Miscarriage Unravelled

 

 

It wasn’t until we shared our story that people revealed theirs– “we had one too,” “it’s so hard, isn’t it? – it took us ages to recover,” “you never forget that baby, we certainly haven’t.”

 

I looked at my friends, and even family members, in disbelief. “You’ve had a miscarriage? How did I not know?”

 

We suffer silently. We suffer a tragic loss, perhaps the most painful kind, but we don’t share it. So many of us trudge through the darkest patch of our lives without the extended support network we would lean on in any other type of tragedy in our life. My question, why?

 

Before we conceived Miss S, Will and I had a miscarriage. Our baby was due on the 26th of December 2015, and at 5 weeks I started to bleed. I knew from the get go that the likelihood was that this was not a viable pregnancy but I had already envisioned holding this child and burying my face in his or her neck. Our world had already enveloped this little life, and now it was being ripped away. What bothered me most was that I had no control over the situation – none. I had been on all the right supplements pre-pregnancy, ensured I was as healthy as possible, done all the text book advice but it was failing and I was devastated , and angry.

 

As GP, I deal with countless pregnancies, but also miscarriages. I have women come in for the
“guess what Preeya, we’re pregnant” appointment (one of my favourites, especially when I’ve worked with a couple preconception). Unfortunately I’ve also dealt with the “something isn’t right, I’m bleeding” moment. I’ve had women have uneventful first trimesters only to have a scan at the 12-week mark that shows no heartbeat; breaking that news is heart shattering, but nothing compared to what the parents sitting opposite me are experiencing. I know this process well from a doctor’s point of view – but none of it helped me when I went through it myself.

 

I know the facts like the back of my hand. Up to 1 in 5 women experience miscarriage before 20 weeks of pregnancy – in fact the rates are likely even higher given many women miscarry without realising they are pregnant and so they think they are slightly late for their period. It is common, much more common that what people realise. Whilst there are things a pregnant woman can do to reduce risk like avoiding alcohol and smoking, in most cases a miscarriage occurs because of serious chromosomal issues within the embryo so the pregnancy is not viable. In many cases there is nothing the woman could have done. I reassure lots of patients with this where I can, but, having been on the other side the reassurance can do very little to alleviate the ruminating thoughts. It is worth noting however, that bleeding in the first trimester occurs in 20-40% of pregnancies BUT not all lead to miscarriage – many go on to have healthy uncomplicated pregnancies (the bleeding can be to cervical issues or implantation for instance).

 

After our miscarriage, I questioned for a long time if I had done something to cause it. I had not consumed alcohol or smoked but I had been to the gym and I had drunk a cup of coffee here and there. That was enough to drown me in a pool of guilt. As a GP, I have told women countless times “it is nothing you have done.” I had my husband, friends and colleagues telling me exactly the same things – “Preeya going to the gym did not cause this,” “Preeya you know full well that a cup of coffee in pregnancy is fine” “Preeya what would you say to a patient in your position? You know you didn’t do this”– but I couldn’t hear their words. Well I could, but I chose to ignore them because I was very much of view that I could have controlled it. It took me a good 4 weeks to gain some insight and realise that this issue had been out of my control. It took much longer to deal with the grief.

 

Many people are not aware of what happens when a woman miscarries. I recently heard of a horrific experience a woman in the media shared about her GP googling how to manage a miscarriage as she sat in the consulting room devastated. Let’s talk about the medical aspect for a moment; miscarriage can be managed in different ways. For some women, they have a heavier than normal period – we usually monitor the pregnancy hormone in the blood (and sometimes do ultrasounds) until it goes to zero to ensure no remnants of pregnancy remain in the uterus (this can cause pelvic infection down the track if left untreated). We call this expectantly managing the miscarriage – we let the body do its thing and monitor to ensure no complications arise. Not all women can attempt to have a natural miscarriage – they may be too far along in the pregnancy (so the contents of the uterus cannot pass through the cervix easily) or they may choose to proceed to a medical or surgical approach because the bleeding and pain are unbearable. The medical approach involves taking a medication called Misoprostol which helps to evacuate the contents of the uterus. For some they attempt to have a natural miscarriage but it fails (the pregnancy hormone remains elevated, material remains in the uterus or the bleeding is too heavy or the pain is too much) and so they can go on to have a dilatation and curettage (D and C) – a procedure performed by a surgeon to empty out the uterus. Some women go on to have surgical management straight away if they choose to or are further along in the pregnancy. That’s the crux medical stuff.

 

I had a natural miscarriage. I had a heavier than normal period and I sobbed every day for about 2 weeks. I drowned in a pool of guilt, lost dreams and the fear of it happening to us again. Thank goodness for my husband and my mother is all I will say. When I was able to face the world again Will and I decided to tell some of our friends – it was obvious something had happened in our life and people were asking if we were OK after missing several social events and being distant. I’ll be honest, I had a moment of “do we share this?” – would I be perceived as less “womanly” because I couldn’t sustain a pregnancy? These are, honestly, the types of guilty thoughts I was plagued with and I strongly suspect I am not alone. I felt somehow inadequate and ashamed. Seriously. Some women will share their experience and inner thoughts and some will not and that’s OK. I’m sharing these thoughts because as I GP I have sat in a room with women who feel their womanhood is in question, that they are to blame – and I want you to know despite all my training and knowledge I had the same inner dialogue – you are not alone.

 

I’ve had women sit across from me devastated at their loss. And only since my own experience can I truly sympathise. I don’t know why but there is some sort of comfort that comes when a person says they’ve experienced a similar loss – you look at them, I know I did, and think “that gives me some hope, maybe I will survive this too.” Recently I’ve told 2 patients that I suffered a miscarriage but now have a healthy daughter – I saw the hope on their face, I saw their shoulders go back just an inch – I had given them a glimmer of hope in a dark time and perhaps that’s the best therapy of all.

 

Sharing our stories (if we feel comfortable) can help. It’s hard as a doctor sharing our own journeys with patients– there are some of my colleagues who would look at me sharing this or my story of anxiety on my blog and think I’m pushing the boundary. There are lots who are supportive though. My personal view is that a doctor is no different to anyone else. I am not immune to anything and I don’t want to portray that to my patients. I respect the doctor-patient relationship and its boundaries but I also know that sharing the right story at the right time might just give someone the hope to get through. Sometimes it’s the human aspect of being a GP that is the best treatment – no pills or treatments, just an ear to listen to and a shoulder to lean on.

 

There should be no shame in sharing our stories of miscarriage. To the woman who might be reading this drenched in tears thinking “will I survive this?” –you will. It takes time, lots of it, and the emotional scar remains but you will survive. Boxing Day is always a day Will and I have a moment to reflect on our loss, but also be grateful for our beautiful gain in Miss S.

 

 

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Your Pre-Pregnancy Checklist

It is an incredibly exciting time when you decide that you’re ready to “try” for a baby whether it be naturally or through IVF. You start envisioning life differently – which room will become the nursey? What will the colour scheme be? Will you have a feeding chair that is stationary or rocks? Which pram will you decide to go with? These are all mammoth decisions; I’ve been there – the planning and dreaming starts early!!

 

Women often get so excited with the idea of the baby (and that’s very understandable!) that they forget about the health checklist that should be ticked off before they even conceive! We call it preconception care and we know that seeing a doctor (and getting as healthy as possible) before you try to conceive leads to better pregnancy outcomes for mum and bub. Preconception consults are 1 of my favourites– I’m passionate about this stuff; to think we can improve the trajectory of a baby’s health both inside and outside the womb is amazing. You can really see my inner nerd shining through now can’t you?

 

Here is my checklist – if you’re thinking about pregnancy (even kind of) then this is for you. It’s not exhaustive; what every woman needs pre-pregnancy is different according to her medical and family history (particularly of genetic conditions).

 

  1. Are you as healthy as you can be?

I cover loads in preconception consults with my patients. Blood pressure, weight and BMI are a start– are you overweight or obese and do you need to try and lose some weight before you conceive? Even just 5-10% of your body weight? We know obesity can be dangerous in pregnancy and that if an obese woman can lose weight before she conceives she can reduce risk of complications for herself and her child. Having said that, being underweight also carries risks – actually getting pregnant can be harder. If you are underweight and not having regular menstrual cycles then discussing some weight gain pre-pregnancy to regulate the menstrual cycle might be a factor.

 

Do you have asthma, thyroid disease, diabetes or any medical condition that needs to be controlled carefully before you conceive to improve baby’s chances of a normal development? Common conditions like asthma can go haywire in pregnancy. It is worth making sure firstly, you are on safe medications for your asthma in case you get pregnant and secondly, that you are well controlled. Poorly controlled asthma (I’m talking lots of symptoms and Ventolin use) can have any negative impacts such as affecting the growth of the baby. Talking about medical conditions – mental well-being is equally important. If you suffer from depression or anxiety is it as well controlled as it can be? And if you are on medication is it safe in case you do get pregnant?

 

Are you using over the counter medications that should be avoided when pregnant? You won’t know unless you check! Lots of non-pregnancy supplements contain Vitamin A which can be harmful. I often discuss with patients stopping some supplements or changing some of their regular prescribed medications so that everything they are on is deemed safe for pregnancy. By the time you get pregnant and come in to the doctor cells have already started rapidly dividing in the embryo and unsafe medications may have had an impact – this is why we try to make the changes before conception.

 

There are now also genetic carrier tests we can offer for women and their partners pre-pregnancy (as a warning – these do cost money and are not currently government funded) – are you a carrier of cystic fibrosis or fragile X syndrome? Is your partner? We can now test to see if you or your partner are carriers for certain genetic conditions which means you can assess what the baby’s risk might be if you were to conceive. Ideally tests like this should be done before pregnancy so you can plan if you and your partner are carriers for a condition (it means the baby is more likely to be affected).

 

So that’s just the generic health stuff – I can assure you in a preconception consult I will calculate your BMI, take your blood pressure and arrange for you to have bloods…if you’re thinking “wow this is a lot” – bear with me, we’re just getting started.

 

  1. Are your vaccinations up to date?

If you come in and tell me you are planning a pregnancy I will always order blood tests. There are certain standard tests every woman gets like rubella antibodies, syphilis antibodies and HIV antibodies to name a few. We test everyone for these things – it is routine. The rubella test is an important one – rubella infection in pregnancy can have devastating consequences for the baby if they are also infected – vision and hearing problems as well as serious development issues. Most women are immune thanks to vaccination BUT if you’re not we ideally vaccinate you before you conceive to make sure you and your baby are protected. The rubella vaccine (MMR) is a live vaccine so pregnancy needs to be avoided for 28 days after  – see this stuff takes planning! We also check you’re up to date with things like Tetanus, hepatitis B and the flu vaccine.

 

  1. Are you taking the right supplements?

The recommendation in Australia is that every woman take 400mcg of folic acid and 150mcg of iodine 4 weeks prior to conceiving and ideally for the first trimester (at least). Folic acid can reduce the risk of neural tube defects like spina bifida and iodine is crucial for baby’s brain development. Some women need higher doses of folic acid (obese women and diabetic patients are 2 examples) and you won’t know if you fall into that group unless you see your doctor beforehand! Iron, vitamin B12, vitamin D – not all women planning pregnancy need these, but some do – it’s worth finding out!

 

  1. Are you covered?

 

This might sound boring but worth thinking about trust me. If you have a baby where would you have it? Which public hospital’s catchment area do you fall into and are you happy to go there? If not, do you have private health insurance so you can choose your obstetrician and hospital? If you decide to get private health insurance – are you immediately covered for pregnancy or is there a waiting time? These are the types of things you want to ideally have sorted before you get pregnant!

 

  1. Are you ACTUALLY ready for this?

Again, no one really wants to talk about this stuff. I raise with women the nitty gritty stuff that we know is important but no one wants to talk about. Family violence is common – far more common that what you realise I suspect. Women exposed to family violence in pregnancy have higher rates of miscarriage. So this is why I try to ask women BEFORE they conceive “do you feel safe at home?”

 

Having a child is hard – alone or with a partner – so planning for the life and financial changes is actually very smart – can you afford a child? If you go down to 1 income can you still pay your rent or mortgage and live? Are you or your partner going to take time off? If neither of you can afford to take time off then who have you got around to help with the baby?

 

 

 

 

So there you have it – the general checklist; like I said not exhaustive because it depends on every woman’s personal history. I know my health check list isn’t as exciting as deciding on wallpaper in the nursery or names – but I can assure you it is vital. Plan ahead, get as healthy as you can- the aim is to do everything you can to improve your (and your future baby’s) chances of a healthy successful pregnancy!

 

 

 

 

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What 39-weeks and Christmas have in common

 

 

I’m the first to admit I’ve gone a touch weird in the last 48 hours.

 

I’m incredibly restless and sleep is hard to come by. You know that feeling where you want to nap but can’t stop moving/thinking/scratching your hair – well that’s how I feel constantly. I’m exhausted but get sudden energy bursts and want to fold literally every piece of clothing in the house so it’s neat – and then I’m back on the couch re-watching Gossip Girl (and it is just as good the second time round FYI!).

 

I am huge. When I go for my daily walk I feel like a bowling ball is about to fall out. I can’t roll in bed without grunting and whispering into the darkness, “Will, you gotta help me!” And don’t even get me started on my feet. They’re not puffy – they are just somehow bigger – and I am telling the universe right now that if I don’t fit into my beautiful boots after this pregnancy is over… there’ll be trouble.

 

And then there’s the bathroom – I wee all night – at least 6 times. Yes that likely means this baby’s head is low and things should be happening – but how low can you go? Seriously!

 

I knew my hormones were slightly erratic this week but when the car seat was fitted and I had a small cry I knew that perhaps things had escalated. Yes, I cried. I felt overwhelmed, tired and irritated – “why are you still in there baby? Come out, we want to meet you- we have a seat for you now!!” But also a pang of – “crap so you drive around with this precious bundle in the car? Do I need to get a special license for this?”

 

I think the overwhelming emotion is utter excitement – “I could explode” kind of excitement. My husband summed it up perfectly when he said “It’s like someone saying – Christmas could be any time in the next 2 weeks – you wake every morning thinking – is today the day?” Perfectly said honey! Every twinge I feel I hear my brain scream – “is this Christmas?” – but nope – still no damn presents under the tree!

 

So hello to 39-weeks!

 

I’ve started questioning the universe – are the last 3 weeks of pregnancy really necessary? I recall having said to my patients before – “this is the good time when the brain develops – just stick with it” – oh sweet innocent Preeya – you had no idea! No idea at all!

 

So back to the couch I go – to patiently wait, catch up on the Upper East Side and wait for Santa!!

 

 

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My 32 Week Pregnancy Itch

 

So I’m officially just over 32 weeks pregnant. Yay right? Yes absolutely, but also a touch of nervousness/panic/“oh my goodness there’s so much to do before this baby arrives” – I think this must be the “32 week itch”. I’ve never actually heard the term being used but I’m sure I’m not alone in feeling like this (feel free to reassure me people!).

 

At around 1130pm every night this week I will whisper to my husband Will, “hey you awake?”Yeah babe – what’s going on?” is the sleepy response. “Can you believe in less than 8 weeks there will be A BABY  in a bassinet in THIS room?” I am not joking – every night it’s the same realisation I have as I drift to sleep. Time is running out and I am so incredibly excited to meet this being – but I also can’t believe how quickly the time goes and how unprepared you feel just before it all happens!

 

Loads of my patients and friends will say to me, “it must be so easy for you being a doctor – you know exactly what to expect.” Um no – I really really don’t. Sure I know about reflux, feeding issues, sleep problems for infants and about the medicine. But – how many sets of cot sheets do we need? Do we really need mattress protectors for the bassinet and the cot?  Am I supposed to know where to go to buy maternity bras? Are we meant to invest in an expresser now before I know whether I will successfully breast feed? And hello, do babies prefer the long suits with their toes covered or the footless ones? I think I would like my feet out because they get hot and I don’t want our baby having hot feet, but does anyone know what babies like!?!

 

There’s SO much I don’t know. Thanks to mums, girlfriends and helpful patients I’m slowly getting these questions answered but hey – its a seriously steep learning curve.

 

Doesn’t help we’ve had our birthing skill classes recently. Unfortunately my husband is also a doctor – cue 2 parties in this birthing team who have the wonderful ability to horrifically over think everything medical. I wish I could delete my obstetrics rotation from my brain, forget all the things I saw on the paediatrics ward and start afresh – but I can’t – and dealing with those fears and having no expectations at all is a skill in itself. And with only 8 weeks to go this is something I am working on (hard!) with relaxation techniques and reading some calming books.

 

So – despite my utter excitement (and trust me I cannot wait for us to hold this baby and see his or her face for the first time) – I am also nervous. And I’ve accepted that’s OK, because the nervousness is just my brain getting me ready for a huge life change. So if there’s 8 weeks left – wonderful, and if we don’t have that much time then that’s fine too – I just need to get the hubby to finish setting up the nursery furniture and figure out how many of those damn cot sheets we need sooner rather than later!

 

 

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10 Things that Shocked Me About Pregnancy

Despite treating women throughout their pregnancy and having done obstetrics as a medical student where I delivered babies there are still some things I am shocked by in this glorious debacle called pregnancy.

 

I honestly thought either “that symptom wont happen to me” or “it can’t be that bad” – but hello empathy – I get it now and no exposure to my patients, stories from friends or literature in the books could have prepared me!

 

The top 10 things I’ve been shocked by in pregnancy so far:

 

  1. The fatigue – are you kidding me? The first trimester is crap and “they” say it get’s better – who is “they”? Are they lying so you have a false sense of hope? Are they men who haven’t done this? It doesn’t get better people – the need to constantly nap or shut your eyes for a second at your desk doesn’t really improve.
  2. Nausea in the first trimester –NOT OK. I don’t want to talk about it too much because it makes me all emotional and ratty – but feeling like you’re on a shoddy boat constantly with a churning gut is not a pleasant experience. You have a constant hangover without the excellent stories and dance floor antics from the night before. I treat a ridiculous amount of women with this issue but the persistence of the symptom shocked me! And to the poor man who I gagged in front of because I suddenly realised I could not handle blood or wounds (and still can’t which is really practical for a GP – NOT!) – please know it was the nausea not me who made that awful dry retching sound in your face when you showed me your sliced fingers.
  3. The aches and pains – hello back and pelvis ache after I climb the 2 bloody stairs at work.
  4. The shortness of breath has killed me. From day dot I’ve been panting when I walk the dogs and try to chew my husband’s ear off (he’s enjoyed the pregnancy immensely so far!). But seriously – I knew about it but now actually understand it.
  5. The breast changes – I knew all about this – but when you look down and see these huge things growing with darkening areolas and enlarging nipples its completely crazy! For a lady who didn’t wear bras all the time- this has been a huge lifestyle change!
  6. The belly touching – old man on the train no you cannot touch me without asking. You may not feel the baby kick, but I’m a great kick if you don’t take your hand off. I thought the t-shirts women wore saying “don’t touch” or “hands off” were full on before – but ladies, I get it. What’s with the invasion of personal space by strangers?
  7. The kicks – when I’m trying to do a pap smear and have a repeated kick in my right pelvis like someone’s trying to burst out of me it’s kind of distracting. But the kicking (especially at night in bed) is such a phenomenal feeling that nothing I’d heard from pregnant women prepared me for it – and I absolutely love it!
  8. The sex drive – I know it can go up or down. But when they say up– they mean up. And that’s all I’m going to say. Total shock.
  9. I’m utterly shocked by the smells and flavours I love at the moment. Artificial banana flavor (Nesquick, banana paddle pop, banana lollies) is my hero. And I love going to the underground supermarket car park for the smell of rubber/oil/I don’t know what – but even writing about it makes me crave it – is that weird?
  10. The love you feel for something you haven’t seen, met, held or touched yet. I have this full heart for a being that I have only dreamt of and seen on a screen and I feel like my heart could explode at any moment – that’s shocked me most of all! The sudden desire to not go 1KM over the speed limit or change lanes too many times on the freeway because now I’m keeping our baby safe too – that sudden “I’m a fierce mama bear” attitude comes very quickly!!

 

So there are surprises galore throughout this journey. Despite knowing about the body changes and kicking and fatigue as a doctor – until it happened to me I realised I lacked some serious empathy before. So when I see pregnant women now and they say how tired they are as opposed to thinking “gosh it can’t be that bad – soldier on lady,” I’m saying “I hear you – do you need time off? Do you need a bed? Shall we take a nap together right now?” – ahhh good old empathy (and a cheeky lunch time nap- Seriously!!).

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The Lies of a Pregnant Lady

The first trimester is tricky (for so many reasons) but I found trying to act like I wasn’t pregnant and not being able to share it really tough! Having survived it (whilst lying through my teeth) I thought I should share my top 5 lies for trying to survive the first trimester without drinking. There will be pressure to “just have a drink” and don’t mind those sneaky glares and whispers of “is she pregnant?.” To avoid that I manipulated my medical knowledge to make the excuses fool proof and now you can use them too!

 

  1. “I’m on Metronidazole for a tooth infection”

 

This baby (excuse the pun!) was my ‘go to’ and worked on groups of doctors at social events who bought the story hook, line and sinker. Metronidazole is an antibiotic that is often used in severe dental infections – you can’t drink on it for 2 reasons: firstly you get very sick and vomit and secondly it can cause major liver issues. So it’s the perfect reason as to why you can’t even TOUCH alcohol.

 

Hot tip – you need to pretend your tooth is a little bit sore! I forgot to do this and it makes you look a little stupid!! So pick a tooth and don’t forget to feign the pain now and then – and ideally don’t order a chewy well done steak for dinner (again – a double mistake I made: you don’t eat steak with a sore tooth and secondly, who has their steak well done other than a pregnant woman?).

 

  1. “My GP said my liver tests were a bit off and to avoid alcohol”

 

This is not uncommon. Fatty liver is a major problem with alcohol use, obesity and poor diet. So it’s not uncommon for me to tell my patients to lay off the booze and change their lifestyle so we can recheck the liver. You can easily use this – strict no alcohol until your next liver test which might be 4 or 8 weeks (whichever suits to get you to the ‘safe’ telling period!).

 

  1. “I’m doing dry [insert whatever month it is]”

 

Stick to your guns. People will try and guilt you into drinking – but just be firm – you are trying to do a health kick. You can only use a reason for so long – so you need to be creative and mix it up – I used this one once I was near the time when I could tell people just to buy some extra time.

 

  1. Glass swap

 

Get your partner or friend (who is in the know) to subtly swap wine glasses with you at social functions. Hold something and pretend to take sips and then subtly pass it to your accomplice who can finish the drink. Trust me – once the non-sober people are lubricated on a dance floor you can stop faking – they just won’t notice anymore!

 

  1. “I’m pregnant you annoying idiot!”

 

If you’re just getting pestered and there’s no way around it (trust me, there are some moments when you just can’t avoid it) perhaps you need to tell some close people. It depends on how comfortable you feel with that plan and the people – but always an option!!

 

Good luck ladies!!! May you lie through your teeth and survive the first trimester – P.S good luck hiding the vomiting if you’re lucky enough to have it! More tips on nausea management in early pregnancy to come soon!

 

Also – I hear you asking – “what’s with the photo and how does this relate to the post at all?” – well I found once I was over the first trimester (the nausea, the lies and the anxiety of miscarriage) I was ecstatic – reflected in this photo – so there you go!

 

XX

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