Miscarriage and stillbirth: Everything you need to know but were too nervous to ask
One in four pregnancies will end in miscarriage. Why don't we discuss it more?
Miscarriage -- the loss of a pregnancy -- is a common occurrence that affects countless women but remains a taboo topic for many.
Statistics differ, but according to the Mayo Clinic, for women who know they're pregnant, about 10 to 20% will experience a first trimester loss. That number is likely considerably higher, as many women miscarry before they realize that they're expecting. Additionally, one recent study indicated that 43% of women who had at least one successful birth reported having had one or more first trimester losses.
Stillbirth, the demise of a pregnancy after 20 weeks, affects about one in 160 pregnancies each year in the United States, according to the Centers for Disease Control and Prevention. About 24,000 babies in the U.S. are stillborn annually.
These numbers mean that if you haven't had a miscarriage yourself, you likely know someone who has. It's time to talk about it.
ABC News Chief Medical Correspondent Dr. Jennifer Ashton, a board-certified obstetrician and gynecologist, demystified infant and pregnancy loss for "Good Morning America."
What is a miscarriage?
A miscarriage refers to a failure or end of pregnancy in any trimester. Typically, we consider a miscarriage occurring in the first and second trimester, and a third trimester miscarriage as a stillbirth. That is the lay terminology.
How common is it?
There are a lot factors that go into determining a woman's risk for having a miscarriage, but in general, singular miscarriage is incredibly common. Most women can or will suffer a miscarriage a lot of times even before they even know that they're pregnant.
Is age a factor?
Age can always be a factor. In general, we have to remember that age is one very important factor when you talk about fertility.
What are the symptoms?
Sometimes a miscarriage will produce no symptoms. Sometimes they're called "incomplete abortions," a type of miscarriage where the cervix dilates, bleeding starts, but the cervix doesn't close again, causing significant blood loss. This is a surgical emergency that needs to be treated with a D&C. Sometimes we refer to a "threatened miscarriage," as a "threatened abortion," which means there might be bleeding, but there's still a heartbeat. We don't totally understand what causes it, but we do know that sometimes women will have no symptoms at all. Other times there can be heavy bleeding, or cramping.
What is a "missed miscarriage"?
Usually when we use the term "missed abortion" or "missed miscarriage," that means the pregnancy is still within the uterus and it's just picked up that there's no heartbeat.
What happens once the miscarriage is diagnosed?
I think the first thing for women, if they're told they've had a miscarriage, is to take a minute and really kind of process that as much as possible from an emotional or psychological standpoint. There's rarely a time pressure to act or do anything unless the woman is bleeding excessively or hemorrhaging with a miscarriage which can occasionally happen. It's not common but it can happen. Otherwise, there is time to think, breathe, process the information initially as best as possible and then make your decision about how you want to proceed.
If we're talking about a first trimester miscarriage, basically the options given to women are to do nothing and wait for it to pass on its own, or undergo surgical evacuation which is called a suction D&C, or dilation and curettage. Usually we don't give medication in the first trimester to evacuate the pregnancy.
Why have a D&C?
A surgical procedure is much more controlled. It's scheduled. The woman is under light sedation, so she doesn't feel any pain. It takes literally minutes. There's very minimal cramping and bleeding afterwards, so she can go about her day, go home to other children, go to work the next day. But it's an individual choice and every woman has to decide with her physician which is right for her.
How much does a D&C cost?
The cost of a D&C is going to vary. It could be over $1000 in some cases, it could be free in other cases.
Is the woman sedated for a D&C?
During a surgical suction D&C for a miscarriage, the woman is definitely under some type of sedation. The uterus is in the pregnant state, and we are using sharp instruments to suction out the pregnancy, so there is a risk of perforating the uterus. The woman really needs to be sedated. It's not only more humane for the patient, but it's definitely safer for the surgical procedure.
Does a woman always need to seek medical attention if she's having a miscarriage?
In general if a woman is diagnosed with a miscarriage, she needs medical follow-up and likely medical management of that miscarriage. Rarely miscarriages that don't pass on their own can become infected and the woman can develop an infection in her uterus. But whether that miscarriage is managed expectantly and the woman is given a chance to pass the pregnancy on her own at home or if it's managed medically will differ case by case, patient by patient.
When can a woman try to conceive again after a loss?
There are rarely any medical reasons for a woman to wait. Sometimes there may be, but the vast majority of women are told when they're emotionally and physically ready. That will differ woman to woman but there usually is no reason why a woman can't try to conceive after getting maybe one period after a miscarriage. Sometimes it happens on its own literally the following month.
Is it true that a woman is more fertile for three or so months following a miscarriage?
The data on this is not clear-cut. In general, there is approximately a 20% fecundity rate per month in young healthy women, meaning there is a 20% chance of conception in any given month.
How soon after a miscarriage would you expect a woman to get pregnant again?
It totally varies. It can happen the next month, or it may take several months or longer.
What happens if a woman has multiple miscarriages in a row?
We call multiple miscarriages in a row recurrent pregnancy loss. It used to be that a woman needed to have three miscarriages in a row before a formal or aggressive workup was done, but now we've kind of dialed that back to even two losses. There's a very well-constructed, well-defined algorithm that we follow to investigate what caused those losses. It involves looking at the anatomy, looking at the genetics of both the man and the woman, doing a variety of blood tests, hormonal tests, sometimes screening for various types of infections, and in some cases, the pathology report from a previous miscarriage can show if there's a genetic or chromosomal cause. But again, this is a very standard workup that any OB-GYN is familiar and accustomed to doing.
Is there anything a woman can do to prevent a miscarriage and/or lower her risk of having one?
For women at average risk, the best recommendation is to be in as good a state of overall health as possible before and during pregnancy. This means not smoking or drinking alcohol while pregnant, exercising regularly, having weight in healthy range, and getting 7-9 hours of sleep a night. For women with high-risk pregnancies, certain medications may help lower risk of additional miscarriage in women who have had recurrent pregnancy loss.
What is vanishing twin syndrome?
Vanishing twin syndrome refers to a pregnancy that starts with twins and then one of the twin pregnancy stops and basically that gets reabsorbed into the placenta, the amniotic sac. When the end of the pregnancy comes, there's just one baby, a singleton that's delivered. We don't totally understand why this happens, so it's hard to pinpoint how common it is.
What is an ectopic pregnancy?
Ectopic pregnancy basically refers to a pregnancy that is located anywhere other than the uterine cavity. The most common place for an ectopic to be located is actually in the Fallopian tube, but there can be ectopics that are located in the cervix, which are incredibly rare and very dangerous, because of the risk of life-threatening hemorrhage. There can occasionally be an ectopic on the outside of the ovary, where it meets the Fallopian tube, and then there can be, rarely, abdominal pregnancies where the pregnancy implants in the abdominal cavity. That is extremely rare.
How common are ectopic pregnancies and how are they diagnosed? How are they treated?
Most cited literature puts the risk of ectopic at about 1 in 50 pregnancies. To be clear, most ectopics are treated successfully but ruptured ectopic pregnancy is the number one cause of maternal death in the first trimester. We don't know what causes ectopic pregnancy, but the vast majority of women who have an ectopic pregnancy have an anatomic problem with their Fallopian tube or evidence of infection or scar tissue in the Fallopian tube.
Usually ectopic pregnancies are diagnosed on either blood testing or with a routine ultrasound. It can be difficult. Typically we look for a doubling or at minimum about a 66% increase in HGC, which is the main pregnancy hormone, over a 48-hour period. Then we correlate that with what we see on an ultrasound which we can check roughly every week in the first trimester. Looking every day by ultrasound doesn't really tell us anything. If it doesn't rise appropriately or if we don't see a confirmed pregnancy in the uterus at the time when we expect to see one, then we make the diagnosis of ectopic pregnancy.
In terms of treating an ectopic, there are basically only two options: an injection of a chemotherapy drug called methotrexate, which will stop the pregnancy because it targets rapidly dividing cells, or surgery. There are certain criteria for one versus the other, but if the ectopic is picked up after a certain point, then laparoscopic surgery is performed. Occasionally if the ectopic has caused a rupture in the Fallopian tube, the tube does need to be removed, but the woman can still get pregnant on the other side.
What is a chemical pregnancy?
We use that term when we have someone who's had a positive pregnancy test, but we never actually see a pregnancy develop to the point of certain ultrasounds findings. We look at ultrasounds in stages in the first trimester. First we see a little sac inside the uterus. Then we see literally something that looks like a ring -- we call it a yolk sac. Then we look for something that we call a fetal pole, which literally looks like a tadpole. And then we look for a heartbeat. Typically you don't expect to see a heartbeat until about six-and-a-half or seven weeks, but that is highly dependent on the technology used, the skill of the ultrasonographer, the woman, various factors.
So if it's a desired pregnancy, many healthcare providers will wait, as long as the woman's not having any symptoms, until we see these signs. When we diagnose a chemical pregnancy, it's because there's usually a positive urine test and then the pregnancy hormones just kind of stop, so we never really see anything in the uterus. We don't know how common this is, but everyone -- midwives and obstetricians -- sees it in their practice.
What is a stillbirth?
Those are oftentimes the most emotionally agonizing types of loss, but to be clear, a miscarriage or loss of a pregnancy in any trimester, they're all upsetting. A stillbirth, generally we're talking about third trimester loss. In terms of how common a stillbirth is -- the cited statistic is 1%, or over 20,000 stillbirths in the country every year. Those numbers may be a little bit in question but what's not in question is that stillbirths can and do happen. Sometimes there are known risk factors. Sometimes they happen with no known explanation or risk at all.
Most of the times third trimester fetal demise is diagnosed on a routine visit to a midwife or OB or actually in labor and delivery. At that time the management of a stillbirth is to induce labor to allow a woman to deliver the fetus.
Is anybody at fault for a miscarriage?
A lot of people feel shame and stigma and don't want to talk about it or feel they can't talk about it openly, and I think, unfortunately, a major reason for that is that a lot of women in particular feel that something is wrong with them or they did something wrong or it's their fault in some way. That is rarely, if ever, the case. The reality is, miscarriage happens. And that is incredibly painful and upsetting for the couple. It's no one's fault. I think it's one of the many topics in medicine that we need to de-stigmatize and we need to bring out of the shadows and make it more acceptable to discuss because it's so common and so many people, unfortunately, experience it.
What would you say to a woman who blames herself?
For some women who have suffered a miscarriage who on some level blame themselves or feel that it makes them less of a woman or that it's a fault or flaw in them, all I can say as an OB-GYN is that's not true. It's not your fault. It doesn't make you flawed. And it certainly doesn't make you less of a woman. I think it's also important to remember that a miscarriage is a painful loss for the other partner in that couple, and that that partner can grieve the loss of a pregnancy even if he or she wasn't carrying the pregnancy. So I think that we need to start expanding our sensitivity when it comes to this and a big part of that is how we look at pregnancy in this country -- that it's always the "Hollywood pregnancy," and it's so easy and then couples get this perfect baby and that's not reality. For most people who suffer miscarriage, it seems that everywhere they turn, they're looking at that Hollywood pregnancy, or they're seeing women who have seemingly no issue with fertility. But it's important to remember that optics are rarely reality.
What should and shouldn't I say to a friend who's suffered a miscarriage?
You don't really have to say anything. You can just be with the person. You can offer them emotional support with just a gesture like a hug. What not to say? "You can always try again." Or, "There will be other pregnancies." I think it's really important to understand that a miscarriage in any trimester is a loss, and that is incredibly emotional and painful for the woman who was pregnant and for her partner. So saying things like, "You can always try again" or "You can always have another baby" doesn't help. It does a lot of damage.
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