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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Woman to Woman Woman to Woman
 

Miscarriage


January 14, 2013

By Alice Y. Chang M.D.

Harvard Medical School


I heard the words that no woman wants to hear: "I can’t find a fetal heart rate." Then, it hit me. I was having a miscarriage.

When I told family and friends about our loss, I was surprised to learn how many other women and couples had also experienced a miscarriage. I found some comfort knowing that we were not alone. Most encouraging, I spoke to many people who had successful pregnancies after their loss.

I discovered that miscarriage — like menstruation, sex, pregnancy, labor and menopause — is a commonly shared but secret experience among women. Or women may only discuss their loss with other women who have experienced it. Yet, when you consider that an estimated 10 percent to 20 percent of all pregnancies will miscarry before 20 weeks, it is a subject that all women (and their partners) should hear more about.

The best words of comfort and advice came from the nurse who cared for me the night my water broke. After the doctor confirmed that my worst fears were true, the nurse told me that she, too, had miscarried. She said, “You are going to cry and grieve, and it will surprise you that it will take a month before your body won’t feel pregnant anymore. But you will feel better, and someday you will become pregnant again. It won’t be easy but you’ll get through it.” Her words would keep coming back to me over the following weeks. She seemed to have prophesied many of the physical and emotional changes I went through. I experienced a sadness that surprised me; the physical changes my body was slow to shed reminded me of my loss.

I also asked the questions that so many women ask:

What causes miscarriages?

The majority of miscarriages occur before the 12th week of pregnancy and result from chromosomal abnormalities of the fetus. Other potential causes include:

  • Infection — It may be that small infections that do not give you symptoms are enough to cause a miscarriage. It is difficult to diagnose and test for these infections and, hence, treat them during pregnancy. Testing for infection after a miscarriage does not necessarily make the diagnosis, because you cannot determine if an infection started before or after the miscarriage. If there are any signs of infection during your miscarriage, (fever, pain or pus-like discharge), you will be treated with antibiotics anyway.
  • Blood-clotting disorders — While rare, you can inherit genetic problems that make you more likely to clot or develop antibodies that have the same effect. In both cases, you are more likely to miscarry because of clotting problems with the placenta or the attachment of the placenta to the uterus. Testing for a blood-clotting problem is usually recommended after more than one miscarriage.
  • Structural problems — If there is a problem with the uterus, the placenta or any of the membranes surrounding the fetus, you also are more likely to have a miscarriage.

In many cases, however, you won’t know why the miscarriage occurred.

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Is it normal for my body to feel this way?

As early as the first trimester, your body has made many of the hormonal changes that prepare it for pregnancy and for motherhood. In particular, the same hormonal surges you felt during pregnancy can make you more emotional during this time. While many of the hormones are excreted through urine, it can take up to a month for some of the larger hormone molecules to be broken down. Some women will actually experience breast engorgement with milk a few days after the miscarriage. You also may experience vaginal bleeding and spotting for a few weeks after the miscarriage. As your hormones normalize, the spotting will eventually stop. If you have abdominal pain, fever or heavy bleeding, you should call your gynecologist for an evaluation.

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Did I do something wrong?

While you may try to blame yourself or things you did for causing the miscarriage, in many cases, you will never know why it happened. I wondered if exercise or stress could have affected my pregnancy. Reviewing the study literature, I could find no convincing argument that these factors significantly increased my risk of a miscarriage. For many of us, it is harder to accept not knowing the cause of the miscarriage, because without knowing the cause we have no way to prevent it in the future. In answer to many of my questions, my gynecologist told me, “Even if you could have tried to fix a problem with the pregnancy, would you have wanted to risk the health of your fetus? There has to have been a reason why this pregnancy ended, and we have to accept that.”

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What can I do differently next time?

You can focus on changing the three behaviors that definitely increase the risk of having a miscarriage:

  • Quit smoking.
  • Do not drink alcohol.
  • Limit or stop your caffeine intake. In particular, more than four to five 8-ounce cups of coffee daily (500 milligrams of caffeine) is associated with a higher rate of miscarriage. But even one cup of coffee will slightly raise your risk.

 

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When can I try again?

Most physicians will tell you to wait two to three months before trying to conceive again. This is not a rule that comes from studies. It is more of a good estimate of how long it might take for you to have normal ovulatory cycles. On the other hand, some physicians will say you can start trying to conceive again after one normal period. Proponents of waiting only one period figure that if you are not ovulating or your lining cannot accept a fertilized egg, then you simply won’t get pregnant. Studies have followed women after miscarriage and found that there were no more problems with pregnancies or babies conceived within the first three months after miscarriage than later on in the year afterward. So deciding what is right for you will depend on how long your grieving process takes, your age, career factors, and planning of other life events.

When the next time comes around, you likely will experience more anxiety. Seek the help of family and friends for support. I personally remember something that many mothers told me. Once you hold your first baby, your old fears and anxieties will melt away only to be replaced by the new fears and worries and joys of motherhood.

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Alice Y. Chang, M.D. is a former instructor in medicine at Harvard Medical School. She is currently associated with University of Texas Southwestern Medical Center. Her clinical interests and experience are in the fields of primary care, women's health, hospital-based medicine and patient education.

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