Why It’s Important to Know Your Options After Miscarriage

In a time of great sorrow, every woman deserves a complete picture of the possibilities.
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In a time of great sorrow, every woman deserves a complete picture of the possibilities.

More than four years ago, I lost a child to miscarriage. No one expects to have one. Once it’s happening, it can be surreal. I knew I should be asking questions, but I didn’t know what they were. Too often, the questions I asked didn’t yield specific or constructive responses.

I’ve since spoken with countless other women about their losses. While every situation is unique, many of us felt lost and alone. We didn’t have all the information we needed about our options for treatment or management of the situation.

The U.S. National Library of Medicine reports, "Among women who know they are pregnant, fifteen to twenty out of every one hundred will have a miscarriage." That means many of us are suffering in silence, confused about what's happening and what we can do to recover.

For this piece, four courageous women shared their stories with me, believing, as I do, that any woman who suffers a miscarriage deserves the truth and the complete scope of the possibilities before her.

Understanding the Possibilities

The Mayo Clinic defines three potential courses of action once a miscarriage has begun: expectant management, medical treatment, and surgical treatment. A doctor or midwife should have the size or gestational age of the child, the mother’s health, and any current medical conditions in mind when offering a recommendation.

A doctor's advice depends on the woman's unique situation (her health and the status of the miscarriage), her preferences (like who performs a procedure or what happens to the baby), and the doctor or hospital's policies (which vary greatly). Additionally, two women can choose the same option, but the outcome can turn out vastly different: what can go well for one woman could turn out to be a disaster for another.

The family may have other concerns, such as having genetic testing done on tissue from the child or placenta to determine the cause of the miscarriage, burying or cremating the child’s remains or otherwise having a ceremony to honor the child and say goodbye, and procuring a death certificate from the state.

For me, a major concern was who would care for our 16-month old-son, should I wait to deliver naturally. We lived forty minutes from my husband's office and an hour away from our closest family members. The anxiety I foresaw adding to what was already a painful situation contributed to my decision to have a D&C, but every woman's situation is unique.

Treatments for Miscarriage

Option 1: Expectant Management // Letting Nature Take Its Course

The term “expectant management” essentially means waiting to see when or whether the body will naturally deliver the baby and placenta. Some women learn they are having a miscarriage from the bleeding that’s part of this process. For those of us who learned the baby died through an ultrasound, there is no way of telling how long it will take. Some may experience cramping and back pain; others will have full-on contractions and heavy bleeding.

Five days after a fateful ultrasound for Elizabeth,* mother of five, she started to bleed—a lot. She called her doctor’s office, but they only told her to keep an eye on it. She couldn’t care for her other children for all the time she was spending changing pads (twenty-six in one hour, when one per hour is an accepted norm). She spoke with her father over the phone and told him that she wanted to sleep. He told her to call an ambulance immediately, knowing what she didn’t: It’s not painful to bleed to death, you just get tired and go to sleep.

At the hospital, an obstetrician/gynecologist was able to avoid surgery by manually removing a piece of placenta stuck in her cervix, which her body was trying to flush out. “It turns out that you can go from fine to very not in a matter of less than two hours,” Elizabeth told me.

Maddy’s experience with natural miscarriage was less dramatic, and she says she doesn’t regret her decision. “I was very informed about my options,” Maddy told me. “My midwives were very supportive.” She opted to wait to pass the baby and placenta at home. When her body didn’t make enough progress, she took misoprostol vaginally (more on this below), to disintegrate and detach the placenta more forcefully. Maddy knew this could mean more bleeding. Her midwives instructed her to call every hour once it started, and they continued to give her information throughout the process. There were times when she discussed going to their office or to the hospital, but ultimately she was able to remain safely at home.

The five days afterward, she recalls, were difficult because she had lost so much blood. Her hemoglobin levels were very low, and her midwives told her she had come close to needing a transfusion. To recover, she took iron supplements, and in less than a month was physically healed.

Option 2: Medication // Helping the Process Along

The Association of American Family Physicians (AAFP) states that for miscarriages that don't pass on their own after some time, doctors may prescribe the drug misoprostol, which is inserted vaginally. "Using misoprostol, the tissue passes more than 90 percent of the time within one week."

"Cramps and bleeding usually start two to six hours after placing the pills and last for three to five hours," the AAFP notes. "Some women get nausea, diarrhea, or chills soon after using misoprostol. This should get better in a few hours."

Pregnancy hormone levels then return to pre-pregnancy levels in two or three weeks, as Maddy mentioned earlier. But it can also take weeks longer, like with my friend Kelly,* who took well over a month to get back to pre-pregnancy levels.

Option 3: Dilation and Curettage (D&C) // The Controlled Option

Verily Lifestyle Editor Krizia learned her child had died via an ultrasound, like I did with mine. She struggled to find a medical professional who not only supported and respected her values, but who could thoroughly answer her questions about the risks and benefits of her options. Ultimately, she opted to schedule a dilation and curettage, also known as a D&C, a surgical procedure to remove the contents of the uterus. After administering anesthesia, a doctor opens the cervix to remove the contents inside using small instruments.

The benefit of a D&C is that the procedure works 100% of the time with any type of miscarriage, lowering the risk of complications and infection. On the flip side, Mayo Clinic lists risks of tearing the uterine lining, cervical damage, scar tissue development and, while rare, there is still a risk for infection. Speak with your doctor to find out whether the benefits may outweigh the risks for your situation.

The American Pregnancy Association notes, "A D&C may be recommended for women who miscarry later than ten to twelve weeks, have had any complications, or have medical conditions in which emergency care could be needed." Krizia fell under all three situations. About 50 percent of women who miscarry undergo a D&C procedure.

Krizia believes it was the best option for her. “Waiting it out was scary,” she said. With a D&C, she was in a controlled environment and would avoid risks of heavy bleeding and infection. The surgery was “a good experience and seemed like a low-risk option.”

Other Considerations: Genetic Testing and Burial

After a D&C, hospitals may send the remains to a lab for testing. For Krizia, it was important to her and her husband to have their child’s remains to cremate and bury. Her husband called several doctors to find one who would guarantee testing the tissue surrounding the baby, and not the child itself. But testing the baby for chromosomal abnormalities risked it coming back to them damaged or not coming back at all. "For us," Krizia shares, "there was no point to invasive testing. We just wanted him in one piece."

Testing considerations aside, many hospitals and doctors they spoke with would not allow or guarantee that they could take their baby home after the D&C. “Most women think that they have to do what the hospital says, which isn’t true,” Krizia said. “We’re afraid to ask because maybe it sounds like too much or it’s crazy.” But the family eventually traveled from New York to California to be cared for by a doctor whom they trusted.

Even after a cross-country trip, there were more obstacles to overcome. For a child to be buried, he must have a death certificate. In New York and California, these aren’t issued if the child’s gestational age is below twenty weeks. Had Krizia passed her baby at home, there would have been no certificate at all because there would not have been a medical professional there to witness it.

“We felt like we were doing something illegal or bad,” Krizia told me, “because we went behind our hospital’s back to send just the placental tissue [not the baby] to the lab. And our doctor had to write a special request for the baby to be cremated. It made us feel like it wasn’t real.”

The Miscarriage Association notes, "Some hospitals have sensitive disposal policies and your baby may be buried or cremated, perhaps along with the remains of other miscarried babies." While hospitals are always improving, many treat the remains of a child lost before 20 weeks as clinical waste, which is sent for incineration. If it's important to you to make your own arrangements or to know what happens to your child's remains, speak with your doctor, a nurse, or midwife in your hospital of care. A patient advisor liaison may also be able to help address your concerns. 

These stories are only a few of the many thousands out there. No matter what decision a woman and her family make, every mother has the right to all the information, to having her pain validated, and to having her questions adequately answered, so she can take the very best care of herself and her family.

*Names have been changed where requested.

Photo Credit: The Kitcheners