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Vol 1 Miscarriages

Shieva Ghofrany: [00:00:00] Hi everybody. Okay, I'm in my garage. It's Wednesday and I'm actually gonna go to sleep super early because I haven't slept in three nights, but I got a good nap this morning. So we're gonna talk about miscarriages tribe, because this week I got many dms and unfortunately some of our own patients have had them. 

And it's a big, big topic. So we're gonna break it up into, I think at least three. Maybe more, but three that I can think of right now. The first part will be really the concrete, like what is a miscarriage? What are the definitions of different terms? What happens when you have one? How do you treat it and what maybe some of the causes are. 

Second is the emotional side of it, because as I joke, hair club member, hair club president, I've had six. I can talk about the emotional part and try to give you hope. And then the third that I. , [00:01:00] um, empathize with as personally, but I can empathize as a woman, is those really just ugh situations that make me grieve. 

Where women have to be put in a position to stop a pregnancy that was wanted either because of circumstances or because of anomalies. Fetal anomalies, which is birth defects. So that's the third part that we'll talk about. So, three separate videos cuz it's too much for one. miscarriage, which is the common term that you guys use in our world, the the technical vernacular is actually abortion. 

So when you hear that term, or you see it on your explanation of benefits from your insurance company or you see it in your doctor's notes, the term spontaneous abortion means miscarriage. And then under the umbrella of spontaneous abortion, you might have a missed abortion, which means it missed coming. 

you might have an incomplete abortion where part of the tissue came out, or a complete abortion where it all came out, and they will [00:02:00] determine that once you've had an ultrasound. So the doctor will see you do an ultrasound and determine if the heartbeat has stopped and if the tissue has come out partially or not at all. 

So the other two terms that we'll talk about briefly also, Something called a blighted ovum where you have just an empty sack without anything in it. And a vanishing twin where you started out with twin pregnancy and one of the twins went away, and the sack sometimes collapses and bleeds. So when would you know you're having a miscarriage? 

Could be one of a couple circumstances. For example, you missed your period and you had a positive pregnancy test, and within just a couple days, That pregnancy test became negative and you had what seemed like a heavy period, like a week late. That's what's called a chemical pregnancy, and that's technically a miscarriage. 

The egg and the sperm got together, but they really never made the correct genetic material. So I would say emotionally it seems. Easier. Still challenging because the [00:03:00] minute a woman sees that P Stick say positive or sees those lines, we've like planned out our future. But again, chemical pregnancy early enough that you, I think, feel less emotional about it and you really don't need to have any medical intervention. 

Sometimes you'll have a blood test just to prove it and make sure that the H CG goes down, but you don't necessarily even have to do that. Other situation would. , you're six weeks pregnant, meaning six weeks from your last period you've called your doctor, you're waiting for your eight week visit, and then all of a sudden you have cramping and spotting and you should call the doctor if that happens, not because of the concern with a miscarriage, which is an emotional concern of course, but because of the small risk of an ectopic, which is when the pregnancy can be growing outside of the uterus and more likely in the tube, and that is dangerous and needs to be checked very quickly. 

So spotting or. Pain on one side or the other, I describe it. In other words, cramps, just like a period without spotting. [00:04:00] Very common as the embryo is burrowing into the uterine lining, but pain on one side or the other or spotting with or without cramps should be evaluated by the doctor. And what they'll do is have you come in and depending on how far you are, if you're anything past about five, five and a half weeks, they'll do an ultrasound to make sure they don't see anything growing on the sides where your tubes are. 

And to ideally, What they want to see in the uterus. And depending on how far you are, my lights just went out. Um, since I'm hiding in the garage, depending on how far you are anywhere past five weeks, there are certain hallmarks of things that we see. So we'll see a sack first in the uterine lining, the gestational sack. 

Then we'll see a yolk sack that looks like a little circle. That's what the baby kind of feeds off of. We say early on in the pregnancy. And then you'll say what we call the fetal pole, which is that. The little bean, little grain of rice, ideally with a flickering in it. If we don't see that flickering, meaning we see the sack, we see the fetal pole with no flicker, then we say it's a miscarriage. 

The miscarriage [00:05:00] then is deemed a missed abortion. I don't use that word, I just say miscarriage, but again, if you see it in the notes or you see it, because the explanation of benefits comes from the insurance company, I don't want you to be even more upset when you see that term. It does not mean anything voluntary. 

In this particular case, it means miscarriage as opposed to a voluntary termination of pregnancy, which is the common vernacular for abortion. Once the doctor has determined that you have a miscarriage, , and we'll talk about the emotional aspects of it in the next video, like the most important emotional aspect, which is you did not cause the miscarriage. 

You couldn't have, I mean, it would be really hard for you to cause a miscarriage. So once you know that you have it, then you have really three choices. One choice is just expectant management. We say wait for watching, and you basically wait and see that when your. Understands that the miscarriage has occurred and then makes your uterus contract to push out the contents. 

You might [00:06:00] guess from my face that that is not. A big taker in my practice. A lot of people just don't wanna do that. I don't blame them. It's not what I ever chose during my miscarriages, because it's very unpredictable. Your body might not realize that this has happened for several weeks because there's still pregnancy hormone in your system. 

So in fact, even when you've had a miscarriage, your pregnancy hormone will be there. So if you take pregnancy tests, they're gonna show up as positive. So that's one choice. It's still, it's not the wrong choice, it's just a choice that I found many women don't want. I don't blame them if they do want it or don't. 

Statistically seems like they don't. Second choice is you can use medication to expedite that process. So prostaglandin medication, there's something called misoprostol, which is a very safe medication that is used to make the uterus contract. It makes you very crampy. And it ideally makes the uterus contract, the cervix dilate and the contents of the uterus get pushed out, even when on ultrasound, the contents look only about that big on the ultrasound, like the whole S sac will [00:07:00] look this big and the the pole will look like a centimeter. 

The amount of tissue that needs to come out, it's pretty significant. So you have to be mentally prepared that you will have a lot of bleeding and cramps and what looks like kind of. Thick tissue and blood clots that come out. So it is something that can be very emotional and many women want to do it to avoid a procedure, but when you, many women choose not to do it because they don't wanna have, again, the unpredictability or the physical and emotional discomfort of being home when this passes. 

And again, I don't. Two points that I want people to know. One is that if you Google Meza Prosol, which I always say don't Google, but if you do, you'll see that we use it for labor induction all the time, which is, I assume a comfort to you. But it's also used for medical abortions, for medical terminations. 

So the medication called, are you 4 86? is what stops the dividing cells in a termination, and then misoprostol is what makes the uterus contract. Don't be mistaken and get [00:08:00] angry at your doctor and say, why are you giving me an abortion pill? She's not giving you an abortion pill. She's giving you a medication that makes your uterus contract to push out the already spontaneous abortion that has occurred. 

Okay? Because these are little things that the medical community doesn't always think of, but when you guys see it, it's upsetting for you. Okay? Then the third choice is that you have a D and. Dilation and cure where under a little bit of anesthesia. Some doctors do it in their office, some doctors do it at the surgical center or the hospital. 

They gently dilate your cervix. You get a little bit of mild, very safe anesthesia, or at least medication. In your IV to make you feel sleepy, not have pain, and sometimes even have, um, an amnestic quality to it, something called verse said, depending on where you're having it done again in the doctor's office or at a surgical center or the hospital. 

So there's different kind of levels of how much anesthesia they'll give you, but the purpose of is for you to be relaxed and ideally not feel very much of this at all. If nothing, my practice tends to do it at the hospital or the [00:09:00] surgical center. So the patients are truly under anesthesia. It's very safe anesthesia. 

It's like colonoscopy. Um, I. Joke that it's actually the best sleep you're gonna get. So as anesthesia goes, it's lovely and we gently dilate the cervix and then we remove the contents. That's the cur part. That means in French it means to scrape, which sounds terrible. So we don't need to discuss that part further unless anyone has questions, in which case may be DM me cuz I don't really wanna talk about that part in detail if people don't wanna hear that. 

But the purpose is to get the tissue out. What I tell patients before I do any DNC. Our trick is that we have to get out the tissue as aggressively as we can to get it all out, but as delicately as we can so that we don't scar the uterus or perforate the uterus. So when you're balancing those two, you would rather err on the side of caution, and that means occasionally a tiny piece of tissue is left inside. 

So when you go home and your doctor might tell you slightly different parameters, but I tell patients you will bleed up to a heavy period up to two weeks is what I would [00:10:00] tolerate heavier than a heavy period, more than two weeks to me warrants. Please come in and do an ultrasound. Okay? Once the tissue is out, you have the choice of either it just going to the pathology lab, which is kind of the routine in any hospital. 

It has to be sent, or your doctor can send the tissue to a special lab where they will look at the chromosomes. The vast majority of miscarriages. I shouldn't say the vast majority, but the majority, over 50% are caused by chromosome abnormalities. The egg and the sperm got together. The egg has certain chromosomes. 

The sperm has certain chromosomes. When they get together, they mix their chromosomes and they create a brand new embryo of its own chromosomes. And sometimes those chromosomes, unfortunately, are not the right genetic material to survive. So over 50% of miscarriages are from abnormal chromosomes, including things like Down syndrome. 

People don't realize this, but, but the majority of embryos with Down syndrome actually don't survive. So the ones that we see survive are a smaller portion. [00:11:00] Besides Down syndrome, there are many other chromosome abnormalities that can occur. So again, it's comforting to know that the majority of miscarriages are already from chromosome abnormalities. 

You don't need to do that test. You can do it. And the nice part is when you get that information back saying yes, it was the chromosomes that comforts you even more. . But the downsides to that test, I will tell you again as someone who went through it, is that insurance does not always cover it. So you might get the confirmation and a six or $800 bill, or you might actually get, oh, the chromosomes were normal. 

Now we don't exactly have a reason for you if it's your first miscarriage or even second miscarriage. We're not that worried clinically, but now we're saying to you like, oh, well, we don't know why, and that's not comforting. and on top of it, you're gonna get a bill for six to $800 from the lab if your insurance doesn't cover it. 

And you might think it's easy to call your insurance company and get that information, but as you can guess, it's not terrible. Um, okay, so besides chromosome abnormalities, what else could cause a miscarriage? Sometimes it's things like [00:12:00] a septum, which is where your uterus. Has that heart shaped, so it's called a septum. 

And if the embryo happens to implant right where that sep septum is, it can miscarry. So if you happen to have a miscarriage and you have a dnc, your doctor often can feel if there is a septum in there. Um, occasionally if you have a fibroid, a fibroid can actually interrupt If the embryo has implanted right where the fibroid is, fibroids or those benign growths of the muscle of the uterus that we've talked about, there can rarely be systemic. 

Problems in your own body that create vascular issues or very microscopic blood clots. That is not so common, but it is something that certainly can be evaluated, though the good news is if you've had one miscarriage. And I should have opened with this. It's actually so common that data would say anywhere from 20 to 25% of pregnancies end in miscarriage in the first trimester or up to 50% if we include all of those really early chemical pregnancies. 

So [00:13:00] it's just so common that the likelihood of something bad needing an evaluation is very small. Once you've had more than two or three, the old data would say three in a row. The new data says two in a row with no live child in between. Certainly if you don't have any children, Then an evaluation can be done where we check certain blood tests, we evaluate your uterus. 

We might check your chromosomes, your own dna, and your husband's DNA N or your partner's DNA N, because if you or the male partner's DNA n a is abnormal, even though you seem normal, you can actually give that to your offspring. That's very rare, but something that can be checked. So a pretty brief workup can be done to confirm that there's nothing wrong, and the vast majority of. 

You'll get pregnant again and it will be okay, but it sucks. Okay, so miscarriages are common. Miscarriages suck. Miscarriages are not your fault. You can either wait till the tissue comes on its own. You can take medication to help the tissue come out, or you can have a D N C A procedure [00:14:00] and you will likely get pregnant. 

How long do you have to wait? We never used to have. Until about a year and a half ago, we had no data and we would say, wait 2, 3, 4 cycles. Now we have data saying right after your miscarriage, you can actually get pregnant in that next cycle if you want. I usually like patients to wait just in one period, just so we can define when their last period is, but that's not technically correct. 

According to the data, you could get pregnant right away. Okay, I hope that helps. I'm done with my 15 minutes , and then I'll try to post another video or two about this in the next day. Okay, bye.