Pregnancy

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Miscarriage and Loss

Miscarriage

About one in four known pregnancies in New Zealand end in miscarriage (that is, they are lost before 20 weeks gestation); and around one in every 200 babies are stillborn (lost after 20 weeks).

By far the majority of miscarriages occur in the first 12 weeks of pregnancy and the actual rate of miscarriage is probably much higher, with around half of all pregnancies thought to end in miscarriage, usually shortly after conception.

Even now, when tests can be done so early and accurately, a large proportion of most women who miscarry aren’t even aware they had been pregnant; in many cases, the fertilised egg may not even have implanted.

“Missed miscarriage" is the term used for a miscarriage where the baby has died, but the woman’s uterus does not expel the fetus, placenta and tissues for a number of weeks, so she may not be aware that her baby has died. Estimates suggest this occurs in around one percent of pregnancies.

Between two and five percent of couples experience ‘recurrent pregnancy loss,’ which means they have been through three or more miscarriages consecutively.

It’s a heartbreaking statistic, made more difficult when a treatable cause can be identified in only around thirty percent of recurrent pregnancy losses.

How will I know if I have had a miscarriage?

If a miscarriage occurs in the first couple of weeks of pregnancy, a pregnant woman may be unaware that it has happened.

In the first week of pregnancy, there is very rapid cell division and growth, with implantation happening about a week after fertilisation. Hormone levels climb quickly and around this time, you may even get a positive pregnancy test result. However, at this stage, the embryo is barely visible to the naked eye.

There are many reasons why an embryo may stop developing; if this happens in the very early weeks, many women go on to have a normal period (though it may be slightly heavier, as the lining of the uterus will already have been preparing for a baby.)

The experience of miscarriage will vary for each person, but characteristically, there will be bleeding (which may be light but is often very heavy), and there are cramps – usually these are stronger than typical period cramping and may be quite painful.

‘Threatened miscarriage’ is the medical term for the symptoms that may occur in the lead-up to a miscarriage (although many women will experience these symptoms in early pregnancy but then find the symptoms disappear and their pregnancy continues normally.)

Symptoms of early miscarriage include:

  • Disappearance of typical ‘pregnant’ feelings such as swollen breasts and morning sickness
  • vaginal discharge (such as a thick blob of mucus which may be blood-streaked)
  • spotting or light bleeding
  • light cramping similar to typical period-cramps

If you know or suspect you are pregnant and you are experiencing any of these symptoms, you should talk to your doctor, caregiver or hospital straight away.

Unfortunately, there is nothing that can be done to prevent miscarriage, but it’s important to get medical advice, check to see if you need to go to hospital, and to ensure you are not in any danger – eg from an undiagnosed ectopic pregnancy.

What happens at the hospital?

If you have gone to your doctor or to a hospital and suspect you may be experiencing miscarriage, usually an ultrasound scan will be arranged.

In around fifty percent of miscarriages, either because of heavy bleeding or signs of infection or due to the couple’s choice, the contents of the uterus are surgically removed through a short operation called a ‘dilatation and curettage’, or ‘D and C,’ usually performed under general anaesthetic.

If the fetus has died but a miscarriage has not started naturally, you have the option to return to their home to wait for the miscarriage to begin.

If there is no medical reason for a D&C, this may be an option you choose; make sure that you understand all of the options available to you and, provided there is no overriding medical reason, that you are able to choose what you feel is best for you.

In a more advanced pregnancy (after 13-15 weeks), a D & C is not possible and the mother may need to go through labour to deliver the baby’s body.

Most hospitals are now very sympathetic to the trauma that couples experience at this time and will recommend appropriate pain relief options and support.

What happens during a miscarriage?

Whether you know that your baby has died – and are therefore expecting to go through miscarriage, or if a miscarriage is unexpected, if you have never gone through the experience of miscarriage before, most women are unsure about what to expect

No matter how you feel about your pregnancy, miscarriage is usually a very traumatic and upsetting emotional experience that accompanies an unpleasant and often painful physical experience.

Many women report that the experience was made all the more difficult because they did not know what to expect, so if you are told that you are likely to miscarry, it may help you to ask for as much information as possible from your caregiver beforehand about what you are likely to experience.

During a miscarriage, muscular contractions of the uterus will cause the cervix to open, and part or all of the contents of the uterus are passed out through the vagina.

A miscarriage will usually start with bleeding. If you are having a miscarriage, you will lose blood, clots and tissue (called ‘the products of conception’) and if the pregnancy is further advanced, may lose a fetus, usually much smaller than a living embryo of the same age.

A miscarriage may occur over a few hours or may go on for a number of days and the bleeding may continue for several weeks.

If you choose to stay at home, it’s wise to make sure you have someone with you who can support you and take you to your doctor or to hospital if necessary.

If you are experiencing miscarriage, you should avoid using tampons or having intercourse and avoid any strenuous activity. Don’t drive and stay in a safe, comfortable place.

If you’re worried about very heavy bleeding or intense pain or if you feel that things are moving beyond your control, call an ambulance.

You can use ‘super’ or ‘maternity’ sanitary pads or towels until the bleeding stops. Your caregiver may ask you to keep pads and towels aside or at least record how much blood you have lost. Try to save anything you pass in a container that you can take to the hospital.

You may feel later that you wish to bury your baby’s body. It is also often possible to run tests to understand why the miscarriage happened.

When the bleeding has stopped, it’s important to see your doctor for a checkup to make sure that all the contents of the uterus have been expelled. Your doctor may recommend a scan to see if a ‘D and C’ needs to be done. This is particularly important if you want to try to fall pregnant again soon.

Reasons for miscarriage

It is very common for women who have experienced miscarriage to feel very guilty and to have a strong desire to understand why their baby died.

In some cases, it is possible to run tests to identify a cause, but more often, it is not possible to find out why the miscarriage occurred.

Miscarriage is generally complex, and often due to a number of different factors.

However, we do know that there are many common reasons for miscarriage – and in most cases, these are beyond the voluntary control of the parents.

These include:

  • a chromosomal abnormality in the baby (thought to cause half of all miscarriages)
  • the fertilised egg not attaching properly to the wall of the uterus
  • a problem with hormone levels or with the placenta
  • mother’s health – infection, high fever or underlying medical problems like diabetes or thyroid condition
  • cervical ‘incompetence’ or uterine problems
  • exposure to chemical toxins, including cigarette smoke and alcohol consumption
  • daily exposure to at least 200mg of caffeine
  • increased age of the mother

Some of the causes of miscarriage can be successfully treated, and some lifestyle changes can be made, but in the majority of cases, a cause is not known.

Trying again after miscarriage

Everyone will react differently to the experience of a miscarriage. While some couples feel they need to take time to grieve before they can even think about trying to fall pregnant again, others feel that another pregnancy will help them to deal with their loss.

Medically, a women can start trying to fall pregnant after her first period following a miscarriage, which usually occurs within 4 to 6 weeks. Most doctors recommend that you have a checkup around six weeks after the miscarriage to ensure that the uterus has returned to normal size.

In most cases, the miscarriage happened by chance and is no more likely to happen in a future pregnancy. However, if you have experienced three miscarriages consecutively, or is it treatable call as has been identified, it is wise to get further medical attention before seeking to fall pregnant again.

Reducing the risk of miscarriage

Unfortunately, the most common reasons for miscarriage are not preventable. However, some lifestyle factors are known to contribute to greater fertility and a healthy pregnancy; these include:

  • avoiding alcohol, caffeine and nicotine
  • exercising regularly and eating a balanced diet which includes folic acid and sufficient vitamins and minerals, ideally from natural sources
  • maintaining a healthy weight
  • reducing stress and getting enough sleep

Dealing with Grief and Loss

Researchers have shown that many couples who have had a miscarriage experience grief responses similar in duration and intensity to those parents who have lost a new baby.

It is quite normal for one or both partners to suffer “temporary depressive feelings,” like sadness and lethargy, and it is also typical for normal eating and sleeping patterns to be disrupted for a period of time.

Grief and loss after miscarriage is often more extensive and intense than society leads us to expect.

Even when unplanned, pregnancy is usually a welcome event. Most New Zealanders have access to world-class, sophisticated medical facilities and generally expect that their pregnancies will have a good outcome.

These expectations make it even more difficult for couples to deal with the experience of miscarriage, where they grieve not just for the baby they have lost, but also for the dreams they have held for their child’s future and the new family they hoped to create.

Common emotions couples experience may include fear (particularly as the miscarriage begins), anger and a sense of unfairness, disappointment, guilt and then sadness and grief.

It is very common for mothers to blame themselves and feel guilty about the loss of their baby, even though most miscarriages are not preventable.

It can be very difficult for fathers to express their own grief when they are trying to comfort their partner and men often feel that they should be showing strength rather than emotion.

Often, women will take longer to recover from their grief and because this is not commonly recognised, they can sometimes feel that their partner is unsupportive if he needs to try to move forward before she is ready to do so.

Bereavement counselling has been shown to be very effective in helping couples to recover from the trauma of miscarriage and to help them to be able to mourn their baby.

In particular, bereavement counselling can help couples to understand the very different ways in which men and women grieve and prevent some of the relationship problems which many couples experience following miscarriage.

Early pregnancy loss leaves little for the grieving parent but if a miscarriage during the second trimester, it may be possible to see and hold the baby. You may also wish to name the baby.

Some hospitals have “Memory Folders” for keepsakes like photographs and other mementos, and you may want to keep certain things like ultrasound pictures.

Formal burial is usually a legal requirement for babies born after twenty weeks gestation but is also possible to arrange a burial service prior to twenty weeks if you wish. Any decision depends very much on individual feelings and beliefs.

Dealing with the reactions of others

For most people who have experienced miscarriage, there is nothing tangible for their grief; there is usually no baby, no funeral, no photographs.

This can make mourning more complicated and, because there are no clear and prominent memories, can make it more difficult for resolution of this grief.

Miscarriage is still treated as a minor loss in most parts of our community and the reactions of friends, family members, and even health professionals often appear heartless and can be very hurtful.

Those who have not experienced miscarriage themselves often do not recognise the extent of grief that a couple may experience and the length of time that it may take for them to recover.

Many people do not know what to say, and are awkward or uncomfortable. It can be hurtful when friends and family avoid the subject, become distant or awkward and indicate that they expect you to ‘get over it.’

Couples who don’t receive recognition or acknowledgement of the extent of their loss can feel they need to disregard their own feelings of loss and grief, but this can make it more difficult for their emotional recovery long-term.

Miscarriage is a very personal loss, something that can be difficult for others to understand or relate to because they did not see or hold your baby; but this does not reduce the importance of your child to you and your partner.

If the reactions of others are not supportive, it can be very helpful to see a counsellor, who can also help you come to terms with your loss and to help you acknowledge and experience the many emotions that you are likely to go through at this time.

Miscarriage – Grief Counselling and Support Services

Bereavement counselling has been shown to be very effective in helping couples to recover from the trauma of miscarriage and to help them to be able to mourn their baby.

The following services are available in your local community.

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