Ep 273: Bringing Miscarriage Out Of The Shadows

Dr. Nicole (00:00): In this episode, you're going to learn about miscarriage including recurrent miscarriage. Welcome to the All about pregnancy and birth podcast. If you're having a baby in the hospital, you are giving birth in a system that too often takes away power from women over what happens in their own bodies. I'm Dr. Nicole Calloway Rankins, a practicing board certified OBGYN, who's had the privilege of helping well over a thousand babies into this world. I've been a doctor for over 20 years and I'm here to help you take back your power, advocate for yourself, and have the beautiful pregnancy and birth that you deserve. This podcast is for educational purposes only, and it's not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it. Hello there. Welcome to another episode of the podcast. This is episode number 273. Whether it is your first time listening or you've been here before, I'm so glad you're spending some time with me today.

(01:03): This episode is inspired by a listener. She sent me this message via Instagram dms. It says, hello, Dr. Rankins. My name is Sierra. I've been a fan of your podcast for years now, and I truly appreciate everything you're doing to provide education and knowledge to women. One topic I would really love for you to do a podcast on is recurrent miscarriage. I've had recurrent miscarriages and though I've listened to almost all of your podcasts, there were things I faced that I wasn't prepared for and wonder if other women could benefit from a podcast on this topic. Besides me, you've had some women who gave birth stories that had elements of miscarriage or infertility, but most of the discussions with them focus on the living children they had afterwards. It would be amazing if you could review the potential test that OBGYNs can perform to determine causes of recurrent miscarriage, questions to ask, how to advocate for yourself when having a miscarriage, et cetera.

(01:57): Thanks for considering. Well, thank you so much, Sierra, for sending this message, and it took me a bit longer to get to the episode than I intended, but we are here and we are going to get all into it today. Now, if you ever have a question that you want me to answer in a podcast episode, whether it is a longer episode, the ones that I do on Tuesdays or a shorter episode, the ones that I release on Thursdays, shoot me a DM on Instagram. My dms are open. I'm on Instagram at Dr nicole Rankins, or you can send it through my website, dr nicole rankins.com/contact. Okay, so in this episode you're going to learn what is miscarriage, what's recurrent miscarriage, how often does miscarriage occur, what causes miscarriages including recurrent miscarriages, the treatment options for miscarriage, what happens with pregnancy after miscarriage? We'll chat about the emotional impact including how to support someone who's had a miscarriage.

(02:54): And then Sierra in her message sent me a series of points, comments that she wants folks to know about miscarriage, and we're going to share those points with you at the end as well. Okay, so let's get into it. What is miscarriage? So a miscarriage also known as a spontaneous abortion is the loss of a pregnancy before the 20th week of gestation, and there are actually several types of miscarriage based on the stage of the loss, and these are the most common types. Threatened miscarriage is when the pregnancy is still viable, but there is a risk of miscarriage due to symptoms like vaginal bleeding and cramping. Typically, the cervix is still closed and the fetus is still alive. Many if not most pregnancies after a threatened miscarriage do go on to be a normal pregnancy, but some may result in an actual loss of the pregnancy.

(03:56): An inevitable miscarriage is when miscarriage is certain, but it hasn't happened yet. The loss of the pregnancy is unavoidable, so there may be symptoms like bleeding, cramping, and the cervix is open or dilating, indicating that the body is preparing to expel the pregnancy out of the body. There's also incomplete miscarriage, which is when some pregnancy tissue has been passed, but some pregnancy tissue remains in the uterus. Symptoms of incomplete miscarriage include heavy bleeding and abdominal pain. In these instances, the body may eventually expel all the tissue naturally or sometimes medical or surgical intervention is needed in order to remove the remaining pregnancy tissue. Complete miscarriage is when all of the tissue has been passed from the uterus. This is when we think of having a miscarriage and it's over. The bleeding has typically subsided, the cervix has closed, there's no further treatment needed. The miscarriage itself is complete, and then a missed miscarriage is when the embryo has died, but the body has not recognized the loss yet, so no tissue is expelled.

(05:16): There are often no symptoms. You may not feel anything, and it's often diagnosed by ultrasound in this instance. You either wait or you can have medical or surgical intervention to remove the pregnancy tissue. And I'm going to go through those treatment options a little bit more detail later in the episode. Septic miscarriage is when miscarriage is complicated by infection in the uterus. It can happen after there's retained tissue from an incomplete miscarriage. There can be fever, chills, abdominal pain, septic miscarriage or septic Abortion could also happen back in the day when people were doing abortions themselves at home using unsterile instruments. Back alley abortions. We don't see this as much anymore, but women actually used to get quite sick from septic miscarriage from doing unsafe abortions. And then finally, recurrent miscarriage is when you have two or more consecutive miscarriages. Okay, so two or more consecutive miscarriages, and in that case, further testing is often recommended to identify any potential treatable causes.

(06:24): So how often does miscarriage occur? Well, miscarriage itself is actually relatively common. It occurs in about 10 to 20% of known pregnancies. However, the actual rate may be higher because many miscarriages happen very early in pregnancy, often before a woman realizes that they're pregnant. Some estimates suggest that up to 30 to 50% of all conceptions may end in miscarriage with many of them occurring before a pregnancy is even confirmed. The risk of miscarriage decreases significantly after the first trimester. About 80% of miscarriages are going to happen in the first 12 weeks. Now, recurrent miscarriage when there's two or more consecutive pregnancy losses is actually not that common. That's in one to 2% of couples trying to get pregnant, and the key there is consecutive. So if you have a miscarriage and then you have a live birth and then you have a miscarriage after that, that wouldn't necessarily be considered recurrent miscarriages.

(07:23): Okay, it's two or more consecutive pregnancy losses. So while miscarriage is common, experiencing multiple consecutive miscarriages is relatively rare and does require some further treatment and evaluation to identify underlying causes like potential genetic factors, anatomical issues, hormone imbalances, and I'll go into those in just a moment. So what causes miscarriage? Well, miscarriage can occur for a variety of reasons. Often, unfortunately, the cause is not necessarily fully understood, but some common potential causes of miscarriage include chromosomal abnormalities, and I should back up and say I'm going to break it out separate between miscarriage and the recurrent miscarriage because the causes are a little bit different potentially. So around 50% of miscarriages occur due to chromosomal abnormalities in the embryo where there are either too many chromosomes or too few chromosomes, and that is going to make the embryo nonviable. The body's going to recognize that that's not normal, that can't go on to be normal.

(08:29): Some examples may be extra copies of chromosomes or missing chromosomes, so a trisomy would be an extra copy of a chromosome. Trisomy 21 is down syndrome. That is one of the few chromosome abnormalities or extra chromosomes that is compatible with life. Most, I would say the vast majority of other chromosomes. Abnormalities where there's an extra chromosome are not compatible with life does mono again, with missing a chromosome and then molar pregnancies when there's abnormal fertilization where either two sperm fertilize an egg and then it leads to an abnormal pregnancy. Other causes of miscarriage or uterine or cervical issues where there are structural problems in the uterus or cervix that can contribute to miscarriage. This is especially more common in the second trimester. So some conditions that can cause this to happen are something like a septate uterus when there is a septum in the middle of the uterus, fibroids, which are smooth muscle growth within the uterus or by corn root uterus when the uterus didn't come together while you were a fetus.

(09:40): So essentially when the way the uterus develops is it's two sides that fuse together to make one uterus, and if that fusion is incomplete, then it can be a bico root uterus and depending on the level of lack of fusion determines how much of a bico uterus you have and all of those conditions. Tate uterus, fibroids, bico uterus can affect the inside of the uterus, the cavity, and can make it difficult for a pregnancy to implant or difficult for a pregnancy to grow. Another issue that can cause miscarriage is cervical insufficiency when the cervix may be weak for some reason, maybe because of prior surgery, like if you had abnormal pre-cancer cells that had to be removed, or if the cervix just opens too early during pregnancy, that can cause a miscarriage. Hormonal imbalances can impact or cause a miscarriage if there's insufficient production of pregnancy, supporting hormones, particularly progesterone that can prevent the embryo from properly implanting and growing PCOS can be associated with hormonal imbalances and can increase the risk of miscarriage.

(10:50): Also, thyroid disorders, both overactive, which is hyperthyroidism and underactive hypothyroidism, can affect pregnancy and the risk of miscarriage. Some infections like sexually transmitted infections like gonorrhea or chlamydia can impact the risk of miscarriage or cause miscarriage. Other viral infections like listeria, rubus, cytomegalovirus, toxoplasmosis can also cause miscarriage. There are immune system disorders or clotting issues that can interfere with the body's ability to sustain a pregnancy. Antiphospholipid antibody syndrome is an autoimmune condition that can cause blood clotting issues and miscarriage. Lupus is an autoimmune disorder that can increase the miscarriage risk as well. Some maternal health conditions can lead to an increased risk of miscarriage. Some chronic conditions like uncontrolled diabetes, those really, really elevated blood sugar levels can definitely cause a miscarriage. Also, high blood pressure can reduce the blood flow to the placenta and potentially cause a miscarriage. Finally, some lifestyle factors can increase miscarriage risk like smoking, excessive alcohol use, drug use trauma like a severe physical trauma or accident can in rare instances lead to miscarriage. That's pretty, pretty rare. Environmental factors like radiation, toxic chemicals, pesticides, those are rare, but that can increase the risk of miscarriage and we know that age also impacts the risk of miscarriage because of the increased likelihood of chromosome abnormalities. Women over 35 have a higher risk and it definitely really, really rises sharply after age 40.

(12:36): Now, unfortunately, in many cases, the exact cause of a miscarriage remain unknown, but there are certainly lots of things that we can evaluate for. Okay, so when we look at what causes recurrent miscarriage is going to be a lot of the same things that I just mentioned that cause miscarriage. And actually when we look for causes of miscarriage, we generally don't look for causes until after someone has recurrent miscarriage, and that's because having a miscarriage is relatively common and the chances for getting pregnant after a single miscarriage are very high. So we generally don't do that extensive workup, and I'll talk about the workup in a minute until there are recurrent miscarriage. But in terms of causes for recurrent miscarriage, they are very similar to the ones that I just mentioned. So it could definitely be genetic factors like chromosome issues. There can also be something called balance translocations, which is more likely in recurrent miscarriage when it's kind of a hard concept to explain.

(13:37): But essentially if you have one piece of a chromosome that swaps pieces with another piece of a chromosome and they flip-flop pieces, but they do it in a balanced way, you could be walking around like that. But when you pass half of your DNA onto a pregnancy, then that balance doesn't go on because you haven't passed the balance all the way down, so to speak. So that can potentially be a factor in recurrent miscarriage just like in any other miscarriage, uterine issues can be an issue in recurrent miscarriage. So whether it's that uterine septum fibroids, polyps also could be asherman's syndrome where there is scar tissue from previous surgeries. For example, if you had multiple DNCs before and you have scar tissue, that can impact the ability of a pregnancy to implant. Again, cervical insufficiency, that's going to be particularly in the case of recurrent second trimester losses.

(14:35): Cervical insufficiency isn't anything we can test for. It's a diagnosis that we make unfortunately after the pregnancy loss occurs. Those hormonal imbalances can be in play in recurrent miscarriage. So inadequate progesterone, PCOS, hyper and hypothyroidism. So low and high thyroid, uncontrolled diabetes and recurrent miscarriage, antiphospholipid antibody syndrome or thrombophilias also are more associated with recurrent miscarriage. Thrombophilias are a group of conditions where there's an increased tendency for blood to clot that can interfere with placenta Development also causes a recurrent miscarriage or miscarriage. In general autoimmune disorders like lupus, I mentioned that these can increase the risk of miscarriage because the immune system may actually be attacking the placenta or the growing fetus. And then all of the same infections like sexually transmitted infections. Also chronic endometritis is something that we would look at as a cause for recurrent miscarriage where there's a low grade infection of the uterine lining that can lead to pregnancy loss.

(15:42): Again, advanced maternal age, those lifestyle factors as well. So the causes are generally very, very similar and I'll talk about how we evaluate those in just a minute. Now, in up to 50% of cases, there's no specific cause for recurrent miscarriage that we can identify despite thorough testing. These cases are known as unexplained recurrent miscarriage. A comprehensive evaluation of course, is very important. Often this is going to end up leading to IVF, but do know that in up to 50% of cases we cannot find a reason for recurrent miscarriage. Okay, now speaking of finding a reason for recurrent miscarriage, it really involves that really comprehensive assessment to identify any potential underlying causes and then fix anything that we can fix while we're there. So of course, we're going to start with a detailed medical history. I think sometimes we underestimate the importance of just having a conversation and understanding a woman and her partner's medical history, including any previous pregnancies, whether there were any previous miscarriages, the timing of the miscarriages, any symptoms that were associated with it, how far along you were in the pregnancy when the miscarriage happens, because that can give us some important clues to the causes.

(17:05): We need to do a history of any known medical conditions, of course, like any diabetes, thyroid issues, autoimmune disorders like I talked about. We're going to ask about any lifestyle factors like smoking, alcohol, drug use, any family history of genetic or reproductive issues. Of course, we need to have an understanding of your menstrual cycle and how regular it is to evaluate for any hormonal irregularities, and then definitely any past surgeries, especially those involving the uterus or the reproductive system to see if that is impacting whether or not you're having a miscarriage. Also in recurrent miscarriage evaluation, we're going to do some genetic testing. We're going to do something called a karyotype, which is a chromosomal analysis that's going to check both partners in a blood test to check for any chromosomal abnormalities such as that balance translocation that I mentioned that can increase the risk of miscarriage.

(18:04): That is actually really, really rare. I can't actually ever recall seeing it happen, but it is certainly a possibility. So we want to test for it. In that case, you would have to do IVF, and if possible, we want to test the tissue from a previous miscarriage to help identify any chromosome abnormalities. If there's a recent miscarriage and we can test that tissue, then that could potentially be helpful. This is often not something that's feasible to do unless there's a surgery or something like that. But if we can't do genetic testing on fetal tissue, that may be helpful. As far as blood tests, when you have a recurrent miscarriage, then you can do a hormonal evaluation with estrogen, progesterone levels, thyroid function test prolactin levels, because elevated prolactin can affect ovulation. We're going to check for a blood clotting test like that, antiphospholipid antibody syndrome, lupus, anticoagulant factor five, glidden mutation, diabetes screening, check for immune disorders.

(19:05): All of those blood tests are going to be important. And I should say that your regular OB GYN, can actually do a lot of these tests. You don't necessarily have to go to a reproductive endocrinologist or REI, fertility specialist, I should say REI is reproductive endocrinology and infertility specialists. Those who do infertility also are in reproductive endocrinology. That's the specialty. So you can get your regular OB GYN to do a lot of these tests because often insurance does not cover going to see a specialist. So your regular OB GYN can start with these blood tests and address some of these issues. And then if needed, send you to a specialist. So some other things that can and should be done are ultrasound to look for any structural abnormalities in the uterus. Trans vaginal ultrasound specifically is the best modality to get pictures of the uterus that's going to be better than something like a CT scan that's going to help us potentially see things like fibroids or any things like a septum or a bico uterus.

(20:13): If we need to get additional imaging, then we can do something called a hysteroscopy, which is a small camera that's inserted into the uterus through the cervix, and that lets us look inside the uterine cavity. We can see any scar tissue, we can see if there are fibroids and potentially treat them. If there's a septum, the septum can be removed that way. So this is a good look on the end side of the uterus. And then in rare cases, we need to use MRI, which can give us a more detailed view of uterine structures, and sometimes we also do something called hyster. It's HSG I'm having blah, blah, blah, ster pgo, which is when you evaluate the shape of the uterus and check for blockages in the fallopian tubes. But blockages in the fallopian tube are generally you're not going to be able to get pregnant at all because you can't get pregnant when you have block fallopian tubes.

(21:10): So that's not as helpful in the setting of recurrent miscarriage, but it may be an evaluation as part of infertility in general. And then we'll screen for infections like sexually transmitted infections assessed for those lifestyle factors and recommend any changes there like smoking, alcohol or drug use, exposure to any environmental toxins, say in a work environment. And then a really important thing that needs to be done is a semen analysis and a partner, although it's less common in miscarriage, a semen problem may be more of an issue in infertility is less common in miscarriage. But it is possible that if there are abnormalities in the shape or motility or DNA fragmentation of the sperm, then that may contribute to recurrent miscarriage. So in about 50, in up to 75% of cases of recurrent miscarriage, a specific underlying cause can be identified through that really comprehensive testing.

(22:07): So testing for those genetic, hormonal, anatomical and immunologic factors can identify a reason in 50 to 75% of cases. However, that does mean in 25 to 50% of cases there is no cause identified, and that is going to be unexplained recurrent miscarriage. And in such cases when there's something that we can't identify as an issue, that's typically when IVF is going to be recommended. Okay, so that was recurrent miscarriage and evaluating recurrent miscarriage. What are your treatment options for when you have a miscarriage? So when you are experiencing a miscarriage, the treatment option depends on the type of miscarriage and whether any complications are present. So basically in big buckets, the options are expected management, medical management, and surgical management. So expected management is when you allow your body to naturally pass the pregnancy tissue without any medical intervention. This can be appropriate for early miscarriages where symptoms are minimal and there's no immediate health risk.

(23:17): It can take some time. This can take a few days to even several weeks for the process to be complete. A lot of people don't like the uncertainty with that, but sometimes people will start with expected management and wait for a period before they move on to the other options, which are medical and surgical management. So medical management is using medications to help expel the pregnancy tissue from the uterus. Most often those medications are going to be misoprostol used alone, or in some cases we use it in combination with Opry stone and those medicines basically cause the uterus to contract and expel any pregnancy tissue. This is appropriate for an incomplete miscarriage or when expected management hasn't been effective. It's also a great option for people who want to avoid surgical treatment. Medical management is going to be effective, very effective. Actually, it works in about 80 to 90% of cases, but it may involve some side effects, like a lot of cramping that can be managed with pain medicine.

(24:21): Also, it can be heavier bleeding, sometimes more than people are comfortable with. And then there's a need for follow-up to ensure that the miscarriage is complete. And then surgical management is a surgical procedure called DNC, and that's actually D and C. Sometimes people hear DNC and they think it's D, and then the letter N and then C, but it's actually D and C, which is short for dilation, and that removes the pregnancy tissue from the uterus. This is used in instances of incomplete miscarriage, missed miscarriage when there's heavy bleeding or if there are signs of infection. It's also used when someone wants a really quick resolution or when they don't want to do medical management. And in A DNC, the cervix is dilated and a surgical instrument is used to remove the pregnancy tissue. It's a quick procedure usually performed under anesthesia. It's very short.

(25:17): Most people are able to resume normal activities within a few days. There is a small risk associated with surgery like infection or scarring, but it's certainly a viable option in terms of managing miscarriage. And then another thing that's really important is pain relief. Having that cramping during a miscarriage can be really uncomfortable. So particularly if you want to manage it at home with medication, pain relief is going to be important. Most people can get by with NSAIDs. NSAIDs are nonsteroid and anti-inflammatory drugs, and the most common one we use is ibuprofen. So you can use ibuprofen also, Tylenol alternate those two, and it's going to be ibuprofen in higher doses, not what you get from over the counter versions of ibuprofen or Motrin. So it's going to be higher doses, but sometimes that isn't enough and people need stronger medicine, which would be like a low dose narcotic type of medicine.

(26:11): This is really to help manage those symptoms and provide comfort. You also may need emotional support, and I'll talk about the emotional impact of miscarriage in a minute. And then specific treatment in the setting of recurrent miscarriage, we're going to correct any hormone deficiencies that may be doing things like progesterone supplements. If low levels or suspected fixing thyroid issues, fixing diabetes surgery may be appropriate to correct any anatomical abnormalities in the uterus. Those can be quite successful, are usually quite successful. Blood thinners may be appropriate, like low dose aspirin or even heparin for women who have clotting disorders in order to help prevent the blood from clotting. And then for couples who have genetic abnormalities, then genetic counseling is appropriate in order to review your options there.

(27:00): As far as pregnancy after miscarriage, the vast majority of women who experience a single miscarriage again, will go on to have a successful pregnancy. So hear that if you've had a miscarriage, unfortunately you are in common company, but most likely you're going to go on and have a successful pregnancy. That number is really 85 to 90% to be more specific. And even if you've had recurrent miscarriages, so two or more consecutive miscarriages, the success rate of subsequent pregnancy is still pretty high, 65 to 75% with appropriate diagnosis and treatment of any underlying conditions. So the chances of going on to have a successful pregnancy are definitely high. Now, even though the success and the chances are high, there's still a very big emotional impact from having a miscarriage. So please know that you are not alone, and it can be very challenging when you have a miscarriage, especially recurrent miscarriage.

(28:03): It can be emotionally devastating. You and your partner actually can experience feelings of sadness, feelings of anger, feelings of guilt, feelings of shame, of just wondering why this is happening to you. But it's so important to remember, so important to remember that miscarriage is not your fault. You haven't done anything wrong. You're not a failure. It's just unfortunately, a part of reproduction is that miscarriage is a possibility, but take care of yourself and that emotional impact and get help and therapy, whether that is with a trained therapist in perinatal mental health, whether that's groups, whether that is Facebook communities, all of those things can be helpful in order to cope with that emotional impact of miscarriage, especially recurrent miscarriage. And if you know someone who's had a miscarriage, then just listen. All right? You don't necessarily have to have the perfect words. Usually just being there is enough or you can even ask the person what specifically they need from you.

(29:13): Please, please do not say things like, oh, you can try again. Or at least it happened early. Oh, you're probably going to get pregnant again. That is completely unhelpful and it minimizes where people are in the moment. So don't do that. People mean well when they do that, but it's actually not helpful. Some things that you can say and say, instead are I'm here for you, or I'm so sorry for your loss, or I'm so sorry that this happened to you. And another word about emotional impact. I know I said that it can be devastating, but for some people it's not. And we should acknowledge that too. For some people, miscarriage doesn't necessarily cause a lot of emotional impact for them. That's perfectly fine. It's not necessarily that people feel a huge emotional impact, but we just want to acknowledge that for some many even that it can be quite an emotional impact to have a miscarriage.

(30:13): And then as I end, I just want to go through some points that Sierra mentioned in her experience with recurrent miscarriage that she wants all women to know about miscarriage and recurrent miscarriage in general. A lot of these were eyeopening and points for me to understand as well. So one is that every follow-up appointment after miscarriage could potentially be charged and not covered under a follow up care. Meaning you might get bills long after your miscarriage still relating to that care, and that can bring back the emotions. This, of course, is going to depend on your insurance, but it certainly is possible that there may be a bill for each particular visit. Billing is something that doctors we don't necessarily get involved in, but we certainly do deserve to be compensated for our time and expertise. So it is possible that you may get follow-up bills, as she mentioned after the initial miscarriage.

(31:14): The second one is you might require multiple ultrasound appointments to be sure everything has passed, or on the flip side to be sure that it's a normal pregnancy that's developing. One thing she said in this setting of requiring multiple miscarriage, it's okay to ask them to turn the screen away from you. That's a really good point that we don't always do. The sonographers don't necessarily always do is ask about whether or not you want the screen turned away. So you can definitely ask them to turn the screen away from you. If you think that seeing an abnormal pregnancy or seeing that the pregnancy isn't normal is going to be hurtful. Okay. Another point that she mentioned is that, and this is an interesting one, a second Dr. May come into the room to confirm a loss, and that is the possibility. Either you have the ultrasound technician who's doing the ultrasound and then a physician will come in to confirm it.

(32:15): Or it may be, especially if a pregnancy is further along, that two doctors will confirm a loss. And one of the things she said that if someone comes in the room, you might still be in the stirrups position and they may leave before your legs are even down that second person. So it might feel a little bit dehumanizing. And this is something that we need to work on in general in terms of how we approach gynecology care. Similarly, she says, we may forget that you're naked below the waist as we go through all of this stuff regarding miscarriage and follow-up care. And again, another thing that we don't necessarily remember or take into account is that people may be uncomfortable sitting there and not completely dressed. It is okay for you to ask them to step out for a moment so you can put your clothes on and then have the discussion once you are fully clothed.

(33:11): We as medical providers should absolutely be asking those questions, but when we don't, please feel free to speak up. Also, she mentioned, which I think is well worth mentioning, that your OB GYN doctor can run a lot of those tests in order to determine the underlying cause of recurrent miscarriage. You don't necessarily have to wait to go to a fertility clinic. Also in the setting of recurrent miscarriage, some doctors may consider two miscarriages instead of three. Our older literature was three or more, but now we're really going to two or more. But you definitely may encounter some doctors who may say three or more. I say all that to say, if you have two miscarriages back to back, it's certainly reasonable for you to start looking for reasons. And then the final thing that she mentioned, which again is something that I don't think we always consider, is that it can be hard to go back to the OB GYN office where you were told that you had a miscarriage.

(34:11): You may have future ultrasounds, you may have future appointments in the exact same spot where you got what may have been the worst news of your life, and it is okay to cry. No one should judge you. It is also okay to say, Hey, maybe can we go to a different room because this particular room brings back negative memories for me. So it may be potentially difficult to go back to that same OB GYN office in extreme instances. And I'm not even going to say it's extreme, but in certain instances, maybe even want to change practices because it's just a lot of emotional difficulties going back to that same practice. Okay, so just to recap, miscarriage is the loss of pregnancy before 20 weeks. Recurrent miscarriages is when you have two or more consecutive miscarriages. Miscarriage is very common, happens in as high as 50% of pregnancies.

(35:05): Recurrent miscarriage is not very common. More like in one to 2% of pregnancies, miscarriage, and recurrent miscarriage can be caused by a host of chromosome or genetic factors of structural factors, of immunologic factors, blood clotting factors. So there is a big range of evaluation that we need to do. If you have recurrent miscarriage in particular, a thorough evaluation can lead to successful future pregnancy in most cases. So that evaluation is important as far as when you have a miscarriage, your options are to wait. That's expected management, or you can do medical or surgical treatment. Your doctor should present all of those options and help you come up with the option that's best for you. Most people will get pregnant after miscarriage. So that is very encouraging, although it can be emotionally difficult and challenging when you have a miscarriage, especially recurrent miscarriages. So do take care of yourself.

(36:05): And then finally, please, if you know someone who's had a miscarriage, please don't tell them, oh, it was early. Oh, you can try again. Oh, you get pregnant. Just be there for them. Listen, say, I'm sorry for your loss. I'm sorry this happened to you. And just be with them and support them in that way. Okay? So there you have it. Please share this podcast with a friend. Subscribe to the podcast also wherever you're listening to me right now. And if you have a question or something that you want me to answer in an upcoming short or longer episode, then shoot me a DM on Instagram @DrNicoleRankins or hit me up on my website at drnicolerankins.com/contact. So that's it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.