Miscarriage: It’s Not Your Fault

Editors’ Note: In May 2015, Einstein researchers released findings from a national survey that showed a wide disparity in perceptions about the incidence of miscarriage. Most respondents believed it was rare—occurring in about 6 percent of all pregnancies. The reality is that one in four pregnancies—25 percent—ends in miscarriage. In about half the cases, no one knows why. The Wall Street Journal recently featured services offered by Einstein and Montefiore’s Program for Early and Recurrent Pregnancy Loss (PEARL)—a center that specializes in studying recurring miscarriages and providing treatment to prevent additional miscarriages when possible. We asked Chavi Karkowsky, M.D., an OB-GYN and one of this blog’s featured contributors, to describe what it’s like for expectant parents to hear the news—and how challenging it can be for doctors to deliver it.

By Chavi Eve Karkowsky, M.D.

I was busy in another room when the expectant parents came in, so I didn’t meet them until later, after the ultrasound technologist came to get me.

“The woman for the 11:45 appointment . . . first pregnancy, and she’s here for her first-trimester screen. She’s supposed to be 13 weeks, but I can’t get a fetal heart.”

Deep breath. This happens—it’s more common than most anybody thinks—but it’s never easy.

“You’re sure?”

“Yeah.”

“What is the measurement?”

Here, I’m hoping it’s just an early pregnancy—one that needs more time to grow before we can detect the heartbeat, usually after seven weeks or so.

My tech knows where I’m going with this. “I’ve got 11 weeks.” So that’s it. At that gestational age, I should see a heartbeat, and movement, and all sorts of unmistakable signs of life. If they’re not there, then this is a miscarriage.

I go into the room and repeat the scan, just so I can be sure, so I can see with my own eyes. I see what the tech saw. I complete the scan so I can give them as much information as possible. I lay the probe down and I say to them: “I have some bad news for you.” This is one way of gently starting to prepare them, but they already knew something was wrong. No matter how many times I have to break this awful news, I am never sure what the right words would be; there’s no way to say this that isn’t awful. And I won’t sacrifice clarity. So I tell them. I say: “I wish I saw something different,” because I do, I really do. And then I tell them that there is no heartbeat; that the pregnancy has died.

I ask them to come into my office so we can talk more. They come, the patient weeping, her partner looking angry. I review what is there, what is not there, what would be there if things had been developing normally. I speak slowly. I listen.

I answer their questions: this may have happened a week or two ago, although we can’t really know. I hand out tissues. I listen.

When she’s ready, she asks about what happens next. I talk about that too; I call their primary OB/GYN doctor, and we make a plan for an appointment, some lab work, a probable procedure later this week. I hand out more tissues. I listen.

The husband leaves momentarily, I don’t remember why—to get the car, I think, or to call her parents. The patient is still sitting across from me: “Doctor. I just . . . we moved last weekend. To a two-bedroom, so we could have a nursery. I . . . I lifted some boxes. Was that when it happened? Is that why?”

I look at her, in the eyes. No, I say. No. It’s not your fault. It’s not something you did, or didn’t do; it’s not something you ate, or that you danced or had sex or a sip of wine. We don’t know why all miscarriages happen, but a large percentage of them are chromosomally abnormal, and were never going to be able to grow and develop and thrive. That’s probably what happened here. But even if it’s not, I’m going to say something important here, so please listen, and please, please believe me: It’s not your fault. It’s not your fault. It’s not your fault.

She sighs. From the slope of her shoulders and the depth of her sigh, I see that she doesn’t quite believe me, but that she would like to. She stands up, puts on her coat, collects the straps of her purse; she straightens her shoulders, lets out a sigh and walks out through our hallway. I head back to my desk, my ultrasound monitors, my unsigned charts. I put my head down on my arms, just for a minute, before I can face the rest of my day.