The stork glides effortlessly and alone through the clear, blue sky. Its sturdy, white body is balanced with black tipped wings spread wide. Hanging from its beak is the swaddled, uncomplicated promise of life. This symbol of hope and arrival is often the first picture of pregnancy for many. Most carry that image forward, unbroken—but for an estimated 10–15% of women, that serene picture is overtaken by clouds of uncertainty, turbulence of grief and storms of loss.1,2 A pregnancy loss can take many forms: chemical pregnancy loss, early spontaneous miscarriage, blighted ovum, ectopic pregnancy, medical abortion, molar pregnancy, late miscarriage and stillborn. This article reviews the role IR takes in the care surrounding pregnancy loss and offering support for colleagues who may be navigating the personal experience.
The role of IR in pregnancy loss
The least emergent role IR may take during pregnancy loss is performing a hysterosalpingogram (HSG). The indication for HSG is the evaluation for structural abnormalities contributing to the loss. These abnormalities span from intrauterine fibroids to blockages in fallopian tubes. While HSG is an aging procedure to the more current sonohysteroscopy, HSG allows concomitant fallopian tube recanalization to be performed, if indicated. In the event that intrauterine fibroids are contributing to recurrent pregnancy loss, IR can offer uterine artery embolization (UAE). As we know, pregnancy is possible after UAE,3,4 and in the case of prohibitive fibroids, UAE may allow a successful pregnancy.
At the time of pregnancy loss, IR may becalled to prevent anticipated significant blood loss or treat life-threatening bleeding. The obstetrician may perform dilation and curettage (D&C) or dilation and evacuation (D&E). To address concerns for significant blood loss related to invasive or adherent placental tissue and/or cultural beliefs of the patient, IRs can work less selectively and with a collaborative approach to offer different options. If time allows, IRs can perform a UAE to reduce blood flow to the postpartum uterus. In more urgent settings, IR can assist in the perioperative period with prophylactic balloon occlusion in the bilateral internal iliac arteries or aorta.5 In the cases of balloon occlusion, IR may have the opportunity to work collaboratively with the obstetrics team in the operating room during their procedure to optimize the occlusion time. Most often, IR is called to treat uncontrolled or persistent bleeding after D&C and D&E.
Postpartum hemorrhage (PPH) from pregnancy loss is comparable to that seen after live births. Large-volume bleeding can be addressed relatively nonselectively with UAE. A more focal bleed from a pseudoaneurysm after D&E can be embolized with super selective catheterization. The topic of emergent PPH management plans can be approached with a collaborative spirit and facilitate the conversation for elective UAE for fibroids.
The human factor
Regardless of the role IR takes and what is treated, special attention should begiven to who is treated. The patient with pregnancy loss—whether a new patient, friend, family or one of our own colleagues—is carrying the emotional weight from a broken promise of a new life. The following is not to replace or serve as clinical management, but is offered as advice in supporting someone you may know navigating the difficult course. It is based on our own 8-yearexperience of recurrent pregnancy loss.
Particularly distinct to pregnancy loss is its grief. With the death of a parent or other family member, one has memories to hold onto, a memorial service or material items. In pregnancy loss the grief is prospective. Those going through pregnancy loss are grieving what would have been. They lost the child they thought they had, their identity as a mother or father, and the upcoming birthdays and life milestones that will not occur. They lost relating to those in their peer group who are still pregnant or actively parenting and moving into a new chapter of life without them. This can be markedly painful and isolating in the social realm of attending baby showers with a mutual friend group or answering well-meaning questions about family planning or an early pregnancy. In the setting of early pregnancy loss, many friends and coworkers are often unaware that a loss has occurred, and this can be even more difficult to navigate.
Colleagues and even close friends typically aren’t aware of a loss, as it is often held silently. This silent suffering impacts the patient internally and externally. With the loss of control in something that had all the right inputs and still an undesirable outcome, internal social anxiety plants itself and can expand over time. Help can be difficult for them because not everyone is comfortable discussing loss while others are but just can’t provide the right support. From our perspective: try anyway. Reinforce that they are allowed to hurt and deserve the time to process through their individual experience. Join alongside them and hold yourself to follow-up with continued support. When listening, listen to understand; do not offer unsolicited advice.
There are many different facets of support. When asking what you can do to help, take consideration of the strengths in your existing relationship. You take one part of many: perhaps make a meal, listen to their most difficult thoughts or offer to sit with them quietly. As a physician, it is imperative to highlight the benefits of therapy. There is no condemnation in seeking professional help to work through pain that can be unbearable to carry.
If you have experienced a pregnancy loss, and if you are comfortable in doing so, share that with the patient. Hearing personally from one other person speaks infinitely beyond any statistic that they are not alone. We learned that many people, even a few very close to us, had experienced a loss, and we could not thank them enough for sharing their story.
Regardless of your experience, and even if you feel uncertain or ill equipped, at least ask and listen. Your presence matters and nothing more may be needed. To us, it was surprising who did show up—and just as surprising who didn’t.
As it turns out, what is less often recognized is that storks, whether in sunny skies or storms, are naturally very social birds. They can even number into the hundreds during migration. In the same way, whether with a new patient, friend, family or one of our own colleagues, you can join their flock to help them find community and understanding in their journey from darkness to light again.
References
- Bardos J, Hercz D, Friedenthal J, Missmer SA, Williams Z. A national survey on public perceptions of miscarriage. Obstet Gynecol. 2015;125(6):1313-20.
- Quenby S, Gallos ID, Dhillon-Smith RK, Podesek M, Stephenson MD, Fisher J, et al. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet. 2021;397(10285):1658-67.
- Akhatova A, Aimagambetova G, Bapayeva G, Lagana AS, Chiantera V, Oppelt P, et al. Reproductive and obstetric outcomes after UAE, HIFU, and TFA of uterine fibroids: Systematic review and meta-analysis. Int J Environ Res Public Health. 2023;20(5).
- Bonduki CE, Feldner PC, Jr., Silva J, Castro RA, Sartori MG, Girao MJ. Pregnancy after uterine arterial embolization. Clinics (Sao Paulo). 2011;66(5):807-10.
- Moirano J, Khoury J, Yeisley C, Noor A, Voutsinas N. Interventional radiology and pregnancy: From conception through delivery and beyond. Radiographics. 2023;43(8):e230029.
