This is a hard topic to discuss. A topic no one really wants to discuss and would rather pretend it is not as common as it really is. However, this has been on my heart lately, because I have dealt with this multiple times in the past couple of weeks. Miscarriages are extremely common affecting 1 in 5 pregnancies. There can be multiple causes for a pregnancy loss. Most commonly, in the 1st trimester a miscarriage occurs due to a chromosomal abnormality. Usually the egg and sperm do not sync up correctly resulting in an abnormal pregnancy (such as an empty sac, no further development or growth of embryo, or absence of a heartbeat). Miscarriages can be devastating to couples and can result in feelings of guilt, anger, depression, and countless questions of why they happen and the cause.
In my job, I have to discuss this topic with my patients more often than I would like. And believe me, it doesn't get any easier telling someone they have lost a pregnancy. Whether it is an empty sac ("blighted ovum" people call it or medically an "anembryonic gestation") or a fetal demise later in the pregnancy, seeing the look on parents' faces when they no longer are going to be able to continue on the pregnancy journey they have set forth for themselves is heart-breaking. What I realize I can do for patients is just be quiet, give them time to process, and answer any questions they may have. Sometimes just being quiet and being there is what someone needs.
When this happens, parents have a lot of questions; and the truth is that many times these questions cannot be answered because in some pregnancy losses, a cause cannot be found.
I was taught in residency that the causes of a pregnancy loss usually is attributed to:
--1st trimester-chromosomal abnormality in the pregnancy (one that would not have survived even if baby was born occurs in ~50%).
--2nd and 3rd trimester- maternal conditions (such as hypertension, thyroid disorders, lupus, sickle cell disease, clotting disorders, obesity, kidney disease, diabetes, etc.), chromosomal abnormalities, infection, placental problems, trauma, drugs, cord abnormalities (~30%), history of obstetric complications in prior pregnancy [stillbirth, preterm delivery, pre-eclampsia], advanced maternal age, multiple gestation (twins, triplets, etc.).
Per the American College of Obstetrics and Gynecology Practice Bulletin on 'Management of Stillbirth' :
"The following recommendations and conclusions are based on good and consistent scientific evidence. (Level A)
--In low-risk women with unexplained stillbirth the risk of recurrence stillbirth after 20 weeks of gestation is estimated at 7.8–10.5/1,000 with most of this risk occurring before 37 weeks of gestation.
--The most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, and obesity (Table 1).
--The risk of subsequent still birth is twice as high for women with a prior live born, growth restricted infant delivered before 32 weeks of gestation than for women with a prior stillbirth. Amniocentesis for fetal karyotyping has the highest yield and is particularly valuable if delivery is not expected imminently."
https://www.acog.org/Clinical%20Guidance%20and%20Publications/Practice%20Bulletins/Committee%20on%20Practice%20Bulletins%20Obstetrics/Management%20of%20Stillbirth.aspx
Since miscarriages are common in the 1st trimester, a full work-up is usually not indicated until there are at least 3 (which is considered 'recurrent pregnancy loss'). Work-up is indicated in pregnancy losses >20 weeks because these are more uncommon and there is a full panel of blood-work obtained on the mother or fluid surrounding the baby to check for chromosomal issues or infection, evaluation of the placenta, and other tests that can be performed to try to evaluate the cause. These would be things to further discuss with your doctor if you face this. The hardest thing I see couples face is the lack of closure when a cause is not found. ~50% of cases are unknown in pregnancy losses above 20 weeks.
Overall, although this was a hard blog for me to write, I feel this is a pertinent topic to discuss. The most important things I feel for people to know when you are or someone you love is faced with this is to know this is nothing YOU could have done to prevent this from happening and nothing YOU did wrong. It is a common thing that happens to 1 in 5 women that many do not talk about. Support groups and blogs are available if you are feeling depressed, overwhelmed, or want to talk to women who have gone through the same thing you have: http://www.pregnancylossdirectory.com/support-groups/
To those who know someone who has faced a miscarriage or loss, it is vital to be understanding and sensitive to them. People respond differently to certain life events so just be supportive.
Being a doctor, you want to explain everything and causes based on scientific evidence. You want to have an answer for your patient. But sometimes, you don't. In those cases, you simply just sit, provide support, and be there for them; and sometimes just by doing that, you fill your role as a provider.
-Dr. Riley
References:
https://www.acog.org/-/media/Practice-Bulletins/Committee-on-Practice-Bulletins----Gynecology/Public/pb200.pdf?dmc=1&ts=20190118T0200591117
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