Early miscarriage

A miscarriage is an unplanned pregnancy loss before 23 weeks. If this happens to you in the first 13 weeks of pregnancy, it is called an early miscarriage. This means that your baby has stopped developing or has died. Most women who have a miscarriage experience vaginal bleeding and/or pain but sometimes there may be no symptoms. If this is the case, the miscarriage may be diagnosed by an ultrasound scan.

In most cases, it is not possible to identify the reason for an early miscarriage. The most common cause is thought to be a problem with the baby’s chromosomes (the genetic structures within the baby’s cells). If this happens, the baby will not develop properly and the pregnancy may end in a miscarriage.

Early miscarriages are very common. Many occur before a woman has missed her first period or before her pregnancy has been confirmed by a positive pregnancy test. In the first 13 weeks, at least one in five women will have a miscarriage.

Some factors can increase the risk of miscarriage such as:

• age – at the age of 30, the risk of miscarriage is one in five; over the age of 40, the risk of miscarriage is one in two
• certain medical conditions such as diabetes
• lifestyle factors such as smoking, being underweight or overweight, excessive alcohol drinking.

There is no evidence that stress or having sex during pregnancy can cause a miscarriage.

Vaginal bleeding and/or pain in the early stages of pregnancy are common and do not always mean that there is a problem. However, sometimes bleeding and/or pain can be a sign of a miscarriage.

If you have any bleeding and/or pain, you can get medical help and advice:

• from your GP or midwife
• from your nearest early pregnancy assessment service. Details of the unit nearest to you can be found at: aepu.org.uk/find-a-unit/
• by calling 111, if you need medical help fast but it’s not an emergency. NHS 111 is a telephone advice service available 24 hours a day, 365 days a year, and calls are free from landlines and from mobile phones
• by calling 999 or going to the emergency department (A&E) at your nearest hospital if you are bleeding heavily, have severe pain or feel very unwell.

An early miscarriage is usually diagnosed by an ultrasound scan. A healthcare professional will offer you either a transvaginal scan (where a probe is gently inserted in your vagina) or a transabdominal scan (where the probe is placed on your abdomen) or both. Both types of scan are safe in pregnancy and do not increase your risk of having a miscarriage.

Your healthcare professional will discuss which type of ultrasound scan is suitable in your situation so that you can make an informed choice. A transvaginal scan may be recommended as it gives a clearer image.

You may be offered blood tests that could include checking the level of your pregnancy hormone (βhCG).

If you have bleeding or pain, your healthcare professional may ask to carry out an examination of your abdomen and/or your vagina using a speculum. An examination will only be done with your consent.

You should be offered a chaperone (another healthcare professional to support you) for an examination or a transvaginal scan. You may also wish to bring someone to accompany you.

For some women, the diagnosis of miscarriage can be made quite quickly but for others the confirmation and ongoing care may take several weeks.

Miscarriages can be described as:

• complete – the scan has found that there is no remaining pregnancy in your uterus
• incomplete – the scan has found some or all of the pregnancy is still in your uterus after having had bleeding
• missed – the scan has found that your pregnancy has stopped developing, but is still within your uterus. You may not have had any bleeding or pain.

If you have had bleeding and your scan shows that you have not had a miscarriage, and you have not had any previous miscarriages, you will be advised to start or continue your usual pregnancy care. If your bleeding gets worse or lasts more than two weeks, you should contact your healthcare professional or the early pregnancy unit again.

However, if you have had bleeding and you have had one or more miscarriages in the past, you will be offered treatment with progesterone. This is medication that you insert into your vagina or anus daily until you are 16 weeks pregnant. Progesterone can reduce the chance of another early miscarriage.

If your ultrasound scan shows that your miscarriage is complete, you may not need any further treatment. Your healthcare professional will ask you to do a urine pregnancy test at home three weeks after your miscarriage. If the test is still positive, you should contact your healthcare professional or the early pregnancy unit (EPU) for further care options.

If the miscarriage is confirmed but some or all of the pregnancy is still inside your uterus (incomplete or missed), your healthcare professional will discuss the options with you. You may choose to wait, to take medication or to have an operation.

Waiting for the miscarriage to happen by itself (expectant management of a miscarriage)

This means waiting for a miscarriage to happen by itself, without treatment. You will have some pain and bleeding as the pregnancy comes out of your uterus. Your healthcare professional may suggest this method for the first 7 to 14 days after diagnosis of your miscarriage. You will be given information on what to expect, pain relief and who to contact if you have severe pain or heavy bleeding, which may mean you need admission to hospital.

Your healthcare professional may offer a repeat scan after the 7 to 14 days of waiting if:

• you have not started bleeding and/or feeling pain
• the bleeding and/or pain are not going away
• the bleeding and/or pain are getting worse.

If the bleeding and pain have settled during the 7 to 14 days, you should do a home urine pregnancy test three weeks after your miscarriage. If it is positive, you should contact your healthcare professional or early pregnancy unit.

If you do not wish to wait for the miscarriage to happen by itself

If you do not wish to wait, your healthcare professional will discuss whether you would like to use medication or have an operation. These options may be more suitable for you and will be discussed with you if:

• you choose not to wait for the miscarriage to happen by itself
• you are at increased risk of bleeding or from the effects of bleeding (for example, an abnormal clotting disorder or are unable to have blood transfusion)
• you may have an infection
• you have previous traumatic experience with pregnancy.

Taking medication (medical management of a miscarriage)

• If you have a missed miscarriage, you will be offered two types of medicine to take 48 hours apart:
• first medicine: mifepristone, taken by mouth
• second medicine: misoprostol, taken by mouth by or inserted into your vagina. The medication helps the cervix to open and lets the remaining pregnancy come out.

For most women, bleeding and pain will start within 48 hours after the second medicine. If it does not start, you should contact your healthcare professional to arrange further investigations and care.

• If your miscarriage is incomplete, you will be offered a single dose of misoprostol. This can be taken by mouth or inserted in your vagina.

When you are taking the medication, you will also be offered pain relief and anti-sickness medication. Some women may have diarrhoea and vomiting. Taking medication to complete a miscarriage does not involve local or general anaesthesia. Your healthcare professional will give you information on what to expect, pain relief and who to contact if you have increased pain or heavy bleeding. You will be advised to take a home urine pregnancy test three weeks after your miscarriage.

You should contact your healthcare professional if:

• the test is positive three weeks after your miscarriage
• you have severe pain
• you have heavy bleeding
• you feel unwell at any time, even if your pregnancy test is negative.

Having an operation (surgical management of a miscarriage)

The operation will be carried out under general or local anaesthesia.

The pregnancy is removed through the cervix. You may be given tablets to swallow or to be inserted in the vagina before the operation to soften your cervix.

Surgery will usually take place within a few days of your miscarriage but you may be advised to have surgery urgently if:

• you are bleeding heavily and continuously
• there are signs of infection.

The operation is safe but there is a small risk of complications including heavy bleeding, infection, or damage to the uterus (womb). A repeat operation is sometimes needed if the first one did not work. The risk of infection is the same if you choose medical or surgical treatment.

If your blood type is rhesus D negative, you will be offered an anti-D injection after your operation. See the NICE patient information Routine antenatal anti-D prophylaxis for women who are rhesus D negative.

For information on recovering after your operation, see the RCOG patient information Recovering from surgical management of a miscarriage.

Your healthcare professional may offer laboratory tests to provide more details about your pregnancy. The results can confirm that the pregnancy was inside the uterus and not an ectopic pregnancy (when the pregnancy is growing outside the uterus). Tests can also find out if there were any abnormal changes in the placenta (molar pregnancy). Your healthcare professional may advise genetic tests if you have had three or more miscarriages.

Options for burial or cremation will be discussed with you depending on your hospital and your own individual circumstances. You can also make your own arrangements through a funeral director or follow regulations for a home burial.

Many hospitals have a book of remembrance. Talk to your healthcare professional about the options at your hospital. Other ways to create a memory are available through Miscarriage UK’s Memorial Certificate, Baby Loss Certificate in England and The Memorial Book in Scotland.

Vaginal bleeding

You can have some vaginal bleeding for one to two weeks after your miscarriage. This is like a heavy period for the first day or so. This should lessen and may become brown in colour. You will be advised to use pads rather than tampons, as using tampons could increase the risk of infection.

If you normally have regular periods, your next period will usually be in four to six weeks’ time. You can return to using tampons then. Ovulation can happen before this, so you can get pregnant in the first month after a miscarriage. Therefore, if you do not wish to become pregnant, you should consider using contraception.

Pain

You can expect some pain and cramping in your lower abdomen on the day of your miscarriage. You may get milder cramps or pain for a day or so afterwards. You can take painkillers to relieve the pain.

If you experience the following symptoms, you should seek medical advice from your GP, early pregnancy assessment service or the hospital where you had your care, or call NHS 111:

• heavy or prolonged vaginal bleeding
• smelly vaginal discharge
• abdominal pain not relieved by painkillers
• nausea and vomiting
• feeling unwell.

These symptoms may mean you have an infection of the lining of the uterus. It occurs in 2 to 3 in 100 women and can be treated with antibiotics. It may also mean that some of the pregnancy is still inside your uterus.

If you had an operation, these symptoms can sometimes mean there was a complication from the operation where there is a damage to the uterus. This is very rare, occurring less than 1 in 200 women.

Emotional recovery

A miscarriage affects every woman differently and can be devastating for partners, friends and family too. Some women come to terms with what has happened within weeks; for others, it takes longer. Many women feel tearful and emotional afterwards. Some women experience intense grief.

There is support for you, your family and friends. Talking to your family and friends may be helpful. Talk to your GP if you feel you are not coping and need support with your mental health. You can find further information and support from:

• Miscarriage UK
• NHS Choices
• Tommy’s
• Sands.

Returning to work

When you return to work depends on you and how you feel both physically and emotionally. It is advisable to rest for a few days. Speak to your GP or occupational health adviser if you need further advice

Having sex

You can have sex as soon as you feel physically and emotionally ready. It is important that you are feeling well and that any pain and bleeding has significantly reduced. If you don’t want to become pregnant, consider using contraception.

You can try for a baby as soon as you and your partner feel physically and emotionally ready.

You are not at higher risk of another miscarriage if you have had one or two early miscarriages. There is a good chance of having a healthy pregnancy in the future.

A very small number of women have a condition that makes them more likely to miscarry. If this is the case, medication may help. For further information, see the RCOG patient information Recurrent miscarriage.

If you are planning to have a baby, you should:

• take folic acid every day from when you start trying until 12 weeks of pregnancy to reduce the risk of your baby being born with a neural tube defect (spina bifida)
• be as healthy as you can – eat a balanced diet and stop smoking
• not drink alcohol as this may increase your chance of miscarriage (see the UK Chief Medical Officers’ Low Risk Drinking Guidelines.