Miscarriage and the loss of your baby: Frequently asked questions

I have been told I have an early miscarriage, what support can I get?

A miscarriage affects every woman and her partner differently. It can be a very distressing time and you may experience a range of emotions: a great sense of sadness, anger, guilt, loss and grief after the event. It is important to ensure that you get the emotional support you need to recover. This can be simply talking to family and friends, particularly someone who has also experienced a miscarriage. If you feel you are struggling to cope you should also speak to your GP for advice and support.

Why has this happened to me?

Unfortunately, early miscarriages,(pregnancies lost within the first 12 weeks i.e. first trimester) are very common, 1 in 5 pregnancies. It is not always clear why a miscarriage has happened although the majority of these are thought to be due to abnormalities in the chromosomes (genetic material or DNA) that make up the pregnancy. These are usually random abnormalities that occur at conception meaning the baby is unable to develop normally. A poorly formed placenta can also cause problems. All these problems are unlikely to occur again, and the most likely outcome is that your next pregnancy will survive to birth. There are certain factors that increase the risk of miscarriage that you cannot control, such as getting older. However, medical conditions such as uncontrolled diabetes or thyroid disease, as well as lifestyle factors such as smoking, caffeine intake and your Body Mass Index (BMI) can also increase the risk. These factors can be controlled and it is worth seeing your GP for advice to optimise your chances of a healthy pregnancy in future.

What happens next and what are my management choices?

In some miscarriages, the body recognises that the pregnancy has stopped developing and you start to bleed, which is often associated with tummy pain. For some women there are no symptoms and the diagnosis is only made during a routine ultrasound scan. Your choice of treatment option is guided by the type of miscarriage you have and the advice from your specialist on your personal circumstances.

• If you miscarry early, the pregnancy may naturally and completely come away from the womb, so you have a “complete miscarriage”. This type of miscarriage does not need any treatment.
• An “incomplete miscarriage” is where a miscarriage has started but not all the pregnancy comes away, leaving some pregnancy tissue in the womb.
• A “missed (delayed) miscarriage” is where the baby has died in the womb and the mother often has no symptoms such as pain or bleeding.
• If you have an “incomplete”, “complete” or “missed (delayed) miscarriage” there are potentially up to 3 different management options available. These are:
expectant (watching and waiting for the pregnancy to pass naturally)
medical, or
surgical management.

In some situations, expectant and medical management may be less appropriate, for example if the pregnancy was quite far along before the miscarriage occurred, or if you are at high risk of bleeding, or there are already concerns about infection. You will be given advice by your specialist nurse or doctor on the options that are most appropriate for you. There is also a very small risk of an infection in the womb; this risk is present with all three management options.

Expectant management

This involves watching and waiting to see if the pregnancy passes naturally. This option has the benefit of avoiding any form of intervention. Up to 50% of women may require further intervention later. It also may take some time (up to a few weeks) for the symptoms to start and bleeding can last up to 3 weeks. You will usually be advised to wait up to two weeks, but if you do not have any bleeding by then you may be offered either medication or surgery. The disadvantages of expectant management are the uncertainty of when bleeding will start and the anxiety while waiting. You may notice the pregnancy sac or the fetus being passed along with the blood clots. You will be carefully counselled by your specialist to make sure this option is the right one for you. You should ensure you have sanitary pads, pain relief and support at home to help you cope with managing the symptoms of miscarriage. Should you have any very heavy bleeding with large clots or pain that is not controlled with simple pain relief you should seek urgent medical attention and attend your nearest Accident & Emergency (A&E) department. You should have follow-up with your local Early Pregnancy Unit (EPU). Your EPU will normally arrange to see you again if you do not experience any significant bleeding or continue to bleed beyond 3 weeks, or develop a high temperature/flu-like symptoms. If your symptoms are consistent with having a miscarriage your EPU may ask you perform a urinary pregnancy test three weeks after the miscarriage, or attend for a repeat ultrasound scan to confirm if the miscarriage is complete.

Medical management

This involves taking some medicine to encourage the miscarriage to start. You will need to insert a medication called misoprostol into the vagina (in some circumstances it can also be taken by mouth). Some EPUs offer women an oral pill first called mifepristone and then advise taking the vaginal medication 2 days later. This medication is successful in approximately 80-90% of women. The medication can sometimes cause some side effects including diarrhoea and nausea. You are likely to experience heavy bleeding with clots as well as cramping pain. Should you have very heavy bleeding with large clots or pain that is not controlled with simple pain relief you should seek urgent medical attention and attend A&E. You should inform your local EPU if you do not experience any significant bleeding within the first 48 hours after taking the misoprostol. You will be carefully counselled by your specialist to make sure this option is the right one for you. We recommend that you ensure you have some sanitary pads, pain relief and support at home to help you cope with managing the symptoms. The advantage of this type of management is that it speeds up the miscarriage whilst avoiding the risk of having surgical procedure. In some cases, the medicine is unsuccessful and women are then offered either a repeat tablet or surgery. There is also a small risk of some pregnancy tissue being left behind; most of the time this comes away naturally with the next period, but some women opt to have surgery to have this removed. You should have follow-up with your local early pregnancy unit (EPU). Your EPU will normally arrange to see you again if you do not experience any significant bleeding or develop a high temperature/ flu-like symptoms. If your symptoms are consistent with completing a miscarriage your EPU will ask you perform a urinary pregnancy test three weeks after the miscarriage. If your test is positive or continue to bleed 3 weeks after a miscarriage, you should inform your EPU so they continue to follow-up.

Surgical management

This is what was traditionally known as a “D&C”. It involves gently opening (dilating) the cervix (neck of the womb) to allow a small suction tube to remove the pregnancy tissue from the womb. The tissue may be sent to the hospital lab for them to look at under the microscope to exclude any abnormal pregnancy tissue. You may be given medication prior to the procedure to soften the cervix allowing it to be opened up more easily This procedure can be done under a general anaesthetic (where you would be asleep) or under local anaesthetic known as an MVA (manual vacuum aspiration). This procedure takes approximately 20 minutes. Additional pain relief, such as tablets or “gas and air” (Entonox) may be recommended. The risks involved with surgical management include heavy bleeding, scarring (adhesions) in the lining of the womb and infection. There is a small risk that some pregnancy tissue remains within the womb which may come away naturally by itself or may require a further operation. The most serious possible complication is a making a hole through the womb, but this is very uncommon. After surgery, if your blood group is Rhesus negative, you should be offered an injection called Anti-D to prevent a condition called Rhesus Isoimmunisation. Rhesus isoimmunisation is where your body develops antibodies to your pregnancy because your blood group is different to that of your baby (i.e. your baby’s blood group is Rhesus positive). In future pregnancies the antibodies cross the placenta and attack the blood cells of your Rhesus positive baby; after surgery in early pregnancy Anti-D should be given to help prevent this happening.

What worrying signs should I look out for?

After a miscarriage the bleeding should settle within about two to three weeks. If you are still bleeding after three weeks you should contact your local EPU. If you have any heavy bleeding, severe abdominal pain, fevers or offensive discharge you should contact your early pregnancy unit or attend your local A&E.

What happens after the miscarriage?

Early miscarriages are very common and 1 in 5 women have a miscarriage for no obvious reason. This can be devastating and makes it psychologically harder to try again, as you want to understand why it happened and will it happen again. However, evidence shows most couples still go on to have a successful pregnancy even after two early miscarriages. If you have had three or more early miscarriages (seen in 1% of couples) your GP can refer you for tests and investigations by a specialist to try to understand why the miscarriages are happening and if treatments are available. Unfortunately, after all these investigations it may still not be possible to find out exactly why a miscarriage happened, which is so disappointing; this area is now subject to a lot of research to answer this question. However, despite this, it is still possible to have a successful pregnancy next time, especially if your investigations results are normal.

When can I get pregnant again?

It is important that you wait until your follow up with the Early Pregnancy Unit (EPU) is complete. Your next period should normally come about 4-6 weeks after a miscarriage. Waiting for your next period before starting to try again to conceive is normally advised to help reset your body clock. It is also important to ensure you are emotionally as well as physically ready to embark on a new pregnancy. Emotional recovery often takes longer than your physical recovery.