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J DFM 2.2 (2012): 60-63 Family Physicians’ Forum Pregnancy Loss, A Grief Unspoken WILLIAM CUTRER William Cutrer (M.D., University of Kentucky) is the C. Edwin Gheens Professor of Christian Ministry and Director of the Gheens Center for Christian Family Ministry at The Southern Baptist Theological Seminary. Dr. Cutrer has authored or co-authored several publications including The Church Leader’s Handbook: A Guide to Counseling Families and Individuals in Crisis. “Like arrows in the hands of a warrior,” the psalmist sang, “so are the children of one’s youth. How blessed is the man whose quiver is full of them (127:4–5). When the wonderful news of pregnancy is announced, we rightly rejoice! But what about those who go on to miscarry, to experience fetal demise or tubal pregnancy, or who are infertile? How can we minister to those suffering such profound pain? As a specialist in obstetrics and gynecology, I have spent much of my life and ministry involved with young couples and families. This article will address several all-too-common situations to aid the caregivers and ministers who serve these couples. First, I will provide the medical information from the patients’ perspective, then I will offer a few practical ministry suggestions. Miscarriage, known in medicine as “spontaneous abortion,” refers to pregnancy loss before approximately twenty weeks’ gestation. Statistics suggest that annually almost onethird of the approximately six million pregnancies in the U.S. result in loss. Perhaps 600,000 of these represent miscarriage, and another 64,000, ectopic pregnancy. Most miscarriages occur in the first trimester (twelve weeks of pregnancy), counted from the last menstrual period. Enhanced testing suggests that as many as half of all pregnancies fail to result in a live birth. God has blessed humanity with the privilege of being fruitful and multiplying, yet the process often becomes the source of intense pain. MISCARRIAGE: PATIENTS’ PERSPECTIVE The excitement of the positive home test can quickly turn to fear at the first evidence of spotting or cramping. The fact that almost half of all pregnant women experience such complications makes the first trimester an anxious time for new mothers. Advances in ultrasound technology grant visual access into the womb whereby diagnoses of developing pregnancy can be made, yet waiting on an appointment can seem like an eternity for a couple when the baby’s future seems in doubt. Sonography can detect the baby’s “gestational sac” as early as three-and-a-half weeks from conception but until the fetal pole with its recognizable yolk sac and heart beat can be detected, only baseline information can be stated with certainty. Yes, a pregnancy has begun, and it is located within the uterus, but until the heartbeat is visualized (about four weeks from conception) or heard with the Doppler (a sound 60
wave device allowing audible heartbeat to be appreciated at about 10 weeks from last period) miscarriage rates are still quite high. After the heart beat is audible and the pregnancy reaches ten weeks, miscarriage risk falls dramatically, but not completely. Treatment of miscarriage depends on several factors. If fetal death occurs at less than six weeks, the mother’s body can generally facilitate the miscarriage without medical intervention, aided sometimes with medications. If the pregnancy has progressed beyond ten weeks’ gestation, a surgical procedure known as “D. and C.” for “dilation and curettage,” is usually recommended. This procedure predictably completes the miscarriage while minimizing the risk of hemorrhage or infection. D. and C. is a surgical procedure, even though no incisions or stitches are required, an it can be physically and emotionally stressful. Pregnancies that progress to sixto-ten weeks before failing require a physician’s judgment in close consultation with the parents. If they live near healthcare facilities, allowing the miscarriage to occur without further procedures may make sense. If they live far from medical care, the miscarriage might involve considerable bleeding and danger to the mother, so safety might dictate scheduling D. and C. SECOND TRIMESTER LOSS (FETAL DEMISE): PATIENTS’ PERSPECTIVE Though far less common than miscarriage, the death of a child in the womb after the first trimester can cause devastating grief as well as marital distress. Typically, the baby has already been seen on ultrasound, the heartbeat heard, and even the gender of the child announced. Whereas most first trimester losses relate to chromosomal abnormalities preventing normal early development, tragedies after the first semester often come without clear diagnoses. Cord accidents, placental problems, and intrauterine infections can be at fault. Certain chromosomal problems may not cause death until the second trimester as well, but often no clear diagnostic picture emerges. Yet even if the diagnosis is known, little relief is felt from such knowledge, because the parents really yearn for the child they have lost, not an explanation. Delivery of the deceased child can generally be accomplished by induction of labor and birth, though physicians often wait several weeks for natural labor to ensue. The mother’s body often takes a little time to recognize that the child has stopped growing. Typically, the physician will induce labor before four weeks have passed since the child’s death to avoid complications related to blood clotting. Unlike losses in the first trimester, delivery with the opportunity to view and hold the child’s body may be possible. Decisions made at this juncture are important for the grieving process, so patience and allowing the couple to come to grips with the devastating reality allow for better recovery. Plans for memorial services and burial should be considered. ECTOPIC PREGNANCY Ectopic means “out of place.” An “ectopic pregnancy” is sometimes called “tubal pregnancy” because the fallopian tube, rather than the uterus, is usually the site of implantation for such pregnancies. This condition represents an impending medical emergency. Ectopic pregnancies can actually implant anywhere outside the uterine cavity, including within the cervix, the portion of the fallopian tube that traverses the uterine wall, within the tubes, or even outside the tubes on the ovary, the bladder, or on the intestine. Such pregnancies will outgrow the tube’s capacity, so eventually either the growing child will die or cause the tube to rupture, leading to potentially life-threatening hemorrhage. The symptoms of tubal pregnancy may not be specific, but they may include bleeding, localized pain, and cramping after about six or eight weeks of pregnancy. Until that time the pregnancy—the baby plus supporting structures—may be small enough to grow normally. Eventually, however, the pressure on the tube causes a pain unlike cramps, usually localized to the side of the ectopic pregnancy. All doctors trained in obstetrics will listen for these symptoms, and must rule out tubal pregnancies by exam and ultrasound. Blood levels of the hormone Human Chorionic Gonadotropin (HCG), the very hormone that turns the pregnancy test positive and gives those symptoms of early pregnancy, rises in a manner in normal pregnancies such that, if the level is not normal, either a miscarriage or a tubal pregnancy can be identified. 61
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J FM 2.2 (2012): 2-5 Editorial: In
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Page 17 and 18: A STRATEGY FOR WINNING UNBELIEVING
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Page 29 and 30: true Church (as opposed to the here
Page 31 and 32: the presence of her Lord in a spati
Page 33 and 34: 27 Plumbe, Mater Ecclesia, 9. Simil
Page 36 and 37: J DFM 2.2 (2012): 34-40 The Challen
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Page 42: ENDNOTES 14 Daniel P. Moynihan, The
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Page 49 and 50: God can use this situation in her l
Page 51 and 52: Would they set an example to Stacy
Page 53 and 54: about Stacy’s change of heart, en
Page 55 and 56: ship and spiritual input. The babie
Page 57 and 58: of Christ’s Church. When Jesus co
Page 59 and 60: GOD NEVER FAILS US One priority in
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Page 66 and 67: J DFM 2.2 (2012): 64-65 JDFM FORUM:
Page 68 and 69: J DFM 2.2 (2012): 66-74 Book Review
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Page 110 and 111: 8 S. Craig Glickman, Knowing Christ
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