Miriam's casebook - After a miscarriage

Liz and her partner, Alan, desperately wanted their first baby and were deeply upset by Liz's miscarriage at 11 weeks, nine months ago.

Alan found it difficult to talk about their loss and buried himself in his work, while Liz struggled to cope with her feelings of bereavement. Liz is now eight weeks into her second pregnancy. Her pleasure at being pregnant is marred by fears that the same thing might happen again.

First reactions to a miscarriage

When she miscarried nine months ago, Liz felt very alone as she battled with her feelings of guilt, despair, and anger. She felt that her doctor couldn't look her in the eye or talk openly about her lost baby. Her family and friends were sympathetic but on occasion their attempts to comfort her were rather clumsy.

Some people said it was all for the best, because there must have been something wrong with the baby. Others reassured her that she could soon have another one. Her unborn baby was not real to them as it had been to Liz, and they did not understand her intense sense of loss.

Understandably, Liz began to wonder if her reactions were normal - perhaps she wasn't justified in grieving for a baby who'd never really existed? I reassured Liz that it is natural and healthy for a mother to mourn the loss of her child, even if the child has not been born. Her emotions as well as her body needed time to readjust. I also encouraged her to share her feelings with her partner, so that they could grieve together.

At first Alan was reluctant to share his feelings with Liz, and she felt she had to force him to talk to her because he found it hard to put words to his emotions. She knew that it would be impossible to care for another baby until she had given herself time to come to terms with losing this one, and this was something that they had to do together. I encouraged them to share their anxieties and frustration, talk through their feelings, and cry together.

I explained how important it was for them to express their grief openly. I also suggested that it might help if they had a private memorial ceremony - perhaps something as simple as planting a tree in memory of their miscarried baby.

Concerns about the baby

After her miscarriage, Liz was taken to hospital and examined to make sure there were no fragments of the placenta left in her uterus, where they could cause bleeding. The doctors said they could find no particular cause for her miscarriage, which was reassuring. Often miscarriage occurs when no fetus has developed at all, or it has died very early on due to developmental abnormalities.

Liz began to blame herself - perhaps the miscarriage was her fault? I explained that one in three first pregnancies ends in miscarriage. There are thought to be two reasons for this. First, an immature uterus might need to mature by having a trial run before carrying a pregnancy to term. Second, defects in the sperm or egg can produce an abnormal fetus.

What research shows about miscarriage

Research on miscarriage in early pregnancy shows that a woman who's had one miscarriage is no more likely to miscarry again than other women. It is recommended that you wait for one normal menstrual period before trying to conceive again.

Some women do miscarry repeatedly, but even for them the chance of a successful pregnancy after three previous miscarriages is about 60 per cent. Women who've had several miscarriages are tested for uterine abnormalities, hormone imbalances, and disorders of the immunological system and blood clotting.

Why miscarriage occurs

The immune system is designed to repel foreign bodies because they can be harmful. Pregnancy normally overrides this, so that the woman's body protects the baby rather than rejecting it. But for unknown reasons, the override fails in some mothers - the immune system reasserts itself and the baby is miscarried.

Women suffering from polycystic ovary syndrome (PCOS) - a condition usually characterized by multiple, tiny ovarian cysts - seem to have more miscarriages. This syndrome is caused by a hormone imbalance that causes the body to make too much testosterone and to overstimulate the ovaries so that immature eggs are produced. Women with PCOS and irregular or absent periods who are thinking of getting pregnant will be tested for hormone imbalances and checks on ovulation. They may be given fertility drugs such as clomiphene, although this will not protect them against miscarriage.

Becoming pregnant again

Now that Liz is pregnant again, she's being extremely careful in every aspect of her life. Most importantly, she's given up blaming herself for the miscarriage and is taking a positive attitude towards her new pregnancy. I told Liz that although she can't be sure what the outcome will be, chances are all will go well this time and that she should try to enjoy her pregnancy. Alan is “sure it's going to be all right this time” but doesn't want to make plans for the future as he did before.

Liz is fit and healthy and doesn't appear to have any condition that makes her likely to miscarry again. Because of her previous history, Liz will be given extra care during her pregnancy. The health of her baby will be closely watched for any signs of distress so that any problems can be averted. Her midwife or family doctor will be only too willing to answer any questions Liz may have.

Liz's baby has every chance of developing perfectly normally. In several ways, Liz's baby will actually benefit both before and after birth because of her mother's history of miscarriage: she will be well nourished because her mother is paying such careful attention to what she eats, and to relaxation and exercise routines.

She will be comforted by the positive thoughts and feelings that Liz is directing towards her. When she's born, Liz's baby will be greeted with relief and delight by both parents because she's making up for a previous disappointment. She represents success.