Slow-Motion Miscarriage

I really wanted medical management of my miscarriage, i.e., to take medication to speed it along.  I wound up not having that option, since my indicators last week were not great, but also not totally inconsistent with a healthy pregnancy.  Since my doctors weren’t sure, they didn’t want to intervene with medication or surgery (a decision I certainly understand and agree with), which meant that I wound up undergoing a slow-motion miscarriage as, over the course of the week, I slowly went from spotting to bleeding to passing tissue and knew that it was over.  An ultrasound this morning confirmed that my body passed the tissue on its own (even though I am still bleeding), so I have officially miscarried.  Gravida 3, para 1.

The strange thing about going through a slow-motion miscarriage is that you can’t just curl up at home with a pint of Ben & Jerry’s and wait for it to pass.  I mean, I guess you could (perks of the flexibility of an academic job?), but mine has gone on for at least a week, and that would require more pints of Ben & Jerry’s than I am really comfortable consuming.  So, as a result, I wound up doing a lot of things that I never imagined I might do while having a miscarriage:

• Having a miscarriage during research meetings with my students and postdoc
• Having a miscarriage while talking with my department chair
• Having a miscarriage while writing an invited major review article on recent advances in my field
• Having a miscarriage while sitting on the grass and listening to a student folk music concert with my toddler
• Having a miscarriage at my department’s end-of-year party
• Having a miscarriage while baking cookies and playing board games with my old college roommate, visiting from New York City
• Having a miscarriage during an ice cream fundraiser for my son’s daycare

I mean, on the one hand, if you have to have a slow-motion miscarriage, many of these things are quite pleasant ways to pass an otherwise depressing time.  On the other hand, I’ve felt weirdly disconnected from my life this week, and it’s bizarre to be engaged in some other activity and then have the intrusive thought “wow, isn’t it weird that I’m doing this while having a miscarriage?”  It also feels strange, and somehow dishonest, to interact with other people when they have no idea that you’re having a miscarriage during the interaction — but not quite enough that I really felt like telling them about it (I did tell the two close friends who happened to call this week, and my visiting college roommate).

It’s also frustrating because my son seems to be old enough now that people feel comfortable asking me if we’re planning to have another baby.  Twice this week alone, I got the question, and not from people that I’m particularly close to.  I wanted to yell at them that I was having a miscarriage, and they really shouldn’t ask questions about people’s reproductive plans (or at least point them to this amusing flow chart).  Instead, I just gave my stock answer of “we’ll see!”

One thing I found both disturbing and reassuring this week was a recent study on 2nd and 3rd trimester loss that was published in 2016.  I wasn’t aware of it until this week, since it wasn’t published yet when I was scouring the literature after we lost our daughter in September 2014.  I thought it was such a great study that I emailed the author to thank her for doing the work, particularly since there seems to be so little research on 2nd trimester loss.  You can read the full article here, but these are the two main takeaways for me:

• Second and third trimester pregnancy losses are strongly correlated, indicating similar etiologies.  Once you have had a 2nd or 3rd trimester loss (including before 20 weeks), you are about an order of magnitude more likely than a typical woman to have another one.  The overall probability is about 4%, with recurrence more likely if the cause of your first loss was placental or maternal, and less likely if the cause was fetal or unexplained.  (This was the disturbing part — my first loss was placental/maternal, which puts me in the higher risk category of ~8% recurrence.  I sort of knew that already, but this was the first time I’d seen the probabilities broken down in that way.)
• First trimester miscarriage is not correlated with 2nd or 3rd trimester loss, including recurrent 2nd or 3rd trimester loss.  Roughly a quarter of previous pregnancies ended in first-trimester loss for all the women in the study, regardless of the number of previous 2nd or 3rd trimester losses, which is not significantly higher than the general population.  (This was the reassuring part — it makes it more likely that my current miscarriage was just run-of-the-mill bad luck.)

So, anyway, here I am, just waiting again.  Waiting for the bleeding to taper off, waiting for my cycles to reestablish themselves, waiting to see if we can get pregnant on our own again.  The OBGYN had me make a follow-up appointment for August, mostly as a chance to check in and come up with a plan if necessary.  She half-suggested that I could go for an infertility evaluation at the local big state hospital system if I wanted, but since I’m already being followed by an RE at the other major hospital system in the state I figured it wasn’t necessary, at least not yet.  As I discussed with her, while it’s great that we spontaneously conceived (and so quickly!), it does make it hard to know how long to wait before going back to the RE again.  I did put in a note through the electronic messaging system to my RE to update her about this pregnancy and ask if she had any suggestions moving forward, and her one suggestion was: stop breastfeeding.  I’m not quite ready to do that yet, and it seems pointless to go back to her before I am.  So I guess the plan is to wait a few months, see what my cycles are up to, and then reevaluate.  I think I’m OK with that plan for now.

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Because Nothing is Ever Simple

So, apparently my HCG levels are still rising.  They went from 1600-something on Monday to 2300-something on Wednesday.  Much lower than they should be at this stage, and not doubling particularly quickly, but still within the “normal” range for the 4w3d ultrasound measurement from Monday.  Argh.  So now they want me to go back for another ultrasound on Monday, just to make absolutely sure there’s nothing in there before giving me the misoprostol to end the pregnancy.

Oh, and to add insult to injury, when I got my blood drawn for the 2nd HCG test yesterday, by the time I got to my office (a 5-minute drive from the hospital lab) my arm had swelled up to the size of a tangerine at the site of the needle stick.  I freaked out and called my doctor’s office, and they said to come in, all so that the doctor could hand me an ice pack and tell me that it happens sometimes (supposedly when they drive the needle out the back of your vein so that it bleeds into the surrounding tissue).  As a bonus, I do have a large and colorful bruise on my arm today!

The doctor called last night with the HCG results, and was awkwardly trying to be reassuring while not giving me false hope — she is a really funny and weird old lady with whom I’ve had awkward conversations before (like the random 3rd-trimester checkup during my pregnancy with S where she said to me, “So, just to make sure, you NEVER, EVER use your cell phone, right?”  My husband and I were looking at each other confusedly, so she repeated herself… and I said, “Um, yes, I do, is that a problem?” and she said, “Oh, I mean, while driving!”)  So on the phone yesterday she kept saying, “Now, I don’t want you to feel like I’m being too optimistic.  But I don’t want you to feel like I’m being too pessimistic either.  I mean, we’ve seen it all.  But that doesn’t mean it’s going to work out this time.  But it might.”  And she kept going until I was like, “It’s fine, I’m glad you’re being thorough so that you can be completely sure before taking any action,” and she seemed content with that.  I like her because she always says exactly what’s on her mind and is very decisive and action-oriented — she’s like a little tornado of doctor every time she comes into a room, even if her verbal communication skills could use some work.  After the bad ultrasound on Monday she walked into the room and two minutes later whipped out a phlebotomy kit and drew my blood then and there for the HCG test — I’ve never seen a doctor do that before!  So I’m actually kind of glad she’s been the one managing this (likely) miscarriage even though I usually prefer the younger, kinder doctor (married to one of the other faculty members at my university) who made me feel so reassured after our daughter died.  I actually just want frank talk and decisive action rather than reassurance right now.

So now I’m just waiting… again.  I’ve been spotting for the past few days and even had some bright red blood this morning, so maybe this will all just end on its own soon.  But otherwise I’m in limbo until Monday.

Too Good to be True

We went for an early ultrasound today, when I should have been 6w1d or 6w2d according to my ovulation date (or 7w based on the date of my last period).  The only thing there was an empty gestational sac measuring 4w3d.

The ultrasound tech and doctor were bending over backwards trying to reassure me that it’s very common to get dates wrong in early pregnancy, but I’m quite certain of the dates (I mean, I had a positive home pregnancy test two weeks ago — it’s basically impossible that I’m only 4w now!).  There’s just no way this pregnancy is viable.  I also had an inkling, since yesterday (Mother’s Day in the US, no less) I had just a bit of mucus tinged with dark brown flecks that looked ominous.  That quick conception was just too good to be true.

I’ve got a lot of mixed feelings swirling around in my head right now.  I’m sad, obviously.  This was a much-wanted pregnancy.  It was a little quicker than we were expecting, but we were delighted that we were able to conceive so easily and looking forward to the prospect of a little sibling for S.  Honestly, I also felt like I might have dodged a bullet — if everything had gone smoothly, it might well have been the end of my reproductive phase of life, which it now looks like is going to drag on even longer with a bit more heartbreak.  I am so done with this phase of life… except that I’m not, because we really want another baby.

On the other hand, there are some silver linings.  The timing of this pregnancy was messing with my tenure clock, and now the odds are that I’ll be able to stick to my original clock, which would be nice.  Also, two under two was a little bit daunting, and now we’ll have a little more time to enjoy our amazing little guy on his own, and he’ll be a little bit bigger and more independent before (hopefully) a future sibling disrupts his universe.  I know these things.  They are not really all that comforting, though. I wanted that baby.  A lot.

The big question now is, what next?  Given how undeveloped the pregnancy is, why is my body still holding onto it?  The doctor drew some blood to check my HCG levels and told me to come back in a week, so there are no immediate plans to intervene (although she did say she’d call later today to discuss the outcome of the blood test).  I hate the waiting game more than anything.  I think that if nothing happens in the next week, I’ll start to ask for medical management with misoprostol.  I just don’t want this to drag on forever — I want it to be over with so that we can move on with our lives, and hopefully with another healthy pregnancy.

In a way, I’m also kind of uneasy about what it means that we conceived so quickly.  Does it mean that the RE won’t want to move forward with the plan we developed before I got pregnant this time?  Possibly not, since I’ve still been having irregular periods since my son was born, and I still have the abnormal HSG — those two things have not changed, although at least now we do have the good indication that my right fallopian tube is still functional after the birth of my son.  I can’t help but be certain that the quick conception was a fluke, and that we’re in for a long haul with conceiving another viable pregnancy.

I guess the other silver lining is that I’m handling this a whole heck of a lot better (at least so far, about three hours after getting the news) than I handled the news of our daughter’s loss at 18 weeks.  For one thing, it’s a lot less unexpected — having no heartbeat on an otherwise totally uneventful pregnancy at 18 weeks was like getting hit by a truck.  At least this time around we knew the probability of bad news was significant.  With early miscarriage rates around 20%, and this being my third pregnancy… well, it was not exactly an improbable outcome.

For another thing… we’ve been in worse places before.  Once you’ve handled second trimester loss, first trimester loss seems somehow more bearable.  That’s not to say that first trimester loss isn’t devastating for many families — of course, it is.  My heart breaks for the stories I read here about first trimester loss — multiple losses, no living children… it’s devastating.  You can’t measure or weigh grief.  Our grief this time is just a little more muted, by two things: the loss of our out daughter “broke us in,” in a way — I just don’t expect good news when I’m pregnant anymore, so this bad news was a little easier to take because of our experience with bad news in the past.  And, the other half of the muted grief is that we have a beautiful, wonderful, amazing little boy at home who means the world to me and whose snuggles take the edge off of the loss of his nebulous, but no less longed-for, sibling.  Plus, he gives me hope that I might someday be able to carry another pregnancy to term.  This time, the statistics make sense.  If we have another early loss in the future, I actually suspect it’ll be a whole lot harder to handle.  Right now we’re at one full-term baby for three pregnancies.  If it becomes one full-term baby for four pregnancies, I’ll start to wonder again what more might be wrong with me that makes my uterus a place where babies go to die.  I also hope we’re not playing “collect them all” with pregnancy outcomes — so far, we’ve had one first trimester loss (still in progress), one second trimester loss, and one full-term healthy baby.  The other outcomes don’t look particularly appealing, so I hope we’ll be able to take a pass on those!

Well, anyway, wish me luck that this doesn’t drag out too long and that we’re able to move on and conceive again soon.

My Blog Title is Apt Again

Well, whaddya know.  I’m pregnant.

It has never taken us less than 8 months to conceive before.  This time, first try.  We are thrilled and a little stunned.  I’ve always been a little skeptical of the stories you read of how people who have experienced infertility/loss often get pregnant quickly after a full-term, healthy pregnancy — I mean, maybe it happens to some people, but I was sure it wouldn’t happen to me.  Well, here I am!

For now, of course.  I know as well as anyone that first trimester miscarriage is a distinct possibility, as are losses at later stages of pregnancy, as are all manner of other health problems (I’m still at elevated risk for ectopic pregnancy and placental abruption, for example).  But for now I’m pregnant, and that’s a very, very good thing.

We’re a little shocked at the timing — I mean, we were trying to get pregnant, obviously, but we just didn’t expect it to happen this quickly.  Of course our minds started jumping to the possible reality of having a new baby join our family in January.  Two under two — yikes!  It would also throw a monkey wrench into my tenure plans (I’d been on track to submit my materials a year and a half from now), but… we’ll deal with that.  Our family is more important than my tenure case, and if I wind up using both my clock extensions and spending nine years on the tenure clock, so be it.

I was also just starting to cut back on pumping at work this week, but for the moment I’m still breastfeeding/pumping four times a day, which is going to start feeling like a lot as I get more pregnant.  But… what if I wean, and then miscarry?  I’ll be mourning the loss of a baby simultaneously to mourning the loss of a wonderful breastfeeding relationship.  I suppose I’ll just keep doing what I’m doing (i.e., weaning from the pump during the day, since I would never mourn the loss of a relationship with my pump!) and see how things go over the next few weeks.  I’ve got a viability scan scheduled for a week from Monday, after which we’ll know a little more (and, if all goes well, I’ll start back on Lovenox).

What a weird and wonderful week it’s been.  Pregnant again.  Holy cow.  Here’s hoping this little bean sticks around!