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Dr. Tim, MD
Dr. Tim, MD, Board Cert. OB/GYN
Category: OB GYN
Satisfied Customers: 1011
Experience:  General OB/GYN, complicated obstetrics, complicated GYN
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I had a private ultrasound at 5 weeks 3 days and the

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I had a private ultrasound at 5 weeks 3 days and the obstetrician thought she could make out a very small embryo sac but no heart beat. I went for a scan today at exactly 6 weeks and 3 days and the midwife who performed the scan told me she suspected a missed miscarriage. This took place in a different hospital without recourse to and the context of the scan 7 days ago. The midwife and myself could easily make out 2 embryo sacs and I am quite certain that there has been substantial growth since last week but I'm told that I'm having a miscarriage because she couldn't find heart beats. Is it possible for embryos to grow from a point of almost invisability to showcase two embryos and then miscarry in the space of 7 days? I still have pregnancy symptoms. I'm not burying my head in the sand but I can't understand how so much growth could take place before a miscarriage in 7 days with sustained pregnancy symptoms and no bleeding. I just want clarification so that I can grieve.

Hello and welcome.

If you are truly 6 weeks 3 days, this would be a miscarriage. However, if you are actually less than 6 weeks, you may have a normal pregnancy with twins.

Unless you know the exact day that you ovulated, I would recommend waiting another week and getting another ultrasound. Going from barely a sac seen to 2 definite sacs sounds like a normal progression from about 4 1/2 to 5 1/2 weeks.

Normally, there will always be a heartbeat seen at about 6 weeks.

Hopefully you'll have 2 heartbeats seen in another week. Good luck!

Customer: replied 1 year ago.
I have been to the library and have found medical evidence which refutes your stipulation that this would 'definitely' be a miscarriage. Your answer gave no details of anomalies. Of the fact that some obstetricians even refuse to do scans before 8 weeks. Of the fact that I may have a tilted uterus. Of the fact that the midwife is not a clinical medical expert. My mother is a midwife and 3 of my sisters are doctors. I have more medical knowledge than most. I was looking for an informed response, I most certainly did not expect to be patronised with probabilities passed of as definitive fact.

I am sorry that you were not satisfied with the answer that you were given. Would you like another opinion as I would be happy to help clarify the situation from my perspective. Please let me know and I will take the time to give you another answer.

Dr. Tim

Customer: replied 1 year ago.
I guess I don't really trust the expertise of the midwife. I would venture to stipulate that I have more medical knowledge growing up in a family which includes parents and siblings who are doctors. Is it possible that, if your cycle is usually more that 28 days, which mine is, that my development could be slower? Is it possible that I have a tilted uterus? I don't think it's appropriate to blurt out 'you're probably having a miscarriage' at such an early stage in pregnancy. When a woman's hormones are already all over the place. But that's not your bad. This is an example of the gross insensitivity of some medical professionals who have been conditioned to seeing people in states of acute distress. I just don't understand how some obstetricians refuse to do scans before 8 weeks and yet a midwife can just discard the efficacy of my pregnancy in such a laissez-fair attitude before sending you home to wait for 3 weeks for a follow up appointment. No bleeding. No pain. Continuing pregnancy symptoms. Surely she is putting the cart before the horse. Surely she should have the humility to entertain other potentialities and, perhaps, acknowledge her limitations as a midwife and not a gynaecologist, to make such a sweeping statement at such an early stage. I have read an article which stipulates that as many as 400 healthy pregnancies are terminated by medications given to women who aren't, in point of fact, actually miscarrying. I have read how many clinicians do not diagnose miscarriage until the embryo is at least an inch, but want the guidelines to change to an inch and a half. The fact that I'm fretting is not your responsiblity. But I guess I needed a more multifaceted, fulsome response which respects my intellectual capacity to grasp complex medical contexts. I needed to be told, hey, that woman shouldn't be brandishing about terms like miscarriage for no reason and leave a pregnant woman in a state of deep distress and anxiety without reason. Because, if my pregnancy is viable, all this cortisol running through my body is going to suppress my progesterone levels and I could end up having the miscarriage she was so keen to subscribe. And yes, my anxiety is that bad. This woman has a duty if care and she has failed miserably. Don't feel compelled to respond. I just wanted you to understand that intelligent pregnant women want the truth, yes, but they want textured, informed, reasoned responses which are contextualised. They find truisms and hackneyed probabilities extremely disconcerting and stressful. Give us the information, but give us all the information. Thank you for taking the time to respond.

I completely understand where you are coming from and unfortunately it is not an uncommon experience. I do not understand why so may Obstetric Providers blow it when it comes to the empathy part of this field AND make assumptions that are incorrect. Not too long ago, I saw a patient with your exact story. She was told she had a miscarriage and that is what everyone assumed. She then showed up in my clinic with an 'undiagnosed pregnancy' at 28 weeks. Now that was an interesting visit! Sometimes I feel like I continue to participate in this site just to do damage control for all of the bad care and advice that patients get. With regard to your situation, the Providers involved were in violation of my 5th rule of Obstetrics: "Never assume non-viability". They made the assumption without ever considering that they were just looking at an early gestational age than they thought. To prove that point, so far, you have not miscarried, you are not bleeding and you still feel pregnant. This would have been so easy to sort out with serial HCG levels (if they did those let me know the results). But in response to your answers and to address some of your comments, here are some thoughts:

1. I agree with Dr. Norm - your first scan puts you at closer to 4-5 weeks. A scan a week later (at less than 6 weeks) would still not show a heartbeat. This is where they made their first mistake in assuming it was a miscarriage. They could NOT have known that at that point.

2. Is it twins? - well that is possible and will be sorted out with future scans. It might be the reason why you are having pregnancy symptoms slightly earlier than the average person

3. Cycles >28 days long - yes there might be enough variation in when you ovulated that you were a week less far along than you or your Provider thought - that would make sense. If you have a longer cycle, it probably means that you ovulated a bit later than cycle day#14.

4. Tilted uterus - yes, if it is tilted backwards it can make the vaginal scan more difficult because the sound waves are going through the cervix and more of the body of the uterus to get to the sacs. Often the images are not as good / grainier

5. No scans before 8 weeks - this is silly. There are plenty of patients in whom we have no idea when their last period was - I wonder what they do in those cases? Yes, the ideal scan for dating is about 7-8 weeks, but in many cases you just do not know how far along you are (and that is where HCG levels can be helpful)

6. Hackneyed - love that word and I am going to use (but I won't overuse it)

So, yea you might have a miscarriage as about 15% of pregnancies miscarry. But if it is NOT a miscarriage, you are probably not going to return to that Provider - what else are they going to be wrong about? The right answer is to tell you "I think that you are slightly earlier than you thought. We should repeat an ultrasound in about a week. In the meantime it might help to sort out what is going on by checking an HCG level". Most people get the HCG level drawn and any future confusion can be sorted about by repeating it and seeing what it did over time.

Does this help?

Dr. Tim

Dr. Tim, MD, Board Cert. OB/GYN
Category: OB GYN
Satisfied Customers: 1011
Experience: General OB/GYN, complicated obstetrics, complicated GYN
Dr. Tim, MD and other OB GYN Specialists are ready to help you
Customer: replied 1 year ago.
This helps. This is what I rationalised myself. I might have miscarried but this isn't necessarily the most likely scenario. However, when an arrogant midwife makes statements in the very early weeks of a much wanted pregnancy, her comments will stick. After all, I have pregnancy hormones surging through my body. She sanctioned three weeks of worry and that is unacceptable. I won't be going back and I will be writing a letter of complaint.

Thank you for the positive feedback for my answer. Yes, I think that you should write this letter. If this is a pattern with this Provider, a written complaint is the only way to address the issues that may exist. I truly wish you the best of luck!

Dr. Tim