Whether you’re trying to conceive or you find yourself pregnant again after loss, one thing is for sure: you will have questions. A lot of questions. All the questions.
At Pregnancy After Loss Support (PALS), we see it time and again in our private support page. Questions about trying again, what to expect, what’s normal for medical care, or how do you advocate for yourself in this situation, etc. I looked at some of the frequently asked questions in the PALS support group and spoke with Dr. Kristen Sharp to get her take on how she would respond to these questions. Dr. Kristen Sharp is an obstetrician in Madison, Wisconsin, a loss mom herself, and also a board member of PALS. She currently runs the Hope After Loss Clinic in Madison, a cutting edge clinic designed specifically for the mom expecting again after loss.
Please note that these recommendations are not a substitute for medical advice from your own obstetrician or midwife. Your care provider is most familiar with your personal situation and is best equipped to answer your specific questions and to formulate a care plan for your pregnancy. The questions and answers provided below are intended only to provide a baseline of information and knowledge for you to help you go into your pregnancy after loss equipped to adequately advocate for you and your rainbow baby.
When can I get pregnant again after my miscarriage or stillbirth?
This is a really good question and one that I hear often. There is a lot of variability in recommendations that you will hear from providers as there is mixed data about when is the safest time to try after a loss. Additionally, some of these recommendations will vary based on how far along you were at the time of your loss and if there were any medical complications related to your loss.
For an uncomplicated first trimester miscarriage, I would recommend waiting to attempt pregnancy until after the first period after the miscarriage. For most women, this will be waiting about a month. For a loss later in pregnancy or at term, I would recommend waiting for a longer period of time. For a vaginal delivery, I would recommend waiting a minimum of 3-6 months until trying again. After a c-section, I would recommend waiting for a year.
Are hCG level checks performed for all pregnancies in the first trimester? Can I request to get one done if they’re not?
Most of the time, beta-hCG levels are not routinely checked in the first trimester. But, this is something that you can request to have checked. When we are monitoring beta-hCG levels, we typically check them every 48 hours as the most helpful information is the rate of change from level to level and not the individual level itself. I do urge some caution in following these levels. There is a wide range of how a beta-hCG can rise in a healthy developing pregnancy. And, if the beta-hCGs are rising on the lower end of this range, it can cause some stress and anxiety about the pregnancy.
How effective is progesterone therapy in the first trimester? Second? When would you prescribe it?
There is mixed data about the effectiveness of progesterone in the first trimester in preventing miscarriage. One recently published study did find a decreased miscarriage rate with vaginal progesterone use in women with three or more prior miscarriages who are experiencing first trimester vaginal bleeding.
I do discuss the option for first-trimester progesterone supplementation with patients for miscarriage prevention. I review that the data is mixed. But, I also discuss that there are not any significant known risks to using vaginal progesterone in early pregnancy. I work with the patient to make a shared decision on whether progesterone supplementation is the right choice for her.
With progesterone supplementation in the first trimester, there are two options on when to start this – one is with a positive pregnancy test and the other option is to start it after ovulation. With this second option, a woman needs to know when they ovulate (I would recommend using ovulation predictor kits) and then start progesterone three days later. If you start the progesterone too early, there is the chance you can prevent ovulation. I typically will have women continue progesterone until 10-12 weeks of pregnancy which at that point, the placenta should have taken over supporting the pregnancy.
How often can I come in for heart tone checks?
I offer women to come in as frequently as they need for heart tone checks.
Should I buy a doppler for at-home use?
There are pros and cons to having a home doppler. This can be helpful in early pregnancy when you are not feeling movement yet. However, sometimes the baby’s heartbeat can be difficult to hear on the home doppler so this can increase anxiety. Additionally, I strongly recommend not using a doppler later in pregnancy to check on the baby if there is a change or decrease in the baby’s movement. This can provide false reassurance and I would recommend going to your OB provider’s office or labor and delivery for further assessment of the baby with an NST (non-stress test).
How early can I be induced?
This depends on many factors – how far along you were when your loss occurred and if you have other medical conditions in pregnancy such as high blood pressure, diabetes, preeclampsia.
The earliest time you can be induced “electively” (i.e. you don’t have any medical issues or risk factors that would necessitate an induction), is at 39 weeks. There is good data supporting a 39-week elective induction through the ARRIVE trial.
What will we do differently now in terms of medical care in pregnancy after loss?
It depends on when your prior pregnancy loss occurred and the medical circumstances/evaluation of the pregnancy loss. For first-trimester pregnancy loss, this can include more frequent visits during the first trimester. For families who experienced a later pregnancy loss/stillbirth, this can include monthly growth ultrasounds, monitoring of the baby starting at 32 weeks (non-stress tests), and an earlier induction/delivery (typically around 39 weeks).
I’m bleeding. When should I call and what does it look like when it’s dangerous?
I think it is always a good idea to call when you are bleeding no matter how far along you are with the pregnancy.
Every pregnant woman has had a moment where they’re nervous something is not normal and something bad is happening. It’s worse for a mom pregnant after loss. Overthinking and worrying is our M.O. The big question then is: Should I call you?
This is really common in pregnancy after loss. I would encourage women to have a conversation with their obstetric provider early in their pregnancy to discuss their concerns and identify times in pregnancy that may be points of increased stress and anxiety. Examples of this can include the gestational age of when they lost their last pregnancy or their anatomy ultrasound if they received devastating news at their ultrasound in a prior pregnancy. I really encourage and empower women to call whenever they need to.
What method of delivery reduces the risk of death?
Typically, I would recommend vaginal delivery as the route of delivery unless there is a medical reason for a c-section (such a prior c-section, breech baby, etc.). But, if a woman has concerns, stress, PTSD regarding a vaginal delivery, I would recommend talking with your obstetric provider about the route of delivery and the options that would be available to you.
How can I make sure that everyone involved in my medical care (clinic nurses, triage, labor and delivery, etc) know about my loss and act appropriately with my fears and anxiety? In other words, how can we make sure everyone has read my chart before talking to me?
I would encourage women to openly share the information about their loss to their OB provider and the RN in that clinic from early on in their pregnancy after loss care and to have a conversation with their providers regarding potential triggers during their pregnancy (for example, this can include times during pregnancy that their prior losses occurred, anniversaries, locations that may be triggers such as a particular exam room or ultrasound suite).
Ideally, anyone on the care team at the hospital should read your chart when you are admitted for labor and delivery. However, another way to ensure that your care team is aware of your loss would be to write a birth plan that you can bring to the hospital with you.
The opinions, recommendations, or advice expressed in this article are not intended to treat or diagnose, nor are they meant to replace treatment by your obstetrician, midwife, or doula. These questions and answers are intended for informational purposes only. Please do not use this article as a substitute for medical advice, diagnosis, or treatment.