Pregnancy loss – Dr. Jessica Farren
While most pregnancies are healthy, sadly sometimes things don’t go as planned. The two most common early pregnancy
If you have experienced a loss it is normal to feel extremely sad, but know that you are not alone. It’s important for you to know that miscarriage is common and there is nothing that you have done to cause this.
Sadly, 1 in 4 pregnancies end in miscarriage. The vast majority of miscarriages occur in the first 12 weeks of pregnancy. Rarely, miscarriages can occur up to 24 weeks of pregnancy.
Signs and symptoms
The most common sign of miscarriage is bleeding and cramping abdominal pain. That said, many women with pain and bleeding go on to have healthy pregnancies, though heavier bleeding makes this less likely. Sometimes women experience no concerning symptoms, and find out at a routine scan.
An ultrasound scan is usually needed for diagnosis. This is generally performed in a specialist early pregnancy unit in a hospital, where, in the UK, you would be referred from your GP, or your local A&E. Usually, when you are less than 10 weeks into a pregnancy, a transvaginal scan (when a small probe is inserted into the vagina) is performed.
Sometimes a miscarriage can be diagnosed immediately on a scan. However, often there is a period of up to two weeks of uncertainty. This is because it is impossible to distinguish a healthy very early pregnancy from a pregnancy that has stopped growing. Given the huge importance of correctly diagnosing a miscarriage, doctors err on the side of caution and only diagnose miscarriage if there is no possibility of a healthy pregnancy. They will be able to give you an indication as to how likely they think a good or bad outcome is from the scan (taking into account what they would expect to see according to your ‘dates’, and how certain you are of these dates).
Sometimes a ‘complete’ miscarriage is diagnosed: this means the baby and/or pregnancy tissue has already been passed, and no further intervention is required.
If there is pregnancy tissue in the womb, there are broadly three treatment options for miscarriage:
- Conservative – waiting for a miscarriage to happen naturally
This can be a good option for people who have already started bleeding, especially in an early miscarriage. However, many women find the unpredictability of when they will bleed heavily, and when it will be ‘over’ hard to manage.
- Medical – when you are given tablets (usually to give yourself, into the vagina, at home) to bring on bleeding and cramping (usually the same day)
This method offers a little more control than conservative management. It is successful in 4 out of 5 women. The advantage is that you can choose when you do it, and some women find it feels like a ‘natural’ approach. However, it is not recommended for later miscarriages due to the risk of heavy bleeding.
- Surgical – a procedure in which a small tube is put into the womb via the cervix (i.e. no cuts are made) and the pregnancy is removed
Some units are beginning to offer these procedures with you awake (called ‘MVA’) – but the majority of hospitals recommend they are performed under general anaesthesia. This is the most predictable management – with a 95% chance of success – though some women do need a second procedure.
We know that the majority of miscarriages are caused by genetic problems. This essentially means there was a very slight ‘mis-firing’ of the very complex chemical reactions that need to take place when the first cells of a baby are dividing – such that the cells did not have the right amount, or right configuration, of genes, and sadly could not form a healthy baby that would be able to survive to the end of pregnancy, and beyond. Unfortunately, this means that the majority of miscarriages are ‘unpreventable’ – and even if there was a way to stop the womb from bleeding, a healthy baby would not be a possibility. These types of miscarriage are more common as we get older, and the quality of eggs declines. This is the reason why, at the age of 40, the risk of miscarriage is as high as one in two pregnancies.
Rarely, there are preventable causes of miscarriage. Because these are so uncommon, and miscarriages are so common, it is generally suggested that you do not test for them after one early miscarriage. Later miscarriages (after 13 weeks) may be more likely to have a preventable cause (including a weak cervix): for this reason you are usually referred for testing after a late miscarriage.
Importantly, miscarriage is not your fault. It is not down to the exercise class you went to, or the night out, or stress. There is nothing you can do to prevent it, and you absolutely must not beat yourself up about it, or look for things that you would have done differently.
In an ectopic pregnancy, the pregnancy develops in a different place to where it should. Most commonly this is in the fallopian tube (the tube that carries the egg from the ovary to the womb). They can also occur in the cervix, in a scar from a previous Caesarean section, or in the ovary. Sadly, there isn’t room for pregnancies to develop in these locations, and they cannot survive. Ectopic pregnancies occur in approximately 1 in 100 pregnancies.
Signs and symptoms
Often the first sign of an ectopic pregnancy is bleeding. Usually the bleeding is less heavy than it is in a miscarriage – and may be quite brown in colour. A concerning sign is pain. The pain comes from the fallopian tube being stretched by the early pregnancy, and bleeding through the fallopian tube into the tummy. You may feel this pain as a sharp discomfort, often more on one side of your lower tummy. You may also get pain radiating up into the tip of your shoulder.
If you bleed heavily into the tummy, sometimes the first thing you know of it is that you get very dizzy, or even pass out.
If you have any of these symptoms in early pregnancy it is very important that you seek medical attention straight away as, if left untreated, bleeding into the tummy can be life threatening.
An ultrasound, again using a vaginal probe, is needed. Often a pregnancy outside the womb can be clearly seen. Sometimes a pregnancy is not seen inside or outside the womb: in this situation blood tests are needed to give a better idea as to what is going on.
Sometimes ectopic pregnancies resolve without any intervention (they ‘miscarry’). However, you will need close surveillance during this time. If you are in pain, often surgery is needed. Surgery usually involves a keyhole procedure to remove the fallopian tube. The reason the whole fallopian tube is removed is because there is evidence to suggest that, providing the other tube is healthy, by just operating to remove the ectopic you increase the chances of a further ectopic, but do not increase the chances of a healthy pregnancy. Sometimes medical management is offered: for this, a medication called methotrexate is given as an injection. Close monitoring is then needed to check the levels of the pregnancy hormone are going down.
You will be advised to have a scan early in a subsequent pregnancy, as your risk of a second ectopic is slightly higher.
Ectopic pregnancy is more likely when you have damage to your fallopian tubes. This may be as a result of endometriosis, previous appendicitis, or pelvic inflammatory disease (often caused by chlamydia), or smoking. They are also more common after IVF. Often, however, there is no cause.
How you may feel after a pregnancy loss
It is very natural to feel extremely sad after a pregnancy loss.
It is completely understandable that you will have built up plans and expectations from the moment you had a positive pregnancy test, and it is usually pretty devastating when those come tumbling down. Many women also experience these losses in a similar way to other bereavements – but sometimes the fact that not many people know about it, and there’s no clear way of acknowledging the loss publicly, make it harder. There’s also a sense of uncertainty about the future: it’s very natural to want immediate reassurance that you will be able to have healthy pregnancies in the future (and no amount of us/others reassuring you that there’s no reason for it to happen again will stop this). It is often helpful to contact other people who have been through something similar. You’ll soon realise that many of the people around you have been through it (remember 1 in every 2 women will go through this in their lifetimes). There are also some great charities that provide support. Our favourite is https://www.sayinggoodbye.org.
Our medical advisor, Jessica, has also done some research looking specifically at symptoms of depression, anxiety, and post-traumatic stress after a pregnancy loss. She found that all these conditions, especially post-traumatic stress and anxiety, are very common after losses. It is very important, if you feel that your mental health has suffered, and is not improving rapidly, after a loss, that you consider seeing your GP. You may need referral for formal support and treatment of these conditions.