Miscarriage is one type of pregnancy loss within the larger category of perinatal loss. Perinatal loss is the death of a fetus or infant during pregnancy or around the time of birth. Medically, the most up-to-date definition of miscarriage, also termed spontaneous abortion, understands it to be the involuntary expulsion of a fetus prior to 20 weeks of gestation, or of a fetus weighing less than 500 grams. Weight is a factor because calculation of gestation is subject to inaccuracy. Both gestation and weight relate to fetal viability, most commonly taken to be age at which a fetus is able to survive outside of the womb.
Miscarriage is the most common cause of pregnancy loss. Although miscarriage occurs in approximately 20 percent of pregnancies, many miscarriages occur before pregnancy is detected and are therefore not realized as a miscarriage. Furthermore, while most miscarriages occur at home, data on miscarriage rates are kept only for those occurring in hospitals. Most miscarriages occur before the 12th week of pregnancy; late miscarriage is recognized to be between 17 and 19 weeks’ gestation inclusive. Male fetuses are more often miscarried than female. About one-third of miscarriages have no identified cause. Some early miscarriages are the result of ectopic pregnancies, where the fertilized egg implants outside of the uterus.
Other causes of miscarriage include chromosomal and genetic anomalies or other disorders that make the fetus incompatible with life, the woman's structural or hormonal makeup, other disorders or diseases preventing sustained pregnancy, and Rh incompatibility between the woman and fetus. As well, miscarriage is not uncommon with pregnancies accomplished through assisted reproductive technologies. Miscarriage has also been linked to maternal and paternal age at time of conception, exposure to diethylstilbestrol (DES) and toxins, smoking while pregnant, pregnancy with multiples, serious accident or violence, chronic malnutrition, and infection. Amniocentesis, a common test to detect chromosomal anomalies, usually done in the second trimester, is said to present a one in 200 risk of miscarriage. Since social determinants of health can compromise women's health generally, they can also increase risk of miscarriage. A pregnant woman cannot will a miscarriage, nor can she will its prevention.
In the case of repeat miscarriages there are tests available to determine causes and potential remedies. Diagnostic procedures, rarely done after a first miscarriage, include blood work to examine hormones, infection, antibodies, and diseases; genetic testing; ultrasound and X-rays to determine structural problems; minor surgery to visualize reproductive organs; and uterine biopsy. Although miscarriage is more likely in women who have miscarried previously, most women who miscarry will eventually have a pregnancy that continues long enough to sustain a viable baby.
Although light bleeding is not uncommon during the first three months of pregnancy, especially seven to 12 days after implantation, it can also signal a threatening miscarriage. Spotting, vaginal discharge, and cramping are considered early signs of miscarriage. Lack of fetal heart sounds indicates fetal death. Miscarriage involves vaginal bleeding, which may be heavy or light and may or may not contain clots. Because the cervix dilates and the uterus contracts, miscarriage may include cramping. When both bleeding and cramping occur, a miscarriage is more likely than as with only one symptom. Bed rest is generally recommended for threatened miscarriage. In the case of incomplete expulsion of the fetus or placenta, a dilation and curettage (D&C), which is a scraping of the uterus, will likely be needed to prevent infection. If a miscarriage occurs after 14 weeks, breastmilk production will likely begin.
Medical, legal, and social meanings of miscarriage show cultural and historical variation, depending, in part, on viability. Viability varies, in significant part, by the medicine and technology available to sustain life outside of the womb. For most of the 20th century, medically and legally, miscarriage was understood as occurring before 28 weeks of gestation, which was taken as the point of viability. However, given medical and technological advances, minimum viability is now understood as 20 weeks’ gestation. Although live birth even before 20 weeks can occur, there is very little probability of survival with or without medical intervention. Twenty-two to 23 weeks’ gestation is now considered the edge of viability, where death is still likely. The time frame for determining viability, and thus the definition of miscarriage, is not expected to change appreciably within the foreseeable future.
The term miscarriage has meaning in jurisprudence, particularly as it relates to abortion laws and wrongful death. Miscarriage is also a psychological and social phenomenon. Consequences of miscarriage, often overlooked by health care professionals, family, and friends, can include feelings of grief, anger, anxiety, and depression, sometimes lasting for long periods. Women experience miscarriage differently depending on the meaning the pregnancy had for them. Some women grieve the loss deeply and others less so or not at all; some women welcome the loss of an unwanted pregnancy. When a woman experiences infertility, the loss might mean the lost opportunity to mother a biological child. Especially after multiple miscarriages, women may feel biologically and socially inadequate in their prescribed roles as a woman. A woman's relation to religious beliefs and practice can affect how she understands and deals with her loss.
When a woman is grieving, it is important to allow her to grieve in her own way and not to offer platitudes such as “It's good thing you weren't far along,” or “You can try again.” While such comments may be well intended, they are not helpful as they invalidate the experience of loss. Women who grieve the loss of their baby through miscarriage do not want judgment; they want acknowledgment of what their loss means to them. Many women turn to online or in-person loss support groups to help them deal with their loss.
While a fetus under 20 weeks gestation does not require legal burial, and is routinely disposed of as “fetal waste,” some women choose burial and or have a ritual recognizing their child's existence. Historical evidence found in texts and artifacts indicates that grief has always been a common reaction to miscarriage, and ritual part of the process of legitimizing grief. Historically and presently there is cross-cultural variation in how miscarriage is understood and ritualized. Miscarriage has been feared since antiquity; it has been considered a punishment from the gods, and embryos were understood as being captured by spirits. Rituals and intricate therapies have been prescribed for prevention, purification, and burial. For its prevention, prayers were offered to goddesses to avert embryo-eating demons; women wore artifacts for protection. In the 1930s and 1940s, nutritional supplements and estrogens were thought to be preventatives. Contemporary Western culture understands miscarriage primarily as a medical problem, and has few established rituals to recognize miscarriage and support grief.
Becoming a Mother, Childlessness, DES Mothers, Essentialism and Mothering, Grief, Loss of Child, Institution of Motherhood, Motherhood Denied, Pregnancy, Social Construction of Motherhood
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