In this episode, Dr. Sarp Aksel discusses first trimester miscarriage, an unfortunate reality for about a quarter of women. He and Dr. Fox clear up confusion around terminology, explain procedure options and when a woman should call her doctor, and more.
“First Trimester Pregnancy Loss (Miscarriage)” – with Dr. Sarp Aksel
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Dr. Fox: Welcome to today’s episode of “Healthful Women,” a podcast designed to explore topics and women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
Dr. Aksel: Glad to be here.
Dr. Fox: How have you been?
Dr. Aksel: Great.
Dr. Fox: Got through the summer of the pandemic?
Dr. Aksel: Yeah, just COVID coping.
Dr. Fox: COVID coping. Well, glad to see you. We’re doing what we can. We’re gonna talk today about the management of first trimester pregnancy loss or miscarriage. And this is a very common situation unfortunately.
Dr. Aksel: Unfortunately, very, very common. The latest status, as you know, about a quarter of women will experience a miscarriage at some point in their careers. But while it’s unfortunate, good news is it doesn’t necessarily bode poorly for future pregnancies.
Dr. Fox: Right. And, you know, the miscarriages, it’s interesting because you’ll find varying percentages out there, either in the lay press or on Google or in the literature. And part of that is because the risk is related to the age of the mother. So the risk in a 20-year-old is gonna be different from a 30-year-old, 40-year-old. It’s more common as you get older. But the other reason is it depends what your starting point is, right? So if you count pregnancy is the point someone let’s say misses a period and has a positive pregnancy test, you may find that 30% to 50% of those don’t end up being a pregnancy, so it’s a miscarriage. Whereas if you wait until there’s like a heartbeat and ultrasound, then it’s like under 10% or 5%, it’s very unusual.
So the numbers that are out there to people are seeing them, it’s you have to sort of be careful of exactly what data you’re reading, but the point is it is unfortunately, a very common event, usually just related to an abnormal embryo from the beginning, genetic loose abnormal, which is again, usually a matter of luck, not a matter of like carrying a gene, like the parents don’t have an abnormal gene. It’s just worked out abnormal in the embryo. And those are sort of, for whatever reason, biology, they know sort of that that’s not a normal pregnancy so the development stops and people miscarry.
Dr. Aksel: Yeah. There’s oftentimes a lot of terms that are tossed around.
Dr. Fox: Yeah. Confuses people, myself included.
Dr. Aksel: Of course. Absolutely. I mean, some of the terms that used to be used when you were in med school, aren’t necessarily used as frequently now.
Dr. Fox: But we didn’t actually have writing yet when I was in med school.
Dr. Aksel: Scripts.
Dr. Fox: It wasn’t even used yet.
Dr. Aksel: Papyrus.
Dr. Fox: Yeah. We just chiseled it on stones and, you know, had apprenticeship one now. But yeah, I mean, listen to, we were just talking before, I mean, there’s terms, miscarriage, spontaneous abortion, pregnancy loss, missed abortion, blighted ovum, and embryonic pregnancy, incomplete abortion, all these words that come out and they’re a little bit complicated, but essentially there’s really only a few things that are described, but many of them have a lot of different words. I mean, miscarriage, just the idea of someone had a pregnancy and they lost the pregnancy, but we rarely use that sort of medically because it’s not as descriptive. I mean, there’s what we call, like what we call a spontaneous abortion. How would you explain that to a patient?
Dr. Aksel: A spontaneous abortion would be a pregnancy that was, and then it stopped growing. And oftentimes it’s because there’s some sort of, like you said, genetic abnormality.
Dr. Fox: Right. And then, but in that case, usually the pregnancy will come out, meaning she’ll bleed and she’ll sort of colloquially miscarry. But what happens though is, you know, nowadays that we use ultrasound so frequently early in pregnancy, we’re sort of getting these terms that are somewhat anachronistic because we used to have terms that were just clinical. So someone spontaneous abortion, I mean, they were pregnant and then they lost the pregnancy. And then this was idea of like these incomplete abortions and threatened abortions. And so that was related to how people presented clinically. But nowadays with ultrasound, when someone has bleeding or some question or just are asymptomatic, and we do an ultrasound and we see that there’s a pregnancy inside, but we believe it’s not viable, so what do you call that? Right. So it used to be called the missed abortion, which means the pregnancy is no longer viable, but it’s still inside.
Some people call that a miscarriage, but again, it’s still inside. And so the terminology is complicated and different people use different terms to mean different things. But what we’ve learned from ultrasound is the sort of older prevailing thought was when somebody miscarries, they have a perfectly normal pregnancy and it keeps growing and growing and growing and then boom, suddenly they miscarry. They believe in they passed the pregnancy. And that’s actually the exception that almost never happens. What happens almost always is the pregnancy stops developing at a certain point, whether that’s before you can see an embryo, after you can see an embryo before heartbeat, after you see heartbeats or developed and then stops and then days, weeks, or even months later, they’ll sort of have that clinical miscarriage. And so if we do an ultrasound in that process or between those times, we can sort of see it unfold so-to-speak.
Dr. Aksel: It’s not unusual for me to have women who come in and they’re just like, I stopped feeling pregnant. You also have that scenario where they come into you, not because they’re cramping or they’re bleeding, but because they don’t feel pregnant anymore. And I get a lot of those calls, especially when I’m on call in the middle of the night and someone calls in and they say, “I don’t think I’m pregnant anymore.” But they’re not bleeding. They’re not cramping. And so you bring them in, and like you said, ultrasound has given us the opportunity to sort of catch it before the cramping and bleeding starts. And so we get to offer patients different options.
Dr. Fox: That’s interesting you said about the symptom stopping because it does not mean that the pregnancy is no longer healthy. That is something that’s a people have. Most of the time, these things are just sort of random people get symptoms and they don’t, or they come and they go or they get better they get worse, they get better again. So we don’t generally go by that. But if there’s a concern, we could always do an ultrasound and find out. For most women who have a perfectly healthy pregnancy, we’ve seen a heartbeat and then they are no longer nauseous, it’s still a normal pregnancy. And then not only, it’s not only unfortunate, it’s quite fortunate because now they feel better. So that’s a good thing. But a lot of times it happens at more following an early pregnancy. Someone comes for early ultrasound. We may not know on the first day, is it a viable pregnancy or not?
Right. Because until the point where we sort of see an embryo, that’s a right size with a heartbeat, we’re not really sure because in the stages before that, there’s like a little empty sack, then there’s an empty sac with a yolk sac, then an empty sac with the yolk sac and embryo. There’s sort of stages that we see, but that’s all pre-heartbeat, right? So you’re not really certain. So a lot of times people leave our office, our ultrasound unit with a little bit of confusion that they don’t know if it’s a viable pregnancy or not, but it’s appropriate confusion because nobody knows. You just sort of have to wait and see how it’s gonna unfold.
Dr. Aksel: The anxiety that comes with that uncertainty also, it’s very common and most of the time, everything sort of works out, but sometimes it doesn’t. That’s where it’s good to have someone to talk through your options with.
Dr. Fox: Right. And it’s sort of a tough question to whether it’s better for women to have ultrasound as early as possible or not. On the plus side if you see someone early, you can potentially diagnose an ectopic pregnancy when it pockets about that. So that’s very useful. Someone has an ectopic pregnancy. On the flip side, you get a lot of situations where there’s uncertainty because you just did the ultrasound very early and they’re supposed to be uncertainty because they just don’t know. And so there isn’t really the right time when someone has to come in, but there’s some benefits of doing it earlier, some benefits to waiting and seeing what happens. The benefits are sort of psychological to waiting, not really medical in that sense.
But if we’re, you know, confident that the pregnancy is no longer viable, it sort of happens three ways. Either someone, they were pregnant, they come to the office because they experienced what people think of as a miscarriage. They were at home and they had some bleeding, some cramping. Then they passed something, right? You know, like a big clot or whatever it is and then they have less bleeding, less cramping. And then we evaluate them. And if everything’s finished, we say you had a miscarriage, you had a complete abortion, you a spontaneous abortion. We sort of use all those terms. I mean, they miscarried essentially. And that’s something that happens.
On the flip side, you could have someone who, again, either because they had some symptoms, whether it’s bleeding or not, or they had just a routine ultrasound, we’re confident from ultrasound the pregnancy is still inside, but it’s not viable. And we’ll talk about that situation. And the third situation, which is a little bit needs action, more quickly is someone’s sort of actively bleeding and it’s not a viable pregnancy, which sometimes we call it incomplete.
Before we go over these three scenarios, I just wanna clarify that we’re only talking about situations where we actually diagnose a pregnancy loss or miscarriage. The majority of women who have first trimester bleeding are not miscarrying and will not ultimately miscarry. We’re gonna do a separate podcast on first trimester bleeding. For now, we’re only talking about situations when we actually diagnose a miscarriage.
Let’s start with the first. So someone is pregnant and then, you know, they have what everyone describes as sort of a miscarriage experience that happens at home when they come and see you afterwards. Let’s first talk about what would you do is sort of an assessment of her and the pregnancy sort of physically. We’ll talk about emotionally after this physically to, to make sure that she’s okay or to sort of confirm what happened. What would you do?
Dr. Aksel: Yeah. So most of the time when patients call with those symptoms, they’ll come in, we’ll have them have an ultrasound. And then when I see them in the office, I’ll end up doing a pelvic exam. We’ll start off with a speculum exam just to see sort of, you know, is there active bleeding going on? And then we’ll do, what’s called the bimanual exam where we check to see if the cervix is open. So if the cervix is open, that sort of helps us, like you said, delineate the clinical diagnosis. You know, if it’s closed and she had some bleeding, then it would be what we would call a threatened abortion. If we see that there’s a pregnancy, there’s a heartbeat, then in that scenario, it’s more about reassurance and just watching and following up in a week or two with another ultrasound. If there’s no pregnancy inside and the cervix is open, then we assume that whatever past was the pregnancy tissue. And at that point, you know, we just make sure that they’re not actively bleeding.
Dr. Fox: Right. And so in that situation, if someone had a miscarriage, the ultrasound confirms that there’s nothing left inside the uterus and her exam is basically normal. Does she need any other treatment, any other care, any other follow-up?
Dr. Aksel: In that scenario, I would send a blood level for the pregnancy hormone just to see if it’s negative, if it’s low, you know. You can get into a pickle with those, if the pregnancy hormones there, but it’s not negative and you sort of need to follow it up and different providers feel differently about that.
Dr. Fox: Right. Because maybe you weren’t, I guess in that situation, if you weren’t sure she had a pregnancy before, it’s hard to know for sure. If you knew there was a pregnancy in the uterus, so I sought an ultrasound and then she has this and comes in and is no longer there you know what it was. You know, it was a pregnancy. She miscarried, I think the situation referring to is, which we talked about with Shria Billet is someone has bleeding, you do an ultrasound and you see nothing in the uterus, and as a positive pregnancy test, it could be that she had a pregnancy that passed, but you don’t really know that for certain because you didn’t see it before. So you can do hormonal levels and make sure they’re dropping in this. So that is sometimes a situation we have to figure it out.
But if you knew it was a pregnancy inside and now it’s not there and she’s doing okay generally, there’s no real treatment you need to. Obviously it’s unfortunate we started talk about the emotional aspect of it and plans for the future and sort of processing in that way. But from a medical side, they do well, it’s not like a miscarriage needs to happen in a hospital or an emergency room or a doctor’s office.
Dr. Aksel: No, absolutely.
Dr. Fox: They happen at home. Mostly they’re obviously troublesome in the sense it’s difficult for people to go through them. But from a medical perspective, it’s unlikely to be dangerous. What would be some warning signs for women if they were experiencing a miscarriage at home that either you would tell them as they called you, you need to come in for this or just so they should know? What are the things that should be concerning aside from just that they’re miscarrying obviously in terms of like their own health?
Dr. Aksel: The first thing is, obviously, bleeding, bleeding that’s too much. And then we dive into, you know, what is too much. And if you’re soaking through, you know, two pads in an hour and that’s going on for an hour or two, that’s definitely a situation where I would wanna evaluate them so I’d have them come in. Or if there’s bleeding, but you know, it may not be going on for so long, but the patient starts to feel lightheaded, dizzy, any of those symptoms that would be concerning that too much blood was lost, that would also be something that I’d want to bring them in for.
Dr. Fox: Right. But that’s an uncommon complication for miscarriage.
Dr. Aksel: Completely. Yeah.
Dr. Fox: But it happens a few percent of the time, but for the vast majority of people, sort of the experience of it physically is they start getting some light cramping and light bleeding then it becomes heavier cramping, at the same time, they have heavier bleeding and then it sort of crescendos. And then it’s exact opposite. The bleeding it’s lighter and the cramping, it’s lighter and then it sort of goes down. And that whole process start to finish is usually matter of hours.
Dr. Aksel: I usually say like 8 to 12 hours from the start.
Dr. Fox: And so sometimes if it’s going on for a long time, even if it’s not that heavy, we’ll say, you know, it’s a little unusual maybe come in and we’ll take a look. Or again, like you said, if it’s heavier. And when someone does have a concern that either the bleeding is prolonged or it’s heavier, what would be the thing you’d be looking for in terms of to value? What are you concerned that might be happening that’s causing the heavy bleeding?
Dr. Aksel: In that scenario, you just wanna make sure that there’s not tissue that’s left behind that’s, you know, causing that bleeding.
Dr. Fox: Right because the term for that, that we use is sort of like incomplete abortion, which means that, you know, that they’re having a miscarriage, but not everything came out. And when not everything comes out, the uterus is not gonna stop bleeding. Sometimes it will. And you’ll find out weeks later that there’s tissue left behind. It’s not the baby left behind because we’re talking about tissue here is point number one is just an embryo.
Dr. Aksel: It’s the sac.
Dr. Fox: The sac won’t be simple placenta or something like that. And so in those situations and that’s diagnosed usually by ultrasound. So, right. So someone comes in, let’s say they are having a miscarriage or had a miscarriage and they’re coming into the office because they’re having heavier bleeding and you do an ultrasound and you do suspect that there is some tissue left behind and she has bleeding relatively heavy, what are the options at that time?
Dr. Aksel: So I think the options are really gonna be dictated by how stable she is. You know, she’s bleeding so much that it’s starting to affect her, her heart rate or her blood pressure is too low. That’s more of an emergency situation. It’s not the most common thing that happens. Those are immediate. Those are the things that we’re on alert for. But most of the time, you know, as long as the patient’s doing okay, it’s a little bit heavier, we have a couple options. We can either give medication to push out whatever tissue was there, medication specifically would be misoprostol or cytotec.
Dr. Fox: Right. That’s sort of like it’s causing us to basically contract, right. We don’t call it a contraction because it’s so early, but it’s like squeezes the muscle, the uterus, and sort of to expel everything that’s left.
Dr. Aksel: Exactly. So it’s kind of like an extra push to sort of finish the process. That’s something pluses and minuses of that. Or, you know, there’s a little bit more privacy. You get to be able to go home, you can manage it if that’s something that you feel comfortable with. And so you sort of take the medicine out of it, if you will. It’s a little bit less institutionalized and medicalized. Oftentimes with that, I do tell patients, you know, with this medication with misoprostol, things to keep an eye out for. It would be, you know, low grade fevers can happen, a little bit of nausea or vomiting, possibly some diarrhea, but generally it’s a very well-tolerated medication. If that doesn’t sound like your cup of tea and we’re in the office, the other thing that we could do is do a quick procedure called a manual vacuum aspiration, where we kind of go in with a straw into the uterus and we remove the tissue in a procedure that lasts no more than three to four minutes.
Dr. Fox: Right. And that’s done vaginally through the cervix?
Dr. Aksel: Through the cervix. There’s no cutting there, there, you know, it’s gentle suction and some intense cramping at the moment when the procedure’s happening. But after that, women usually tolerate it very, very well. They go home, you know, Motrin alone, Motrin or Advil is enough to sort of take care of the cramps.
Dr. Fox: Right. And generally, you know, procedures like that, where we go into the uterus from below through the cervix, the painful part of it is putting something through the cervix, dilation of the cervix. And so if someone’s in the midst of a miscarriage, generally the cervix is a little bit open. It’s a little bit soft. It’s not as difficult as if someone just sort of walks in and you’re trying to get something in a cervix that’s closed. And so that’s one of the reasons it’s a little bit easier for women to tolerate that procedure in an office setting. I mean, it’s also possible to do in a hospital with anesthesia. So there is a way to do it.
Dr. Aksel: Of course.
Dr. Fox: It’s a little bit more elaborate in terms of planning because you’re not in the offices of the hospital, but okay it’s quite doable and these are procedures that are done all the time. And so if someone is having exquisite pain or we have concerns, maybe that she’s not so stable and maybe needs to be in a hospitalized setting with more, you know, monitoring and an anesthesiologist, we could do it there. But I think for most women do it in the office as an option because again, the cervix is already a little bit open and this is gonna actually make them feel better usually because it finishes process.
Dr. Aksel: The miscarriage. Yep.
Dr. Fox: And then they sort of they get to be in the back end of it quicker than they would have plus the coming in because they’re having symptoms. So you have the option of the procedure, the medication. Are there any circumstances may just sort of like, wait and see how it happens?
Dr. Aksel: That’s an option where you’re not having heavy bleeding. In those scenarios, if the bleeding’s not too heavy and there’s no real sort of concerns that it’s going to get heavier, waiting a little bit, it’s an option. You know, but I usually reserve the watch and wait approach for folks who are sticking around, who are in town. I don’t recommend that for, you know, right, if you’re flying down to Florida or going skiing and Aspen, I don’t usually recommend that just so that we can stay in close communication. But I think that the main risks that you wanna keep in mind with watching and waiting is, A, it’s unpredictable. So it could take a relatively long period of time. It’s not unusual to go two to three weeks and the process is still ongoing and more rarely, you know, some sort of infection when you watch and wait, because the pregnancy tissue is still kind of hanging around, especially if the cervix is open, it’s possible that you could have an ascending infection from the vagina.
Dr. Fox: As a review for the vast majority of women who are unfortunately experiencing a spontaneous pregnancy loss or miscarriage, it will happen at home or out of a hospital setting, out of a doctor setting. It’ll be unpleasant, certainly both physically and, you know, emotionally, but is very rarely dangerous or requires any medical intervention whatsoever. And for the women who might either because they’re having more pain than they think they should be having or more bleeding, generally they come in and the evaluation is pretty straightforward and the treatment is usually pretty straightforward as well either do nothing, do some medication or do a procedure, which is a low risk procedure. And then they’ll physically recover pretty quickly from this.
Now what about the setting where we diagnose that the pregnancy is no longer viable, but it’s still inside? So either we call that the missed abortion or it’s a miscarriage, but it hasn’t passed yet. And that again happens much, much more commonly nowadays than it ever did before, because we have ultrasound and we see this all the time. So she feels fine. She has no symptoms whatsoever in terms of, you know, bleeding or cramping and she either does have pregnancy symptoms or doesn’t have pregnancy symptoms, but she has this there and we know it’s not gonna grow anymore. So how do you counsel them about their options at that point?
Dr. Aksel: You know, at that point, I tell them that they have the opportunity to make their miscarriage experience their own. They have all four options, they can watch and wait, they can sort of wait for the symptoms that we talked about, the light, like bleeding, like cramping that sort of builds and then it stops on its own. That would be the most hands off approach. They could go for medication, the same medications that we use to help complete the process can also be started that used to start the process. So there’s a two medication approach where one of the medications, mifepristone is used about 24 hours before you take the misoprostol, the medication brings on the cramping
Dr. Fox: And that first medication is actually, it’s sort of like an anti-progesterone. So it’s sort of like blocks the progesterone hormone, which is sustaining the pregnancy. You know, it’s not viable. So blocks that. And then you do the medication and that’s sort of a little bit newer, right?
Dr. Aksel: Yeah, it’s new. In 2018 there, you know, there is relatively new research that shows that it helps quicken the time to completion of the process. And so, yeah,
Dr. Fox: It lowers the chance you’ll end up needing a procedure afterwards.
Dr. Aksel: Exactly.
Dr. Fox: Because sometimes the medications don’t work exactly, right?
Dr. Aksel: Exactly.
Dr. Fox: And then they’re not 100%. So the odds are better if you take the two medication regimen versus just the one, again, this is for someone who’s not having symptoms.
Dr. Aksel: Correct. Right. And so you, you know, you can take the two medication regimen and then you can also…you still have the surgical options. So the procedures either they’re in the office or you could go into the hospital and to the operating room.
Dr. Fox: Right. So if someone is deciding, thinking about the first option, the least sort of hands on approach or the more hands off approach we just watch and wait, how long might it be until she actually miscarries from the time you notice it on ultrasound?
Dr. Aksel: I’ve had patients where it can take about four to five weeks.
Dr. Fox: You know, when I see people and I unfortunately have to diagnosis and ultrasound almost every day, because it’s a very common occurrence and I go over the options with them and ultimately, you know, she’s gonna decide with her doctor. If I’m her doctor, then you know, we’ll decide together. And when I tell him about the expected management is that it’s perfectly safe, right, for her. It’s not a risky thing to do sound a dangerous thing to do. There’s always the risk that you’ll have those complications of a miscarriage, like, you know, bleeding that we spoke about before, but not high. It’s still very low. The real downside is that it’s unexpected when it’s gonna happen. It could be tomorrow. It could be in six weeks and that’s sometimes very troubling for people. You know, they’re like, “You mean I might be at work or I might be on vacation or I might be home. And I don’t really know.” And yeah, I don’t know what’s gonna happen.
Now someone comes in and sometimes they’re already bleeding and I see the pregnancy sort of lower down in the uterus, I can give her a better sense that it’s gonna be earlier rather than later, but that’s very rough. There’s no way to say for sure when it’s gonna happen. And so some people are just not comfortable with that uncertainty on the timing. Also, sometimes people are eager to try again and the longer it takes to complete this miscarriage, the longer it will be until you can, you know, try for the next pregnancy. So that’s a reason someone might not wanna do it. Okay. What about the medication? What might be a reason someone, you know, would choose it or wouldn’t choose it?
Dr. Aksel: Again, privacy and sort of having more control over this scenario is usually what’s appealing to a lot of patients for that option. I would say that, you know, someone with a history of significant blood loss, either during their periods or at baseline, you know, they might be a little anemic. I’d probably steer them away from that.
Dr. Fox: From the medication.
Dr. Aksel: From the medication. I usually tell them that it’s gonna be heavier bleeding than a period. So if at baseline they lose a lot of blood to begin with or, you know, they need transfusions or to come through their periods, then I don’t think that’s the right option.
Dr. Fox: That’s unusual, right?
Dr. Aksel: It’s very unusual. Yeah. Yeah. Sometimes, you know, you’ll have someone come in. I’ve only had like one or two patients, but they’ll come in and they’ll say, “Oh, I can’t take that. I’ve taken it before and I’ve had a bad reaction to it.”
Dr. Fox: For medical reasons they can’t it.
Dr. Aksel: Medical reasons. But typically it gives them a little bit more control. You know, they’re able to take the first medication. They take the first medication in the office. They usually have to wait 24 hours and then 24 to 48 hours. And so it gives them a little bit more flexibility on the time. You know, I have patients who take the first medication on a Friday and then on Saturday.
Dr. Fox: So it happens over the weekend potentially.
Dr. Aksel: Over the weekend or they’ll time it such that it happens while they’re sleeping or at night. It gives a lot of patients control in a situation that otherwise feels very helpless and out of their control.
Dr. Fox: Yeah. I feel the same way. The way I explain it as it’s sort of like the first option, but with a little bit better timing in terms of, you can say, he could say when it’s gonna happen. So, you know, you’re getting a little bit more intervention not a procedure, but a pill, but it helps you sort of on the expectation. And it’s pretty effective. I mean, it’s generally based on the study, like 70%, 80%, 90% of the time it works. They miscarry as they would have naturally, but just expedited. It happens when they do the medications. And then there’s a percentage of people they take both medicines and nothing happens. Nothing. They’re just like what it’s like, they didn’t take it. And other people will get, you know, sort of the miscarriage that doesn’t complete and they ultimately have to do something else, but that would be true if they waited also, there’s always that risk.
So it just really changes the timing. And again, I find that some women are just like, it’s just a mental. And someone like, yes, I’m that person. And I was like, no, I don’t want any part of that. And it’s almost like a gut decision for a lot of people. And then in terms of the decision, let’s just say to do any procedure, like whether it’s in the office or hospital, what would be the advantages or disadvantages to going to like a procedure to complete the pregnancy loss?
Dr. Aksel: The quickness with which that episode resolves, I think is the number one reason why a lot of women do choose a procedure, right? They come in, you diagnose them in the morning with a miscarriage. I see them 30 minutes later, I have the ability to solve that and fix that problem in the next like hour or 2 hours. And then I send them home with a prescription for wine and Netflix and relaxing with their partner. I think that that quick resolution is something that’s really appealing, but you ended up sort of trying to balance that quickness with people’s fears of a procedure
Dr. Fox: Sure.
Dr. Aksel: Period, right?
Dr. Fox: Right. There are risks to proceed.
Dr. Aksel: There are.
Dr. Fox: Again, the risk is very, very low.
Dr. Aksel: Thankfully they’re low. You know, the chances of poking a hole in the uterus called the perforation is really only 5 in 1,000 to, you know, 1 in 100.
Dr. Fox: Less than 1%.
Dr. Aksel: It’s less than 1%. You know, it happens, but it doesn’t happen often. Over 99% of the time you get the tissue. You decrease the chances that anything’s gonna be left behind that you know, which can happen with the medication. Like you said, if not, all of it comes out, then you’re at risk for needing a procedure anyway. And so for some people they’re like, well, if I don’t wanna do the medication and then also risk having to do a procedure, I’d rather just go ahead and have the procedure.
Dr. Fox: I tell people the same thing that it’s the most predictable, but what’s gonna happen because you’re gonna go into the procedure and they’re gonna come out and it’s gonna be done. So that’s a big plus. And for people who want this done yesterday, that’s the way to do it. But there’s some risks to a procedure. There’s a risk to not doing the procedure also, right? There’s risks to either way, you know, there are different risks, right? So like poking a hole in the uterus, uterine perforation is specific to having a procedure, but that risk of the retained tissue and having the bleeding and that this is specific to not doing the procedure really are more common if not doing the procedure. But the risks are really low across the board, even then they’re slightly different.
And I usually tell people that the decision about whether to wait, do the medicine or do the procedure is much more of a personality decision than it is a medical decision, because all three are safe, all three are reasonable, all three will ultimately work so-to-speak, meaning she’ll ultimately miscarry the pregnancy completely. And it’s just a matter of what women want. The people who are sort of like, I want this done yesterday. I want to wake up tomorrow and not be thinking about what’s gonna be, what’s gonna be, I just wanna be like sad and that’s it, they generally choose the procedure. And for women who are like, I don’t wanna be touched, no doctors, no procedures, no poking, no product fine, then they wait and that’s okay. And then the people are sort of like in the middle, like I’d rather not poke in broad, but I sort of wanna do this little quicker, we’ll take the medicine.
And I encourage them to make the decision that’s best for them. Whatever sits right for them is certainly okay with me. And it’s bad enough to have to go through a miscarriage. You know, at least they can have some agency over what’s gonna happen to them and that circumstance. And so I’m fine with all three options, unless there’s a compelling reason to pick one over the other, in which case I would tell her. But that’s the exception.
Dr. Aksel: Right. The other question that I often get is which option is gonna not impact future pregnancy.
Dr. Fox: Right. None of them will.
Dr. Aksel: None of them. The answer is none. You know, you get to pick whichever one helps you emotionally move forward in a way that works for you.
Dr. Fox: Right. The only difference is the procedure. You can try quickest because you’ve miscarried, earliest the medications, but that’s just gonna just timing, not in terms of like future ability to have kids or complications, causing the inability to have children. It’s not really relevant to any of those three fortunately. Now, we discussing the procedure. You were mentioning, you could do it in the office sort of right away, or you can do it in the hospital. And so we set for the woman who’s already bleeding at a source little bit open, it’s pretty straightforward to do in the office. But for the woman who is not having any of those symptoms, what are sort of the pros and cons of doing it as an office-based procedure like you were describing versus doing it in the hospital with an anesthesiologist, getting some sedation?
Dr. Aksel: The anesthesiologist being that we’re not in the hospital, the options for pain management are significantly limited. Now, it doesn’t mean that I don’t have patients who tolerate it perfectly fine. And oftentimes the more motivated patients are the ones that do the best. You know, the ones who want to get it over with and who want to move on often when we do very, very well with a Percocet of Valium and then some local numbing medicine during the procedure.
Dr. Fox: On the cervix.
Dr. Aksel: On the cervix. Right.
Dr. Fox: And then, whereas in the hospital, it’s intravenous medication, right. They’re sort of, they’re not leaked out to the point, like if you’re getting your gallbladder removed or put a tube down your throat.
Dr. Aksel: They’re not gonna remember the process.
Dr. Fox: You’re sleeping off.
Dr. Aksel: You’re sleeping off. Exactly.
Dr. Fox: Yeah. Right. What would be the reason? Is it just is it simply just convenience that if you do in the office, you can sort of schedule it easier because you could do right away versus the hospital maybe takes a day or two to schedule it? Is that really the main thing meaning for the plus side for doing it in the office?
Dr. Aksel: For the plus side for doing in the office, I mean, scheduling is really about it. I mean, it’s more if their history of medical issues or certain surgical procedures, if I think it’s gonna be a difficult process and it’s gonna be a little bit more uncomfortable, I need a little bit better control over it, then I would probably suggest, you know, doing it in the hospital.
Dr. Fox: Or also the later they are in pregnancy potentially.
Dr. Aksel: The further they are long. You know, we do limit how far along we do them in the office. But generally if they’re beyond 10 weeks, I typically would say that it should be done in the hospital except for certain case by case.
Dr. Fox: Just because you have to dilate the cervix a little more because the pregnancy is just a little bit wider, you know, to get out. So, and that’s just gonna hurt more. Now, if someone has either of these procedures, what do you typically tell them to expect the day of like when they go home and then the next couple of days in terms of symptoms and pain and whatnot?
Dr. Aksel: I usually say the first couple fist days they could expect bleeding like a period. You know, at that point I do counsel patients that it’s not unusual to go through, you know, as many pads as they would during a period. The key thing to keep in mind is that not many of my patients use pads generally to make it through periods. So trying to find that tampon pad conversion factor, I think is also important. But usually the bleeding’s on par with a period and it can last a couple of days, but then it should start tapering off. And along with the bleeding comes cramping also like a period can be managed with Advil or Motrin or whatever was used to deal with menstrual cramping. And then usually within a week, week and a half, you start to see significantly less bleeding and less cramping. And by the time they show up at the two-week follow up visit, you know, all their symptoms are gone, no more cramping.
Dr. Fox: When do you tell them they can go back to work for example?
Dr. Aksel: They could go back to work the next day. There’s no time off. Obviously with in the hospital with the procedure, you need some time for the anesthesia. I usually give them a day, day and a half. But with the office-based procedure, you know, I have some patients who walk in and have the procedure, go home later that day and get back to work.
Dr. Fox: Yeah. For most women the day after, or if they have it in the morning, the night of, it generally doesn’t feel much different from a period, maybe a heavier period than normal, but it’s usually nothing too remarkable fortunately. Sometimes if people have severe pain afterward, that’s a clue to us that maybe there’s some tissue that stayed behind or maybe there was something going on and we’d like to evaluate. But then again, that’s really unusual in those circumstances. Someone need a lot of pain medicine. And I generally tell people that, you know, just like you said, usually the bleeding stops within a couple of days and a couple of weeks sort of depends on who they are, but usually towards the shorter end of that window. And then at a certain point, their body’s gonna sort of like reboot and they’ll ovulate again. And I don’t give women restrictions on when they can get pregnant again. I don’t say you have to wait one, two, three cycles. People used to do that. And then, yeah.
Dr. Aksel: I actually say next cycle.
Dr. Fox: Whatever. And I say, usually what happens is it’s unpredictable when you’re gonna get pregnant, if you do it right away, because you don’t know when you’re gonna ovulate. So usually what happens is after the procedure, somewhere between four and eight weeks later, she’ll get the next period and then it’s a little more predictable. But if she happens to get pregnant between the procedure and her next period, it’s not dangerous, it’s not an increased risk of anything. And I tell them that that’s okay if they’re sort of emotionally ready to try again. And that’s certainly okay with me. Some of them aren’t some of them, aren’t obviously that’s their choice, how they wanna proceed.
But generally after the procedure’s done, you know, they come back in a couple of weeks just to talk, see how they doing a lot of it’s more emotional slash social than actual medical because if there was a complication we would have known. And sometimes by then, if we’ve sent that the tissue from the miscarriage for like genetic analysis, sometimes we’ll have the results back because how we go about the next pregnancy may depend on what that showed again, which is for another podcast, but just that’s something else to talk about. Is there anything else you really go over in that two-week postoperative visit?
Dr. Aksel: You know, the two week post-operative visit? I usually, like you said, it’s just a, check-in. It’s a check-in to see how they’re doing. I take it as an opportunity to remind them that if they want to get pregnant, if this was a desired pregnancy and sort of the miscarriage was not expected, we go over the same sort of talking points that they can start trying to conceive as soon as they want. Some of them choose to wait, most of them choose to keep trying. And I usually see them in a couple months. Occasionally I have patients who, you know, this was an unintended pregnancy that they miscarried.
Dr. Fox: Sort of like a wakeup call. Wait.
Dr. Aksel: Exactly. And so I take that opportunity to kinda sort of sit down and be like, you know, is this something that you wanted? Is this something that we wanna start planning for? You know, do I need to start you on prenatal vitamins or on the flip side, do not wanna experience this at all again and do you want some sort of effective contraceptive method? It really kind of depends. It’s individualized that two-week visit. For some patients, they just wanna come in and chat for others. They feel like they’re totally fine and we do it virtually. Like you said, if they’re there usually is some sort of complaint, if something were to go wrong, then clue us in. So I generally don’t find things that are unexpected with the two-week visit.
Dr. Fox: Right. Exactly. If they came in and said, I’m still bleeding, then all right, maybe, you know, there’s something wrong or my pain is unusual, but if those things aren’t happening, it’s very unusual. This is really important stuff. And I think it’s a great review. And again, the key points is that, unfortunately this is very common and some women, their experience with this will be, it sort of all happens on its own at home. And then everything’s sort of done and then they don’t have to do anything medically. It’s just obviously emotionally, potentially difficult, but not medically. Some women have that and it’s not complete and then they come to us and there’s various options for what to do to help complete that miscarriage.
And then unfortunately, a lot of women sort of find out just by an ultrasound, “Hey, you’re pregnant, but it’s not viable,” which is, you know, it’s sort of like a sad moment. And then you have to not only process that, but we got to figure out what to do. But fortunately there are several options that are all safe. They’re all reasonable. It’s unusual that one wouldn’t be an option for a woman and she can sort of choose what sits best for her or, you know, which is the least undesirable. I mean, none of these are desirable obviously. And so she gets to choose, and fortunately they’re all safe. And then when it’s finished, if she wants to get pregnant again, she can.
Dr. Aksel: Yeah. The other thing that I’ve started sort of talking to, especially as I start to see partners that are involved, you know, it struck me, I was out with some friends and I don’t know how we got around to it. I guess this just happens when you’re an OBGYN. People started talking about how their partners or their wives or their girlfriends, you know, miscarry. And it always ends up being this like aha moment where it’s like, “I didn’t realize you also dealt with that.” And so I find myself sort of tossing that out there and encouraging partners to sort of talk about this because just like, you know, losing a baby or losing a child or a loved one grief associated with miscarriages are, or is very real. And so we, you know, I do explain to patients that you end up having patients who experienced grief, not just for that pregnancy, but the future that was previously being planned or, you know. And so I try to make as much space as possible for the patient as well as their partner to sort of talk about this because I feel like the more they’re talking about it, the more common it’ll be in our society to sort of communicate about and ultimately end up supporting each other when we’re faced with early pregnancy loss.
Dr. Fox: Yes. It’s such a good point. And, you know, when we had the podcast before was Shria Billet talking about pregnancy loss, in that podcast, we’re talking about later pregnancy losses, people grieve over the early pregnancy loss, different people to different degrees. Obviously some people, a little bit, some people moderate, some people devastating, again, based on who they are, what their circumstances are, what was going on with that pregnancy and it’s real. And that itself is something that needs to be remembered and addressed and talked about. But on top of that, one of the other sort of complicating wrinkles in this is people usually don’t tell anybody that had happened. Most people, you said, don’t even know how common it is. And until they have a miscarriage themselves and they start talking to people and they find out that nearly everybody they know, went through this, and that’s one of the ways in which people can sometimes heal or process or grieve is knowing that this isn’t unique to them. This happens to others, which is somehow, you know, it’s comforting in the sense to know that you’re not sort of like uniquely troubled.
Dr. Aksel: Or that there’s something wrong with you. And it is a lot of…
Dr. Fox: Yeah, that this only happens to me. Yeah, exactly.
Dr. Aksel: You know, while medically and physically there, you know, the two week-post-op post-procedure follow-up, either for taking the medicine or for the procedure, I do find it, you know, it serves as a sort of peer-to-peer counseling and support opportunity because it’s really hard to, you know, it’s almost nonexistent the support out there for people who have experienced early pregnancy loss and it can have an impact emotionally on the way that, you know, they move forward. So I think I like to take that opportunity to sort of talk to them about that as well.
Dr. Fox: Yeah. That’s a really important point. I think that’s really a key lesson in sort of finishing this, there’s so much more than just sort of like the medical management of it. It’s just the overall experience of it and how to process it and grieve through it. And it’s just a really important thing for us to remember, obviously, as we help care for women going through this, but for the women themselves, that it’s these feelings and, you know, grief are normal and expected in a sense. Excellent. We’ll start. Thank you so much for coming on to talk about this topic.
Dr. Aksel: Thanks for having me.
Dr. Fox: And I’m certain we’ll have you on again.
Dr. Aksel: Looking forward to it.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com, that’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at firstname.lastname@example.org. Have a great day.
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