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Understanding Miscarriage

Understanding Miscarriage

Miscarriage affects the lives of many women and their partners and the true impact is often underestimated by health professionals, family and friends. Just because miscarriage is a relatively common event does not mean it is insignificant or that it should, or will, soon be forgotten.

Why does miscarriage happen?

Story

When Tanya and Daniel first fell pregnant after only a couple of months of trying they were ecstatic. There seemed to be no reason not to tell family and friends the good news. Tanya even bought a gorgeous baby outfit and bunny rug at the January sales. They made plans to turn the spare room into a nursery and had long discussions about baby names. Eight weeks into the pregnancy Tanya woke up with cramps. At first she put it down to the curry they had had the night before but then she started to bleed. At the hospital the ultrasound revealed that the baby had no heartbeat and a miscarriage would occur. Tanya and Daniel were devastated. Tanya didn’t know anyone who had had a miscarriage or so she thought. Over the next few days as they were comforted by friends and family she found out that her mother had had two miscarriages and her Aunt had had several. They had just never talked about it. The hardest thing Tanya said was not knowing the sex of the baby they lost. Months later the couple found the due date of the baby hard to cope with as they were reminded of what they had lost and they might have been celebrating if all had gone as expected. Within a year they became pregnant again and this time everything went well and they had a lovely little girl called Jessica. Tanya says, however, she has never forgotten that first pregnancy and still wonders what may have been.

Miscarriage is a term used for loss of a baby before 20 weeks of pregnancy. In Australia every year more than 50,000 pregnancies end in miscarriage or stillbirth. It has been estimated that half of all conceptions end in miscarriage before 12 weeks, though many women will not be aware they were even pregnant. Around 20 to 25% of known pregnancies end with miscarriage and 80% of these will occur in the first 12 weeks of pregnancy.  Around 1-2% of couples experience recurrent miscarriages.

The majority of spontaneous miscarriages are due to major fetal or genetic abnormalities. Other causes are an unusually shaped uterus, exposure to certain drugs, early opening of the cervix, hormonal imbalances, immunological factors, direct trauma to the lower abdomen, poorly controlled illness like diabetes, and environmental factors such as smoking, alcohol, radiation, infections and exposure to certain chemicals. As a woman’s age increases so does her risk of miscarriage and this is mainly due to the fact that the incidence of genetic abnormalities increase with increased age.

It is important for women to realise that it is very rare for a miscarriage to occur because of something they have, or have not done. Unfortunately with the majority of miscarriages the cause will not be known and this can make dealing with the un-answered questions difficult. This lack of information can make couples feel frustrated, helpless and fearful about future pregnancies. Tests can be done to determine some causes but in most instances no cause is found.

Types of miscarriage

A ‘threatened’ miscarriage is where vaginal bleeding may occur over several days or even weeks in the first half of pregnancy. The woman’s cervix remains closed and the baby remains in the mother’s uterus. Bleeding occurs in around 30% of pregnancies and roughly half of these women will go on to miscarry whilst the rest will continue the pregnancy. Bed rest has not been shown to be effective in preventing miscarriage. A ‘blighted ovum’ is another common term used when women miscarry. This is where an egg is fertilised but it doesn’t go on to divide or develop into an embryo. The pregnancy test will be positive and miscarriage usually occurs around at 7 to 12 weeks. Ectopic pregnancy can also result in miscarriage and is potentially quite serious for the mother. It occurs when the fertilized ovum implants in the fallopian tube or some other place outside the uterus (1:100 pregnancies) Normal pregnancy symptoms occur and then usually by the 8th week bleeding and pain begin (pain is almost universal with ectopic pregnancy). Sometimes the fallopian tube will not need to be surgically removed but this is still the mainstay of treatment. Because you have two fallopian tubes you should be able to get pregnant again.

What happens with miscarriage?

The general course followed when miscarriage occurs is- a missed period, pregnancy symptoms, a positive pregnancy test, followed days or weeks later by vaginal bleeding , lower abdominal cramping, backache and miscarriage of the baby. Generally a doctor will take your history and examine you. They will take blood for a pregnancy test and suggest an ultrasound to see whether there is a baby in the uterus, if there is a heart beat or whether there is some tissue left inside after the miscarriage. Most miscarriages in the first few weeks of pregnancy are complete and women rarely need admission to hospital or intervention. After 6 weeks there can be an increased tendency for some of the tissue to remain in the uterus causing continued bleeding and even infection.

Management of miscarriage

A modern dilemma!

With increasing numbers of women having early ultrasounds in pregnancy some women are being told of problems that will mean they will most likely miscarry at a stage when they feel well and have no symptoms. For these women it is very hard as they have to wait until they have signs of a miscarriage or have had a repeat ultrasound in a week or so.

For many years the routine management for women having a miscarriage where some tissue was suspected to remain in the uterus was to have a surgical emptying of the uterus (commonly referred to as D&C). This is a short operation usually conducted under a general anaesthetic but it can be done under a local anaesthetic where the cervix is dilated and the lining of the uterus is gently scraped or removed by suction. This approach is now being challenged and women have three options. They can ‘wait and see’ if all the tissue passes through the vagina on its own. Where the ‘wait and see’ approach is used, particularly when women are less than 12-13 weeks pregnant, around 80% of women will not need surgical intervention. Another approach is called the ‘medical evacuation’ approach where hormones like prostaglandins are used to encourage the tissue to be passed. The third approach is ‘surgical evacuation’ where the tissue is removed by gentle scraping or suction to the uterine lining. When suction is used rather than traditional scraping of the uterus the procedure seems to be faster, less painful and associated with less blood loss.

Any tissue from the pregnancy that is passed through the vagina or removed during the D&C is usually sent to pathology for examination to see if they can determine the cause of the miscarriage. Unless you request for the tissue to be returned to you it will be disposed of by the hospital after it has been examined. It is important that you know you may not be able to identify the baby in the tissue after a D&C.

What happens after the miscarriage?

It is important to have medical follow up a couple of weeks after the miscarriage to make sure you are healthy. If you lost a lot of blood during the miscarriage then it is good make sure the iron levels in your blood are at a healthy level. It will also enable you to ask questions and talk about your feelings and the future, if you feel ready.

Breast milk is produced from 16 weeks onwards so if you had a late miscarriage you may find your breasts produce milk. This can be very distressing for some women but for others it can actually be comforting as though a confirmation that they really were pregnant and a link to the baby they have lost. The best way to suppress breast milk is to avoid stimulating the breasts, wear a firm bra and use cold compresses.

Vaginal bleeding continues for one to three weeks and progressively becomes lighter. Women who experience ongoing heavy bleeding, pass clots or have pain should seek medical advice. Sanitary pads are better than tampons for the first couple of weeks following a miscarriage to reduce the risk of infection

Generally waiting to have sex for a couple of weeks until the bleeding has ceased reduces the risk of infection. After this some couples gain great comfort from resumption of sexual intercourse whilst others prefer to express their love in other ways for a while.

Pregnancy symptoms should subside two to three days following the miscarriage and disappear within one week

Coping with loss

It has been said that whilst the loss of an adult represents the loss of the past, the loss of a baby represents the loss of a future.  It is not just memories that cause grief but lost hopes and dreams can also have a huge impact.

Miscarriage often represents a major loss to women and their families and reactions can be very similar to those that follow the death of any close friend or family member. Parents describe feelings of disbelief, sorrow, anger, pain, guilt, exhaustion and confusion. It is common for physical changes to occur such as problems with sleeping, eating and concentrating. These are all normal grief reactions to loss.  It is important to remember though that the range of emotions are vast, and while one woman may be feeling devastated over the loss of her baby, another woman may be feeling guilty that in fact this wasn’t a wanted pregnancy and perhaps her emotions even caused the miscarriage. It can also be hard when one partner appears to be getting on with life and resolving their grief and the other is not. This can be misinterpreted as not caring by the other partner or that there must be something wrong with them. Try to talk to each other or close friends and family about your feelings and remember everyone experiences grief differently.

Parents often have feelings of sadness re-surfacing around the date the baby would have been born. Getting pregnant again, or someone else announcing their pregnancy, can also bring back painful memories. Seeing pregnant women, or families with babies can also be distressing for some parents.

One of the hardest things for many parents following miscarriage is the lack of societal rituals such as a funeral, photos, hand and footprints (especially if the baby is too small). Parents can be left even wondering if they really were pregnant. They often feel there is no way to mark the significance of the event or capture the memories.

Unfortunately there is often nothing much to see when the miscarriage occurs really early on. Parents have the right, however, to mourn their baby as they see fit. This may involve planting a special tree, or even a plant that flowers around the time of the expected birth date, or time of year the miscarriage occurred. Naming the baby that was lost can help, as can deciding on the baby’s sex if this is unknown. Whilst you do not have to have a funeral for a baby that miscarries and is born dead under 20 weeks, you can if you chose to.

Other children need to also be considered when dealing with miscarriage. Whether you have already told a child or not about the pregnancy, they may be well aware that you are upset and normal routines and reactions are altered. It is entirely individual as to whether the parents share the miscarriage with their child or not. Be aware that children may become more clingly and sensitive or even be aggressive, disruptive or withdrawn. You may also find you want to be around your children more and want to keep them close. On the other hand you may feel unable to comfort them when you are hurting so much. Children are capable of much more than we give them credit. Explaining simply what has happened and how you feel can often be the best way. Children’s questions can also help you to understand how to best comfort them.

Helpful things to say and do when someone has a miscarriage

The most important thing to do when someone has a miscarriage is to acknowledge the loss. Its okay to say-“you have just lost a baby, it is very sad.” It is also important to help dispel guilt. Remind them it’s not their fault that this happened. You need to be prepared to listen to the same story again and again. Don’t forget the father! Remember to ask both the parents how they are going. If they gave the baby a name then use the name, as it means so much to parents. It also helps to offer practical help like cooking a few meals, helping with child care and daily chores.

Unhelpful things people say and do when someone has a miscarriage

The worst thing you can do when someone has had a miscarriage is pretend that nothing has happened. If you start avoiding the parents because you don’t know what to say you will make it so much worse and they will know exactly what you are doing. Trying to make it better is a natural instinct in humans. Some common and hurtful things often said to people after a miscarriage are-“it was only a miscarriage,” “you can always have another baby,” “you already have children,” “get on with your life,” “it’s natures way.” Hurrying parents through their grief is also very unhelpful.

Future pregnancies

One of the most common questions women ask following a miscarriage is “will it happen again?” The good news is women’s chances of not miscarrying again are excellent. In fact, after one miscarriage the chance is the same as for a woman who has never miscarried. Around 97% of couples who experience a miscarriage end up having a baby in the future. Even after several miscarriages your chances of having a successful pregnancy are higher than miscarrying again. It is advisable though if women have had three consecutive miscarriages to see a doctor who will recommend further investigations to try and determine a cause. As to when to get pregnant again following a miscarriage, this is entirely up to you. There is no evidence that waiting a certain period is advantageous, unless you have been advised to do this by your doctor. Future pregnancies don’t negate the losses of the past. They give hope and meaning to our lives and a reason to move on beyond grief and into joy once more.

Support Groups

Good Books

  • Loss of a baby, Margaret Nichol, Bantam books, Sydney Australia, 1990
  • A Silent Love, Adrienne Ryan, Penguine Books, Australia, 2000
  • Miscarriage: Information for parents and families, SANDS NSW
From the Australian College of Midwives Presidents report December 2010. Dr Hannah Dahlen is the Associate Professor of Midwifery at the University of Western Sydney. She has been a midwife for more than 20 years. Hannah is also an executive member of the Australian College of Midwives, NSW Branch. She has researched women's birth experiences at home and in hospital and published extensively in this area. Hannah's website is www.hannahdahlen.com.au

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