Miscarriage is nature’s way of discarding a pregnancy that didn’t proceed in a way compatible with life. Even though it may be mere disposal, to prospective parents it is a real tragedy, with hopes and dreams and a certain romantic vision of their child-to-be dashed before their broken hearts. But the fact remains that it does happen, and it happens for a reason.
As physicians, we obstetricians must treat the discarding aspect scientifically and the human tragedy aspect with compassion and understanding. Often it happens very early. Since a lot of miscarriages happen even before implantation, a woman may not even miss a period. The fact that this occurs at a rate of almost 60 percent is a staggering thought, but when one realizes how many things must go perfectly to make a baby, it’s a wonder that it happens at all. “Miracle” is never a worn-out word for the conception and healthy birth of a baby.
Miscarriage occurs in about a fifth of all clinically diagnosed pregnancies. This is a staggering amount of anguish since most couples never consider this possibility when they choose to have a child. And if one were to include the very early miscarriages that happen silently around the time of an expected period, the numbers are much higher.
Miscarriage can happen for a number of reasons. Almost always it is because of some random genetic mismatch unsuited to progressing all the way. Once again, we’re at the mercy of the biological rules. It is nature’s way of assuring a continuing healthy species. Miscarriage can also happen due to infection; maternal diseases such as lupus, diabetes, and thyroid problems; and abnormalities with the anatomy of a woman’s reproductive tract. The sad fact is that it happens to people who are blind-sided by this loss. Sometimes it happens to the same couple more than once, prompting evaluation for known causes. But most of the time there is no known cause, and the couple feels they are being sent away with only an invitation to return to the obstetrician for the next try, as if finally pulling it off tomorrow would undo today’s tragedy.
This is the illusion, especially for a couple who feels that the loss is their own private catastrophe, and they can’t seem to share enough with others no matter how hard they try. Unfortunately they are somewhat left on their own, because there are no rituals for this type of human loss, no funerals, no memorial services. Friends and relatives, often misguided into thinking that mentioning the miscarriage will only be upsetting, are instead seen as uncaring in their silence. The grieving couple has only each other, and that may not be enough for the feelings of guilt and self-examining retrospection. And anger. After all, this isn’t just some tissue that was discarded, like an appendix or a gallbladder. This was their son or daughter. There were dreams of seeing little league events, helping with homework, attending dance recitals, and walking down an aisle. The whole sense of what might have been is lost to a clinical world of procedures, blood tests, and insurance forms.
A mathematician can count on his fingers, but that in no way reflects the beauty of mathematics. This word processor can lay down words at the direction of certain keystrokes, but that in no way compares to the actual beauty of what is written. I manage the complication of miscarriage, but that doesn’t reduce my feelings for what might have been. So I do not merely send a couple on their way with an invitation to return for the next try. Instead, I applaud them for going back into the world to once again play by the biological rules. They will have that baby not to replace that permanent little hole in the heart left by a miscarriage, but because they want a baby.
The science of in vitro fertilization (IVF) has brought about advances in our knowledge of conception and survival of the zygote and subsequent embryo. We now know that there are many miscarriages that go undiagnosed, a fertilized egg unsuccessfully implanting or unable to do so because of severely distorted fusion of chromosomes. Such miscarriages are completely absorbed or fall away with what is seen as the routine menstrual flow. Taking this type of miscarriage into account, we’re careful now to say that miscarriage happens in 20 percent of all diagnosed pregnancies. But total miscarriage risk is probably closer to 60 to 80 percent when the silent ones are considered.
Perhaps it is fortuitous that the majority of miscarriages go unnoticed, for we would be one “bummed out” species otherwise. Even the 20 percent is overbearing—just ask someone who has experienced a miscarriage. The more we learn about this, the more we realize just how precious each person is. I think that a couple that experiences a miscarriage really knows this. It takes about three months before a couple can deal effectively with their loss. This is quite a requiem, which only underscores the importance of what has been lost. My advice for those who know such mourners is to ask them how they’re doing. They really don’t want to be alone in all of this. At the appropriate time they’ll file this tragedy away for safekeeping and get on with the rest of their lives. Until then, let them share their grief.
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