I knew nothing about miscarriage

WTF, how is this possible, I am a women's health fanatic

I am excited to share that my essay How to Have a Miscarriage was published in the May/June issue of Literary Mama, a literary journal with a twenty-years history of publishing the work of mother writers. Along with that publication, I wanted to share here some of the things I learned about miscarriage that I was shocked I didn’t know before. If miscarriage isn’t a good topic for you right now, please navigate over here to watch some baby goats jumping for joy and forget about this whole thing.

Also! There’s a special promo at the end of this piece that expires soon. I do not make a habit of running sales, so if you’ve been considering an upgrade to support this work, this is the best time to do it.

Illustrated by Stephanie Davidson, written by Rae Katz

Today we are going to cover things I learned about miscarriage from having one that I didn’t know before, most of which are DEEPLY BASIC and it is TOTALLY UNBELIEVABLE that I did not know these facts as a fully thirty-five year-old woman who has a strong interest in women’s health and READS WIDELY (if slowly) about the topic.

Ok, ok, I know, calm down.

But really, it’s unbelievable. My complete ignorance on the subject is, IMO, a failure of our culture to talk about this extremely common experience, and also in some instances a failure of my doctors to communicate even the most basic information in a timely way.

Just a note that this is not an account of the emotional journey that accompanies miscarriage, which I think deserves a more literary treatment, and which I attempted here.

How it started

I now see that my full education about miscarriage, until mine, came from Hollywood. I am picturing a woman sitting at a restaurant chatting happily, when suddenly she feels something and runs to the bathroom. She bleeds into the toilet and is oh-so-embarrassed and sad, and then, basically, it’s over. I have in mind a specific scene here, but I don’t know from what, and it is possible that this one movie comprised my entire education on miscarriage, which is totally insane and unacceptable.

Of course every miscarriage is different and a lot depends on the stage of pregnancy, but since I had mine I’ve looked into it, and the miscarriage-over-dinner scenario seems unusual if not impossible.

In my case, the inviability of my pregnancy was confirmed at eight weeks, when an ultrasound showed that there was a gestational sac growing but no baby inside. This is called an anembryonic pregnancy (or sometimes a “missed miscarriage”), and is one of the most common types of miscarriage.

Even though my husband and I knew the sad news after this ultrasound, the miscarriage hadn’t started, and the gestational sac was still growing. Because it is primarily the sac, not the embryo, that produces the hormones that make you feel sick in early pregnancy, my nausea and fatigue continued to worsen, even with no baby to speak of. What?! That seems ridiculously unfair. Also, it would have been really nice to hear about this from my doctors, rather than from internet searches like “having miscarriage but more nauseous.”

The options

At this point, I had assumed that the default option would be to let the miscarriage happen naturally, and that any intervention would only be done in the case of a problem or emergency. I did not realize that I would be presented with three equal options, all of which were considered reasonable and valid approaches to manage a miscarriage.

Expectant management is the approach where you wait for the miscarriage to happen on its own. I assumed that I would do this, based on my general tendency to prefer less medical intervention when it’s not strictly necessary.

Medication is also available to cause the miscarriage to start immediately.

Lastly, I could choose to have a procedure to remove the pregnancy tissue, which is typically either a D&C (dilation and curettage) or an MUA (manual uterine aspiration), depending on the medical facility.

Still, it hadn’t started

A week after my tragic ultrasound, I was much more tired, much more nauseated, much more bloated, much more pregnant, even though I wasn’t pregnant. There was not a drop of miscarriage blood in sight. It was a complete surprise to me that it could take weeks before the miscarriage even started, during which time I would feel increasingly mired in first trimester symptoms. At this point, I had a major “fuck this” moment and scheduled the procedure. No way was I going to spent weeks suffering this way because of a growing, empty gestational sac.

The procedure

I was scheduled for my procedure the day after Thanksgiving, (which made for a really joyful holiday, as you can imagine). I thought I was getting a D&C, since that is the colloquial name that people use for the miscarriage procedure, and I only learned after it was over that I had gotten an MUA. Dear God, can someone just give me the basic facts?!

An MUA is a procedure where the cervix is dilated and the uterine lining is sucked out with an electric syringe. I did not realize until I was sitting in the surgery prep room that I would be fully awake for the whole thing. Suddenly it struck me that the nurse didn’t seem to be preparing to give me an IV. She offered my husband a full-body surgery suit and hairnet, which was the first time we understood that he would be in the room with me, (since I would, it seemed, be fully awake).

Again, I treated the emotional impact of that procedure in a different essay, but suffice it to say that I lucidly experienced the doctor slurping out the lining of my uterus with a syringe over and over, and I saw the bloody contents of the clear tube as it emerged from my body, and I was prepared for none of this. Not that this would have been easy if I had known what was going to happen. But not knowing, and being completely blindsided by the sheer intensity of that procedure, was an unnecessary cruelty on top of the pain.

How long it lasts

I might have thought that would be the horrible end of it, but I bled for two more weeks. After that, I had to continue to get weekly blood tests for HCG, the hormone that indicates pregnancy, waiting for it to go to zero. If it stayed positive, that would indicate that not all the miscarriage tissue had come out, and I would need another procedure. My HCG lingered in the “pregnant” zone for a full six weeks after the MUA, meaning that, also, my body remained affected by the miscarriage for at least that long. So this whole thing had at this point been a two month ordeal.

It was a far cry from the miscarriage-over-dinner, and I thought perhaps mine was unusually long. But once I started hearing other miscarriage stories, I began to feel like mine was actually expedient. For miscarriages that use expectant management, it is not uncommon for some of the pregnancy tissue to be retained in the uterus, meaning that even after weeks of waiting and bleeding, women sometimes then need to have the procedure I had. The pamphlet that my clinic gave me estimated that tissue is retained in about 30% of expectant management cases. With medication, there is a similar risk of retained tissue, in which case another round of medication or a procedure is required. I am sure that miscarriages can come in every form, including perhaps fast and uncomplicated ones, but personally I have never heard of one like that.

Why this matters

Miscarriage is all around awful, but it is made worse when you have to go into the experience ignorant of even the most basic facts. During the whole horrible thing, I felt like I was walking around blindfolded. Having to learn these basics while also processing the loss and also having to make big, real-time decisions added a huge cognitive burden. In addition, the repeated surprises left me with an ongoing sensation that I had been lied to about miscarriage by everyone everywhere. The lies were mostly those of omission, but still. It’s painful to feel lied to.

This is by no means a primer on miscarriage—mine was only one type of many, my experience only one of many—but it illustrates some miscarriage basics that I really wish I had known.

I dearly hope this information never matters for you. But if it ever happens that you or anyone you know has to suffer through a miscarriage, I hope that at least you can go into it with even slightly more knowledge than I did.

Coming this Thursday…

As late as the 1970s, period symptoms were deemed to be indicative of a personality disorder. One textbook, also dug up by Dusenbury, stated that severe menstrual pain and cramps “is generally a symptom of a personality disorder, even though hormonal imbalance may be present.” In her book Womb, Leah Hazard presents perhaps the most succinct example of the cultural hatred of female hormonal changes through the example of an ad for Premerin, one of the first available hormone replacement therapies for menopause. The ad from 1966 featured “an image of a slim, attractive woman talking to two men at a party; she appears to be laughing enthusiastically at something one of the men has said, and the caption suggests simply, ’Help keep her this way.’” The message has been clear throughout history: women’s fluctuating sex hormones are a problem.

My experience with this long legacy has been the modern, subtle but pervasive derision about “PMSing,” which has emanated from my own lips as readily as from the schmuck next door. “I’m PMSing,” has been an excuse and an apology, “she’s PMSing” has been a dismissal and an insult. I wasn’t trying to be mean to myself or to her, my mental universe just simply contained no other way to think about the topic. So the question is, by painstakingly cataloging the actual neurological and physiological changes that occur due to sex hormone fluctuations—in other words by saying that hormones do affect moods, and even that they, in Hill’s words, create the experience of feeling like ourselves, am I simply lending fuel to that long historical project torching of women’s feelings by chalking them up to PMS? Am I just providing proof that we are, in the end, not in control of ourselves, and they were right all along that we are at the mercy of our hormones?

You probably guessed my position on this already but…no, that’s not what I’m saying at all. Rather, I think having all this information can help with a subtle but tectonic reframing that absolutely must happen in our culture regarding women’s hormones.

There is power in having information about one’s body and beginning to identify with all the parts of oneself. It is a completely different approach from the path of minimizing and problematizing and solving the female sex hormone issue. It is, as Hedberg put so beautifully, perceiving a symphony instead of a cacophony. Symphonies need tension and release, they need dissonance and resolve, they need movements, they need to go on a journey, otherwise they would be pretty boring. Now, that’s a new way to think about my ovulatory cycle.

This excerpt is from my upcoming essay, available this Thursday. To get the full, fact-filled essay, which includes a list of helpful resources, please consider a paid subscription, now 20% off when you upgrade before the end of the month!