By Dr Pauline Burton
It happens to so many people but is rarely spoken of—until it happens to you. Then, mention what happened and all the stories come out. As well as taking comfort from realising you are not the only one, it tends to reinforce the old saying that there is always someone else worse off than yourself. Pauline Burton, our doctor-in-membership, describes what can happen.
Miscarriage is very common; at least 15% of women with a clinically recognised pregnancy miscarry spontaneously, usually in the first 12 weeks of pregnancy. Most miscarriages occur around 6-8 weeks of pregnancy ie 6-8 weeks after the last period. Miscarriage rarely has long-term physical complications; the cause usually remains unknown and most women who have a miscarriage are able to have a normal full term pregnancy.
The emotional difficulties of a miscarriage can be much greater than the physical problems. It is bereavement not visible to the outside world and it can be very difficult to grieve. An unanswerable question is ‘why has this happened to me?’
Miscarriage can be a distressing, frightening and lonely experience and people react in many ways. There is no ‘correct’ way to deal with it. Doctors are usually good at providing medical treatment but often seem pressed for time and are not best at providing emotional support.
Other sources can often be very helpful and the Miscarriage Association, a charity providing advice and support can be contacted at: www.miscarriageassociation.org.uk.
Ruth Bender Atik, National Director Tel: 01924 200795 (Mon-Fri 8.00 – 16.00) or e-mail: email@example.com (e-mail out of office hours: firstname.lastname@example.org)
Medical classification of miscarriage.
The terms miscarriage and abortion are synonymous in medical speak. The word ‘termination’ of pregnancy is used for induced abortions.
Threatened abortion. Bleeding in early pregnancy usually without pain. The uterus (womb) does not usually undergo contractions and the opening of the uterus (cervix or os) stays closed.
Inevitable abortion. Bleeding in early pregnancy usually with some pain due to the uterus contracting and opening of the os. This can lead to either complete abortion – when the whole pregnancy is expelled, or incomplete abortion – when there is only partial expulsion of the pregnancy.
Septic abortion. Any of the above with infection in the uterus. (Now rare, probably due to the low use of back street termination.)
Missed abortion. This is when the embryo has died but nothing else has happened i.e. no bleeding or pain. Usually picked up on routine ultrasound scan and can come as a shock.
Recurrent abortion. 3 consecutive abortions.
Ectopic pregnancy. A pregnancy outside the uterus. usually in a fallopian tube.
Bleeding in early pregnancy what to do and what to expect.
Probably the first person to contact is your GP who will try to decide why you are bleeding and will want to check that the pregnancy is not ectopic. The GP is likely to do an internal examination and may need to organise an ultrasound scan. An early pregnancy ultrasound scan is likely to be transvaginal (though the vagina).
If the GP thinks an ectopic pregnancy is likely, a scan will be urgent. If an ectopic pregnancy is confirmed the pregnancy cannot continue; but a scan is not always conclusive and blood tests may be needed. Ectopic pregnancy can be very dangerous, leading to rupture of the fallopian tube and even maternal death, so surgical removal of the pregnancy is advisable. This often includes the tube.
If the GP thinks you have a threatened abortion, a scan may be able to reassure you that the pregnancy is currently fine but it might be too early in the pregnancy to tell what is happening; a scan a couple of weeks later might be needed.
If the GP thinks you have an inevitable abortion or incomplete abortion you are likely to be offered admission to hospital to have an ‘ERPC’ (evacuation of retained products of conception.) This means a general anaesthetic for about 20 minutes while the uterus is cleared of all the products. This is a relatively straightforward procedure.
If complete miscarriage has occurred you probably don’t need further treatment but it is difficult to be certain that a miscarriage is complete. If some small parts are left this can lead to prolonged bleeding and possibly infection, so you are likely to be offered a scan and ERPC. (see above).
With a missed abortion you are also likely to be offered ERPC. (see above)
Septic abortion will probably need treatment with antibiotics and recurrent abortion will need special investigation to try to find a cause. (Ask for a referral to the repeat miscarriage clinic at St Mary’s.)
Miscarriage is very common. There are a number of different types of miscarriage and you do need to be advised on your particular symptoms. People react in many different ways, but do not underestimate the psychological affects as they can be deep and long lasting.
One person’s story
Before I had my first child one of the things that annoyed me most was being asked when we intended to start a family. “You mustn’t leave it too late,” the favourite advice. I felt like saying that, if they were so interested in my private life, perhaps they would like to know I was taking my temperature every morning and the length of my menstrual cycle. (Mothers in law reading, take note.)
I got 18 months reprieve after child no. 1 before it was, “when is he going to have a little sister or brother?” usually from someone with whom I did not have a habit of confiding, accompanied with a ‘go on, you can tell me’ expression. Having sussed the thermometer technique for getting the timing right, getting pregnant again was straightforward. However, the moment the blue line appeared in the window I had a feeling that this one would not go the duration. I almost lost the first one with a threatened abortion at 14 weeks—just when you think you are home and dry. Two bouts of very heavy bleeding a week or so apart, no pain but the cervix had started to open. I was confined to bed for a week and off work for a month.
Whereas I had felt tired but otherwise fine the first time, with the second one I felt awful. I knew every pregnancy is different but this didn’t feel right. Though not sick, if I didn’t keep eating I felt nauseous and, harder to deal with, perpetually exhausted. And I had a toddler to entertain.
At 11 weeks we went for the first scan. With total lack of thought for dignity, the scan chap told me lie on the couch, pull my clothes down/up so he could cover me with gel, then he launched into the lengthy speech about my age, tests and what would we do if we got this result rather than that. Whatever one’s answer, it is difficult to express it when supine, exposed belly slathered in sticky stuff and having to crane one neck at an uncomfortable angle to avoid addressing the ceiling, all whilst not feeling wonderfully well.
Having finally got to the end of his set piece and left us in no doubt of his own opinions, he got to work with the giant Ladyshave thing. It was immediately clear to me that what was on the screen was not what we should be seeing. “Ah,” he said abruptly, “No sign of life, sorry.” And that was that. He took a second look at the blob dangling lifeless from its string and said from its size it appeared to have expired three weeks earlier—ironically, when I had started to feel a little better.
I was told I could “let nature take its course” (and be in a playground or the midst of my toddler’s second birthday party when bleeding started—no thanks) or have a D&C that afternoon or the next day. I went for the latter. I had a totally clear head for working out what to do, taking into account practicalities such as someone to do toddler-duty; it was my husband who was stunned into temporary silent disappointment. My immediate reaction was, “Thank goodness it’s over and I’ll be feeling better soon.”
The D&C was not too bad—a pessary to get the cervix to start opening, progressively uncomfortable cramps whilst they debated whether they could do me that day after all then, finally, into theatre at 8pm. I came round 20 minutes later after the best night’s sleep in months. The next day it was out of hospital and into the cook shop for birthday cake tins. I felt fine with none of the expected psychological after-effects—unlike 20 years before when I had an abortion that affected me for months / years afterwards. Perhaps it was the relief at being a functioning person again.
We followed advice to wait a couple of months before trying again. My gynaecological plumbing was less co-operative. It did very strange things. I was having periods that were most odd for me—two days of extremely heavy bleeding, nothing at all for a day then a week of spotting. Meanwhile, the temperature chart was not normal. Before it had been a text-book example, with a distinct peak the day before ovulation. Now it was all over the place.
People knew about the miscarriage because I had been so obviously unwell in the first few weeks of pregnancy it wasn’t something one could keep quiet about until knowing one was in the clear. When I miscarried I discovered how many others had lost babies, often several. I had got off lightly—apart from anything else, I already had one child.
After a few months I started asking whether anyone else’s system had been thrown out by the experience. None had, though someone at a tea morning told me how, before having her daughter, she had previously taken a year to conceive before miscarrying several times. She had been sorted out by a Russian herbalist iridologist doctor so I went along, paid my £75, had a picture take of my eye the size of a dinner plate (revealing no apparent problem) and left with a bottle of stewed plant potion. It did have some effect, making my periods less strange, but I was not sufficiently convinced to pay £50 for a return visit.
Next I called an old friend who trained as a homeopath after we graduated. Now with 15+ years experience and five children, she was familiar with reproductive systems and their various oddnesses. She sent me a couple of remedies which, though tasting far better than the boiled weeds, didn’t do anything either.
Eight months after the miscarriage I turned 40. Knowing how fertility declines I had a word with a GP acquaintance. She told me about a drug that kick-starts the ovaries that had worked when she had prescribed it. I stopped following every duck that quacked and went to the doctor.
A series of monthly blood tests revealed my ovaries not working two out of three months. Looking at my date of birth she decided not to hang around and prescribed ovarian rocket-fuel. The next three blood tests showed it gradually working, with whatever they were measuring slowly going up. She was on holiday for month four so I got a repeat prescription and it was not until I went back, triumphant that it had finally done the trick, that I found out she had not intended to prescribe more than three courses—the referral to the IVF clinic had just come through.
How did all this affect me? I didn’t grieve the lost baby the same way I had the one over whom I took the life/death decision because I knew I didn’t have any medical condition that caused it, so something must have been wrong with the foetus. But having the option of a sibling taken away was a shock. Briefly I wondered if I made the right choice back in 1982 (in which case life would be totally different and the child I now have wouldn’t exist), or whether I should have left things so late; another line of thought that went nowhere because we do what is best or what we want at the time and would resent forever feeling we had been forced to do otherwise.
One thing I could do was deliver the ultimate shut-up line when asked when I was going to have another. “I just had a miscarriage, actually.” No advice would follow as they shuffled away with an uncomfortable “Oh.”