Month: October 2022

When you first learned the facts about pregnancy — from a parent, perhaps, or a friend — you probably didn’t learn that up to one in three ends in a miscarriage.

What causes miscarriage? How is it treated? And why is appropriate health care for miscarriage under scrutiny — and in some parts of the US, getting harder to find?

What is miscarriage?

Many people who come to us for care are excited and hopeful about building their families. It’s devastating when a hoped-for pregnancy ends early.

Miscarriage is a catch-all term for a pregnancy loss before 20 weeks, counting from the first day of the last menstrual period. Miscarriage happens in as many as one in three pregnancies, although the risk gradually decreases as pregnancy progresses. By 20 weeks, it occurs in fewer than one in 100 pregnancies.

What causes miscarriage?

Usually, there is no obvious or single cause for miscarriage. Some factors raise risk, such as:

• Pregnancy at older ages. Chromosome abnormalities are a common cause of pregnancy loss. As people age, this risk rises.
• Autoimmune disorders. While many pregnant people with autoimmune disorders like lupus or Sjogren’s syndrome have successful pregnancies, their risk for pregnancy loss is higher.
• Certain illnesses. Diabetes or thyroid disease, if poorly controlled, can raise risk.
• Certain conditions in the uterus. Uterine fibroids, polyps, or malformations may contribute to miscarriage.
• Previous miscarriages. Having a miscarriage slightly increases risk for miscarriage in the next pregnancy. For instance, if a pregnant person’s risk of miscarriage is one in 10, it may increase to 1.5 in 10 after their first miscarriage, and four in 10 after having three miscarriages.
• Certain medicines. A developing pregnancy may be harmed by certain medicines. It’s safest to plan pregnancy and receive pre-pregnancy counseling if you have a chronic illness or condition.

How is miscarriage diagnosed?

Before ultrasounds in early pregnancy became widely available, many miscarriages were diagnosed based on symptoms like bleeding and cramping. Now, people may be diagnosed with a miscarriage or early pregnancy loss on a routine ultrasound before they notice any symptoms.

How is miscarriage treated?

Being able to choose the next step in treatment may help emotionally. When there are no complications and the miscarriage occurs during the first trimester (up to 13 weeks of pregnancy), the options are:

Take no action. Passing blood and pregnancy tissue often occurs at home naturally, without need for medications or a procedure. Within a week, 25% to 50% will pass pregnancy tissue; more than 80% of those who experience bleeding as a sign of miscarriage will pass the pregnancy tissue within two weeks.

What to know: This can be a safe option for some people, but not all. For example, heavy bleeding would not be safe for a person who has anemia (lower than normal red blood cell counts).

Take medication. The most effective option uses two medicines: mifepristone is taken first, followed by misoprostol. Using only misoprostol is a less effective option. The two-step combination is 90% successful in helping the body pass pregnancy tissue; taking misoprostol alone is 70% to 80% successful in doing so.

What to know: Bleeding and cramping typically start a few hours after taking misoprostol. If bleeding does not start, or there is pregnancy tissue still left in the uterus, a surgical procedure may be necessary: this happens in about one in 10 people using both medicines and one in four people who use only misoprostol.

Use a procedure. During dilation and curettage (D&C), the cervix is dilated (widened) so that instruments can be inserted into the uterus to remove the pregnancy tissue. This procedure is nearly 99% successful.

What to know: If someone is having life-threatening bleeding or has signs of infection, this is the safest option. This procedure is typically done in an operating room or surgery center. In some instances, it is offered in a doctor’s office.

If you have a miscarriage during the second trimester of pregnancy (after 13 weeks), discuss the safest and best plan with your doctor. Generally, second trimester miscarriages will require a procedure and cannot be managed at home.

Red flags: When to ask for help during a miscarriage

During the first 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

• heavy bleeding combined with dizziness, lightheadedness, or feeling faint
• fever above 100.4° F
• severe abdominal pain not relieved by over-the-counter pain medicine, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). Please note: ibuprofen is not recommended during pregnancy, but is safe to take if a miscarriage has been diagnosed.

After 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

• any symptoms listed above
• leakage of fluid (possibly your water may have broken)
• severe abdominal or back pain (similar to contractions).

How is care for miscarriages changing?

Unfortunately, political interference has had significant impact on safe, effective miscarriage care:

• Some states have banned a procedure used to treat second trimester miscarriage. Called dilation and evacuation (D&E), this removes pregnancy tissue through the cervix without making any incisions. A D&E can be lifesaving in instances when heavy bleeding or infection is complicating a miscarriage.
• Federal and state lawsuits, or laws banning or seeking to ban mifepristone for abortion care, directly limit access to a safe, effective drug approved for miscarriage care. This could affect miscarriage care nationwide.
• Many laws and lawsuits that interfere with miscarriage care offer an exception to save the life of a pregnant patient. However, miscarriage complications may develop unexpectedly and worsen quickly, making it hard to ensure that people will receive prompt care in life-threatening situations.
• States that ban or restrict abortion are less likely to have doctors trained to perform a full range of miscarriage care procedures. What’s more, clinicians in training, such as resident physicians and medical students, may never learn how to perform a potentially lifesaving procedure.

Ultimately, legislation or court rulings that ban or restrict abortion care will decrease the ability of doctors and nurses to provide the highest quality miscarriage care. We can help by asking our lawmakers not to pass laws that prevent people from being able to get reproductive health care, such as restricting medications and procedures for abortion and miscarriage care.

About the Authors

Sara Neill, MD, MPH, Contributor

Dr. Sara Neill is a physician-researcher in the department of obstetrics & gynecology at Beth Israel Deaconess Medical Center and Harvard Medical School. She completed a fellowship in complex family planning at Brigham and Women's Hospital, and … See Full Bio View all posts by Sara Neill, MD, MPH

Scott Shainker, DO, MS, Contributor

Scott Shainker, D.O, M.S., is a maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center (BIDMC). He is also a member of the faculty in the Department of Obstetrics, … See Full Bio View all posts by Scott Shainker, DO, MS

Making friends and finding social opportunities can sometimes be difficult, particularly for children with neurodevelopmental disabilities, such as autism spectrum disorder, attention deficit hyperactivity disorder, or an intellectual disability. Here’s what parents can do to help.

Building inclusive communities

Friendships and social connections are an important aspect of our lives. They provide a sense of belonging and allow people to be included in their communities.

People with neurodevelopmental disabilities may communicate, learn, and behave differently. Sometimes these differences make it harder than usual to develop friendships and participate in social activities.

But parents and others can help create more inclusive communities and opportunities to build social relationships, especially for people with neurodiverse abilities.

Below are some tips and strategies to help children learn and develop the social and emotional skills they need to make friends.

Practice at home: Tips for common social situations

Navigating social settings and making friends involve many skills you can practice with children at home.

• Greetings and questions. Make a habit of practicing greetings throughout the day. Model good listening for your child, and take turns asking and answering conversation starters like, “How are you?”
• Calm body movements. Sometimes it can be hard for children with neurodevelopmental disabilities to keep a calm body. Have your child practice giving their body enough room and keeping personal space between themselves and others by using an arm’s-length distance.
• Appropriate level of voice. Encourage your child to listen and match the level of your voice. Imagine your voice has a volume dial and practice turning the volume up and down.
• Eye contact. Looking directly into someone’s eyes can be difficult, so help your child instead look at different parts of your face or practice looking at their own eyes in the mirror.
• Reading and responding to social signals. People regularly communicate using more than just words. Social signals are the variety of ways in which we communicate through body language and facial expressions. Often this can be tricky to detect for children who are neurodiverse. Help your child recognize common social signals by asking what someone’s body or face might be saying.

Rerouting challenging behaviors to help children build friendships

Challenging behaviors may get in the way of making and keeping friends. It is important to address challenging behaviors like impulsivity and aggression through therapies and programming. Additionally, practicing the following fundamental skills can help reduce challenging behaviors.

• Patience. Learning how to wait for a turn to play or a time to speak in a conversation is an important social skill. Practice waiting with a timer, gradually building up from 10 seconds, to one minute, to five minutes.
• Flexibility. Help your child make compromises using first/then statements, such as, “First we play your way, then my way.” Model flexible play and redirect with new toys to show how play can evolve.
• Communicating strong emotions.Handling strong feelings can be difficult sometimes. Practice communicating these feelings effectively either by asking for help, using an emotions board, or taking a break.

How to throw a wide net socially

Encouraging social opportunities is an important part of supporting friendships and social relationships for children with neurodevelopmental disabilities. Social spaces offer chances for children who are neurodiverse to find activities they enjoy. They are able to practice the social and emotional skills they are learning and even meet other children practicing these same skills.

• Structure and organize play dates. Set up the environment before a play date by making a list of activities to do with a friend, then picking out of a hat which activities to do and in what order.
• Make a list of things that are fun to do and invite others to join. Look for free or low-cost programs or events out in the community.
• Connect with other parents of children with disabilities. Set up an activity for your children like an ice cream date, going on a walk, or a game night with adults and kids together. These encounters can give rise to repeat, planned social interactions.
• Check out organizations in the community for children with disabilities, like Special Olympics, or recreational programs that foster inclusive environments through Unified Sports.
• Look into facilitated recreational activities like a Lego club or pizza parties with teachers. Plan to bring a support person if needed.

Your child’s doctor or teacher may be able to suggest additional community or web-based resources designed to help families support friendships for children with neurodiverse abilities.

About the Authors

Sydney Reynders, ScB, Contributor

Sydney Reynders, ScB, is a clinical research coordinator in the Boston Children’s Hospital Down Syndrome Program. She assists in research investigating educational, behavioral, and medical interventions in Down syndrome and other neurodevelopmental disorders. She received her … See Full Bio View all posts by Sydney Reynders, ScB

Nicole Baumer, MD, MEd, Contributor

Nicole Baumer, MD, MEd is a child neurologist/neurodevelopmental disabilities specialist at Boston Children's Hospital, and an instructor in neurology at Harvard Medical School. Dr. Baumer is director of the Boston Children's Hospital Down Syndrome Program. She … See Full Bio View all posts by Nicole Baumer, MD, MEd