Miscarriage: What Does it Mean?

Miscarriage. What does the word really mean?

If you look at the actual definition, you will find the following:

1. the expulsion of a fetus from the womb before it is able to survive independently

2. an unsuccessful outcome of something planned

Both of these definitions are so incredibly loaded and emotionally intense as they refer to pregnancy. When we talk about miscarriage in medicine, we use medical jargon that actually changes the nuances of the situation. Either way, whatever terminology we use, whatever way the fetus is lost, most people think of a miscarriage as the loss of something desired. Even if the pregnancy is unplanned, a miscarriage clearly carries the weight of grief and guilt. It is so incredibly common--about 1 in 4 fertilized eggs result in loss and up to 1 in 10 pregnancies that have been recognized do not go to term. What does this mean? First, it means that if you go out to dinner with 4-10 of your friends, it's pretty likely someone had a loss of a pregnancy. At least one. Or two. Or more. Think about all that collective lack of conversation. Think about those collective "unsuccessful outcomes". Think about what your friends to the right and left of you have been through. Then think about their Instagram feeds. Think about the "perfect families" so many have. And then, think about how different things could be if we just started talking.

In obstetric terms, the first trimester refers to the first 13 6/7 weeks of gestation. A pregnancy that is nonviable in this window is either called a miscarriage, a spontaneous abortion or an early pregnancy loss (if it's before the 13 week mark). Miscarriage is defined above. Early pregnancy loss is the newest term of the group, and perhaps the most accurate. And quite frankly, the kindest. BUT-how do we live in a country where Roe v Wade is so fragile, and pro-life rallies threaten every entrance to a later term abortion center and yet the loss of what may be a highly desired pregnancy be called a spontaneous abortion? Abortion implies a decision, a choice. Either we need to stop fighting about a woman's right to have an abortion once and for all OR get rid of this antiquated term from every piece of our literature (perhaps AND is the best word here...). Miscarriage is not a choice for most women. What a crappy term to have stamped on your discharge papers. Isn't it bad enough?

To add to the distaste around this issue, if a pregnancy has started, but there is an empty sac, or a fetus or fetal pole without a heartbeat prior to 20 weeks gestation, that's a missed abortion. Now not only do we have the abortion word, but what have we missed? The chance to get to have a spontaneous abortion?

If a woman starts bleeding at home and can't pass the tissue at home, she comes to the ER mid-loss and has what? An incomplete abortion--she likely gets to have the process finished in an emergency room. Fortunately, in 2015, our governing body, ACOG (American College of Obstetrics and Gynecology) released a statement on management of this situation--Early pregnancy loss was the term of choice dedicated to loss by 13 weeks. I can tell you, however that the majority of coding documents and procedural notes still carry the word abortion. I believe things will change, but slowly.

So for most of us, a miscarriage either happens on its own, or it doesn't and intervention is needed. If you're pregnant and you start to bleed and pass tissue or clots, and the pregnancy is lost, and the uterus is empty when you see your doctor (ugh, that's called a completed abortion--yes, we use the abbreviation complete ab; it still upsets me), this is what I believe most of the world means when they use the word miscarriage. This is often a painful, lonely process. It happens to you, from within you, but your body takes care of the process for you. Even though the actual process is out of your control-when it happens, how much bleeding there is- it becomes something that so obviously disrupts your life that it isn't hidden. In that moment, hopefully someone knows. Someone--your partner, a friend, your doctor, spouse, someone--knows right then and there and when it's over you make an appointment to be seen pretty quickly. It starts with the dread of spotting. Then the knowing, the anxiety builds, and you start to bleed. It's messy, and often painful and real in technicolor. Sometimes there's a scan in the office and there's still a fetus, and so the torture gets dragged out for longer and then it's finally done. This is how a miscarriage happens for so many of us.

Then there's the other kind of miscarriage that NEEDS desperately to be talked about. Because I worked at a High Risk unit in a hospital, I was often seeing women to confirm a suspected early pregnancy loss. Not infrequently, women didn't know why they were there, or weren't prepared. They were hoping the "machine in their doctor's office wasn't good" or they just thought I was taking a closer look. To have to tell a hopeful woman there's an empty sac, no heartbeat, a "nonviable pregnancy"--it's truly horrible. To see the look of hope extinguished. To explain that not seeing a heartbeat meant that the pregnancy wasn't going to progress. That's very, very different. It's conceptually understanding that this pregnancy wasn't going to result in a baby. It's not a spontaneous miscarriage. This time it's being free of symptoms, but instead being told the unthinkable--that actually this fetus isn't alive. I'm often struck with the immense challenge women face comprehending what they're being told. I'm still so devastated for the hundreds of women with whom I've shared this news. Women are often alone when they come, too, because they just believe everything's OK. Then there's coordinating what to do about it once you've come to terms with the news. Wait for a spontaneous loss? Schedule a D&C? Since it's not an emergency, you may have to wait to be scheduled for a procedure in which you wake up and it's over. It may be your doctor, it may not be. You may be offered pills, and get to do the whole thing on your own, and bleed at home. This whole issue is enough to comprise a few more posts, so I'll keep it there for now. But before we get to what to ask your doctor after a miscarriage, I wanted to be very clear about what a miscarriage means to the thousands (yes, literally) of women I have cared for that have had them. To about half of women, a miscarriage is something that happens TO their bodies, not BY their bodies. The loss remains the same, but the nuances of recovery, of experience can be so different.

So what to do about this?

We have to start talking.

First, the majority of losses like these that happen occur because of a genetic abnormality of the fetus--this was not going to likely be a normal, healthy, viable baby. Please know that, and understand that. It's so important not to forget. It doesn't make it OK, but it makes it somewhat more understandable. Our bodies are trying to somehow protect us from nurturing something that wasn't healthy, or may not have been the baby you thought you were going to have. However, this was, with that first positive pregnancy test, for so many of us, the beginning of that dream. Without honoring these experiences, we keep the opportunity for grieving properly and starting to heal properly at bay. We need to start talking more about these losses. We need to start to normalize things that happen to SO MANY WOMEN a collective problem that has to be addressed. So we as women can talk about uncomfortable things with greater ease. To find solace from our families, our caregivers, our peers. If we talk about this now, imagine how much more support might walk into that first scan with you the next time around, to collectively hold their breath with you. I promise to help you figure out what to ask your doctor after a miscarriage. But right now, for his moment, let's start to TALK about the things we are going through as women. Let's demand the help we are entitled to. If more mental health care providers need to be comfortable talking about this, let's make the need heard. More training if it's needed. More variation in who we can talk to. More support groups, more community, more sisterhood.

Miscarriage may mean a lot of different things to different people. But what it means to everyone is something that will impact you emotionally--and we need to be here for each other. And YOU need to start finding and receiving the support and care YOU are entitled to.

Xo Dr. Tracy