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  1. #1
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    Default All About Miscarriage

    My Story

    When I lost my little River died at around 12 weeks I didnt find out till I was 16 weeks. I had started spotting and some mild cramping before the scan showed bubs was gone so I decided to wait to see if it would happen naturally and nothing. I got constant mild pain that I normally get for a week before AF and spotting that stopped and started. Two weeks after the first scan they admitted me to give me misoprostal to see if my body could push it out with help. It worked. They admitted me simply because I was futher along and they were worried about me bleeding too much.

    After going through this and discovering lots of things that stressed me out at very unfortunate points in time I thought that maybe it would help other women if it were all written down in simplistic black and white. Knowing what if going on takes a lot of the fear away and helps you when you need to make these choices later on. If anyone has anything to add, feel free as my information if solely coming from my experience so I dont pretend to know everything.

    Spontaneous Miscarriage - Natural, Unassisted

    If it does happen spontaneously you can expect a decent amount of pain and some bleeding but if after you pass the majority of the tissue you are soaking through a pad in an hour, you are probably bleeding too much so get help asap. Your bleeding should start to taper off to normal AF levels along with your pain as soon as you pass the main tissue and bubby, though the cramping contraction type pain did continue infrequently all day for me at much more manageable levels. The pain came in contraction form for me (what a depressing first taste of labour that was). When the pain was really strong and I had a strong desire to go to the toilet, that was the signals that everything was going to come out so go sit somewhere where you can let it all go and not worry about a mess like the toilet. The contractions not only push the tissue out, they also serve to stop the bleeding afterwards so while pain killers are ok, try not to take things that will slow or stop them.

    The benefits to doing it naturally is that it carries the least risk of side effects and the least risk of damage to your uterus. The risks associated with this way are as follows:
    1) If you are not close to a hospital and on your own then hemmorrhaging can be very dangerous. If after the main tissue has passed you are soaking through a pad in an hour then call someone asap and get to emergency. The further along you are the greater the danger is.
    2) There is the chance of some tissue being retained and this can cause infection later on so get an ultrasound done a few days after to ensure you are all clear. Keep an eye out for signs of infection like dizziness, nausea, temperatures, unusual or smelly discharge and the rigors (shaking and feeling cold when you are hot). If you do have retained tissue you will need a D&C. The further along you are, the greater the danger is.
    3) The longer you wait for it to happen naturally, the higher the chance of tissue adhering to the uterus causing scarring and possible retained tissue. Doctors normally consider up to 6 weeks to be the safe zone before they start to try getting you to try other options.
    4) The further along you are and the longer you wait, the more chance is that things will get stuck on the way out. Tissue that is stuck in the cervix will cause large amounts of pain and if left there can send you body into a form of shock. It is a rare and unusual situation where your heart rate and blood pressure both drop at the same time and if the tissue is not removed the chances of you becoming unconscious are high. This is rare but is also serious.

    Walking away from the horrible clinical description now. . It is an incredibly emotional time. I lost it so bad when the worst was over. Be kind to yourself and do whatever you need to do to get through this. If it starts and you feel like you cant cope then get to emergency and they will help, at the very least with pain medication and someone to talk to if you need it. They sent a social worker to me before they gave me the drugs to make sure I was in a good headspace under the circumstances. Depending on how you are, it may help to have someone stay with you or visit frequently if you are really worried about it happening at home.

    The wait is horrendous. A constant reminder that you cant get away from but hang in there. You are strong and you can get through this.

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    Medical Management - The Drug Option

    The drug they use is Misoprostol which is a synthetic prostoglandin. Primarily used in much smaller doses to treat stomach ulcers due to it stimulating the secretion of stomach mucus. It triggers uterine contractions and helps to soften and dilate the cervix. Prostoglandin is produced naturally by the body in labour and during spontaneous miscarriage. It can be given either orally or placed against the cervix. There was much debate in the hospital as to whether I could administer the drug myself if I chose not to take it orally. The midwives said why not and the consultant doctor on hand with heaps of experience said I wouldnt be able to place it properly because they have to use a tool and get it in the right spot. I chose orally instead. The dosage is lower when given orally due to increased risk of some side effects. This makes it slightly less effective but not a great deal. They give doses every 4 hours till miscarriage has occurred or till they decide it's not going to work and start to discuss other options.

    The risks include all of the risks for spontaneous miscarriage but include:
    1) The very small risk of uterine rupture. They are not concerned about getting anything out alive so the contractions this induces are very strong and end up so close together that I could not tell the difference. They all ran into each other and became one. This is very hard on the uterus and could cause rupture though the risk is very small.
    2) Side effects include nausea and vomiting, diarrhea, rigors/chills , and temperatures.

    They gave me 3 pills and it was done in less than 4 hrs for me but I had already had light bleeding and cramping which may have helped in this situation. They will also offer you pain relief for this as it can get quite bad. This option may be difficult or impossible to access in some areas unfortunately. So you will need to check with your hospital or clinic first.
    Last edited by Tildy; 23-05-2013 at 19:38.

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    D&C - The Surgical Option

    This is the quick and most controlled option. The benefits are that it is over and done with quickly helping you to gain closure and grieve properly sooner. It is also a very controlled and monitored procedure allowing them to act quickly if things do go wrong. I discussed this option extensively with the doctor as it was a very real possibility for me but I did not personally experience it. My description is the procedure as done by my local hospital.
    You will be asked not to eat anything or drink anything for a certain period of time beforehand (just like any other surgery). Half an hour (can be up to 4 hrs depending on your hospital) before the procedure they will give you a dose of Misoprostal to help soften the cervix and to stimulate uterine contractions which help stop the bleeding afterwards. They will put you under a general anasthetic at a lighter level than major surgery. They give you enough to render you unconscious but not enough to interfere with sub-conscious body processes such as breathing and bladder control. They insert a temporary catheter for long enough to drain your bladder as this allows them to navigated the uterus unhindered. The tube that goes in the throat only goes far enough to keep the airways open allowing you to breathe on your own and provide extra oxygen.
    They dilate your cervix part of the way using a metal tool which keeps it open for the procedure. Next they insert the curette. This is a metal tool with a handle and a sharp metal loop on the end. This is used to scrape the tissue away from the walls of the uterus. They aim to remove the gestational sac and the part of the lining that would normally be shed during a period. They then use suction to fully removed all the tissue.
    The whole procedure only takes about half an hour and then you wake up. Often if you are recovering well you can go home the same day they do the procedure. Cramping and pain can be expected and is actually a good sign as the uterus contracting is what stops too much bleeding from occurring. There can be some light bleeding afterwards.

    The risks involved do not commonly occur but can be serious. These risks are:
    1) All the risks associated with general anasthetic.
    2) They will usually err on the side of taking less than more so there is the risk of retained tissue leading to a second D&C to prevent infection.
    3) If they do take too much and damage the second layer of the uterus this can lead to Asherman's Syndrome which can cause infertility and further miscarriages amongst other things. This is a serious syndrome and Starf1sh has provided more detailed information further down in this thread. I urge you to read it before making a decision.
    4) There is the chance of puncturing the uterus and causing scarring which can lead to attachment issues in following pregnancies such as placenta previa.
    5) As with all miscarriages, there is the chance of hemmoraging.
    6) As with all surgeries there is the chance of infection from the tools and whatnot.

    I was concerned about the catheter triggering my recurring cystitis but the doctor assured me that the temporary catheter makes this risk extremely low.

    In Conclusion

    If you find yourself in this horrible decision making process then I hope this information makes it a little bit easier. I have tried to include everything the doctors told me yesterday as well as my own knowledge stemming from my experience. If anyone has any important or useful information to add to this then post it in the thread and I will add it to the relevant section. Question asking goes right out the window when having to cope with this distressing, heartbreaking situation but knowledge will help to alleviate fears and help you to make the choice that suits you best. Aim for the method that will traumatise you least and be kind to yourself. Do what you need to get through it. It does help to have a support person to help you through but if you do not have one of these then please ask your GP or hospital if you need someone to talk to. They can help. If you find yourself faced with these options then know that you are strong, and you are not alone. You will make it through.
    Last edited by Tildy; 08-08-2012 at 21:05.

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    Tildy you described this perfectly! I had a D&C yesterday and they only difference I had was they gave me my misoprostal 4 hours before my surgery. I had intense period pain and was given panadol which helped settle some of the pain. The misoprostal worked very quickly for me, within about 20 minutes. I went into hospital at 12.30 after fasting since breakfast and I was home by 9pm.
    This morning I have only light bleeding and some mild pain not enough for panadol.

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    Thank you for this it has helped

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    I'm so glad you have put this up when I was looking for information regarding termination in the second trimester due to chromosomal abnormalities I wish this was here to read you are brave and courageous for being open in the process even though it is even harder going through with all the roller coaster entails after coming through the other side and being supportive and kind to yourself your able to share this thank you I'm not as strong as you but I thank you again

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    Default Know the risks of D&C's: Asherman's Syndrome

    Thank you Tildy for outlining the options available to women facing this horrible situation. I also thank you for making mention of Asherman's Syndrome as it is a potential risk of having a D&C. I have included my story below which is also a sticky on the IVF thread.

    If you are interested in the full thread it is here:
    http://www.bubhub.com.au/community/f...man-s-Syndrome

    I have recently been diagnosed with Asherman's syndrome after having 2 D&C's post early miscarriage in 2010 and 2011. I was completely unaware of the significant risks of this 'routine' procedure which is carried out by many FS and gynaecologists as a 1st line intervention for miscarriage management and can be acquired after a single procedure including suction evacuation. In fact it can be acquired after any type of gynaecologic surgery, however D&C's are thought to be the most common cause.

    While there are certainly circumstances where a D&C is warranted, particularly if the pregnancy is more advanced, know the risks before you consent to this procedure and ask your doctor about the option of nonsurgical intervention such as misoprostol. if the pregnancy is more advanced, a guided D&C using a hysteroscope will minimise the risks.

    Why is it so risky? Because the procedure consists of blindly (without ultrasound guidance or a hysteroscope) scraping away the top layer of the endometrium (the functional layer) which can vary in thickness between women but is often not thicker than a few millimeters in most parts. It is simply impossible for a doctor to know whether they have scraped too deeply into the basal endometrium which can scar the uterus and in some cases cause permanent damage.

    The following information comes from http://www.ashermans.org/

    What is Asherman's Syndrome?

    Asherman's Syndrome, or intrauterine adhesions/scarring or synechiae, is an acquired uterine condition, characterized by the formation of adhesions (scar tissue) inside the uterus. In many cases the front and back walls of the uterus stick to one another. In other cases, adhesions only occur in a small portion of the uterus. The extent of the adhesions defines whether the case is mild, moderate, or severe. The adhesions can be thin or thick, spotty in location, or confluent. They are usually not vascular, which is an important attribute that helps in treatment. Click here for more on Asherman's Syndrome grades.

    Symptoms

    Most patients with Asherman's Syndrome have scanty or absent periods (amenorrhea) but some have normal periods. Some patients have no periods but feel pain at the time that their period would normally arrive each month. This pain may indicate that menstruation is occurring but the blood cannot exit the uterus because the cervix is blocked by adhesions. Recurrent miscarriage and infertility could also be symptoms (1).

    Causes

    Asherman's syndrome occurs when trauma to the endometrial lining triggers the normal wound-healing process, which causes the damaged areas to fuse together. Most commonly, intrauterine adhesions occur after a dilation and curettage (D&C) that was performed because of a missed or incomplete miscarriage, retained placenta with or without hemorrhage after a delivery, or elective abortion. Pregnancy-related D&Cs have been shown to account for 90% of Asherman's Syndrome cases(2). Sometimes adhesions also occur following other pelvic surgeries such as Cesarean section, surgery to remove fibroids or polyps, or in the developing world, as a result of infections such as genital tuberculosis(3) and schistosomiasis(4).

    There is a 25% risk of developing Asherman's Syndrome from a D&C that is performed 2 to 4 weeks after delivery(5-8). Dilation and Curettages may also lead to Asherman's Syndrome in 30.9% of procedures for missed miscarriages(17) and 6.4% of procedures for incomplete miscarriages(2). The risk of Asherman's Syndrome increases with the number of D&Cs performed; after a single termination the risk is 16%, however, after 3 or more D&Cs, the risk increases to 32%(9). Each case of Asherman's Syndrome is different, and the cause must be determined on a case-by-case basis. In some cases, Asherman's Syndrome may have been caused by an "overly aggressive" D&C. However, this is not often considered to be the case. The placenta may have attached very deeply in the endometrium or fibrotic activity of retained products of conception could have occurred, both of which make it difficult to remove retained tissue. For the most comprehensive information about D&Cs and Asherman's Syndrome, please click here to visit DandCnow.info.

    There is a variant of Asherman's Syndrome called "Unstuck Asherman's or endometrial sclerosis that is more difficult to treat. In this condition, which may coexist with the presence of adhesions, the uterine walls are not stuck together. Instead, the endometrium has been denuded. Although curettage can cause this condition, it is more likely after uterine surgery, such as myomectomy. In these cases the endometrium, or at least its basal layer, has been removed or destroyed.

    Incidence

    Asherman's Syndrome is thought to be under-diagnosed because it is usually undetectable by routine diagnostic procedures such as an ultrasound scan. The condition is estimated to affect 1.5% of women undergoing a hysterosalpingogram (HSG) (10), between 5 and 39% of women with recurrent miscarriage (11-13), and up to 40% of patients who have undergone D&C for retained products of conception following childbirth or incomplete abortion (14) (see Causes above).

    Diagnosis

    Direct visualization of the uterus via Hysteroscopy is the most reliable method for diagnosis. Other methods are sonohysterography (SHG) and hysterosalpingogram (HSG).

    Prevention

    Ideally, prevention is the best solution. It was suggested as early as in 1993 (9) that the incidence of intrauterine adhesions (IUA) might be lower following medical evacuation (eg., misprostol) of the uterus, thus avoiding any intrauterine instrumentation. So far, one study supports this proposal, showing that women who were treated for missed miscarriage with misoprostol did not develop IUA, while 7.7% of those undergoing D&C did(15). The advantage of misoprostol is that is can be used for evacuation not only following miscarriage, but also for retained placenta or hemorrhaging following birth. Alternatively, D&C could be performed under ultrasound guidance rather than blindly. This would ensure that the surgeon stops scraping the lining when all retained tissue has been removed, thereby avoiding injury. Early monitoring during pregnancy to identify miscarriage can prevent the development of, or as the case may be, the reoccurrence of Asherman's Syndrome as adhesions are more likely to occur after a D&C the longer the period after fetal death (2). Therefore, immediate evacuation following fetal death may prevent IUA. There is no evidence to suggest that suction D&C is less likely to result in adhesions than sharp D&C. Cases of Asherman's Syndrome have been reported even following manual vacuum aspiration, (16) and the rate of Asherman's Syndrome has not dropped since the introduction of suction D&C.

    Treatment

    Asherman's Syndrome must be treated by a very experienced surgeon via hysteroscopy (sometimes assisted by laparoscopy) Those few surgeons experienced enough in treating severe Asherman's Syndrome recommend the avoidance of energy sources inside the uterus (this means removing scars with scissors rather than with energy-generating instruments such as resectoscopes or lasers, although not all surgeons agree with this). Adhesions have a tendency to reform, especially in more severe cases. There are different methods to prevent re-scarring after surgery for Asherman´s Syndrome. Many surgeons prescribe estrogen supplementation to stimulate uterine healing and place a splint or balloon to prevent apposition of the walls during the immediate post-operative healing phase. Other surgeons recommend weekly in-office hysteroscopy after the main surgery to cut away any newly formed adhesions. As of yet, studies have not confirmed the method of treatment that is most likely to have a successful outcome, which would be one where the uterus/cervix remains scar-free and fertility is restored.

    Non Reproductive Consequences of Asherman’s Syndrome


    The reproductive consequences of Asherman’s Syndrome, including infertility, recurrent miscarriage, intrauterine growth restriction, placenta accreta and others, are well known. However, for all women with intrauterine scarring and amenorrhea, including those who may have completed childbearing, there are other concerns. Although the lack of menstrual periods could be secondary to hormonal abnormalities, it is more likely caused by either complete destruction of the uterine lining or by obstruction of the cervix or lower portion of the uterus; thus, menses are either retained in the uterus (leading to pelvic pain and a condition called hematometra) or flow into the abdominal cavity leading to endometriosis. Women with Asherman’s Syndrome may develop uterine cancer, either before or after menopause. This risk is NOT increased and may be lower than in the general population. However, the usual warning sign of uterine cancer is excessive uterine bleeding: those with obstructed menstrual flow cannot have that symptom even if they harbor a uterine growth. Therefore, pelvic ultrasound should be a routine part of their annual gynecologic visit.

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    Thank you Starf1sh for your addition to this thread. I knew a little about Asherman's but no where near the detail that you have provided and this is something that needs to be more widely known about. I can only hope that between my base information and valued additions from others like yourself we can cover all the bases and help women to make the best informed choice that they can.

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    Tildy this thread is a very thoughtful idea. I will share my story so hopefully it helps also. In April 2012, I lost twins through a miscarriage. It was a missed miscarriage and I was immediately pushed by my GP to have a D&C. I wanted time to make my decision so asked for a follow up scan a week later. The week later I asked for the tablet to help me miscarry. My GP stated that the D&C was required due to the risk of infection and I had run out of time. It had been roughly 15 days since my twins had stopped living. I had had no bleeding or cramping at all. When I was at the hospital waiting for the surgery, I had a chance to speak with the surgeon. I asked again for Misoprostol, telling her that I would prefer this as my fertility was my primary concern. The surgeon was impatient with me. Explained how rare scar tissue is and how much training they have. I live in Wollongong, NSW. I was asked to fast for my surgery. I waited for nearly 6 hours for my surgery to start. I was not given any medication for any purpose. The D&C was completed, and I had no pain and very minimal bleeding afterwards. Seven months later, I still had not had a period, and started pushing to have Asherman's Syndrome investigated. My period returned in Dec 2012, and lasted for two days of light spotting each month. I was hoping (silly) that perhaps it would take time, but that it would return to normal. A bit of denial here I think. Then in Feb 2013, we fell pregnant! I was so so happy, but scared too. We had a 7+5 scan that showed a little heartbeat. My GP did not consider me high risk, so I had my next scan at 12+1. This scan showed that my lil bubba had dies at 8+1. I had had no bleeding or cramping. No indications at all that something was wrong. At this time, I was very upset, but had switched to protection mode, as I was not going to be bullied again into having a D&C. I demanded that my GP give me Misoprostol. She advised that only the hospital could give to to me. So the next day I presented at my appointment with the Pregnancy Unit. I again declined the 'urgent' D&C that was required, and asked for Misoprostol. Wollongong Public Hospital is NOT licenced to provide the medical management of a miscarriage. The Midwife advised me that I could attend a local Termination/Abortion clinic to have access to medical management. GCA (Gynaecology Centres Australia) in Wollongong offer a procedure for if the pregnancy is less than 9 weeks. The cost was roughly $600 and you had to stay at the centre. They did not specify what medication they were going to use, and if they were 'not happy' with how you progressed, then they completed a D&C without ultrasound. So for myself this was no better an option that the D&C that was offered by Wollongong Hospital. There were no other options open to me in Wollongong. I then decided to call Professor Vancaillie, and asked if he would complete the D&C with ultrasound. He accepted me immediately! I had my initial appointment on Tuesday, where he confirmed from my ultrasound images from December 2012 that I do indeed have Asherman's Syndrome as a result of the D&C in April 2012. He is completing my D&C this Saturday May 25th. I feel safe with him, and am feeling positive about future babies. The main thing that I wanted to state is that Misoprostol is not always readily available. The risks of AS increase if you have a missed miscarriage. Prof V said that this is due to infection. If you do have a D&C I would talk to your GP about antibiotics (I was given none by the hospital in 2012, Prof V has instructed that I start taking them two days before the surgery). I am disgusted that Misoprostol is not available as an option in my area. I choice was effectively taken from me. I am just blessed that Prof V is taking care of me, and that we had the money to do it. Prof V only charges $500 to complete the surgery, but the Hospital costs are around $1500 - $2000. My heart goes out to anyone who is trying to research this information while dealing with the loss of a bubba.

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    MrsBtobe, Thank you so much for sharing your story. You make a really valid point about medical management (misoprostol) not necessarily being available outside of capital cities. It is available at both the Women's Hospitals in Melbourne and Sydney (their guidelines for medical management are published on their websites) and I attached them to the Asherman's thread above. BUT sadly I have still heard of women having to fight with Dr's at these hospitals about having this option made available to them because "Asherman's is such a rare complication" which is complete rubbish!!! And it certainly doesn't feel rare when it happens to you. It makes my blood boil when I hear women being rebuffed in this way by misinformed medicos and having to be strong advocates for their rights when they are at their most vulnerable

    I was also treated by Professor Vancaillie for severe Asherman's following 2 'routine' D&C's after early miscarriages. Because they were early pregnancy losses (approx 8 weeks) I would have been an ideal candidate for misoprostal but it was never mentioned as an option for me and I live in Sydney! It took 3 surgeries with Prof V to clear my uterine cavity of scarring and I count myself as one of the lucky ones as I am now 34 weeks pregnant. I absolutely credit that man with restoring my fertility and also restoring some of my faith in the medical profession after I was also rebuffed for almost a year by my treating Dr when I knew something was seriously wrong.

    I just wanted to also say there are other Asherman's aware Gyno's out there and I know of one in Sydney who runs a private miscarriage management clinic using only guided (not blind) D&C's and he is very familiar with Prof Vancaillie's work in this area. Here is the link: http://www.miscarriagecare.com/.

    MrsB, all the best for your procedure on Saturday and I hope those much wanted babies are just around the corner for you

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