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Miscarriages suck but..

[00:00:00] Good morning guys. It's Thursday morning. I wanted to talk about miscarriages because they happen all the time. They've happened. They happen in clusters in's, offices, I feel like, which sounds funny because again, they kind of happen constantly, but if you're a doctor out there, I don't know if you agree, like things happen in clusters and listen, miscarriages, they just suck. 

There's no way about it. They suck. They suck when you go through them. I've had six of them. Um, that said, as I say jokingly, and I say this jokingly to anyone's going through it, not to be disrespectful, but almost to just give you hope that I always say I've had six miscarriages, but now I have more babies than I can handle. 

So it is a really tough thing to go through. But the parts that I really want people to realize are, take heart, you will have a baby. And I'm not saying that just to be optimistic, like, oh, of course you will. Rah rah. It's just statistically the majority of women are able to have healthy babies. Some need help getting pregnant. 

Some need help staying pregnant, but the majority are able to [00:01:00] do it. So let's go through the terminology. So the terminology, unfortunately, has to do with the word abortion because abortion is not by, um, Latin and medical definitions meant to be a voluntary interruption of pregnancy. It is when a fetus aborts itself. 

So the terminology that you might see on your bill, for example, if you, if you have a miscarriage, we'll use that term. Obviously in today's vernacular concerning and upsetting, but I just want you guys to know why it's that way. Um, because of the, again, the origin of the word abortion. It means the, the fetus aborted itself. 

Okay? So, um, you can have a miscarriage and typically what happens, you find out you're pregnant, you go to see the doctor. Anywhere from six and a half to eight weeks is when we can see the heartbeat on the ultrasound sometimes earlier, but that's typically the window. Machines in the doctor's office. 

Some doctor's offices really, really encourage you to wait until eight weeks, which I do not think is a bad idea. In fact, if we waited until eight weeks, [00:02:00] most patients would see the heartbeat and it would actually be comforting because many patients come very early and maybe we see the heartbeat, maybe not come back in a week or two, and that just adds to the anxiety that said. 

When patients are nervous and anxious, we just don't say no. So we let people come in. Um, I don't think that's always the best practice, by the way, but it is comforting on in the immediate. So you go to the doctor's office, we're gonna talk about the new OB visit at another time, but basically your first visit most of the time is to confirm that you are pregnant, confirm that it is in your uterus. 

And confirm what the date is, meaning they will measure what's called the crown rump length. The little nugget, the little bean I call it, with the heartbeat and confirm if that makes sense, with what you think your period is and when you think you got pregnant. And believe it or not, 25% of the time when women think they got pregnant, they've shown in studies we got pregnant at a different time, which still confounds me and makes no sense. 

But that is what the data. So you come in, they look for the heartbeat. If they don't see the heartbeat, but the little measurement looks like [00:03:00] the same amount of time you should have been pregnant. Then they've essentially confirmed that you had a miscarriage. In medical terminology, it is called a missed abortion, meaning the fetus has aborted itself, but it has not come out on its own. 

Okay? That's one scenario and we'll talk about how to take care of that in a sec. Second scenario is you come in, you think you're. Pregnant, your last period was eight weeks ago, and they go to look and lo and behold, it's only measuring six weeks. In two days. For example, the little crown rump length is called head to butt. 

It's a little teeny nugget, and it is the most accurate way to date a pregnancy because all babies, whether they're gonna be 10 pounds or six pounds, We'll measure the same in that first trimester, so it's actually more accurate than going based on your period. I know that sounds weird. So they'll measure it. 

Let's say they see the heartbeat, but it's not measuring what you think. Then the good news is maybe it's just a pregnancy that was, um, occurred at a different time than what you thought, and then they'll typically have you come [00:04:00] back in anywhere from like one to four weeks to remeasure it and make. Two points on the line that that little embryo is growing now with a different due date than you might have imagined. 

Unfortunately, the second choice there is that it's lagging in growth and that difference in size is showing an already unhealthy pregnancy that's not progressing. Um, so you might go back in a week or two in the heartbeat might have stopped. Okay. The third choice is that they don't actually see any intrauterine pregnancy intrauterine inside your uterus and. 

They have to go down the route of making sure that it is not an ectopic, where it's growing outside of your uterus. Um, so if it's growing outside of the uterus, which they have to do a series of blood tests and ultrasound to look, then they have to deal with it. And we'll talk about ectopics at another time. 

Um, it might turn out again, you just very early in the pregnancy and you didn't realize, okay, let's talk about what happens if you have a miscarriage. So miscarriage they see. They see there's no heartbeat. You've had a missed abortion, meaning it has not come out. And then you have to make [00:05:00] one of three choices to either just wait for your body to appreciate and understand that it is not growing, and then your body will push the remainder of the tissue out. 

But, That can actually take a long time. I mean, that can be a couple of days or sometimes weeks where your body kind of gets the signal that the HCG hormone is not continuing and then it will realize to release the tissue. But if you do pregnancy tests, you'll still show up as pregnant. So just know that Second choice is you could use medication called merool, which you take orally or vaginally. 

And it is medicine that was originally used to, um, protect the lining of the gut from the effect of things. Ibuprofen and the NSAIDs because those can cause ulcers, but they've found as a secondary side effect, it causes uterine contraction. So we use it when people are trying to get, be put into labor as an induction agent, and we use it to help your uterus contract and push out the tissue when you had a miscarriage. 

Um, it's actually wonderful to use if it works, [00:06:00] because when it works, you don't need to have an any procedure done. And sometimes that's psychologically beneficial. Sometimes patients don't have access to providers as easily as we. Parts of like the Northeast. Um, sometimes patients just don't wanna have a procedure, and in theory the chance of scarring of the uterus is far less because you're not putting anything in to scrape anything out. 

The downside is that it's unpredictable. Some patients will use these medications and their body doesn't respond. Me being one of them with some of my miscarriages, I tried it with one of them. I tried it and it just didn't work. I mean, I kind of was ready for cramping and pain and bleeding. And it just did not, for whatever reason, my uterine receptors didn't, um, respond. 

So I ended up having to have a dnc And the second psychological side effect of that is some women don't want to kind of wait and see what's gonna happen. They either don't have time with work or childcare or psychologically, they just don't wanna wait. They'd rather have a procedure. So the third choice is you have a dilation and curto. 

C, that's when you go to a facility. Sometimes doctors [00:07:00] do it in their office. If they have surgical facility capabilities, they give you a little bit of mild anesthesia, which I describe as heavy enough that you don't feel anything. I'm doing mild enough that you're essentially breathing on your own. So it's very safe. 

Anesthesia, the doctor gently dilates your cervix. With, um, little dilators that are narrow and we're talking up to about a centimeter and then uses a device to remove all of the material from the uterus. Again, you're asleep, you wake up, crampy, you wake up. I tell patients you'll have bleeding and I kind of like to really prepare them. 

So I say you might have up to a heavy period for up to two weeks. It's usually not that. But that's what you could expect, and I wouldn't be worried about it. The trick during the DNC is to make sure you get everything out, but do not over aggressively scrape the lining of the uterus. So sometimes that means a little piece of tissue might be left and that can lead to heavier bleeding, rarely needing a second dnc. 

Um, the benefit to the DNC is [00:08:00] that you walk in, you have it, and then you can leave. And there's a little bit of psychological closure. The downside is, Theory, it can risk, um, scarring the uterine lining, but that's rare, especially in people who have unfortunately done them a lot. It's unlikely that that's gonna happen. 

Um, the other benefit is that in theory, you could take the tissue and send it to check for the chromosomes. The majority of miscarriages happen over 50% because the chromosomes, the genetic material, when the egg and the sperm got together didn't create the right thing. Things like. Down syndrome or other trisomies they're called will lead to miscarriages. 

And so that's the majority. And the guidelines don't say to check, believe it or not, because we can kind of comfort patients by saying the majority are because of abnormal chromosomes. That doesn't mean something that's gonna recur. And so that knowledge is comforting enough. We could send the tissue to prove it. 

The downside, at least in our facility, is if we send the tissue insurance does not always cover it. And I learned the hard way when I got a bill for like five or [00:09:00] $600 after one of my miscarriages that the insurance didn't cover and only to confirm. And my case actually the chromosomes were normal. That meant something else was going on, but not necessarily something onerous. 

Many women will have miscarriages up to two to three miscarriages, depending on your age and different um, issues, is considered the norm. And if you tell people you've had one, you'd be shocked at how many people come out of the woodwork. Your mother, your aunt, your best friend, all these women will go, oh, you know what? 

Yeah, I had it too. I had a couple of 'em. And now look. And these are women. Families of, you know, two to 10, two to 11 babies. So once again, I find it comforting to be open. So I hope that you guys consider telling people when you've had it because there is comfort in numbers, right? Okay. So miscarriage, you can wait to have it pass on its own, take medication or have a dnc, and then what? 

How long do I have to wait before I try to get pregnant? And believe it or not, up until a year ago, there was no. So most doctors went on our feeling, which was anywhere from like wait two or three [00:10:00] cycles to let the lining regenerate to, oh wait, six months, which was kind of the old-fashioned, um, way of doing things. 

Now, luckily they did come out with the study saying, after a miscarriage, women can try to get pregnant in that next cycle. And they have just as high pregnancy rates, ironically, slightly, maybe more than if they waited more than six months. The old-fashioned me still with a very non-scientific, um, reason, says to women, I don't know, maybe let yourself have one period just so we have an index of where to go. 

That's not correct, but that is what I tell tend to tell patients. So you should ask your doctor. Because I might not be your doctor. In fact, I'm definitely not most of your people's doctors cuz you're coming from across the country. Um, and the most important thing, promise me, any of you guys who are going through it right now or just went through it or go through it in the future, you're gonna have a baby. 

I can almost guarantee it and I can say it with statistical. Confidence. Forget like, oh, I'm just gonna be positive. Statistical confidence you will have a baby. It will likely be fine. That does not mean that there are not, um, [00:11:00] trials and travails along the way in hardship. Okay. All right. I hope that helps. 

This was a long one, but there's even more to say, so I'll have to do like a part two about when you walk into the doctor's office, what the new OB visit entails, what the different aspects of how to check for an ectopic. Okay. Bye.