Miscarriage

After the fun part of baby making comes the hard part. Not the labor, the diaper-changing, or the child-rearing, but the intricate division of cells and genesis of an embryo. This is the most fragile time in development. This is the time when a mother is most likely to lose her child. This is when she is mostly likely to miscarry.

According to a classic medical textbook, Williams’ Obstetrics, 12-26% of all clinically recognized pregnancies end in miscarriage. One study published in the New England Journal of Medicine in 1988 found that 31% of pregnancies ended in miscarriage, also called spontaneous abortion. 

Yet despite knowing of this risk, when my first pregnancy ended abruptly in October 2006, I was stunned and totally unprepared. It was just before my 26th birthday and I was over 11 weeks along, but my doctor estimated that the fetus had died at eight weeks. 

I was vaguely aware that the first trimester of pregnancy is dicey, and that I should wait until the second trimester to tell the world that I was pregnant. But the harsh statistics eluded me until I became one.

The experience drove me to understand the causes behind miscarriage, how it can be prevented, and ultimately, why no one – not doctors, friends, colleagues or even my own mother – had prepared me for this traumatic possibility. 

In truth, it’s a wonder that babies are ever born, given the intricate molecular machinery and trillions of delicate steps that must work like clockwork in order to succeed.

First, the sperm has to find the egg and combine with it to make a new human cell, the zygote. All of the estimated 100 trillion human cells in your body arise from this zygote. Every time the zygote divides - into two, four, eight, sixteen, thirty-two cells and more - 23 pairs of chromosomes must replicate, untangle and share their halves evenly between pairs of splitting cells. Pieces of DNA can be torn off, mutated or left behind. 

The newly split cells must also differentiate. Each one turns on or off different genes to become a specialized cell type - heart, skin, brain or muscle. This requires exacting regulation on the part of master genes. Molecular messages that coordinate the process can trigger an immune response from the mother’s body, attacking the budding being as it grows.

Miscarriage, or fetal death before 20 to 24 weeks of gestation, is most often an unavoidable consequence of this process of cell division, differentiation and growth.

In most cases, the exact cause remains unknown. Of the miscarriages that have been studied, at least half are due to fetal chromosomal abnormalities, again according to Williams. Still other developmental defects can occur in the zygote, embryo or fetus that will cause miscarriage. 

Miscarriage can come in many forms, including complete (fetus dies and body expels it), delayed (fetus dies and body does not yet expel it), or incomplete (some tissue passes but some remains in utero). 

If the woman’s body does not complete the miscarriage, there are ways to remove the tissue; you can take a pill called misoprostol that stimulates uterine contractions and tissue expulsion within 24 hours. This is what I elected to do, and although it was quite painful (it was essentially a preview to labor), I was at home and in control. Alternatively, you can undergo a minor outpatient surgical procedure called a D & C, which stands for dilation and curetage. For this, you are locally or sometimes generally anesthetized while your cervix is dilated and the tissue manually removed. Physical recovery is typically only a day or two. Finally, you often have the option to wait a week or two for your body to take care of things itself, unless there is a risk for infection. 

For most women, miscarriage should be considered a normal part of reproduction rather than a devastating failure at pregnancy. There are, however, known factors that increase the risk. Age is among the strongest. A February 2007 study of 603 women led by Noreen Maconochie at the London School of Hygiene and Tropical Medicine found that women over 35 were 75% more likely to miscarry than women aged 25-29 years. 

Women of any age can reduce their risk by avoiding tobacco and alcohol. Maconochie showed that women who drank everyday had 319% (or about three times) the risk of miscarrying than women who drank less than once per week or not at all. The 2007 paper also showed that stress, partner change, and previous pregnancy termination were factors that contributed to miscarriage risk. 

Happiness and a healthy diet (lots of fruit and vegetables, especially) reduced the chance of miscarrying. Caffeine, though often cited on other studies of miscarriage risk factors, didn’t seem to have any affect on this group of women. 

Yet even armed with this new information, I kept wondering - if miscarriage is so common and generally unavoidable, why wasn’t I informed? 

It wasn’t for lack of opportunity. Doctors and educators have plenty of chances to present this fact of life to young women: 4th grade coming-of-age class, high school sex ed, a woman’s first pelvic exam, or her first prenatal appointment. 

I found out about miscarriage when the doctor couldn’t find my baby’s heartbeat on the ultrasound. It was too late. With nearly a one in four chance of it happening to me, I am certain that I would have preferred to be exposed to the possibility of miscarriage before it happened. 

Motivated by frustration at my own naivete, I began sharing my miscarriage story and urging other women to tell me theirs. Nearly every woman I know who has children had at least one miscarriage. Even my mom had one, but before my experience I had no idea what that meant, how it was resolved, how she felt about it. My mom’s miscarriage came after three normal pregnancies, and she said that the miscarriage was the hardest labor of them all, both physically and mentally. It was comforting to talk to her about miscarriage and to bond in our shared experience. 

Why don’t women talk about miscarriage with other women? Is it because women move on, have babies, and talk about them? Or perhaps women have some latent insecurity about miscarriage, despite the fact that it is completely normal? Maybe that’s the problem: young women aren’t informed because no one talks about it; therefore when it happens we feel anything but normal. 

It is our responsibility to share our miscarriage experiences with women of all ages. If not to expand our personal support network then to inform women when doctors won’t. You or someone you know will experience the one in four, so the least we can do is educate each other. 

Heather’s family is about to expand, as she is happily awaiting the arrival of her first child in October of 2007.  Although she is no stranger to outreach, this is her first attempt at using the written word and owes a debt of gratitude to Christine Mlot, without whom this essay would not have been published.