Miscarriage: causes, complications, and clinical management

¶ … Quiet Mourning

One has a tendency to remember special events when they are happy, disastrous, or sad. I remember the very moment I first suspected that I was pregnant: where I was, who was present, and, most importantly, how I felt at that very moment. It was a spring day, and while I was out walking my dog, I stopped for a moment in the park to admire the day. I sat on a bench and I let the bright sun wash over me as though it was washing away the gloom of winter. There, basking in the warmth of the mid morning day, from what at first seemed at a distance, then nearer, caught my attention, and I turned to see children playing. Imagine that, children playing in a park. It was just then that a very pregnant woman stepped into my view, and I smiled at her roundness. Then, I realized that in the past months I had become so comfortable with the idea of if it happens, fine, if not, don't worry about it, that I had lost track of time and dates, and that I, too, might be pregnant.

At that moment I jumped up, raced home, put the dog up, and raced to the drug store to pick up the latest home pregnancy test. The few minutes that I had to wait for the test stick to react seemed like suspended time. I thought about how to express my happiness; should I call my husband at work to tell him the good new -- if indeed there were good news to share. Or should I prepare a quiet and romantic dinner for two at home to spring the news on him. When the test stick told me that I was pregnant, the answer as to what to do was clear to me. I took an afghan from the closet, and snuggled with my new life on the couch. It was my first real bonding with the tiny life inside of me.

I know that most people, including physicians, do not think an embryo at eight or twelve weeks is a human life. This is not about the debate for that idea, or against it. It is just about the way I felt about the life growing inside of me at that moment in time.

As my pregnancy progressed, I felt closer to my growing baby. I thought about names for a girl or a boy, and how I would decorate the child's room. I thought about clothes, and I went shopping for the essentials: crib, blankets, diapers, and a stroller. I was too excited to contain myself, even though others advised me to wait to buy things like the stroller and the crib. I didn't care, and I didn't listen, because I felt so connected the child inside me.

I had loved Dr. Seuss children's books as a child, and I had also read that parents should begin reading to their children while they're in the womb; I did that. I enjoyed that, and I even put my favorite music -- the gentle music -- on the stereo and put the headphones on my either side of my small belly so that my child could listen to my favorite music. I was bonded with my child. I loved my child.

OBGYN

Obstetrical and gynecological visits are a very impersonal thing for a woman. Whether the physician is a man or a woman, most women seldom get excited about seeing their OBGYN; until they're pregnant. This happy moment in a woman's life is shared with her physician as the physician monitors the progress of the pregnancy in terms of the mother's and child's health. My first sonogram, when the heartbeat of my child filled the room brought forth from me a flood of tears of happiness. The very sound permeated me, and I felt a love that I had never known before. My physician smiled, assuring me that everything was progressing as expected.

Then, in the fourteenth week of my pregnancy I woke to find myself lying on sheets soaked with my blood. Panic overwhelmed as I realized what was happening to me. My body was rejecting my child, and was spontaneously aborting the fetus. I was alone at the time, and as quickly as I realized what was going on, I began feeling excruciating pain in my lower abdominal area. The pain was the most ferocious cramps I had ever experienced, and it took all the focus and strength I had to dial the phone and get help. When my sister arrived with a bag of pads, I had managed to dress myself, but I had in that short period of time gone through more than a dozen pads already. I tripled them up, and we rushed to the hospital emergency room. On the way, I called my doctor, who was at the hospital but was in surgery. I was assured that I would see him as soon as he was finished with surgery. I could hear the sadness, the sympathy in the nurse's voice when I explained why I had called. Sad, sympathetic, but final, and I knew that there would be no saving the child I come to love over the past weeks.

In the emergency room there were sad looks and expressions of finality from the hospital staff. There was no saving this child, and the ER physician broke that news to me with the saddest look of anyone. He told me that he and his wife had lost a child to miscarriage. He shared more than needed to, but I was grateful for his sharing that with me, because it took away the sterile medical impact of the environment for a moment.

By the time I was taken to surgery I felt as though I had spent a lifetime in the emergency room. Perhaps I did, because the entire lives of myself and the child that I had just look flashed before my eyes: the quiet hours nursing, the photographs, the playgrounds, and so many other things that we might have done together. I did not know the sex of the child I lost that day, and, going forward, depending on my own mood, some days I would imagine it to have been a daughter, other days a son.

When I returned home from the hospital I arrived home to a big sense of emptiness, a sort of black hole in my world, in my home, and in me. My favorite place on the couch where I had snuggled the day I learned I was pregnant, where I first bonded with my baby, was a place that I now avoided. Without even thinking about, I gave up my favorite place on the couch and began sitting in a large overstuffed chair where I had never sat until I came home from the hospital.

Days later, when I still was unable to pull myself out of the funk that I was in, I thought about the ER doctor who had shared just a little bit of his own life with me. Then the social worker, who had visited me and left a card for a self-help group for people who had lost children. I found a book by Nancy Kohner and Alix Henley (2001), When a Baby Dies: The Experience of Late Miscarriage, Still Birth, and Neonatal Death. I didn't think that it exactly pertained to me, but I bought it, because I thought that losing a child at any age must be the same emotional experience, even though the actual experience of child birth and rearing might be different up to and at any age or stage in the child's development.

I read the stories in Kohner's book with something that was almost a hunger. I wanted to relate to others, to be closer to people who experienced the same loss I had. The book brought me a certain comfort, because I quickly realized that while I bonded with a child inside of me, that child was nonetheless a mystery to me as to his or her personality, and that I had only imagined the many life experiences between us, while others, the people in Kohner's book, had actual life experiences that they shared with their child. The children were born, and they were real personalities who were interactive in the lives of the parents, the families. Mine was interactive on a level that was surreal, but nonetheless real, because there was for a period of fourteen weeks a life growing inside of me. That life, though invisible to the world around me, was very much a part of me, inside of me.

As I thought about the child inside of me, I suddenly realized that my child was gaining its vital nourishment through me. I suddenly began to wonder if I had perhaps done something that was not healthy for my child. Was my womb poisoned by something I had eaten, or an environment I had been in, and had that killed my child? This was a question that had no answer, but one which tormented me for the two weeks I was home before I saw my OBGYN for a check-up.

I am not sure what I expected about my check-up. I suppose I thought that the new relationship I had the OBGYN because of my pregnancy would continue on as a special relationship. I was wrong. My visit was, once again, the sterile, medical kind, and not the kind that I had with him while I was pregnant. My OBGYN performed the post surgical exam, and then spoke with me briefly.

"You're healthy," he said, "and I would recommend beginning again, as soon as you're ready, to get pregnant again. If that's what you." Then he was gone, and the nurse came in with a prescription.

"This, she said, is a prescription for a mild pain killer for cramping. Really, it's just a prescription strength aspirin." Then she looked at me and added, "I know what you're going through."

I thought she was the connection I needed. Someone who had a miscarriage in the past, and in whom I could confide, commiserate with. "Yes," she continued, "we see those frequently with first-time mothers. Not to worry, if you got pregnant this time, you will probably get pregnant again."

It left me empty. How could people who worked with first-time mothers who lost their children be so clinical, medical, and sterile about a loss so painful? I wanted to scream at them, and to make them feel what it felt like to have the life of a child scraped out of them. That, of course, would have been futile, because people do not see the child involved in a miscarriage. Nothing ever epitomized the old the saying out of sight, out of mind more than the child lost to miscarriage. The dilation and curettage (D&C) is a clinical procedure, and it scrapes the inner wall of the uterus to remove the remains, the debris, of the unborn child. That my uterus could be scraped, like a burnt cooking pan, to remove the remains of my child was a hideous thought to me.

The fact is, one's loss of a child is measured by people in terms of visibility. The more visible the child, the greater society perceives the loss to be. Since my child was nothing more than pile of debris scraped from my uterus wall, my loss was measured by others in life as negligible. In other words, no loss at all really, and everyone, including my own husband, assured me that to become pregnant again would somehow compensate me for the loss I had suffered. If my child had been far enough along to have been removed and to have been a recognizable human shape, then my loss would, I suppose have seemed greater, more real to people. If there had been a funeral, a casket with a body in it, then people could believe it was real. They would send flowers, make the visitation, and tell me how sorry they were for my lo9ss. Now, I was only encouraged to try again, as soon as possible. It was being treated as though I fell off a horse; the only way to ride again is to get up, get on the horse again to be sure that fear would not prevent you from enjoying the ride again. I laughed at myself as I equated the image of horse with that of my husband, and that I should merely mount him to erase the fear of becoming pregnant again.

The closest I came to explaining my feelings, my loss, for me, was a poem in a book by Laura Seffel and Jessica Kingsley (2006). The poem was called Like Ink on a White Blouse.

"It is an indelible loss -- like ink on a white blouse,

Something ruined, irreversible.

Bright red swirls in the morning waters.

You stare silently, you think it might be a dream,

A dream just before waking.

You're losing something, but you cannot stop it.

Your husband is running up the stairs.

Waiting for the doctor to phone.

Watching television blindly.

What they didn't tell you is that it's not over in a minute, or even a half hour.

You will eat lunch in an Indian restaurant

And at an odd instant recall

You are having a miscarriage.

It was never visible, the doctor explains.

You can't seem to hear her -- you notice her kind eyebrows.

The nurses locate places for you to weep.

"Get my husband -- I can't understand the doctor."

Tears spring as if to wash away this wrong story.

Waiting for her to say there is still a little baby somewhere

I cannot find myself. I have slipped out as well.

Perhaps something broken open.

Something has been lost.

And now what to do with the prenatal vitamins?

The cherries on our tree, tiny hard miracles,

Have quickly turned over ripe.

Sitting in the metal bowls, they exude their sticky juices.

There seem to be always more of them.

How will it end? How many pies can I bake?

My hands are already stained

With working of slitting each one and Pulling out the stone (21-22)."

It is what Soffel refers to as "grief unseen," and I refer to as the quiet mourning. There is no baby to bury, and, so people think, nothing to mourn. But the mourning does happen for the mother. I was so glad to find Soffel's book, because finally someone was expressing how I felt over the loss of my unborn child. Soffel says she had signs that were asymptomatic of a healthy pregnancy: no morning sickness, And her home pregnancy tests were inconsistent: first, a negative, then a positive with a second test a short time later, then another negative (22). Like me, Soffel hoped that the bleeding was not a sign that the pregnancy was over (22). Of course, the amount of blood I experienced was enough to alert me to the fact that it was over, but I had aged the child over the weeks in my mental relationship with him (I was sure it was a boy). He was not a fetus at the time of the miscarriage. In fact, he had graduated college and was becoming president of the United States. I knew he was destined for greatness; instead, he was scraped from my insides and disposed of as hospital hazardous waste.

The loss of my unseen child has left a hole in my heart for what was, what could have been, what would never be. Beginning within days of the event -- it's an event, if it's not a birth -- I began forcing myself to move forward. I closed my mental baby book of my child's life, and moved on. Whether or not to conceive again was not the question. The question for me was how long I would quietly mourn the loss of my child, because I was certainly in mourning alone. There is no group response to the unseen child. It was my alone to mourn. No one but me had bonded with it, so it was up to me alone to grieve the loss, and then, perhaps one day, I would wake and it would be a distant memory -- or not, but life must go on.

Soffel was so keenly aware of these feelings of being alone, of the unseen child is tantamount to not existing at all, that she has not just put her thoughts in a book, but also on a web site, found at http://magazine.wustl.edu/Winter02/alumniprofiles.html. Those women, like her, and like me, are the group she refers to as "The Secret Club (Soffel, 2009, online)."

"The Secret Club" of women who have lost a pregnancy (900,000 pregnancies end in loss each year in the United States). These women are linked by the emotional aftermath of "an indelible loss, like ink on a white blouse, something ruined.

'Miscarriage leaves no body for the couple to grieve,' she says, 'so it is also an invisible loss (online).'"

Soffel expressed her grief, the life she had known only through the bonding with the unborn life force inside her, through painting. Her book, too, is about healing yourself from the loss of miscarriage through the arts. Perhaps if Soffel paints enough of those feelings for which there are no words to express oneself over the loss, the grief, and the coldness of people who treat it like riding a horse, then others will begin to realize that there is no need to see or touch something so special, so miraculous as the force of life within us. Yet I realized that Soffel was on to something, and I wanted to see more of how mothers who had suffered miscarriages (yes, we are mothers too) dealt with their losses. I found these online at http://www.geocities.com/babiesinheaven/poems/mothertoo.htm.