I have been so blessed with two wonderful, uncomplicated pregnancies and two beautiful, healthy daughters. But, there was another pregnancy. I will admit, even as an obstetrician, this is a sensitive topic that requires a lot of vulnerability to discuss openly. But miscarriage is so common and important to discuss, and just like my incredible experience delivering my girls, my experience through a miscarriage has made me both a better mom and a better physician.
A journey through loss
I will never forget that day. I was driving with my daughter in the car to meet my husband at the car dealer. We were all so excited about our new car! About halfway there, I felt something wet. I had started bleeding, and not just a little bit. I called my husband and told him to meet me at home. We wouldn’t be buying a car that night. I remember staying calm, so my daughter did not know what was happening, but in the front seat I was frantically using baby wipes to try to keep the seat clean. After all, we couldn’t trade in a blood-stained car!
I pulled into the driveway and went straight to the bathroom. I was hemorrhaging, but my two-year-old daughter needed her mama. She sat on my lap while I sat on the toilet, bleeding too heavily to get up. I used her diapers to line my underwear and called my ObGyn and best friend. In the moment, I could not think logically about my own care. She patiently walked me through my options, knowing all too well that I have said those same words so many times to my patients.
We talked about the first two options for management: expectant and medical.
Expectant management. Watch and wait. In the absence of heavy bleeding or infection, expectant management can be a safe and effective option for the management of early pregnancy loss. It is successful in approximately 80% of women if given enough time, sometimes up to 8 weeks. This method is more effective in women who are already symptomatic with cramping and bleeding. Patients undergoing expectant may have heavy vaginal bleeding, which may be unpredictable. And surgery may be required if complete resolution of pregnancy is not achieved.
Medical management. A medication called misoprostol is inserted into the vagina, which expedites the resolution of pregnancy. Women often have heavy bleeding and cramping a few hours after administration. This process is successful in about 71% of women with a first-trimester loss within 48-72 hours. For women who would prefer to avoid surgery but would like to expedite pregnancy resolution, misoprostol can be a wonderful “at home” option. As with expectant management, women should be counseled on expectations and bleeding precautions – soaking two pads per hour for more than two hours is generally considered “too heavy.” It is also important to understand that if expectant or medical management are unsuccessful, surgical management may be required.
I chose medical management. My husband picked up my medication. I bled. A lot. And then it stopped. I thought it was over and felt relief. I was a busy doctor and mom and was ready to move on. My sister and I went to get a pedicure that weekend, a treat few and far between for a resident physician. I relaxed and let my guard down. My nails were done, and my toes were drying, and I felt it again. I was hemorrhaging. Again.
The third option
This time I knew what was happening and knew my options. I had failed medical management. The next step was to go to the hospital where they did an ultrasound and labs. I gave them my best guess of my “estimated blood loss.” My ObGyn met me there. We both knew I needed to move on to the third option for management of this miscarriage.
Surgical management. This is completed with a procedure called a dilation and curettage or “D&C.” The cervix is dilated, and the uterus is surgically cleared of the products of conception with a suction device. The benefits of this method are that it is quick and definitive. The disadvantage is the nature of the surgery itself, with inherent risks for infection and injury. I remember my eyes watering and holding, at that moment not my ObGyn, but my best friend’s hand as they put me to sleep.
I often joke with patients that I’ve had the “poo poo platter” of miscarriage management, a little bit of everything in a bad situation. There are certainly reasons to choose one management option over another and this is a conversation you should have with your ObGyn. Just know, so many other women have stood in your shoes, and the rainbow is so much brighter after the rain.