Medical Aspects of Pregnancy Loss and Infertility

(The following is a synopsis of a talk given at the 2012 OCAMPR conference)

As a high risk obstetrician, I care for many mothers and fathers who are experiencing, or have experienced complications including early pregnancy loss (miscarriage), infertility, stillbirth and newborn death. When I encounter them in the midst of a loss, my purpose is two-fold. In the ultrasound room, when the parents first hear the news, often I am simply comforting them and helping them be certain that the loss is real, that the tiny heart has, indeed, stopped beating. Frequently, this is the only bit of information which can be absorbed, as the mind is too shocked by the loss to take in anything more. I will sometimes schedule the mother back for a follow up ultrasound so that she can see again, for herself, that the baby really is not living. We use multiple ultrasound modes to demonstrate that the heart is still, if the parents require this evidence. Alternately, blood testing of pregnancy hormone levels falling over several days can confirm this adequately. Secondly, I try to ascertain, if I am able, any causative factors which may have lead to the demise of the unborn baby.

This search might include ultrasound, maternal history, blood tests from mother or father, and eventually pathologic evaluation of the placenta and/or baby. Amniocentesis for chromosomal evaluation may be offered, especially if it appears that the demise happened some time ago (more than 3-4 days, as evidenced by overlapping of the skull bones on ultrasound). Chromosome testing can certainly be performed after delivery, but the possibility that the fetal cells will not grow in culture increases with passing time, and some situations warrant obtaining the karyotype as soon as possible.

Time is then allowed for parents to begin to ask their questions. Many times, mothers are plagued by doubt and fear that something they have done has caused the death of their baby. This is almost never true, and the more possibilities that she presents which I can assure her did not contribute to her loss, the more she can begin to accept and start to work out her grief without guilt. We discuss at length the important temperamental differences between individuals, and between men and women, when it comes to grief responses. Each of them may be in a different “place” regarding their need to discuss and express their grief on any given day. Planning ahead to forgive each other for sharp words or not listening adequately, and having other sympathetic ears to hear them can help to preserve marriages that may be torn apart by pregnancy loss.

An important aspect of pregnancy loss is sharing this news with other children in the family. Knowing that their children’s greatest need is to know that the parents are sad but unhurt, and that the parents will not be leaving or dying, is critical to the security siblings need to deal with the grief of their own loss. Some children may also feel that the pregnancy loss is their “fault”, and if this is discovered during discussion with them, they will need reassurance that they didn’t cause any problems with the pregnancy. Sharing the news with adult family members can also be very difficult, as well meaning phrases like “God must have wanted another angel in heaven” or “You’re young, you can have another”, or “At least you weren’t very far along/ the baby wasn’t born yet and you didn’t have a chance to get attached” pour from the lips of those who love the bereaved parents but have no clue what to say. Advice from families who have walked this road is to limit comments to “I’m so sorry to hear of your loss. I’ll be praying for you. Is there anything I can do to help you right now?” and then following up over the ensuing weeks. Parents will often need to speak of their deceased baby much longer than those farther from the pregnancy expect them to. Providing a listening ear is important.

The next step is to conclude the pregnancy, which may consist of naturally allowing the uterus to deliverl the baby and placenta, or encouraging this to happen at a particular time with medication to bring on labor. This is a valid approach up to 10 weeks’ gestation, but is not successful or particularly safe to consider between 11 – 14 weeks. During that time period, a D & C procedure is safer, with more control over blood loss. After 14 weeks, a D & E procedure would be necessary, which is more complicated, so once again reverting to labor induction may be a safer route. Following 20 weeks, labor is safest and also allows families to see and hold their stillborn baby. This has the added advantage of allowing chromosomal or physical evaluation of the intact unborn baby after delivery. Obviously, a much more detailed conversation occurs with the family at the time of a loss. During labor, the mother may have any means desired to help her be physically comfortable, as there is no concern for risk to baby. However, I do encourage mothers to be awake and physically take part in pushing their baby out. Having too much anesthesia can cause amnesia, and mothers can then have terrible nightmares “remembering” events which never happened at the time of their delivery.

Though it may seem that a cesarean delivery for a term, stillborn baby would be “kinder” to a mother than asking her to labor and deliver her child, the action of delivery prepares her body for a future, successful pregnancy and imparts much less medical risk to the mother than major surgery, in the form of cesarean section. After delivery, in most US hospitals, there is a grief support team which offers photographs, hand and foot prints and other mementos of the baby for the parents to cherish. Stillborn infants may stay in the mother’s room as long as she desires. Nurses and social service workers help the family with burial arrangements. The mother is informed that, especially after 20 weeks, her milk may “come in”. Though this may seem like a painful reminder of her empty arms, it is also an important milestone indicating her ability to nourish a healthy newborn, someday in the future. She is given advice about how to make this episode briefer and more comfortable. Some mothers desire an abbreviated hospital stay, preferring to go home and grieve in their familiar surroundings. Returning to work after pregnancy loss is an individual decision, based on mode of delivery, length of gestation, type of work, and mother’s preference.

When parents are referred to me for evaluation of recurrent early pregnancy loss, I take a careful history to understand the characteristics of each episode and try to pinpoint possible causes. We discuss the possibility of anatomic abnormalities of the uterus or cervix, metabolic medical problems such as hypothyroidism and diabetes, infections, chromosomal abnormalities, progesterone deficiency and immune/ clotting factors. Specific tests and treatments are ordered where appropriate. Importantly, parents should know that, after a single pregnancy loss, the likelihood that a next pregnancy will be successful (with NO intervention) is over 90%. After two losses, over 80% are spontaneously successful and after three losses, mothers will conceive and bear a child over 70% of the time. These statistics can give hope to families who feel the burden of pregnancy loss as something which makes them a “failure”, especially if no particular cause is found for their losses and they are simply advised to “try again”.

The timing of a future pregnancy attempt is dependent upon many factors. After a full term loss, I advise families to wait a full year prior to attempting another conception. This is very difficult for parents to hear, as some wish to conceive again right away. Complications such as early pregnancy loss, anemia, cervical weakness, uterine rupture, preterm delivery and preeclampsia are more likely with a short interconceptual interval. Also, allowing a full calendar year to pass before another pregnancy begins will help families come farther in their grief work and embrace the joy of a subsequent pregnancy more fully. After an early pregnancy loss, I recommend waiting until three menstrual cycles have passed before attempting conception.

Infertility evaluation is not a large part of our practice, but the conversation that I have with families who present to me with infertility includes factors from husband and/or wife which may be contributing to the difficulty in conceiving. Female infertility may be due to inefficient ovulation, blocked fallopian tubes, thin uterine lining, or hormone deficiency from the ovaries. Male infertility is caused by lack of quantity of sperm or “poor quality” (unusual forms, poor motility) of the sperm. From an Orthodox Christian perspective, the most critical part of my consultation with infertile couples is to understand how important it is to continue in a loving, forgiving and patient relationship with one another. Blame for infertility is a weapon that can destroy the home and the marriage.