Recurrent miscarriage and anxiety

Her blood pressure was high- she told me soon after we started her annual visit.

“I just get so nervous at doctors offices…especially the OBGYN.”

I explained to her it’s very common- there’s even a name for it “White Coat Syndrome.” She seemed relieved. We talked of ways to make sure her general blood pressure was normal outside my office- like at her primary care provider or at-home monitoring. She went on to tell me she has been feeling anxious lately. She’s always had anxiety but the past few months it has been ramped up- every since her miscarriage.

Reviewing her OB history she told me she had an unplanned pregnancy a few months ago and a few days later miscarried. The experience plunged her into a deep anxiety. She had a family member announce her unplanned pregnancy around that time too, which added to her complex emotions. We launched into a conversation about loss. She has had multiple miscarriages and two living children. Her recent miscarriage made her realize she how she in a way would want another child but doesn’t think she could handle the anxiety behind the risk of miscarriage. We were able to come up with a reliable birth control plan that would take away that anxiety. “It made me realize I guess I should be happy with the two children I have.” I understood her thinking, but wanted to shout, No! You can want more children! You deserve to go through a pregnancy without anxiety! I instead comforted her how I could. We side tracked a bit and talked of her family member who announced her pregnancy early, about how difficult it can be to watch others go through pregnancy without any obvious worry, without the real threat of miscarriage and loss hanging over her head. She was tearful at times and I think it felt good for her to say the words and feel validated.

At the end of the visit, she looked at me, tears still in her eye. “Have you gone through something like this, “ she asked hesitantly.

“I had a baby last year and she died after birth,” I told her. “I’ve never miscarried before. It’s a different kind of loss, I know, but I do know what it’s like to have the same feelings you do.” We talked a little more about loss and watching others seemingly easy pregnancies. She was good to me- expressed her sincere condolences and was very sweet. But what I appreciated most was the gratitude in her eyes. I could tell she just felt so thankful to have someone who understood.

Have you been on the other side of things- able to be the comforter, showing understanding?

Validation at work

“You’re really good at this!” she exclaimed as we finished up her visit. I had just put in a Nexplanon in her arm (a small subdermal form of birth control that lasts 3 years). It’s popularity is growing, mostly in my younger patients, who love the idea of something easy and long acting.

I smiled somewhat sheepishly. “Thanks!”

“No really, I mean it,” she went on, with her teenaged enthusiasm. “You’re so thorough and just really friendly. I’m so glad it was you who did this. You’re really good at your job, you know. It’s so cool, finding something you’re good at.”

Her words were well timed. I often have so many doubts about my place at work. Some days I feel like an empty shell. I smile and say all the encouraging words that I’m supposed to, but then go how and stew over things people say, especially around pregnancy. It doesn’t feel good to be “faking it” all the time. But on a visit like this, it was really easy. I love my teenaged and early 20s patients. I’ve made it known in my practice that I have a special interest in the adolescents, so my staff and fellow colleagues often book patients in that age range with me.   I need these patients right now- they remind me (even without them saying so) that I enjoy parts of my job, that it can be fulfilling and that I can find meaning in it.

“Thanks,” I told her more earnestly. “I sometimes need to hear that. I do love my job sometimes.”

She jumped off the table, her arm neatly bound by the pressure dressing, and I knew she’d be back next year to see me.

A few patients later, I sat in front of one of my prenatal patients. She comes weekly for an injections that helps prevent preterm labor in those who have already had a preterm birth, so I’ve see her frequently. Last time I saw her, she had been struggling terribly with heartburn that made her vomit and caused bad headaches after. She had exhausted all the over-the-counter and lifestyle changes to try to combat her discomfort without any relief. Las time I tried a non-traditional medicine- one for nausea that helps with headaches, though not usually used for heartburn. I told her I was unsure it would work, but worth a try because the safety was well established and her symptoms were non traditional.

Now, two weeks later, I asked how she was doing. She told me the new meds still didn’t help. She had waited to talk to me about it, avoiding the topic at her last visit with a different provider.

“I think it’s time we try a prescription heartburn medication,” I said. I explained how the medication is “category C”- a category given to medications to rate their safety in pregnancy. We usually try to stick to category A and B medications and take category C medications on a case by case basis. In her case, I think its worth the risk (not that there is established risk, simply many of the category C medications there is just not enough information).

“See, this is why she’s my favorite,” she turned her head and was speaking to her husband and brother in law who tagged along to the visit. “She explains everything and really tries to help.” She looked back at me and continued, “let’s give it a shot. If this doesn’t work, then really, I’m just going to have to deal. I don’t have that much longer anyways.”

I smiled for several reasons. Her compliment, like my other patients, was well needed, especially coming from a pregnant woman. I also appreciated her attitude- she felt like she didn’t have that far to go, she could put up with discomfort if she had to. She was 24 weeks and had plenty of time to go. I know so many patients who feel like the last 3-4months are an eternity with their discomforts, and here was this woman who understood the transience of pregnancy and recognized that sometimes we just have to put up with discomfort to simply be pregnant. It was a relief for someone to understand that. I put up with many discomforts during Mabel’s pregnancy- and though I might have mentioned some of them to my providers and friends, I always tried to make the point that I wasn’t complaining, just stating- because really I was just so grateful to be pregnant. Every day I had still pregnant was a gift, considering how high my risk for loss was. Even without that risk, I do truly believe everyday being pregnant is a gift. I just wish some of my patients realized that.

What gets you through the days? Where do you get your validation?

I’ve always wanted a big family

I sat across from her in the exam room. She was there with her partner and the youngest of her two children, a toddler. She had no clue when her last period was, but based on some recent negative pregnancy tests and now positive, I knew she was in early days. I had congratulated her when I entered the room and she welcomed my words with a smile.

“So were you guys trying or was this a surprise?”

I ask pretty much all my patients this, especially at these kind of visits- one we call “confirm pregnancy” appointments. It’s a quick early visit, to establish with our test that a woman is pregnant and to see if they need an early ultrasound. Plus we are able to start some education and answer questions before the typical initial pregnancy appointment at 8-10 weeks. I ask this question because sometimes people come to this visit to discuss options- I’m trying to see if I need to discuss termination or just plow forward with all the excitement of a new pregnancy. I’m also trying to assess her emotional needs- does she have support? What are her worries?

“Oh, it was a surprise!” She said with a laugh.

“So were using any birth control recently then? Pills? Condoms…?” I ask this to help assess her pregnancy dating. Recent pill use can affect timing of ovulation and thus pregnancy due dates.

“No…” A typical answer that always makes me laugh internally. In my world if you’re not contracepting, you are actively trying to get pregnant.

“But you seem happy about things?”

“Oh yes! I’ve always wanted a big family!”

I looked at her, in her twenties now pregnant with her third child. No history of loss. Smiling, happy, accepting and expecting that things of course would work out.

I’ve always wanted a big family. In the beginning of our relationship, Chris and I discussed how many kids we wanted. He wanted two. I wanted five. He came from a family of two kids; I came from a family of five. No wonders there. Because I got married and would be starting a family later in life, I knew that five was unlikely- we sort of agreed on three (though he would sometimes would argue for two still). When Mabel was diagnosed with Down Syndrome, I became firm in my belief I wanted three kids. We needed to ensure she had siblings who would care for her when Chris and I were no longer able to or weren’t around.

I now laugh at myself- even then- at the naivete of those thoughts. As if we have some sort of control of how many kids we get to bring home (I recognize in a way we do- with the medical marvels of birth control and all…). I didn’t realize that when I was wanting three kids I should have been hoping for three living children. Silly me!

I recently posted about grieving parenthood but I’m also grieving the loss of my future family dreams. If I’m lucky enough to get a take home baby- I no there are no guarantees that I’ll be lucky enough to get another. In another world I thought being an only child seemed like a cruel thing. But I wasn’t thinking about the fact that parents might not have had a choice. My childhood was defined by my large family- I want a semblance of that for any future child I might be lucky enough to have. But I feel like asking for more than one living child is greedy. Just give me one, please. In addition to grieving active parenting, I’m grieving parenting a large family- and the innocence in that statement I heard in the office… “I’ve always wanted a big family!”

How have your visions of your future family changed after loss?