Pregnancy & Infant Loss Awareness Month

 

October 28, 2021

By Abigail Finder, DO

 

Caring for the Whole Person in Miscarriage Management

Editor’s Note: As with so much in medicine, the management of miscarriage must go beyond meeting medical needs to caring for the human being who experiences this significant loss. Dr. Abigail Finder was in her last year of medical school when she interviewed Maria, a woman who has experienced miscarriage more than once. Though each instance was difficult, the ones where she felt supported and cared for as a human being brought healing rather than compounding her pain. The interview highlights the advantages of such a compassionate, medically sound, and holistic approach in the care of these families.

A Mismatch Worsens Grief

Maria was 30 years old, married, and ready to start a family. Maria and her husband, Thomas,* were not using any methods of family planning at the time. In fact, she believed she was pregnant, so she went to her local Ob-Gyn’s office to request a pregnancy test, and they checked her human chorionic gonadotropin (hCG) levels. In the midst of her excitement, she received a call from the nurse, who said the hCG level was low and Maria should make an appointment in five days, since the office was closed for the holiday weekend.

The next day, Maria began to bleed, which ended up being the first sign of a miscarriage. She had no warnings, no expectations, and was caught off guard while volunteering at an out-of-town youth retreat. Afterwards, she desired to bury her baby’s remains, but her practitioners did not understand her needs. They called her baby “a product of conception” and insisted on using the remains for further testing. Through this experience, Maria felt like this was just another pregnancy, and just another spontaneous abortion.

A Better Fit

She believed there had to be another option for her and any future pregnancies. So, she joined a social media group and eventually heard of Natural Procreative Technology (NaPro). Two months later, she contacted a NaPro-trained Ob-Gyn physician whose office was four hours from her hometown in rural Missouri. This physician told her about fertility awareness-based methods (FABMs) and taught her how to use one of them, the Creighton Model. Maria learned how to chart her cervical mucus and bleeding patterns every month, which gave her objective data that reflected the inner workings of her reproductive hormones.

Charting was challenging for Maria. She did not have an instructor and could not identify her fertile window because she had daily cervical discharge, no mucus pattern, and her cycles were 30-60 days long. A healthy female should have a fertile cervical mucus phase lasting 4-8 days and a total cycle length within 21-35 days. Through charting, Maria learned she had estrogen dominance, which is why she had multiple irregular days of cervical mucus throughout her cycle. To pinpoint her fertile window despite the abnormal mucus pattern, Maria began testing her urinary luteinizing hormone (LH) levels. She learned that when LH rises, the ovary releases an egg within 24-36 hours; therefore, timing intercourse on days with elevated LH will increase the probability of conception. In Maria’s case, it worked! She had a positive home pregnancy test and was thrilled.

Support in Pregnancy and Beyond

Now that Maria was pregnant, she needed to ensure the baby’s survival, and her NaPro physician was most concerned about her progesterone. Since Maria’s estrogen was elevated, the ratio of estrogen to progesterone was abnormal, meaning she could require bioidentical progesterone supplementation to maintain her pregnancy.

After conception, progesterone is secreted by the corpus luteum until the placenta develops, after which the placenta takes over progesterone secretion. If a woman’s progesterone is too low, the embryo may not implant in the uterus or survive after implantation, resulting in a miscarriage. After seeing a positive home pregnancy test, Maria immediately called her physician and received a prescription for a progesterone intramuscular (IM) injection to take to her local pharmacy. She took daily oral progesterone and received progesterone IM injections twice weekly until 24-25 weeks of pregnancy. Her progesterone levels were tested every week.

Several months later, Maria and Thomas were overjoyed to welcome a baby girl!

Since then, the couple had another successful pregnancy, a son, and then experienced another first trimester miscarriage. Maria’s experience during her second miscarriage was completely different. Her NaPro-trained Ob-Gyn physician called her to offer medical and emotional support, and sent her for hCG testing to confirm there was no viable pregnancy. He said, “This is your baby we are talking about.” Once the outcome was clear, her doctor encouraged her to name and bury her baby as part of the grieving process.

After her second miscarriage, Maria decided to take charting more seriously because she desired more children. She plans to work with a Creighton instructor to learn how to chart her cycles accurately, identify any problems, and find solutions before another pregnancy or miscarriage can occur.

Through fertility awareness-based methods like the Creighton Model, women can chart their cycles to differentiate between fertile and infertile times and identify their peak days, which signify ovulation has occurred. In Maria’s case, knowing when she ovulates could affect the timing of progesterone supplementation. By taking bioidentical progesterone immediately following ovulation, a woman’s progesterone can reach an adequate level in time for implantation. Maria believes this targeted approach could have saved her fourth baby from miscarriage. She also believes the culture surrounding miscarriages needs to change. Medical professionals should display patience, respect, and empathy toward any parent suffering from the loss of a child, including through a miscarriage.

Editor’s Note: Charting with a fertility awareness-based method can transform the care of a woman and impact not only her family but also entire communities. For compelling stories of how charting the menstrual cycle with FABMs is changing lives, we invite you to read:

A Curse Broken: A Healing Conversation about FABMs

NaPro-Trained Physicians Change a Woman’s Life

Below are two important recent additions to the literature regarding the evaluation and management of recurrent miscarriage. An editorial written ahead of the 2021 series on recurrent miscarriage published in The Lancet calls for “a worldwide reform of care” in the setting of miscarriage.

  1. Coomarasamy A, Dhillon-Smith RK, Papadopoulou A, et al. Recurrent miscarriage: evidence to accelerate action. Lancet. 2021;397(10285):1675-1682. doi:10.1016/S0140-6736(21)00681-4.
  2. Coomarasamy A, Devall AJ, Brosens JJ, et al. Micronized vaginal progesterone to prevent miscarriage: a critical evaluation of randomized evidence. Am J Obstet Gynecol. 2020;223(2):167-176. doi:10.1016/j.ajog.2019.12.006.

* Names were altered to protect the privacy of the couple.

Keisha Pierre-Lys, DO

ABOUT THE AUTHOR

Abigail Finder, DO

Abigail Finder, DO is a first-year Ob-Gyn resident at the University of Buffalo – Sisters of Charity Program in Buffalo, New York. She wrote this article while taking the FACTS elective as a fourth-year medical student at Kansas City University College of Osteopathic Medicine in Joplin, Missouri. Dr. Finder is passionate about fertility awareness-based methods of family planning and enjoys applying the science behind these methods to educate and treat her patients. Her goal is to empower women through surgery and medicine, including FABMs.

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