My second pregnancy was a very planned pregnancy. I had conceived so easily the first time I was careful not to conceive again until we were absolutely ready for a second child. I wanted a three-year difference between my children. That usually meant the youngest would be out if nappies and a little more independent and going to Kindergarten soon. I therefore could give my undivided attention to my second child whilst Rupert went to Pre-school for a few hours four times a week.
I did conceive as planned. I once again had relentless morning sickness. At 10 weeks gestation it started to dissipate and I was grateful that this time the morning sickness wasn’t lasting as long as it had last pregnancy 16 weeks.
At 13 weeks, we were having tea at a friend’s house. I went to the toilet and noticed a scant amount of bright blood on the toilet paper. I was concerned but went home that evening and got up the next day, all was ok. I went to my afternoon shift where I was working as a midwife in maternity and gynaecology emergency department. I had started to feel a few lower abdominal cramps. I was the triage nurse that day. As people presented to emergency it was my job to assess their presenting symptoms and categorise them as to urgency for medical attention.
I was standing up talking to a women who was explaining her symptoms to me. I was getting stronger cramps and I could feel bleeding. I couldn’t concentrate on what she was saying. I was miscarrying myself and I needed attention. I was trying to assess her and thinking I can’t deal with what’s happening to you any longer, I have my own situation going on. I told another staff member what was happening and she took over the other women’s care.
I rang my obstetrician who was away and had another very good obstetrician covering her. Miriam the covering doctor who I knew well professionally said wait there I will come and scan you. We went into the scanning room in the emergency department where I worked and she proceeded with an ultrasound. I could see there was no heartbeat. I look at these first trimester scans everyday in my job. Amongst a grey mesh of tissues was a black circle and in that I should have been able to see a tiny grey like shape with a movement of two little valves flapping – a heartbeat. In that black circle was basically nothing. What was supposed to be a baby but it had only grown a millimeter or so and definitely not enough to even have any recognisable sign of a heart.
A disappointment came over me. I had what was called a blighted ovum. This is when the sac and placenta continues to develop but the baby doesn’t. You still get all the symptoms of pregnancy, you are pregnant, but the genetic material to a form the baby isn’t enough. The placenta is what produces the hormones that make you feel sick. You still get all the signs of pregnancy but no baby.
I had another midwife say to me when I told her I had a blighted ovum, ‘oh so you weren’t pregnant anyway, there was no baby’. Yes I was pregnant, but it failed to continue healthily. Every emotion that comes with a pregnancy I had. Once I had that positive pregnancy test, I was excited. Every dream that comes with thinking you are going to have a child I had.
I needed a curette. I my pregnancy had failed, I had in laymen’s terms, miscarried. I tried to contact my husband but he was at a function for someone leaving their place of work. This was back in early nineties so mobile phones weren’t in use like today. People weren’t as contactable. I rang the police station where he worked. I asked to speak with my husband. Initially the police officer didn’t want to tell me his where abouts. I said, I’m pregnant and I’m miscarrying, I need to speak with my husband.
They got the message to him immediately and he came straight to the hospital, collected me from work and we went home. A curette was booked for the next day. I was really disappointed, I so wanted this baby. When you find out your pregnant you mind starts thinking way ahead. You start thinking about your future life with this child and start preparing yourself for being a mum again. As a female from the moment your body conceives your body is having a myriad of chemical reactions that bring about physical change, the symptoms of pregnancy. Tender breasts, bloating, nausea, and tiredness as your body starts to go into overdrive growing a human.
The pregnancy in my case stopped most likely around that 10 week mark when my nauseas was easing and then took a couple of weeks for my body to attempt to abort it.
The attempts to dispel the embryo/fetus from the uterus. It’s like mother nature’s way of throwing out the bad egg or sick chick in the nest. One of the many reasons a pregnancy can fail is because chromosomally there is something amiss with this embryo. There’s a defect. If before 6-9 weeks the products if conception are usually broken down by a natural process within the body and reabsorbed. However after around 6-9 weeks gestation the full products of conception will be dispelled from the uterus as hormonal changes occur and the blood cells, the decidua, come away as like a period, along with that the embryo embedded in it. This can be categorised as a complete or incomplete abortion.
Abortion is an emotive word so I want to clarify abortion by medical definition.
As health professionals we refer technically to miscarriages as abortions.
*There are spontaneous abortions such as in my case where the pregnancy fails to continue and ceases on its own accord but the products of conception ( POC)remains in utero.
*A complete abortion is where the pregnancy ceases spontaneously and is completely expelled from the uterus, there are no products of conception (POC) left.
*A threatened abortion is when there are signs such as bleeding or cramping, contraction of the uterus that the pregnancy may abort, however the fetus is still alive. A heart beat can be seen or heard. At this point it’s an ongoing pregnancy.
*A surgical termination or abortion is when a surgical procedure is performed to abort the pregnancy.
*A medical termination or abortion is where medications are taken to stop the continuation of the pregnancy and abort the pregnancy.
*An ectopic pregnancy is a pregnancy that is outside the uterus, commonly in the Fallopian tubes. This can be a life threatening situation. Women haemorrhage when a Fallopian tube ruptures due to the growing embryo within the Fallopian tube. Fallopian tubes are less than 1 cm in diameter and as the growing embryo exerts pressure against the wall of the Fallopian tube it causes pain and eventual rupture of the tube. This type pregnancy will abort. Working in emergency in the early 1990’s, prior to real time scanning machines and the training of midwives in the emergency department to do ‘real time scans’ (RTS) and determine the site of the embryo whether it was in utero or is ectopic, we saw more ruptures of ectopic pregnancies than today. The introduction of RTS availability has been lifesaving for many women. Early diagnosis is crucial to prevent rupture. Prior to this, we didn’t have portable ultrasound machines in the emergency department, eventually we did but only some doctors were trained in RTS. If there was no machine available for scanning or a doctor trained in RTS, then the patient was booked a ‘department’ scan by a sonographer and or had serial blood test to ascertain if the pregnancy hormone produced by the placenta was rising as expectant for a healthy ongoing pregnancy. The beta human chorionic gonadotropin (BHCG) doubles every 2-3 days throughout the first four weeks or so. In ectopic pregnancies or failing pregnancies it continues to rise but not at expected levels. These blood tests are important to ensure there isn’t another fetus, a twin growing elsewhere in the body/uterus. If there is no other ongoing pregnancy the levels will fall to zero. The risk of this monitoring of an ectopic pregnancy is that everyone is different and rupture of the Fallopian tube could happen at any time usually happen between 6-10 weeks gestation. By being able to locate the embryo via an ultrasound scan, and definitively diagnose and ectopic pregnancy meant treatment could be swift and effective. Ectopic pregnancies if early can be medically terminated or will require surgical termination where the Fallopian tube is removed with the embryo. It cannot proceed to viability because of rupture if the Fallopian tube is inevitable. This diagnosis is often devastating to women.
One of the different presenting symptoms of a uterine pregnancy threatening to abort and rupture, is the bleeding and location of the pain. A women with an ectopic pregnancy generally presents with lower abdominal pain towards one side increasing in intensity but no vaginal bleeding or very little spotting. Threatened abortions of a uterine pregnancy often present with central lower abdominal pain, some vaginal bleeding with or without other pregnancy symptoms. An ectopic pregnancy cannot proceed and requires intervention. 1 in 4 pregnancies fail in the first trimester however many women who present with a threatened abortion go on to have healthy pregnancies and healthy babies. Technically ectopic pregnancies end as a surgical termination hopefully before the tube ruptures.
The seriousness of an ectopic pregnancy can be highlighted in this story. I once triaged a women who presented to emergency who had come to Melbourne for a girls weekend from interstate. It was a Saturday evening and she had been out with friends. She was pregnant and throughout the afternoon had developed lower abdominal pain. She presented because by evening it had gotten worse. She was between 6-9 weeks pregnant at the time.
I triaged her as a category 2, which was to be seen urgently within 10 minutes. She had walked into emergency, I suspected from her symptoms she could have an ectopic pregnancy and required urgent attention. Whilst she was having her initial observations done she was showing signs of suddenly being in shock, hypovolemic shock. The type of shock that happens when hemorrhaging. Had she presented to emergency 15 minutes later she may have died. Her Fallopian tube ruptured.
When this happens it’s an obstetric emergency and you literally have minutes to stabilise the situation, stop the bleeding or she will haemorrhage to death or could risk getting disseminated intravascular coagulation (DIC). When someone rapidly haemorrhages they use up all their clotting cells and their body is incapable of producing clotting cells quick enough to clot blood and stop bleeding. We have about 5 litres of blood in our body.
When a person bleeds in a situation like this there isn’t time to cross match blood or give any blood. An intravenous infusion is started with a product called a volume expander in an attempt to keep her blood pressure up preventing cardiac arrest whilst you prepare her for theatre to operate and remove the source of bleeding, her Fallopian tube, and stabilise the blood loss. During this medical emergency blood is being cross matched by the blood bank to transfuse to the patient in a life saving attempt.
This woman was now in the resuscitation cubicle, with multiple doctors and midwives trying to keep her alive and get her to theatre as soon as possible, within minutes. Observations need documenting, what drugs are given, what intravenous fluids are given, the patients vital signs. Theatre needs to be alerted, so they can prepare the surgical team for an immediate surgical procedure.
Relatives need to be informed and comforted. If the patient is conscious they are scared, they do not know what is happening to them. They are suddenly surrounded by up to 10 doctors and nurses and technical staff. Their clothes are being cut off, they are having oxygen masks placed on their face, blood taken, and intravenous access gained. They are consented for surgery where possible and given explanation of everything that’s happening. It takes a very experienced team in this situation. Everyone has a role within their own expertise and everyone knows what that is. I loved working in emergency for these reasons. To work with highly skilled professionals to save a life. When someone’s loved one is literally on the brink of death, to work together and keep a person alive is so rewarding.
This woman was slipping away. She had become unconscious very quickly and was intubated by the anaesthetist no longer being able to breathe effectively on her own. A tube was guided via a laryngoscope down her throat and into her trachea and the anaesthetist manually squeezed the leardal mask bag delivering oxygen to her lungs with every rhythmic squeeze that emulated a natural breathing rhythm .
She was taken rapidly to theatre where her bleeding was stabilised. She had bled 3 of her 5 litres of blood circulating her body into her abdomen from the site of the ruptured tube. I have never forgotten this women because it showed how serious an ectopic pregnancy could be. This women who walked into our emergency department and spoke with me, went from feeling a bit of pain to rupturing her Fallopian tube and within minutes was nearly dead and survived as a result of a highly skilled medical team working in a first class tertiary hospital. It’s what I trained for, it’s one of the reasons I love nursing. It’s to make a difference, to help people, to help save someone’s life is an incredibly wonderful feeling, and that day we did just that.
Working in a tertiary hospital involves all types of care to people. I am pro women rights. If a women decides having a pregnancy or child is not right for her for her own personal reasons then she should have choice. Criminalising abortion forces some women to have a termination of pregnancy in illegal unsterile premises and under dangerous conditions which can result in the unnecessary infections, septic shock and death due to complications of this underground procedure. It’s her body, her right to control what happens to it and she should have options to do what she wants to, safely. I feel fortunate to live in a country, democracy and state that supports women in their right to abortion. In all my years of having women present for theatre for a termination of pregnancy I never felt these young women chose to do this flippantly. It was an emotionally difficult situation each women found herself in and needed to be treated respectfully and with kindness.
For me however, I wanted this pregnancy. That night laying in bed, the cramps came and went. Early morning I had woken to abdominal cramps that had intensified. I was getting scared. Something was happening within my body and it was scaring me.
When I was told in emergency by the obstetrician that there was no heart beat it was awful. But over that night I had accepted the pregnancy was over and I wanted it out of me, to me I now had something dead inside me.
As routine I had to have a ‘department’ scan by a sonographer, to officially say the pregnancy had failed and no heart beat could be seen.
I sat in the waiting room and watched women come out smiling with a photo of their healthy live baby in their hand and thought to myself, ‘I’m here to confirm my baby is dead, I am so envious of you’. As expected my scan confirmed no heart beat and I was prepared for theatre, a curette. This procedure was done under a general anaesthetic with a surgical instrument which scrapes the lining of the uterus, effectively clearing the uterus of and POC. It’s done to prevent infection occurring, and further potential bleeding. The uterus heals over the following couple of weeks and your ovulatory cycle should return to normal within a few weeks, for me this didn’t happen.
I was wanting to conceive again but my period hadn’t returned months later. I was not ovulating. This became distressful. I booked an appointment after several months with my obstetrician and gynaecologist. I had a holiday booked in the coming weeks after my appointment. She reassured me if I hadn’t conceived after the holiday to see her and she would discuss fertility options.
It was like this huge weight was lifted. Someone was going to help me. I had become so worried I wasn’t going to have another child. But there was help. We went away and I did fall pregnant on that holiday. It was as if the stress lifted and my body was free to work as it should have been.
And along came Jane ♥️
Love Lucy x