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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.
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