A miscarriage is an experience no woman would ever want to have. Yet, it is not a very rare fact: there are many, many who experience the pain of a pregnancy that does not go well. The problem is that too many still don't talk about it, they shut themselves up in silence and are overwhelmed by a kind of shame which, in reality, has no reason to exist. On the contrary, we have decided to break the taboo wall surrounding the expression "spontaneous abortion", to tear the veil of fear and anguish that surrounds so many mothers. And let's tackle the subject bare and raw, talking about it first with a gynecologist, Antonio Cannizzaro, medical director of the Buccheri La Ferla hospital in Palermo, and then with a psychologist and psychotherapist, Loredana Messina. Together they set up the “Georgia” association which, among its objectives, also has the support of couples who live this very difficult test of life on their skin.
Antonio Cannizzaro-Loredana Messina
What can be the causes of a miscarriage?
“For spontaneous abortion we mean the termination of a pregnancy, which occurs for reasons beyond the control of the woman, before the 24th week. It is not such a rare phenomenon: in fact it is estimated that about 10-20 percent of pregnancies result in a miscarriage. But in reality the number is probably much higher, considering that many miscarriages occur when a woman doesn't even know she is pregnant. Spontaneous abortions occur in some cases because the fetus does not develop normally. Abnormalities related to genes or chromosomes of the fetus are usually random and not related to problems inherited from the parents. Examples of anomalies are: • Empty egg. Anembryonic pregnancy, that is when the implantation of the fertilized egg takes place, however the fetus does not develop and does not grow. • Intrauterine fetal death. In this situation the embryo / fetus is present, but its development stops. Fetal death usually occurs before the onset of termination symptoms. • Molar pregnancy. A molar pregnancy occurs due to a genetic error at the time of conception. Cells in the placenta (trophoblastic) develop a mass of abnormal cells (mola) that causes pregnancy loss. However, this is a rare circumstance. In many other cases, miscarriage can be due to the mother's health conditions such as thyroid disease, diabetes, blood clotting disorders (thrombophilia), hormonal problems, infections, anatomical problems of the uterus or cervix. ".
Can a mother's lifestyle and age have an impact?
“Various factors increase the risk of spontaneous abortion and among these certainly age. Women over the age of 35 have a higher risk of miscarriage than younger women. At 35, the risk is around 20%. At 40, the risk rises to around 40%, at 45 it is around 80%. However, paternal age could also play a role. Some studies suggest that women who become pregnant with older men may be at a higher risk of having a miscarriage. Furthermore, the woman who smokes during pregnancy is at greater risk than the one who does not smoke as well as the consumption of alcohol or drugs increases the risk of miscarriage. Finally, the condition of underweight and overweight was correlated with an increased risk of spontaneous abortion ”.
What are the signs that something is wrong? Are they always there?
"Symptoms may be: abdominal pain or cramps or back pain, fluid or tissue discharge from the vagina (white-pink mucus, clots), more abundant vaginal bleeding or bleeding (brown or bright red discharge), contractions painful at intervals. It is important to note that in the case of vaginal discharge or bleeding in the first trimester, the majority of pregnancies continue successfully. The doctor can do a series of tests: gynecological examination to check for any dilation of the cervix; ultrasound to check a variety of indicators of well-being or pathology; blood tests: it may be useful to measure the pregnancy hormone (beta HCG) ".
How is it done?
“In the event of a miscarriage, the choices available are as follows: • Wait. If there are no infections, one can wait for the expulsion to occur naturally. A circumstance that normally occurs within two weeks following the death of the embryo. However, it is not uncommon to have to wait up to four weeks, an emotionally difficult time for a woman. If expulsion does not occur on its own, drug or surgical treatment can be used. • Pharmacological treatment. After the certain diagnosis of pregnancy loss, if the woman does not want to wait and chooses to speed up the expulsion of the abortion material, the doctor can use a drug that activates the expulsive process. The medicine can be taken orally, but your doctor may recommend that you take a medicine vaginally to increase its effectiveness by minimizing side effects such as nausea and diarrhea. In 70-90 percent of cases the drug produces its effects within 24 hours. • Surgical treatment - curettage. This is a minor surgery called 'dilation aspiration and revision' of the uterine cavity. During this procedure, the doctor dilates the cervix and removes tissue from the inside of the uterus. Complications are rare, but could include damage to the connective tissue of the cervix or uterine wall. Surgical treatment is necessary in the case of a miscarriage accompanied by heavy bleeding or symptoms of an infection. "
In the event of recurrent miscarriages, is there anything that can be done to prevent them? Are there any particular diagnostic investigations?
“There are no problems getting pregnant after a miscarriage, it is possible to get pregnant even during the next menstrual cycle. However, before attempting a new pregnancy, make sure you are in the right physical and emotional condition (very often a woman feels a sense of guilt over a miscarriage). It is important to remember that spontaneous abortion is usually an extraordinary event, the majority of women who have gone through this experience, in fact, successfully carry on the next pregnancy. Only 5% of women have had two consecutive miscarriages, and only 1% have had three. If the woman has had more than three miscarriages, the causes should be investigated. The doctor has many tests and tools at his disposal to check uterine abnormalities, coagulation problems, chromosomal abnormalities and all risk factors, making the appropriate pharmacological or interventional corrections. However, if the reason is not identified it does not mean that the woman should give up trying to become pregnant. In fact, 60-70 percent of women with repeated miscarriages from unidentified causes then carry on a successful pregnancy ”.
Let's move on to the psychological aspect: what are the feelings that triggers a miscarriage?
“I always say that a woman becomes a mother when she sees the pink line on the pregnancy test for the first time. From that moment the future mother begins to imagine what her baby will be like, if it will be a boy or a girl, what the first meeting will be like, what she will do when she cries, how much fun they will have when they go to the park together. Mom begins to experience it mentally before physically. This mental process causes protective thoughts to be activated towards the baby as it slowly develops in its womb. However, our human condition imposes a limit on us in the management of everything, even pregnancy. When a miscarriage occurs, the sense of guilt and impotence are just some of the feelings that are activated, especially in the mother, and very often the context (families of origin, friends, etc.), unintentionally, increases these feelings and related underlying thoughts, blaming, asking questions like: "but did you do some bad movement?", "did you lift weights?", "were you scared?". From one excess to another, it can also happen to feel the pain caused by the loss diminished with phrases such as "it will be better next time" or "do another one now so you don't think about it anymore". Even the reaction of the medical system produces effects, in fact, experiencing the abortion event as something biological, natural and ordinary, unintentionally diminishes the experience of the parents considering a lot of obvious information and, for this reason very often, does not give useful information relating to it. what to do next and what to do. Many parents then ask themselves: What to do? What procedures to follow? What can I or can't I do? Who can give me useful information about why this happened? Who can I contact? All this leads mothers and fathers who are experiencing the event to close themselves more and more in a bubble of silence and withdrawal, isolating themselves in a pain that often cannot be heard and that is diminished by the social context because it is not understood or because it simply becomes intolerable to sustain and contain. Surely the sense of guilt that is activated is a feeling that speaks of the desire for total management that each of us has, but unfortunately I repeat that the human condition does not allow to have everything under control and spontaneous abortion is one of those events that inevitably they put mothers and fathers in front of the impotence of this condition. The sense of guilt would have no reason to exist, but it is difficult for a mother to go from a thought of life related to the birth of her child to a thought of death very often without an understandable reason and this inevitably generates that kind of feeling. After all, if we stop for a moment to reflect we will realize that when something unexpected happens in life, the first thing we do is look for a culprit.
How does man live such an experience? How to approach his pain?
“For fathers who lose a child the situation is considerably different because in those dramatic moments it is required to be the strong figure of the couple and therefore asked to put aside his pain. Paradoxically, this unconscious request made to him, which in some way is linked to a cultural context in which man must not cry or be seen as weak, is not functional at all. The effects that are caused on the wife are related to feelings of misunderstanding. Very often the mothers I meet tell me that they cannot share and talk about the pain of the loss of their baby with their husband because the latter has proved cold and detached. So, in fact, what should be a support on the part of the husband, who shows himself strong in that situation, often turns into a sort of closure and lack of communication that at times creates a detachment and estrangement even in the couple. I believe that in situations of miscarriage even fathers should give themselves permission to cry and share that pain with their mates because basically the only thing that can be done in such situations is to go through and share that pain and then slowly go back up and find a sense to what sense does not have ".
How can psychotherapy help?
"The loss of a loved one, or in any case of all those events that we somehow feel that take something away from us, touches us deeply and each of us lives this experience by trying and showing different feelings and attitudes precisely because bereavement is unique, so how unique is each person. The sense of emptiness and profound suffering are often disabling and it is essential to ensure that the process of elaboration is not experienced as a dead-end road and that the person suffering from the loss has the hope of finding a new path to living the past, the present and the future. In our society, those in mourning often remain isolated in a pain that cannot be heard, that does not dare to express itself: therefore without the possibility of sharing and processing it. Asking for help without the fear of being rejected or judged can help to get out of solitude and silence, and can increase the search for a vital response to the loss of meaning and orientation that a death, or a loss in a broader sense, leaves. It is important to emphasize that, when we talk about bereavement, we must not only refer to the loss of a loved one, but also to the loss of our expectations, our desires, the idea we have of how to live our life, and how much, what we live and perceive as a failure of them, can cause pain and bewilderment. I believe that there can be a different way of seeing and living a loss, bereavement and psychotherapy can help mothers and fathers to change their point of view by allowing a fundamental transition from a position in which one feels cornered and he thinks he has no choice in a position in which that experience becomes more manageable and more digestible. Of course I emphasize that the pain of losing a child, at any gestational age, will never end, but surely by making sense of what happened, one can learn to live with and manage that initially disabling pain. Taking the time to do this also allows you to create a mental space in which to experience pain by creating what in literature are defined as the "places of mourning" that often in a situation of miscarriage cannot present itself in the cemetery, but only in the heart. of mom and dad ".
Also in this case is there a real elaboration of mourning?
“Yes, even spontaneous abortion activates a process of mourning. When you experience a miscarriage you lose both a real baby, which we never held in your arms but that the mother physically lived inside her womb, and an imagined baby, that is the baby that mom and dad they have been thinking since the first day of pregnancy. Each child and each child is unique and for this reason it becomes necessary and fundamental to "mourn". What complexes the elaboration process is, very often, the physical absence, "empty arms". In many hospitals, in fact, time is not yet given to get to know that child who has been lost and doctors, obstetricians and nurses very often think that taking him away immediately will help the parents. It is not so! Fortunately, the situation, albeit with a lot of resistance, is slowly changing, for example at the Buccheri la Ferla hospital in Palermo a specialized operating unit directed by the doctor has been activated, equipped with a multidisciplinary team, of which I personally belong, whose purpose is to welcome, support and accompany couples and families who find themselves having to hear the ominous news. When we talk about mourning, two concepts that are immediately activated are the times and places of mourning. Times are linked to those moments immediately before and immediately after the event that opens a window in which parents feel inside a film, as if at that moment they were living someone else's life; moreover, by “time of mourning” we also mean that temporal space in which the couple and those around them experience the process of understanding the loss, of elaboration and of acceptance which are naturally subjective. Let us remember that, as a great professional and fellow psychologist and psychotherapist, Enrico Cazzaniga, tells us, we must give "the possibility to parents to see the child, photograph him mentally, to touch him, to have him for a short but important time". This is fundamental because it is precisely this that allows those parents to have the space to experience the child they have lost, to experience the pain and emotions related to that child and slowly process them until reaching the moment in which "allow themselves the time to desire another child without feeling guilty. We at "Georgia" always say that to find meaning in what it does not have, such as the loss of a child, you have to "go through" the loss, allow yourself the time to live it in order to then look to the future with new eyes and new awareness. ".
Is it possible to leave the past behind and look forward to trying to find a new pregnancy?
“Losing during pregnancy or soon after delivery is a traumatic experience. We are never prepared and everyday life acquires a different value both for mothers and fathers and for the whole family system that surrounds them. We cannot say that we “leave the past behind”, but we can certainly learn to live with and manage that pain by making it a resource, a strength. It should be emphasized that living after bereavement does not mean forgetting to have lost a child, nor does it mean hiding it from oneself or from others. What can help and make the journey less difficult is the awareness of not being alone. Just recently I have been told that in Sicily there are no realities or structures that help parents feel less alone. The news is incorrect. In addition to us at “Georgia” in Palermo, there are other associations in our region that deal with precisely these situations; some examples are the association "A drop in the ocean" in Torretta and Catania we find a detached section of "Ciao Lapo" (Association led by Claudia Ravaldi, psychiatrist and psychotherapist) which, although intervening in different ways because the point of seen from which they start, they are all very valid and very important resources ".