Pregnancy loss

‍

Pregnancy loss is a difficult experience for anyone. In medicine, we essentially think of pregnancy loss and two distinct phases. The first phase, commonly called miscarriage, happens in the first 20 weeks of pregnancy. The second phase, commonly called stillbirth, happens in the second 20 weeks.

‍

Depending on the research, estimates for pregnancy loss of all pregnancies, whether known or unknown, range from 40% to 70%. The actual number probably is somewhere around 50%. The vast majority of these pregnancies end because the fetus has a genetic error that prevents survival. Essentially, the genetic blueprint is good enough to get them to some point in the pregnancy, whether that is 8 weeks, 14 weeks or 28 weeks, but not good enough to continue past that.

‍

The high number of miscarriages often surprises people. However, only about 10-20% of known pregnancies are lost. The difference, driving the number of known miscarriages upward, is that we are diagnosing pregnancy earlier and earlier, now as early as 8 days after conception with at home urine tests. This means that women who have not missed a period can be diagnosed with pregnancy.

‍

The important thing to remember if you experience an early pregnancy loss is that you did nothing wrong. It was not the food you ate, the exercise you did, or even the alcohol that you might have drunk prior to finding out you were pregnant, or even after you were pregnant. Pregnancy loss is very normal, just as normal as having a normal pregnancy go to delivery.

‍

Medically, we have different names for how pregnancies end. For example, when the fetus stops progressing and there is no longer a heartbeat, the pregnancy may or may not spontaneously miscarry – or result in stillbirth. We call this intrauterine fetal death (IUFD). If a pregnancy spontaneously ends before 20 weeks accompanied by bleeding and—depending on the age of the fetus—passage of fetal tissue; that is called a “spontaneous abortion”. This is not to be confused with an elective abortion, which is when a pregnancy is ended by the choice of the patient—whether or not it was due to a health issue for the mother or the fetus.

‍

Pregnancies are measured in trimesters. The first trimester ends at week 12. The second trimester goes from week 13 to week 26. The final trimester starts at week 27 and goes until the end of the pregnancy. Deliveries are considered “premature” from 20 weeks through 37 weeks and “term” from 38 weeks on. About 90% of all pregnancy loss occurs before 12 weeks.

‍

However “premature” does not equal “viable”. Viability is a measure of how likely the delivered infant is to survive to discharge from the hospital. Most institutions agree that infants born prior to 23 weeks are not likely to survive or have a good neurological outcome. Typically, parents are given considerable say in whether or not a 22 week to 23+5 premature neonate should be resuscitated (treated aggressively) or allowed to pass away without aggressive treatment. However, the earliest preemie to survive was born at 21 weeks and 4 days, and is doing well. At the institution I trained at, Naval Medical Center, San Diego, the NICU was so advanced—and had such a persistently good record on the youngest neonates—that  babies at 22+4 weeks and above without significant co-existing conditions were resuscitated (treated aggressively) regardless of parental desires.

‍

What is a typical miscarriage like? Usually, the pregnant patient begins to experience either vaginal bleeding, or pelvic or back pain or both. Depending on the age of the pregnancy, bleeding can be light or very heavy. This usually lasts for a few days, with a period of about 8 hours where the bleeding and pain are the heaviest. Most patients having miscarriages do not have to go to the hospital if they already know that their pregnancy is an IUP (Intrauterine Pregnancy). However, if there has been no ultrasound in the pregnancy, or if the patient is undergoing fertility treatment, it is best to get a formal ultrasound to rule out an ectopic pregnancy (a pregnancy outside the uterus). An ectopic pregnancy can be life threatening, and requires treatment, so it is important to rule that out with an ultrasound showing the pregnancy is inside the uterus and in its appropriate place. For more information on ectopic pregnancy, please look for my upcoming article on the subject.

‍

Another reason to go to the hospital if you are experiencing heavy vaginal bleeding or pain, associated with a fever or feeling very ill, during early pregnancy is to rule out a septic abortion—this is a medical term which means that the uterus is infected. This can happen when IUFD (Intrauterine Fetal Death) has occurred but not been detected, and infection sets in. This is also life-threatening to the mother.  Also, I always let my pregnant patients know that they should go to the hospital if they have bleeding which is greater than 2 pads per hour for more than 4 hours. Pregnancy loss is one of those times that women can easily bleed to death from the vagina, so it should needs to be evaluated if the bleeding is heavy and prolonged.

‍

What about pregnancy loss that doesn’t result in a spontaneous miscarriage? Typically, IUFD is detected on routine ultrasound. Often we will discover it in the Emergency Department when we have a patient we discover is pregnant through our routine testing, and so we perform an ultrasound. Or, there might be a slight amount of pain or bleeding, and so we perform an ultrasound to rule out an ectopic pregnancy.

‍

What about pregnancy loss after the 1st trimester? This is much less common. Only about 10% of pregnancy loss is after the 12th week, and of that, 95% is before the 20th week. Only 0.5% of pregnancy loss occurs after the 20th week. This can be discovered through women going into labor and testing reveals IUFD, or the fetus is so premature that it cannot survive, or routine ultrasound revealing that the fetus has died, or has some malformation that will not permit survival to birth.

‍

How do people feel about pregnancy loss, is it normal to feel like they have lost a child? Yes, absolutely. From the moment we know about a pregnancy, we begin to feel a bond with the developing life. We begin to have dreams and visions about how our lives will change, what the new person will be like, how we will interact with them as their parent. Losing that pregnancy is losing all of that potential, that love that we are developing that is just as strong, just as natural, as the love we feel for a child who is born and breathing.

‍

Do some people not feel grief? Is that normal? Yes, that is also fine. Many people, especially those who have experienced pregnancy loss themselves, or vicariously as nurses and doctors, will essentially refrain from having expectations of pregnancy success until well into the pregnancy.

‍

When I found out I was pregnant, it was initially with twins. At just before 8 weeks, one twin died in utero. We were in Japan, and because of the high-risk nature of my pregnancy, we were being cared for by Japanese specialists. Due to our lack of apparent grief or distress at the news, the Japanese doctor—who spoke excellent English—asked us if we had understood her, and understood that the other fetus was now also at risk. We explained that, yes, we understood, but that as I was a doctor, we knew that this was essentially likelihood for any pregnancy at my—ahem—“advanced” maternal age. We were just glad that the other fetus was still there and still going. We did not announce our pregnancy widely until 12 weeks into it, because we knew that the risk for miscarriage declined sharply by that point. While I am at times still wistful about what that other child might have been like, I have never experienced any grief at the loss, and am delighted with the daughter we do have.

‍

In summary, pregnancy loss is common before the 12th week, and still occurs throughout pregnancy. Very rarely does the pregnant person have anything to do with the pregnancy loss. In the vast majority of cases, pregnancy loss is the natural result of the genetic make-up of the fetus. The process of making sperm and eggs with half of the parental genetic code followed by combining two halves into one is complicated, and rife with opportunities for error. I often find myself amazed that this process works out so well, so often.

‍

If you care for someone who is experiencing pregnancy loss, remember that there is no one way to respond. Reactions range from severe grief to acceptance. Even those who have pregnancies that they were not expecting, and perhaps didn’t want, might still experience grief at the loss. Pregnancy loss is a normal part of maternity, but that doesn’t make it easy or painless. The best thing anyone can do for the parent(s) is to be there and listen empathetically, without judgment or advice.  

‍

As always, if you have any questions, please feel free to call me at 760-575-7272 or email me at DrEdwards@wowhealingcare.com.