What Happens When My Patients Lose a Pregnancy

Health and medicine explained.
Jan. 8 2014 11:50 PM

Second-Trimester Tragedy

What happens when my patients lose an almost-viable pregnancy.

The particular sadness of second-trimester pregnancy loss.
A miscarriage in the second trimester is a particularly liminal and surreal tragedy, felt very differently depending on the reality of the person going through it.

Photo by Jupiter Images/Getty Images

I knew the patient’s pregnancy was over because I overheard my colleague discussing it on the phone. I was finishing up making rounds on the postpartum patients on the OB-GYN floor and trying to write notes in all their charts before running across the hospital to perform a surgery.

The patient had come in for something minor—slight vaginal spotting or minor cramps—at 19 weeks gestation but over the course of the morning had become more uncomfortable. “The cervix is open, it’s an inevitable abortion,” my colleague said, using the vaguely poetic medical term for a pregnancy that is all but lost. The pregnancy was pre-viable, before 24 or so weeks, so there was no way to sustain the fetus outside the patient’s body. My colleague made the plan with the emergency room to bring the patient upstairs to our OB-GYN floor. “We can watch her here,” she said. “If we have to, we can deliver her here.”

Twenty minutes later, I am still at the nursing station trying to finish up my notes when I hear a lot of noise coming down the hall. A woman, in a stretcher, is arching her back in pain. The transport guy is working as fast as he can to get her into the vacant room. The patient’s mother is cursing at the transport guy, at the nurses who swarm the stretcher, at me.

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I’m not supposed to be her doctor, but I’m there, so now I am. I talk to her. I move her into a more comfortable bed and explain what she has already heard. I offer her morphine; I warn her that it might make her forget, but she is grateful to accept it. Ten minutes later, she delivers a tiny waxy fetus with extensive bruises under its translucent proto-skin, followed by a small placenta. The fetus shows no spontaneous movements and has no heartbeat.

I wrap the fetus up in a blanket and put a hat on it, which is what we do. It makes it look larger, more like a full-term baby. The bundle still looks too small, the barely formed eyes still alien, but with the blanket the bundle now has a more familiar heft; it feels like something with substance.  I put the bundle in the patient’s arms. Her mom, no longer combative, is on the phone, hunched, small, her voice breaking. “She lost the baby,” she says. “The baby ... it’s gone.”

* * *

In the land of grief, there is no currency. There’s no equality, and there never can be: My tragedy and yours are different. This is true even if they are the same event, because we are different people, with different contexts, and choices, and reactions. In the land of grief, there’s no bartering—not because it’s physically impossible to trade but because even if you could, the tragedies wouldn’t be the same. My tragedy is different from yours.

Is this especially so for second-trimester miscarriages? They have always seemed particularly liminal and surreal; a tragedy that is so very different depending on the reality of the person going through it. On the one hand, the pregnancy is old enough that the woman has sometimes felt fetal movement inside her. She may think she is past the risk from miscarriage, which primarily occurs in the first trimester. The pregnancy is established enough that, unlike most first-trimester miscarriages, there is usually an identifiable organism. Sometimes it is has a heartbeat, and movements, and takes a while to leave us.

But it’s before 24 weeks. It’s before 23 weeks, or 22½ weeks, or wherever science and bioethics have placed our ever-moving goalposts of viability. Right now at least, we can’t do anything for this pregnancy outside the mother’s uterus. So there are ways in which it never had a chance.

There are many roads to the land of grief, and the second-trimester loss is an incontrovertibly awful one. But that’s where the incontrovertibility of it ends, I think. Like most things related to pregnancy, what it is is both weaker and more powerful than the physical reality. It is a potential, a reflection, an aspiration, and an emptiness.

That doesn’t mean that the pregnancy wasn’t someone’s child, or that the patient wasn’t a mother.

Sometimes it is the incontrovertible belief that those things are true, and that is an absolute truth.

Sometimes it is the belief that it is very much not true. That is also an absolute truth.

After a long time here, I know that the land of grief has only the laws of its inhabitants.

* * *

Many years prior, I was finishing up a tough night of emergency department consults. My pager goes off just as my shift was about to end. A 29-year-old woman, with a history of one prior uncomplicated pregnancy, is here. Now at 15 weeks with pain. The emergency room physician is concerned.

Down in the emergency room, the patient says she is pregnant and tells me she usually gets her care upstate. She’s in the city with her husband and 4-year-old son, who’s getting treated for a rare brain cancer at the children’s hospital down the block. He’s having a surgical procedure today, a port placement. It’s minor, but he gets really scared when he has to go under anesthesia, so she really has to go back. She is in visible, physical discomfort.

I examine her; there’s no cervix left. She is fully dilated, and her pregnancy is almost here. I tell her this, and she nods. She thought that might be it, she says. I explain about gestational age, and viability, and what we can’t do. She nods again. I offer her morphine, and she says she doesn’t want any. I tell her that if she bears down once or twice, we might be done.

The pregnancy emerges from between her legs. It is en caul; the membranes have not ruptured, and a pearly, luminous structure falls into the plastic basin on the hospital stretcher. I’ve never seen this before at such a late gestational age. The orb is complete, intact, perfect. Faintly, I can see the shadow of the fetus on the southern pole of the globe. Her bleeding is minimal.

I am not sure what to do. Should I open the membranes? Should I wrap the fetus, like we usually do? Does she want to see it, spend time with it, mourn?

“I’m sorry, doctor,” she says. “I just ... if I’m OK, I just need to go. I just need to get back down to the children’s hospital. If I leave now, I can get back before he wakes up scared. I need to get to my baby.”

Chavi Eve Karkowsky is a specialist in high-risk pregnancy, also known as maternal-fetal medicine, in New York City.

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