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Let’s talk about Miscarriage

I don’t have good news.

I have uttered this phrase more times than I care to count over my career. Many people would be surprised by this as I am an OB/GYN and everyone tends to think this is a very happy job. I do have the privilege of being with people as they bring their babies into the world which is one of the happiest and most memorable experiences to share with someone. However, I practice obstetrics in one of the most populated cities in the world, a city where many women and couples are deciding to delay child bearing until later in life. Because of the nature and demographics of my patient population, I see a higher than average number of miscarriages and almost weekly have to relay the heartbreaking news to someone who was excited and ready for a baby that they have had a miscarriage. This never gets easier and often the first time I am meeting a patient is when I have to tell them that they have had a loss. I walk into the room, introduce myself, and as gently as possible tell them they have lost someone they never met but whom they already love and are waiting to share their lives with. I want to share a few insights from my experience and conversations with patients and friends in the hopes of helping those who have a loss to feel less alone and those who have yet to start their pregnancy journey to better understand miscarriages.

Early pregnancy loss is very common, occurring in 10% of clinically recognized pregnancies. The frequency of clinically recognized early pregnancy loss for women aged 20–30 years is 9–17%, and this rate increases sharply from 20% at age 35 years to 40% at age 40 years and 80% at age 45 years. This means that miscarriage is even more common when accounting for the many pregnancies that are a very early loss. A woman may have thought her period was delayed and not even realized they had an early loss. As home pregnancy tests have become more sensitive, more women are getting a positive test even before a missed period and then having to face the news of an early loss, before anything is seen on an ultrasound or confirmed on a blood pregnancy hormone level.

About 50% of early losses are related to chromosomal abnormalities. Many people are not aware that although babies with Down syndrome can survive to life, the vast majority do not. There are other common genetic abnormalities that are lethal or incompatible with fetal development. Countless factors can lead to an early miscarriage, but the most important fact to relay to someone who has just lost a pregnancy is that it is not her fault. Women immediately start to think of everything they have done since conception and blame themselves- their stress level, job, busy schedule, fights with their partner, thoughts of not being sure they had wanted to be pregnant, having a prior termination, working out, having sex, or any other multitude of behaviors for the loss. I always tell my patients that a healthy pregnancy that was meant to be will stick in the uterus and thrive and that none of their actions or thoughts could have caused the early loss of the pregnancy.

It is also a common misconception that earlier pregnancy losses are easier for the mom and other family involved to grieve than a later loss. The dreams and thoughts of having the baby start for many women and partners prior to even getting the positive pregnancy test. Even a very early loss can be devastating and felt as the loss of a family member. Telling these people that miscarriage is very common may seem like a comforting statement but it can also feel very clinical and as if the event is being diminished- the loss of a parent or friend is also a common occurrence in life but it does not mean it hurts any less.

Perspective moms and partners may also react very differently than each other to the news; there is a wide spectrum of responses that are normal for different people. I have had patients appear indifferent or unresponsive, in shock, or devastated and crying. Others start processing the facts and data right away, asking about the technicalities and rationalize what happened. Others yet are in disbelief and want to return at a later date to repeat the ultrasound and bloodwork. Some may even be relieved as they were contemplating termination and no longer have to make the very difficult decision. There is no right or wrong way to respond and the outward reaction may be very different from the inner thoughts.

Many women are shocked due to the fact that they had no clue how common miscarriages are. Many miscarriages also happen without any symptoms like bleeding or pain and so come as a complete surprise to those who think someone must have symptoms to have a miscarriage. A sense of innocence around pregnancy and starting a family is lost as they previously had not fathomed this happening. They can also be upset that no one else has shared their stories of loss to help prepare them for this possibility. When they open up about their experience to friends or family they often hear their loved one’s stories and can not believe that they had not told them prior. Miscarriages are often extremely private and difficult struggles for those who experience them and many people do not feel able to discuss their experience even with those closest to them as the loss can remain very raw and emotionally charged for a long time.

There are many different ways to manage an early miscarriage and often the mom needs time to process before even discussing the options. No one should be rushed or felt forced down a certain path they are not comfortable with. I have had many patients who even though the ultrasound and/or bloodwork are conclusive feel the need to come back and see it again or get a second opinion before taking other actions as they are hoping for a miracle or just want to be 110% sure they are not taking any action that would end a normal pregnancy. They should never be made to feel bad for wanting this time and confirmation. Many women can not stand the thought of having a dead baby inside of them and want a procedure or medication immediately so that they do not have to walk around any more knowing that the baby that is no longer alive is still a physical part of them. There are many other responses as well and I want women to know they are all ok- how each of us responds to pregnancy loss and grieves is very different and you should do what feels right for you.

What I do want to encourage is that women take the time to grieve and process what has happened. Please treat yourself with compassion, self care, and love. This will always be part of your story, however it will not be the only part of your story. If sharing your story is therapeutic, please share. Your words will help someone else. If you need to keep it to yourself because it is still so painful, I understand. I have heard from women late in life who have never told their families of a miscarriage they experienced when they were younger. They still think about the lost baby and have carried the experience with them quietly through the rest of their lives. No matter how you go through this time, please know that you are not alone on this journey.

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