By Dr. Jane van Dis, OB-GYN and Maven Medical Director

Miscarriage is an important, vital, essential topic in women’s health—in part because so many women experience it, and yet so few women talk about it. So let’s talk about it.

As an OB-GYN, I think one of the most important jobs I have is to hold space for women and couples who experience the wrenching pain of a miscarriage at any stage, and for women who have a stillbirth at or close to term, or who are forced to terminate a wanted pregnancy for medical reasons.  All of these spaces are important. Though healthy pregnancies are the norm, pregnancy loss at any stage of development is also normal. It doesn’t make it easy, but it should not be shrouded in shame. The loss alone is enough; the shame women carry is too much. When I counsel women I first provide comfort, reassurance, and biological or medical explanations, if appropriate.

Every woman’s experience of pregnancy loss is different. Some women need to memorialize their loss—plant a tree, have a funeral, make an ornament—and others want to get back to work and try to move on. Both, and everything in between, are okay.

We know that finding emotional support and specialized care while navigating a loss is especially challenging. At Maven, we have a care program for women and partners who have experienced loss, personalized to meet their unique needs. We have expert providers who specialize in understanding loss and miscarriage, including mental health specialists and grief counselors, reproductive endocrinologists, high-risk OB-GYNs, genetic counselors, and career coaches. Emotional support and community is core to our program and resources, to help our members navigate this time, know they’re not alone, and find the support they need to move forward however and whenever they’d like.  

For Pregnancy & Infant Loss Awareness Month marked in October, let’s continue to end the shame and the silence around loss, and to give space to ourselves and to others who need to grieve and heal and feel on their own terms.

Understanding miscarriage and loss

Let’s look at some facts to ground ourselves, because miscarriage is both simple and complex, and fraught with contexts that are medical, social, political, and deeply personal.

The facts

  • A miscarriage is a loss of a pregnancy and it’s called a “miscarriage” (from English to “wrongly” “carry”) before 20 weeks. After 20 weeks, it’s termed a stillbirth; and after 24 weeks, an IUFD (intrauterine fetal demise), though many women use the term stillbirth throughout 20+ weeks
  • Pregnancy loss is quite common, especially early in a pregnancy:
  • Miscarriages are extremely common: 10-20% of all confirmed pregnancies miscarry by 13 weeks
  • 31% to 50% of women miscarry before knowing they are pregnant
  • 1% of all pregnancies end in miscarriage between 13-20 weeks
  • Less than 1% of pregnancies end in stillbirth after 20 weeks
  • 50% of all miscarriages are due to genetic or chromosomal abnormalities – often the combination of egg and sperm producing a non-viable pregnancy. Importantly there is nothing inherently “wrong” with the genetic material of either parent, generally, just that that particular combination of DNA didn’t produce an embryo.  
  • Your chances of having another miscarriage are dependent on the reasons for having your prior miscarriage(s).

Emotions and psychology

Any emotion that you feel after a miscarriage is “normal.” Some women are angry, others are sad and feel profound grief and sense of failure of themselves, of their body. Women who might not have wanted to be pregnant might feel relief. Others might not want to feel anything and would rather ignore the loss for a while and come back to it later, or not at all.  And some women feel clinically depressed.

All of these are completely normal, and, in fact, it’s normal to cycle through different emotions after a miscarriage. Miscarriages can be tied up with ideas about our partners or husbands, and miscarriages can have cultural and social implications that make us feel like we disappointed our family or the expectations of others.

In my 20’s, I had an ectopic pregnancy and nearly died from internal bleeding after it ruptured my fallopian tube. That was also a miscarriage. I felt relief that I didn’t die, I was sad at the loss of the pregnancy, and I was angry at my fiance for abandoning the relationship when he found out I was pregnant—three very powerful emotions around a single pregnancy loss.

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Reasons for miscarriage

  • Genetic/chromosomal
  • Infections
  • Antiphospholipid antibody syndrome/lupus
  • Smoking, drinking, exposure to environmental hazards, radiation
  • Uncontrolled diabetes
  • Thyroid disease
  • Drugs like Accutane
  • Other risk factors for miscarriage include advanced maternal age, previous spontaneous pregnancy loss, and maternal smoking
  • There are some myths around what can cause a loss. These activities do not cause miscarriage: exercise, regular physical activities, minor accidents or falls, or sexual intercourse

Symptoms

  • Bleeding
  • Cramping, pelvic pain or back pain
  • Loss of breast tenderness or nausea of early pregnancy
  • Fever/chills, which are a sign of an infection and one that needs immediate treatment

Diagnosis

  • Blood test to check for beta-hCG (beta-human chorionic gonadotropin) or the “hormone of pregnancy”
  • Ultrasound
  • Pelvic exam

Prevention

  • Nearly all miscarriages, once they start, cannot be reversed or stopped.  There is no medication to prevent a miscarriage.
  • Sometimes, when women have what is termed an “incompetent cervix” we can put a stitch in the cervix and sew the cervix shut so that the cervix doesn’t allow the pregnancy to pass. Ideally this is done at around 14 weeks gestation.  
  • In the days leading up to viability (technically 24 weeks, but some will use 23 weeks) we can give drugs to stop uterine contractions and to accelerate the fetus’ lung development in event born preterm.

Management and treatment

There are multiple ways pregnancy loss can be managed, depending on the stage of pregnancy, the institution’s availability (or religious objections) for care, the individual’s overall health or complications, as well as their own preferences. For those early in their pregnancy who are considered medically stable, miscarriages can occur non-invasively and safely at home, with 80% of miscarriages completing on their own—meaning the pregnancy tissue will pass from the uterus—in 8 weeks. This can be sped up using medication to occur within 2 days, in most cases.

Dilation and evacuation (D&E) can be offered for women from 14 weeks until 24 weeks gestation—if there are skilled OB-GYNs to provide the care—performed in an operating room with sedation to ensure prompt passage of stillborn. Some individuals prefer to deliver their stillborn vaginally, in which case labor is induced.

When it’s safe to try again

One of the many common questions we hear from Maven members is: “should I try to conceive again and when is it safe to?As Dr. Brian Levine and I discussed in our weekly Ask Maven Anything Instagram Live chat recently, you can try as soon as you’d like. Psychologically, I recommend women have at least 1 menstrual cycle before trying again, but there’s no data to show that if you get pregnant again right after your miscarriage that you are at increased risk for another miscarriage.

The bottom line

Miscarriage and loss is complex, common, personal, and so many things to different people. As I said before, every individual’s experience of pregnancy loss is different. And that’s okay. While Pregnancy & Infant Loss Awareness Month may be coming to a close, let’s continue to end the shame and silence around loss all year long. If you’ve experienced a loss and you’re looking for emotional support or specialized care, we at Maven are here for you.  

Resources

Dr. Jane van Dis is Maven’s Medical Director, a board-certified OB-GYN, and a frequent writer and speaker about gender equity in medicine. On our blog, Dr. van Dis shares insights on improving outcomes during pregnancy and beyond, as well as the latest clinical guidance in women’s and family health. Follow her @JanevanDis.

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