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Pregnancy Loss: The Rainbow After the Storm
April 10, 2024
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Dr. Judy Campanaro
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Pregnancy loss is so common, but part of the isolation and guilt that people feel comes from the stigma and thinking that you are the only one who has experienced it. Approx. 1 in 4 pregnancies end in a loss so it is far from an uncommon occurrence. There is a growing number of people sharing their stories and experiences with loss to decrease the stigma and support people who feel isolated in this difficult time. In sharing information of pregnancy loss, we hope to educate people on what may happen if you experience a loss, what medical interventions may occur, and how you can move forward with your journey. Whether from a spontaneous pregnancy or through Assisted Reproductive Technology (ART), pregnancy loss is profound and you deserve support every step of the way.

 

Many pregnancies are lost prior to someone even being aware they are pregnant, especially if they were not trying to conceive. These early losses are often biochemical pregnancies where an embryo began to implant but did not continue to establish. This could be due to genetic anomalies in the embryo, an unsuitable endometrial environment, or many other factors; we often don’t know what causes the failure to fully implant. In a biochemical pregnancy, someone may get a positive pregnancy test then begin to menstruate a few days later. If someone was not aware of the pregnancy, they may just notice their period is a few days later than normal. This often doesn’t apply to fertility patients who are carefully tracking their cycle and get their blood work (including a pregnancy test or bHCG right after their treatment cycle) so they know right away if the test is positive. A biochemical pregnancy is still a loss and many people grieve it as such; seeing that positive test makes everything real and just because it was early, doesn’t mean the loss doesn’t hurt.

 

An early miscarriage typically occurs between 6 – 12 weeks of pregnancy; this typically what people think of when you describe a miscarriage. For fertility patients, this is around the time of a dating ultrasound (~6 weeks) and prior to their 12-week ultrasound and discharge to an OBGYN. A miscarriage can occur spontaneously where you experience bleeding and cramping or it may be a “missed abortion” in which the body continues to act like it is pregnant and the placenta continues to develop but the embryo/fetus is no longer growing; this is typically discovered at an ultrasound visit. Most people will have a miscarriage induce spontaneously, but medication like Misoprostol can be given to stimulate contraction of the uterus. In some cases, a dilation and curettage (D&C) procedure may be performed if there is tissue remaining. Causes of an early miscarriage can be many factors: genetic issues with the embryo/fetus, insufficient placental development, low progesterone or other hormonal variations, infection, pre-existing conditions such as autoimmune conditions, diabetes, etc.; and environmental exposures such as radiation or medications that are not compatible with pregnancy.

 

One type of loss that can occur in the early period is called a blighted ovum (anembryonic pregnancy). This is a term that means that there is no embryo/fetal tissue present, but the placenta/sac continues to develop. In these cases, HCG levels are normal and it is seen on early ultrasound that there is no developing embryo/fetus.

 

A late-term miscarriage occurs after 12 weeks until approx. 25 weeks. After 25 weeks, if the pregnancy is not successful, it is typically deemed a stillborn/neonatal death as it is past the window of potential viability. Later term loss is much less common but can still occur. Causes for later term loss are similar to early loss, but it can also be due to an incompetent cervix that begins to dilate too early or some blood clotting disorders. In most of these cases, a D&C or Dilation and Evacuation (D&E) is performed as there is more tissue present is more than could be managed using medication alone.

 

There are also two unique cases of pregnancy loss; ectopic and molar pregnancies.

 

Ectopic pregnancy

An ectopic pregnancy occurs when an embryo implants in a location that is not the endometrium (lining of the uterus). The most common alternate location is within the fallopian tube but it can be elsewhere such as on the ovary itself or in the abdominal cavity. Based on location alone, this pregnancy is not viable. An ectopic pregnancy cannot be “relocated” to the uterus. An ectopic pregnancy is high-risk, it can cause rupture of the fallopian tube, excessive pain and bleeding, ovarian torsion, and infection. Typically, a medication called Methotrexate is given. This is a chemotherapy drug that stops cells from dividing and the embryo will stop growing. If this doesn’t work, then surgery may be needed to remove it and possibly the associated structure (the tube, ovary, etc.). Ectopic pregnancy is relatively rare, but the chance is higher when doing fertility treatment like IUI or IVF.

 

Molar pregnancy

A molar pregnancy occurs when an egg does not contain any genetic material and a single sperm (or occasionally two) will fertilize the egg and it continues to grow into a mass (called a mole). In this case, there is likely no fetal tissue and it is the trophectoderm (placental) cells growing rapidly to form the mass. It will often duplicate what chromosomes are present so there will be more than 46 chromosomes in the cells. The person will not know until their first ultrasound as their HCG levels rise normally and are often very high. Molar pregnancies are extremely rare, but can be dangerous; some can even be cancerous. Molar pregnancies are typically removed through surgery and may be followed up with Methotrexate to ensure that all the cells are removed. It is recommended to wait at least 6 months before trying to conceive again, but overall, the risk of having another molar pregnancy is low.

 

Following most types of loss (except a molar pregnancy) you can try to get pregnant again when you are ready. Most people (~85%) will go on to have a successful pregnancy following a loss and one miscarriage does not necessarily mean that there is an underlying problem. If you have three or more miscarriages (or many biochemical pregnancies) then you may have Recurrent Pregnancy Loss (RPL). In that case, regardless of how long you have been trying to get pregnant, you should be referred to a fertility clinic to assess if there is an issue such as chromosomal translocation, immune condition, low hormone levels, anatomical defect (abnormal shaped uterus), or others.

 

Miscarriages take a big emotional toll in addition to a physical one, and you should never feel rushed to try again if you aren’t ready. Our team can recommend you to counsellors who are trained in loss and grief counselling and it may help to speak with a therapist and discuss your feelings surrounding the loss. Talking with close family or friends can help as well; having a strong support system will give you encouragement and love. Everyone grieves differently and having someone in your corner will decrease the isolation that many people trying to conceive experience.

 

The term “Rainbow Baby” came from the TTC community to demonstrate the hope and promise that comes following the storm of negative situation and emotions associated with a loss. Many people have their Rainbow and always hold the loss of previous pregnancies in their hearts; it is possible to celebrate new life while still remembering those that are no longer here. Some people may feel sadness or guilt about “moving on” or finally having a baby after loss(es); but moving on does not mean forgetting. You are allowed to be happy and celebrate your new baby or your decision to continue on your path forward.

 

At Generation Fertility, we affirm our commitment to provide compassionate care to anyone who experiences a pregnancy or infant loss. Whether it was a biochemical pregnancy, miscarriage, stillbirth, or infant death, your loss matters and there are those who support you in your journey.

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