Notes From the ER logo Did You Know

When Death Approaches


I walk into the next room with my patient's chart. The nursing notes say "pregnant, spotting blood, and cramping." I knock softly, open the door, and am immediately met by two frightened glances. The unspoken question is whether they have lost their pregnancy.

Miscarriage, which is known in medical terms as spontaneous abortion, is far more common than most people realize. Miscarriage is roughly defined as the spontaneous termination of a pregnancy before the halfway point, or 20 weeks. Twenty weeks is chosen because this is a date prior to which the survival of the fetus is extremely unlikely.

Every day, several pregnant women who are spotting are seen in our emergency room. Approximately 25% of all women will spot in their first 20 weeks of pregnancy. Fifty percent of these women will carry their pregnancy to a live birth, whereas the other 50% will miscarry.

Whether a woman miscarries or not is rarely affected by anything she or I can do. Understandably, many intense emotions surround the threat or occurrence of a miscarriage. Yet a miscarriage is no one's fault. Exercise, sexual activity, or most any other event is unlikely to have caused a miscarriage. So often couples or women mistakenly blame themselves.

In the first 20 weeks of pregnancy, it is only a rare circumstance when a doctor can intervene and prevent a miscarriage. A famous study carried out in 1943 demonstrated that the overwhelming majority of miscarriages are due to an abnormality of development incompatible with fetal life. This abnormal development is most commonly due to a genetic error.

Couples or individuals experiencing either a threatened or completed miscarriage have unique needs for emotional support. Family members, friends, and colleagues often don't recognize the enormity of the stress or loss. This isn't to place blame on others for their insensitivity, but the experience of a miscarriage or its potential is usually far more private than other losses in our lives. Our need for privacy can translate into less support from those around us.

Miscarriage is a loss that requires a period of grieving. There should be no shame or guilt.

To say that we have little control over the eventuality of a miscarriage is not meant to take away from the importance of good medical care and health during the pregnancy. It is quite clear that inadequate nutrition; smoking, alcohol, and drug use; and delayed healthcare evaluation all may adversely affect the growth and development of a new life.

The couple tells me that this is their first pregnancy. The spotting and cramping began a few hours ago. I listen to their story and am reminded that it is surrounded by expectations, hopes, and dreams. In the next few hours, I hear very little of these stories, but this emotional experience is always one of the most difficult to share. Should the grieving begin? Do they retreat from their visions? Is there still hope? Often there is an ache of blame or guilt. Most often the uncertainty as to whether the pregnancy will survive or not will last for days or weeks.

If you or someone you know experiences a miscarriage or its threat, recognize that often there is significant unspoken support that is needed. We all can be more mindful of the common loss of miscarriage among those in our midst.

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