With between 25-50% of pregnancies ending in miscarriage it’s something that unfortunately many women will experience. Despite this frequency however, research shows that women feel isolated and lonely following pregnancy loss and many recall vivid negative social responses and poor support.
This episode Claire unpacks a range of different types of early pregnancy loss and then jumps into how to practically support someone through miscarriage, what to do and say and what to avoid saying…
In Australia a miscarriage is defined as a pregnancy that spontaneously ends before 20 weeks gestation. After 20 weeks the loss of a baby and pregnancy is known as a stillbirth. Most miscarriages occur in the first trimester (12 weeks) and are generally due to the fact that the baby wasn’t healthy and had some sort of abnormality. It is estimated that up to 50% of pregnancies end in miscarriage however a lot of these occur before a woman would even know she is pregnant, and the bleeding is often mistaken as a period.
It may be helpful to get a better understanding of some of the types of early pregnancy loss so that you can be a better, more educated and informed support when someone shares with you their experience. So here are some of the categories of miscarriage briefly explained:
Usually the first signs of miscarriage include vaginal bleeding or spotting along with pain in the abdomen and possibly lower back. However, these symptoms are also quite common in pregnancies that do progress to full term (confusing, I know!). Bleeding can be due to a range of reasons including implantation of the embryo onto the lining of the uterus or later in the pregnancy can be due to positioning of the placenta, possibly over the cervix, among other reasons... With a threatened miscarriage, the symptoms of miscarriage appear however the cervix upon examination is closed and the baby continues to grow appropriately for its gestation.
These symptoms can obviously cause a lot of anxiety and presentation to either ED or a public hospital's EPAS is a great way to be assessed and counselled around what is going on.
If vaginal bleeding occurs and isn’t stopping and the cervix appears to be opening, it is pretty much impossible to prevent a miscarriage. Women generally report feeling strong abdominal pain or contractions until the baby is delivered.
All of what’s known as ‘products of conception’ or pregnancy tissue has left the mothers body. Depending on the timing that the miscarriage occurs will determine whether the passing of the pregnancy appears like a heavy period or (if further along) may actually resemble a small baby and placenta.
When a miscarriage is complete the symptoms of pain and bleeding normally stop.
Following a miscarriage, women generally require blood tests which check the Bhcg levels to ensure they are falling, which shows the body no longer is looking after a pregnancy.
Sometimes not all of the ‘products of conception’ or pregnancy tissue miscarries which is known as an incomplete miscarriage. This is normally picked up either by the blood test just mentioned not showing the Bhcg level decreasing or reaching a number of <5. Symptoms of miscarriage may also persist like pain and bleeding. Because the uterus still contains some part of the pregnancy, the cervical os will remain open which increases risk for infection.
To diagnose an incomplete miscarriage an Ultrasound may be performed which can identify retained products. From here a woman can choose to wait for the rest of the pregnancy to miscarry (often whilst taking oral antibiotics to prevent infection) or she may be offered a D&C. D&C stands for dilatation and curettage, which is a surgical procedure under general anaesthetic. It is a short operation, usually just through day surgery, where an obstetrician will enter through the cervix into the uterus and scrape the internal lining of the uterus, meaning that anything that is left will be scraped out. The uterus can then clamp together and return to pre-pregnant state and the cervix can close up. Again, following a D&C, blood tests will be performed to ensure the Bhcg is now falling and showing that the body recognises there is no pregnancy anymore.
This is the type of miscarriage that I actually experienced before falling pregnant with Rupert. So basically a missed miscarriage is one where the woman doesn’t experience any physical symptoms of miscarriage (like bleeding and pain) even though the baby has actually died. Which means the baby or the ‘products of conception’ remain inside the uterus. As you can imagine, if you’re not experiencing pain and bleeding, you tend to just keep on tracking through the pregnancy thinking that the baby is growing normally. You then attend either an ultrasound (in my case the dating scan at 8 weeks) or a doctor’s appointment expecting everything to be normal, but when they go to listen to the heartbeat, no heartbeat is found. And often, because its early in the pregnancy and check-ups are fairly spread out at this point, the baby can appear far smaller than you’d expected for how far along in the pregnancy you are. In my case, I went along to my dating scan expecting to be around 8 or so weeks but the baby was measuring just smaller than 6 weeks, with no heartbeat. Depending on how early in the pregnancy it is discovered, it will be diagnosed as a miscarriage or not. In my experience, because it was so early and I hadn’t had any previous ultrasounds, they did not want to confirm a miscarriage, and instead thought that maybe my dates (LMP as mentioned in ep1) were off, so I had to return in two weeks time to see if then the baby hadn’t grown and continued to have no heartbeat. (That was a long 2 weeks).
With a silent miscarriage women can be offered a range of management options including the D&C which I’ve touched on. Women can also choose to just wait for their body to finally realise its not needing to look after the baby and naturally miscarries (known as expectant management), and then there’s also in some hospitals the option for medical management, which is a pill or pessary taken to speed up the process of miscarrying (although this option is shown to be linked to increased risk of haemorrhage).
Sometimes following a miscarriage, the Bhcg doesn’t seem to decrease and what’s known as a molar pregnancy is diagnosed. A molar pregnancy is basically abnormal growth of the placenta which either stops the baby from developing (complete molar) or means the baby develops abnormally and cannot survive (partial molar). A molar pregnancy appears the same as a regular pregnancy with early pregnancy symptoms etc due to the rise in Bhcg. Unfortunately, this pregnancy is always going to end and once a molar is diagnosed it needs to be removed from the uterus (usually by D&C). In some rare cases a molar pregnancy can cause a rare cancer to develop where chemotherapy will be required to manage it. Obviously this is quite serious, so not only is a woman losing a pregnancy, but there is the added stresses associated with potential complications. If you are interested to hear more about molar pregnancies, midwife and mum Krystal Richardson shares her experience in episode 13, so check it out.
A chemical pregnancy is one which miscarries generally in the first 5 weeks, once the embryo attaches to the lining of the uterus. Basically a pregnancy test confirms early on that there is a rise in the hormone Bhcg which means you are pregnant however a subsequent pregnancy test then follows which is negative. At this stage a baby or gestational sac is not normally able to be seen on ultrasound so the pregnancy was based off the hormone tests (either through urine or blood). Despite the fact that this occurs so early on, it can still be just as devastating if you’ve had that initial positive pregnancy test to then only a week or so later have a negative test. Also because a chemical pregnancy occurs so early on, many women may not even know they are pregnant as the miscarriage can appear like a period.
An ectopic pregnancy is fairly uncommon, is where the fertilised egg implants outside of the uterus (most often in the fallopian tube which is part of the pathway from the ovary to the uterus). It is very serious and can be life threatening as the growing pregnancy can cause rupture of the fallopian tube and internal bleeding. Even with an ectopic pregnancy, the uterus undergoes the same changes as a normal pregnancy so women may experience the same early pregnancy symptoms. Prior to rupture, an ectopic pregnancy may look similar to miscarriage symptoms however if rupture occurs most women will experience severe pain, and often signs of shock due to internal bleeding.
These are obviously very brief overviews of some of the types of early pregnancy loss that can occur. I hope it’s helpful getting an idea of how many different miscarriage experiences there are, and of course every woman will experience each of these differently – so there’s no stock standard.
One of recurring feelings women report following pregnancy loss is self-blame or guilt. It can be so hard experiencing a miscarriage and not knowing why it happened. And generally, unless you've had three recurrent miscarriages, doctors tend to not investigate a cause or reason. But overall there is some understanding about the main reasons for miscarriage, the most common being that there are abnormalities with the embryo – genetic defects or chromosomal abnormalities which mean the baby is not able to continue developing or survive. It is also understood that miscarriage is more common for women of advanced maternal age, so basically 35 or 40+ years. Research shows higher rates of miscarriage among women who have infections eg. bacterial vaginosis, herpes, rubella among others… and also higher rates in women who have some specific autoimmune diseases. Another known cause for miscarriage, and unfortunately for recurrent miscarriage is uterine abnormalities. These include things like fibroids and anatomical differences to the uterine shape like a bicornuate uterus where a septum makes it hard for a baby to grow.
Other emotional effects that miscarriage can have on women and their partners include significant trauma, grief, psychological distress, and at times anxiety and depression. In terms of support, women have reported feeling isolated and lonely after miscarrying. This could be due to a range of reasons and an Australian article called “It’s just one of those things people don’t seem to talk about... women’s experiences of social support following miscarriage” highlights that societal tradition where women don’t tell their friends and family about their pregnancy til after the first trimester, could be part of the reason women feel not well supported. The article also explains that because miscarriage is such a common occurrence which can be easily managed, and because it happens so early in the pregnancy often, family and friends can be dismissive of the emotional impact miscarriage can have on women and their partners.
I asked the MWK community what their experience of social support had been following pregnancy loss and was inundated with phrases and stories of both positive and negative support. So to help equip ourselves with practical tips of what to say and do when someone tells you they've had a miscarriage, I thought i'd share:
Positive social supports:
- Talking with other women who have been through it themselves and who could ‘speak hope into it, from the other side’
- People being there. Sit in loving silence and grieve the loss together
- Acknowledge that it is awful and that pain and suffering is valid
- Hugs, food, flowers, cards, ‘care package’, teas and things to prioritise self care and encourage physical healing
- Acknowledge the medical procedures and physical recovery as hard
- Text to say they’re thinking of me but not being intrusive
- “I’m sorry for your loss” “let me know if you need anything”
- Continue checking in about how I feel months/years after not just the immediate week or so.
- Remembering the anniversary of the loss or the due date - people acknowledging the baby’s existence
- Buy a piece of jewellery/memento to acknowledge and remember the baby. Planting a tree in honour of the baby
- Recommendations of books/contacts/resources about miscarriage “I was desperate to relate with someone and understand my feelings and emotions”
- The midwife from the hospital checking in afterwards on the phone. Talking with GP about your grief and how you’re coping
- Resources like Pink Elephants, Bears of Hope, PANDA, Beyond Blue IG community, Christian pointed back to the bible as a comfort. Hearing others stories of loss eg. Australian birth stories
Negative social responses:
- Not great support from people who hadn’t experienced miscarriage themselves
- Phrases like “you are young, you will have another” ”its for the best” “it was meant to be” “everything happens for a reason” “there was probably something wrong with it” “aren’t you relieved” “at least you know you can get pregnant” “it will happen for you” “you can just try again” “there’s always someone worse off than you” “it wasn’t really a baby”
- Saying its super common and so many people experience it – made me feel like my baby wasn’t special or unique and I shouldn’t feel too deeply about the loss – it almost cheapened my grief
- People asking how far along in the pregnancy I was when I miscarried like for some reason if it was early it wasn’t as bad
- People being awkward and unsupportive – no one knows what to say and everyone avoids the topic
- If you told people about the pregnancy but then those people didn’t acknowledge the loss or ask about how I was doing ‘undermined our loss’
- Hard when friends who knew I’d just miscarried then started talking about themselves trying for a baby or falling pregnant - insensitive
- People offering to help but then being too busy to show up when you need them
The Australian study i mentioned (and referenced below) ended with recommendations for improved social support which were suggested by the women interviewed and included ‘ending the silence around miscarriage’ – getting rid of this tradition to not tell people you’re pregnant in the first three months, and then another significant recommendation that came up was the importance of ‘showing support, acknowledgment and sensitivity around women’s feelings of loss and grief’ where women felt they needed better, non-judgemental support and care from people about the miscarriage they’d experienced.
The study concludes that by raising awareness about the frequency and also the psychological impact of miscarriage, women and their partners can receive improved and appropriate support from friends and family.
What are your thoughts on this? Would you share your pregnancy news as soon as you found out?
Hear more about my experience and thoughts in the episode. Follow along and join in the conversation through IG and FB @mumwillknow and subscribe to the podcast so you don't miss further episodes.
Art by @betty.ratbag
“It’s just one of those things people don’t seem to talk about...” women’s experiences of social support following miscarriage: a qualitative study: https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-018-0672-3