It wasn't there.
Piarulli's experience of miscarriage began differently from that of many women, but after its initial shock, it unfolded in much the same way.
"When it first happened, I felt so alone," she said. "Very soon after, when I was at work and told a couple of friends, all of a sudden people came out of the woodwork."
Those people — co-workers and friends who had never mentioned their miscarriages to Piarulli — shared their stories with her in an expression of solidarity and understanding.
"It was good to hear you're not alone," she said.
A shared sorrow
The statistics around miscarriage can provide their own comfort to those who have lost a pregnancy, reiterating the message that Piarulli heard loud and clear from those near her.
"Most studies suggest the (miscarriage) rate is between 15 percent and 20 percent of all pregnancies," said Dr. Christopher Wagener, an obstetrician and gynecologist with Affinity Medical Group in Appleton.
Dr. Shawn Laibly, an obstetrician and gynecologist with Aurora Health Centers in Neenah and Oshkosh and a fellow of the American College of Obstetrics and Gynecology, said, "Some sources suggest it may go up to 25 percent to 40 percent of pregnancies that are unrecognized."
In other words, many women may miscarry before they even realize that they're pregnant.
In helping their patients cope with a miscarriage, both Wagener and Laibly stress that the occurrence of miscarriage is almost always completely out of a woman's hands.
"If we're talking about first-trimester miscarriage, about 50 percent of the time it's a chromosomal problem. … It's sort of nature's way of taking care of things when the embryo or the fetus wasn't normal," Wagener said. "(My patients) will say, 'What caused this?' Most people are thinking, 'Did I lift something too heavy? Is it because I had sex? Is it because I didn't get enough sleep or because I had one glass of wine before I found out I was pregnant?' It's very unlikely that any of those things people would typically do would cause a miscarriage."
"I make sure the couples know that this was beyond their control," Laibly said. "If you can recognize that … that helps people to move forward."
A natural process, most of the time
When Piarulli's doctor discovered that her embryo was no longer viable, he offered two alternatives: She could choose to let the miscarriage unfold naturally or have a dilatation and curettage, or D&C, to remove the tissue that her body would eliminate eventually.
Distressed by the thought of waiting for a physically and emotionally painful process to occur, she chose to have the medical procedure. While she found completing the necessary paperwork annoying — "I was angry at the world that day," she said — her time in the hospital also yielded positive memories. Most notable was her recognition of the anesthesiologist who cared for her that day.
"I remember looking up and seeing his eyes and saying, 'You gave me my epidural when I had my daughter,'" Piarulli recalled. "And he said, 'And we got you through that, and we're going to get you through this, and then we're going to help you bring the next one in."
While a doctor will want to see a patient who suspects she is having or has had a miscarriage, procedural intervention like Piarulli's is not necessary as a rule.
"We really try to counsel couples, and especially the moms, to try to let this occur naturally," Laibly said.
Typically, heavy bleeding accompanied by intense cramping occurs over the course of a few hours. Following a miscarriage, Laibly said, "(Women) may spot irregularly for a couple of weeks, similar to after they've had a baby."
Persistent bleeding and cramping, sometimes accompanied by fever, pain or lightheadedness, can indicate an incomplete miscarriage. In that case, doctors will perform a D&C, bringing the process to completion to protect the health of the woman.
A hope for the future
Piarulli found her daughter Isabel, 2 at the time of her miscarriage, a great comfort.
"I could look at this little girl and feel good about what I have," she said. "I could say, 'Hey, my body can do this. It did it once.'"
While that's not the case for women who miscarry during their first pregnancy, they can take heart, too.
"(A miscarriage) does put you at risk to have another, but it doesn't change your fertility rate," Laibly said.
That means that for a woman who has been pregnant, the odds of getting pregnant again are good.
Most doctors recommend their patients wait a period of time before trying to conceive again, with their recommendations varying by patient.
"The physical healing usually is quicker than the emotional healing," Wagener said.
Piarulli's doctor told her and her husband, Mike, to hold off for a month before attempting another pregnancy.
"I couldn't wait to try again," said Piarulli, who even wrote the date that they could take their next pregnancy test on the calendar.
Other doctors suggest a more cautious approach. Laibly generally recommends his patients wait three months before attempting another pregnancy.
"First, it allows the uterine lining to go through three cycles and helps some healing occur. Second, it allows a woman to know where she's at in her cycle. And third, there's a certain amount of grieving that goes on for some couples, and it allows them to get through this together," he said.
A grieving process
Mourning the loss of their pregnancy together was an important part of the Piarullis' healing.
"Mike was very, very supportive," Piarulli said of her husband. "On the day of the procedure, he came in and was just holding me and cried with me. It hurt him the same way — not his body like it did mine, but it hurt him just as much. It made it easier to know he was right there with me."
Not every couple will approach their grief in this way.
"Sometimes as a couple, men and women grieve differently, and that can be important for couples to understand," Wagener said. "Sometimes the husband feels like he needs to be the strong one."
In addition to support from her spouse and conversations with friends and family, Piarulli said writing in her journal helped her cope with the loss. "It does help to be able to just write it down," she said.
She also kept a box of mementos of the pregnancy, including cards people sent her and an angel pin she received at the hospital.
And less than a year after that difficult time, Piarulli had the opportunity to start another box of mementos — for her second child, 18-month-old Dominick.
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