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Survey has proof about one in four women loses a pregnancy in her lifetime.

Then when you lost your baby, what happens and what comes next?

DEFINING THE TERMS
Early pregnancy loss means losing a pregnancy earlier than 20 weeks after the first day of your last menstrual period. The medical term for this loss (which occurs without anything being done to cause it) is spontaneous abortion. Because the word “abortion” is associated with a procedure done on purpose to end a pregnancy, early pregnancy losses often have been referred to as miscarriages.

Most women become aware that they might be losing a pregnancy when they begin spotting or bleeding, even though they have tested positive for pregnancy. Sometimes a pregnancy loss is suspected during a routine prenatal exam, even when no vaginal bleeding has occurred. In such a case (called a missed abortion), your clinician (doctor, nurse midwife or practitioner, or physician assistant) might find that the fetus no longer has a heartbeat or that your uterus is not enlarging as expected.

WHAT HAPPENS NEXT
In the past, women with early pregnancy loss almost always went to a hospital operating room for dilatation and curettage (D&C), in which the doctor opens up the cervix and removes the remaining blood and tissue from the uterus. If you tell an older female relative that you are having a miscarriage, she might tell you that you need a D&C — however, your clinician now has other ways to manage pregnancy loss safely, without surgery.

If you are bleeding vaginally, your clinician first will determine if you are losing the pregnancy. This can be done with blood tests every few days to see if your level of “pregnancy hormone” (human chorionic gonadotropin, or HCG) is going up, staying the same, or going down. In a healthy pregnancy, HCG levels rise steadily; dropping levels signal that the pregnancy is no longer progressing normally. A woman can experience spotting or light bleeding even when her pregnancy continues, so an ultrasound often is performed. Before any treatment is advised, you and your clinician will be certain that pregnancy loss is actually happening. If the process of pregnancy loss is confirmed, nothing can be done to stop it.

TREATMENT CHOICES
Options for managing pregnancy loss depend on your medical condition, your clinician’s experience, and what resources are available in your area. One choice is expectant management: letting your body finish the process of expelling the pregnancy on its own. An advantage of expectant management is that no medications are used, so no drug-related side effects will occur. However, if you choose this option, you should be aware that bleeding might continue for several weeks. Many women who “wait it out” need no further treatment. But for some women, enduring several weeks of bleeding is difficult both physically and emotionally, and after a week or more they request treatment to speed the process. Expectant management is less likely to succeed in women with missed abortions; half of these women might need further treatment.

A second choice is medical management, with a drug called misoprostol, to help expel the remains of the pregnancy from the uterus. Women with very early pregnancies (up to about 7 weeks) who are treated with misoprostol generally complete the process within 1 week (and many do so by the third day). Although many women who are treated medically for early pregnancy loss are satisfied with this treatment, some experience side effects such as heavy vaginal bleeding, nausea, vomiting, and diarrhea.

With either of these options, sometimes tissue from the pregnancy stays in the uterus and must be surgically removed. Surgery is also an appropriate first choice for women who would prefer that the physical pregnancy loss be over quickly, or who (for medical or other reasons) are not candidates for expectant management or medical treatment.

In the past, surgical treatment of early pregnancy loss meant being given anesthesia in a hospital operating room. Now, however, surgical treatment often can be done in a medical office. The in-office procedure usually is done by manual vacuum aspiration: After medication has been given to lessen pain and help with relaxation, the clinician inserts a flexible tube connected to a specially designed syringe to remove the remaining tissues from the uterus by suction. Having the procedure done in a medical office has the advantages of privacy, lower cost, and less likelihood of heavy bleeding and its related complications.

THE EMOTIONAL SIDE OF PREGNANCY LOSS
Coping with pregnancy loss does not end when the pregnancy itself ends. Whether the pregnancy was unexpected or long awaited, women (and their partners) experience emotions ranging from relief to despair. Common feelings are anger, guilt that you might have done something to harm the pregnancy, and fear that you might never be able to become pregnant again. There is no particular way that you are “supposed” to feel after losing a pregnancy and no single way to recover from the loss.

Most women find it helpful to talk about their feelings with their partners, friends, family, or a therapist. Making some time for yourself (perhaps by taking a few days off from work or usual activities) to think about your loss and what it means to you is often beneficial. If you have a partner, talk with him or her about how you both are feeling, and take some time to be together. Writing a poem, lighting a candle, praying, writing in a journal, or creating another type of remembrance can provide relief. Be aware that friends and family members, in a sincere attempt to comfort you, might say things that seem insensitive. It is okay to ask them just to listen instead of offering advice. Finally, talking with women who have been through similar experiences can be supportive. Your clinician can direct you to a pregnancy-loss support group in your area.

If you find yourself unable to recover from the grief of losing a pregnancy — or if you feel excessively sad, guilty, worthless, or uninterested in usual activities, are thinking about harming yourself, or have ongoing changes in appetite or sleep — you could have symptoms of serious depression. Contact (or have a friend or partner help you contact) a therapist or your primary care provider for help.

IN CONCLUSION
Losing a pregnancy is a sad but relatively common experience. Women who experience early pregnancy loss might not need any treatment. However, if treatment is necessary, medication or an office procedure usually is adequate — with no need for surgery or hospitalization.

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