and a specific blood clotting disorder but these cases are rare.
The miscarriage can occur very shortly after a missed menses before fetal tissue develops. This is a chemical pregnancy where the pregnancy test is positive and then shortly after the woman starts to bleed like a period. The pregnancy test then becomes negative quickly after. The next form of miscarriage is called an anembryonic gestation or blighted ovum, where the pregnancy stops growing after the gestational sac forms. The gestational sac forms at 5 weeks so if you are beyond 6 weeks and there is no fetus in the sac this is an anembryonic gestation. The next miscarriage is what I described above where a fetus is seen with a heartbeat and on follow up ultrasound there is no longer a heartbeat. This is called an intrauterine fetal demise.
If given enough time women will begin to have symptoms that the pregnancy is abnormal, such as cramping and bleeding. It may take up to 4 weeks for the body to recognize that the fetus is abnormal but most of the time the body will realize this sooner. Miscarriage can be managed by waiting for the body to pass the tissue naturally or through a surgical procedure which removes the tissue; this is called a dilatation and curettage. Regardless of when the fetus stops developing, whether it is right after a positive pregnancy test or 10 weeks along it is heart breaking for the woman and her family. The reassuring fact is that they are common and often don’t recur, and without any medical intervention most women will go on to have a healthy pregnancy the next time along.
Some other reassuring points — if your ultrasound shows a fetus with a heartbeat the miscarriage rate drops significantly and if you get to 12 weeks with a healthy baby, the miscarriage rate drops even further. This is the reason many people wait to tell people they are pregnant until they are 12 weeks along. I do not think people have to wait 12 weeks to tell people they are pregnant especially if they are excited about the news. But what I do advise is to only tell people to whom you are close. If you tell someone early that you are pregnant and you lose the pregnancy you want the people you tell to be supportive and loving when you are sad and grieving.
Like I said earlier no matter how far into the pregnancy a loss is a loss and you need to allow yourself to be sad. But the good news is that studies show you can try for another pregnancy as soon as your next natural menstrual cycle and this does not increase the chance of another miscarriage. In fact your fertility is highest within the first 6 months after a miscarriage.