Purpose and Disclaimer

This writeup attempts to cover both the facts and the feelings of this difficult topic. Before we proceed, please note: I am not a medical specialist. My only expertise is that of personal experience, and subsequent attempts to understand what happened. As always, nothing on Everything2 should be considered medical advice. Consult with your own medical doctor before making any decisions about your health. See also the Everything2 medical disclaimer.

Introduction

Miscarriage is a traumatic experience. Most people who experience a miscarriage are completely unprepared to face it. It takes so many people by surprise because it is seldom discussed openly. Western society is increasingly forthright about sex and sexual choices, about childbirth and menopause, but miscarriage remains taboo. We feel that we can't discuss it with even the closest friends and family, and so it is shrouded in mystery and misinformation.

For those experiencing miscarriage, my deepest sympathies. You will find it hard to talk about your loss, and harder to know who you can talk to. Some of your friends and family will have been here, but you probably won't know it. Those who have not won't know what to say, and often will say deeply hurtful things with the best of intentions. Your health care providers have resources for you to fall back on, and you should take advantage of them if you need outside support.

For those who have not experienced miscarriage, or if you might ever become pregnant, please read on. I hope that you never need this information, but if you do, that something here may help you to understand.

Definition

Any pregnancy which terminates before the 20th week of gestation (that is, up to 20 weeks after the last menstrual period) is deemed a miscarriage. This corresponds to the halfway point in a regular pregnancy term. Loss of the pregnancy at or after 20 weeks is called stillbirth.

Miscarriage is not a discrete event. It often starts with the onset of unexpected bleeding (though this alone is not a sure sign) and lasts until the pregnancy is eliminated from the body. This process can take several weeks.

Miscarriage is technically referred to as spontaneous abortion, to distinguish it from a therapeutic abortion. However, the term abortion carries significant emotional baggage for most people, so it is not used in informal conversation.

Causes

Although miscarriage can happen by accident or misadventure, the vast majority of miscarriages occurs because of gestational irregularities -- something that went wrong at the time of conception. These events are totally beyond the parents' control. If you are having or have just had a miscarriage: it is not your fault. It is a common and natural event. Something went amiss in the incredibly complex process of reproduction. It is terribly sad, but it is not unusual, and it is not the end of your dreams of parenthood. In most cases a first or second miscarriage will not harm your chances of a subsequent successful pregnancy in any way.

Most miscarriages occur because the embryo or fetus stopped developing. The pregnancy is "non-viable" and terminates. In some rare cases, the fetus is sound, but the woman's cervix is weakened (due to congenital defect or previous surgery) and is unable to bear the weight of the developing baby. This condition, tactfully called cervical incompetence, is almost inevitably fatal to the fetus unless detected early enough that the woman can be completely restricted to bed rest.

The most commonly diagnosed cause of miscarriage in the first trimester is chromosomal abnormality. Soon after the sperm and the egg meet inside the fallopian tube, their chromosomes match up. The sperm and egg each normally contribute 23 unique chromosomes (via meiosis) to the future embryo. In a small percentage of sperm, and a larger percentage of eggs, an abnormal number of chromosomes present, a condition called aneuploidy. Improper chromosome counts are usually, but not always, fatal to the pregnancy. 50% of chromosome-related miscarriages are found to be due to trisomy, the presence of a third copy of one chromosome. For most chromosomes, trisomy is not survivable. Trisomy 21, known as Down syndrome, is the most common exception. Duplication of chromosome 23, the sex chromosome, is also survivable1. Another 25% of chromosome-related miscarriages are due to monosomy, where only a single copy of a chromosome occurs. Monosomy is usually fatal2. The remainder of chromosome-related miscarriages involve rarer problems such as translocation of chromosomal material. Increasing age is a significant risk factor in chromosomal abnormality, especially for women past age 35.

The end of the first trimester is the point at which it is traditionally "safe" to tell others that you are pregnant. Chances of miscarriage fall off significantly. Risks in the second trimester include serious illness or injury, or structural problems in the reproductive organs. Cervical incompetence, mentioned previously, may be a risk.

Symptoms

The most common symptom of miscarriage is the sudden onset of vaginal bleeding. Some spotting is normal and expected, but any amount of brightly coloured blood is potentially serious, and you should see your health care provider or visit emergency immediately. Your provider will want to know how much bleeding there has been, and if there was any 'tissue'. (Aside: At no point during our visit to emergency did anyone define 'tissue' for me. I thought it was a euphemism for 'fetus' in some sort of bizarre attempt at delicacy. In fact, the vast majority of 'tissue' shed during an early miscarriage is placental, as the lining of the uterus dissolves and is expelled.) Though it is enormously difficult to think about, if there is tissue it should be preserved for testing, as it can give vital clues to the cause of the miscarriage.

Note that bleeding also can accompany successful pregnancies! Bleeding occurs in 40% of all pregnancies, and half of those go on to successful completion. A mild tear ('abruption') where the forming placenta attaches to the uterine wall, or an embryo implantation that happens to hit a blood vessel, can cause alarming bleeding that is actually harmless. Heavy vaginal bleeding (soaking more than one pad per hour) is cause for alarm -- immediate medical attention is warranted.

Cramping, either mild or severe, may also be present. Again this symptom is not conclusive. Some cramping is normal may be a result of the womb and other organs adjusting to accommodate the pregnancy. Cramping and bleeding together are cause for serious concern, and immediate medical attention is warranted. This may indicate that the womb is disposing of the embryo, placenta, endometrium, and other materials.

For women in the 6th to 12th weeks of pregnancy, when signs of pregnancy such as nausea and breast tenderness are most common, the sudden loss of these signs is also cause for alarm. Such signs usually start around week 6, are strongest at week 10, and taper off by week 13. A sudden stop may mean that the body has stopped producing HCG, Human Chorionic Gonadotrophin3. This in turn means that the pregnancy has already terminated, though no bleeding or cramping has yet occurred. Again, you should see your health care provider right away.

Even with no symptoms, an early indication of trouble may come from blood tests during the first weeks of pregnancy. There is significant variation in 'normal' HCG levels, and there is no 'right' number. However, the HCG numbers should double every 2-3 days, and quickly mount into the thousands. Numbers that remain in the hundreds and grow much more slowly (as ours did), stay flat, or fall off, indicate that the pregnancy is failing or has failed.

Diagnosis

If a miscarriage is suspected, a physical examination will be conducted to determine the extent of the bleeding and to check for cervical dilation. There will very likely be urine and/or blood tests, including a "beta" blood test for HCG levels. In many cases a blood typing as well. Even if you know your blood type, it will be checked again, in case a shot of RhoGAM is required. Your health care professionals will also check for ectopic pregnancy and molar pregnancy, both of which are very serious and life-threatening conditions which will require immediate surgical action.

If symptoms such as bleeding and cramping were detected early in the pregnancy, all of these tests may be inconclusive. It may be too early to see the developing embryo in an ultrasound. In this case (as it was for us) the medical advice may be to continue blood tests, wait one or two weeks, and have another ultrasound. This was the case for us, and the wait was excruciating. Our "beta" levels were in the low hundreds and not rising, and bleeding continued, so the implication was clear. Nonetheless, successful pregnancies with low betas are not unheard of, and so we waited two weeks, continuing with more disappointing betas and hoping against hope that everything was fine. It wasn't -- two weeks later a second ultrasound confirmed it. There was no embryo, and the endometrium was thinning out.

Process

Most miscarriages occur because the embryo or fetus did not implant properly, did not cause the proper hormones to be generated, or simply stopped developing. The body then ends the pregnancy and breaks down the "products of conception". Many books on miscarriage use the seemingly grisly term "liquify" for the process that breaks down and expels these products. This process can take between one and three weeks. During this entire time the woman must deal with daily bleeding and cramping, both at times quite severe. Even worse, until the levels of HCG return to normal, the hormone continues to send pregnancy signals to the body, resulting in breast discomfort and other 'false' symptoms of pregnancy. This can be particularly heartbreaking -- the woman feels pregnant, yet knows there's no baby.

If the miscarriage does not completely clear on its own, this is an 'incomplete abortion' and medical intervention is required. The most common form of intervention is surgical, the "D&C" or Dilation and curettage. An alternate treatment is the administration of Misoprostol, a drug which makes the uterus contract and expel any remaining products. Both procedures have their risks for future pregnancy, and should be discussed in detail with your health care provider.

Coping

There are many online resources available, and your medical practitioner will be able to recommend support groups and the like. Your hospital chaplain will also be available to discuss any spiritual issues. (And no, it's not punishment. God does not hate you. It's regrettable, but it is not divine vengeance. Not from any God I'm willing to believe in, anyway.)

Sadly, though, the best advice I could find from others who've been here was to support each other and to understand that you can't accept it overnight. It can take a long time to come to terms4.

Sorry I can't offer more than that. If I find something that works better, I'll add it here.

Aftermath

Immediately after a miscarriage, the body has to return to normal. The menstrual cycle must resume, and the pregnancy hormones must dissipate. The cervix must close, if dilated, and the "mucus plug" which prevents infection must reform. In the week immediately following a miscarriage, nothing should be inserted into the vagina (tampons, penes, etc.) in order to prevent infection.

Most experts agree that a normal menstrual cycle should follow before sexual activity is resumed. Studies have shown that chances of successful pregnancy following a miscarriage are no different than chances otherwise. Some studies even suggest a slightly elevated chance of conception in the two or three cycles following a miscarriage.

Emotionally things can be quite difficult, even once past the pain of the miscarriage itself. A subsequent pregnancy can be fraught with concern. Instead of experiencing the joys of pregnancy, couples who have had a miscarriage often spend the months of gestation waiting for something to go wrong. Again, the best advice is that a past miscarriage is no indicator of future difficulties. Each spin of the wheel is independent. You can only wait and hope, and thinking positively is the best remedy for your fears.

Statistics

Most sources put the number of miscarriages in "known" instances of pregnancy at around 20%. One in 5 pregnancies will end in the first or early second trimester due to some problem with the process, as described above. It is felt that significantly more pregnancies fail before the mother even knows she was pregnant. For example, trisomy in all but a few chromosomes will render the embryo non-viable almost immediately after conception. These pregnancies may seem just to be a slightly late and/or unusually heavy period, and often go undetected unless the mother is having a blood test for another reason.

References

My biggest source of information and inspiration was Miscarriage, Why it happens and how to reduce your risk by Henry Lerner, M.D., OB/GYN. This is an excellent and very readable book with a wealth of detail I have omitted here. In addition I read numerous online articles, but I was not as rigorous in tracking them as is my wont. The eMedicine Consumer Health Web Site at http://www.emedicinehealth.com/index.asp was helpful in preparing this entry.

Afterword

Corrections are most welcome, and will be duly recognized.


  1. Various syndromes such as Klinefelter's syndrome and XYY Syndrome may result.
  2. On chromosome 23, monosomy is survivable, with Turner's syndrome the result.
  3. This is the hormone detected by home pregnancy test kits.
  4. I've been trying to write this entry for weeks.

It was a Wednesday night, right after dinner. Paul was trying his best to be good company for Vanessa, but she felt distracted, anxious, her husband's voice the background noise of a radio playing in some distant room, tuned to a station no one ever listened to. Vanessa busied herself clearing the dishes, then wiping off the table and kitchen counters.

She was one week into her third month of pregnancy.

They finished dinner. Paul helped her gather up the dishes and insisted that she go sit down and rest, let him take care of the clean-up, but Vanessa was having none of it.

"Stop treating me like I'm some goddamned china-doll, all right? I'm fine."

"But you look tired."

"You happen to glance in a mirror anytime these last few days? You look like something out of Invasion of the Body Snatchers, only without the breezy wit and sidesteps of whimsy."

Paul laughed. "Things have been kind of busy at the restaurant."

She grabbed his shoulders and turned him around. "All the more reason to let me take care of you, dummy. Now, go, leave and do not darken my towels again."

"Huh?"

"Line from a Marx Brothers movie. Go. Sit. Relax. In a month or two, you'll be doing this full-time for me."

"And don't think I'm not looking forward to it."

"You're still here."

"Leaving now."

"That's my good boy."

She was just adding dish soap to the water running into the sink when she felt the smallest of twinges deep inside. She paused for a moment, waited for it to pass, and was reaching for the first plate when the twinge returned, stronger this time, hotter, shooting into her back.

"Something's not right," she said to herself.

"What's that, hon?" called Paul from the other room.

"Huh? Oh, nothing. I, uh...I have to go to the bathroom. Could you watch the water for me? Make sure the suds don't run over the edge."

"I've been doing dishes since I was four years old, my love. We have dishes at the restaurant, as well, remember? I think it might be okay to leave me unsupervised for a minute or two."

Vanessa smiled at him, then left to do her business.

By the time she got to the bathroom, the twinge and heat had passed and she felt just fine- well, she needed to remove her bladder and slam it up against the wall a few times, but what else was new?

She peed ten to fifteen times a day now, something her doctor and other pregnant women assured her was par for the course in the wondrous journey toward motherhood. If she could lay claim to no other epiphany resulting from this, she could firmly state that, in the past few months, she'd learned the truth about the so-called "radiance" of an expectant mother: It had nothing to do with her carrying the miracle of life in her womb; oh no, that was a romantic myth best saved for the daytime soaps and cheap tearjerker novels.

The truth was, if a pregnant woman appeared to "glow," if she took on a "luminous" quality, it was because she had just peed, or needed to pee and had discovered there was a bathroom nearby.

Vanessa laughed as she unbuckled her belt and unzipped her jeans and slid the works down past her calves as she sat down on the toilet.

A breath, a sigh, a contended hum in the back of her throat, and the sweet, waterfall sound of radiance filled the cramped bathroom.

For a few seconds, it was bliss.

Then an invisible hand rammed itself deep inside of her and dragged rusty steel hooks down the throbbing walls of her uterus.

For the rest of her life, she would remember the next sixty seconds in all of their terrible detail: First, the pain, wrenching and merciless; then the sound she made, somewhere between a shriek and a scream; next, the floor rushing up to meet her as the invisible hand wetly tore itself free and shoved her off the toilet seat; and then she was curled up on the floor, knees pressed against her stomach, feeling the blood seep from between her legs as she shook, her hands clasped together tight, mashed against her vagina.

She lay convulsing for what seemed hours before she heard the sound of the bathroom door being opened and then there was Paul, his warm, soapy hands cupping Vanessa's face, tears streaking his cheeks, muttering "Oh honey, my love, my love" over and over as he gently helped her to sit up, and then embraced her, rocking her back and forth, stroking her sweat-soaked hair and whispering, "All right, it's all right now, shhh, there, there, it's over, it's passed, it's all right, I'm here, I'm right here, honey, you don't need to--"

Vanessa pulled away from him, wiped the sweat and tears from her own face, leaving streaks of blood in their place, and saw that Paul had looked over her shoulder and was staring into the toilet.

"Oh my dear Lord," he said.

Vanessa moved forward to look but then Paul was there, holding her back, saying, "Don't, hon, you don't--"

Vanessa pushed him out of the way and leaned over, her hands gripping the edge of the toilet bowl.

And there was their baby; small, like a bumblebee, like something you could balance on the tip of your thumb, Tom Thumb, that was its name, floating around in the center of the blood and urine and placenta and what remained of the amniotic sac, wriggling around as the force of its mother's beating heart against the porcelain created ripples in the water, little swirls, and as she stared Vanessa could make out things, little things, microscopic Tom-Thumb-things like fin-flaps that would have been arms, knobs that might have been its hands, a bump that could have turned into a more flattering version of her own nose as Tom Thumb grew older, a dark pinprick of eye, all of it curving into a semi-human shape my child, my baby, swim to shore, swim like a good strong little boy, over here, I'm right over here--

They managed to temporarily staunch the worst of the bleeding with a knot of Kotex pads, then Paul sat Vanessa on edge of the bath tub, closed the toilet lid, and spent a minute mopping away the blood on the floor, all the time checking with his wife to make sure the bleeding hadn't worsened.

"I'll go get...uh, a few things, hon. Why don't you come out and lay down on the couch?"

"No. I'll just...wait here."

"Do you think you ought to--"

"Yes."

"All right, then."

Paul quickly returned with a plastic ladle and a large, clear plastic freezer bag. "I poured some rubbing alcohol on the ladle so it'd be sterile and this bag's got an airtight seal. I figure something like this would be best." He opened the toilet lid and knelt down.

"Paul?"

"What is it, honey?"

"I'd like to do it."

"Want me to stay here with you?"

"No, that's all right."

"You be okay?"

"I'll be fine." She placed her hand against his cheek. "You're a wonderful man. I love you right now more than I ever have, I think. Thank you."

Paul's eyes misted over. "You don't have to thank me, Vanessa. You're my wife. I'd do anything for you. I love you."

"I love you, too." She was stunned by the sudden, deep rush of affection she felt toward him.

"You were always there for me, weren't you?"

"Even before either of us were born." He softly kissed Vanessa's forehead, rose to his feet, then left, making sure to give one last smile before closing the door behind him.

Vanessa knelt down, wincing against the pain and the bloodstone-knot of Kotex pads, took a deep breath, then did it quickly, making sure not to stare at the thing that would have been their first child for too long. Everything went into the bag--fetus, placenta, blood, urine, amniotic sac- then with a quick zzzzzzzip! the bag was sealed. Maybe this time the doctors at the hospital would be able to test the remains and figure out why they'd lost the baby.

She closed the toilet lid and sat on it, holding the bag near her chest.

Two minutes. She allowed herself to sit there and hold the bag and cry for two minutes, no more.

Paul filled a small Styrofoam cooler with ice and Vanessa placed the bag inside, then attached the cracked lid.

"Ready to head over to the hospital, honey?"

Vanessa felt as if she were folding in on herself; the pain was still screaming through her center, the nausea was still rising, and the shaking had only worsened. "I d-don't know. I think I c-could maybe use some help." Then came the dizziness.

The next few minutes were a feverish blur: Paul's voice, Paul's hands helping her to sit, to move, then the smell of exhaust fumes and a strange man's voice saying, "Please let us take over, sir," then a second pair of hands, hard and calloused and strong, helping her onto a gurney, then motion, sick-making motion that caused her to leak all the more, so wet down there, so warm and wet so why did she feel so cold?...

...voices and images, people in a drunken pain-dream swarming around her...

...bright lights, other voices, other hands, squeaking wheels and faster motion, her clothes taken away, sterile smells, pain still there, still leaking, her legs gently lifted, ankles into cold stirrups, a needle in her arm, a plastic mask placed over her mouth, numbness, my baby, oh Paul, empty, so empty....

A genetic defect in the fetus compounded by structural problems of the uterus was the explanation the doctors gave to her. They were all very nice and showed the proper amount of sympathy and concern but, despite their words of comfort and their patient explaining of all the medical jargon and Paul's reassuring words and gentle embraces ("We can still try again, honey."), all she heard was Empty, empty, empty...

She came back from the hospital dazed and tired, weak and enormously sad. She tried to remember if she had ever experienced such deep emotional pain before, then decided it didn't matter. The loss was great and complete in the way only death is.

For the first few days she couldn't talk to anyone, but at the same time it hurt too much to be alone. She would just cry and cry without stopping; over this, she had no control. One of the clearest reminders that she was no longer pregnant was the speedy change her body went through. Within three days her breasts, once tender and swollen, were back to their normal size; her stomach, which had grown hard, was soft again. Her body was no longer preparing for the birth of a child: it was simple and blatant and cold.


Explicating the scene, since some have asked: if a woman miscarries, she does not have to take the embryo/fetus to the hospital, but if she wants to get a definite medical explanation of why she lost her baby, the hospital's having the remains on hand for testing is extremely helpful. Obviously, this step is more than some people can handle, so nobody expects them to. A death certificate is not issued in the case of a miscarriage.

The world spun, then tilted on its axis. Not again, I thought to myself, my hands grabbing onto the edge of the desk with violent force, draining the blood from my knuckles, so they turned paler than normal against the honey wood beneath my sensitive fingertips.
My aunt walked past, carrying a tumbler into the kitchen. She turned her head.
"you okay?" She asked, not knowing, she wouldn't believe me if I told her.
"I'm fine, my period's really bad this month." An acceptable lie. They'd believe it.
A huge lump traveling, moving. Pain, nausea, dizziness. Can hardly move can hardly breath. cold, shifting, chills and heat. Panting, fighting sobs.
The lump shifting itself again, and the pain grew exponentially until I nearly fainted. A Vicodin chased with some herbal tea. Good night.

Again the world tilted, but this time from shock, not pain. I sat on the edge of the couch, staring at my best friend, as she read over something on her computer screen.
"Do you remember when you were so sick in June, on your vacation?" She asks, her voice deadly serious].
"Yes." My voice is deadpan by now. I'm numb.
"You had a miscarriage." I blink, then curl up, fighting tears. I won't let her see me weak, not like this. She's seen me fall to pieces once before, and I can't afford to let her see me like that again. It'd be too much.

Mis*car"riage (?), n.

1.

Unfortunate event or issue of an undertaking; failure to attain a desired result or reach a destination.

When a counselor, to save himself,
Would lay miscarriages upon his prince.
Dryden.

2.

Ill conduct; evil or improper behavior; as, the failings and miscarriages of the righteous.

Rogers.

3.

The act of bringing forth before the time; premature birth.

 

© Webster 1913.

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