Articles

Key takeaways

● A miscarriage is the loss of a pregnancy before 24 weeks of gestation

● Around 1 in 5 pregnancies end in miscarriage.

● You have options for care: expectant, medical, or surgical management.

● Support is available for your physical and emotional recovery.

Understanding miscarriage and what to expect

A miscarriage is the loss of a pregnancy during the first 23 weeks. It is estimated that around 1 in 8 known pregnancies end in miscarriage. In the first three months, 1 in 5 pregnancies may end in an early miscarriage.

Types of miscarriage

There are several types of early miscarriage and pregnancy loss. These include chemical pregnancy, a missed miscarriage, incomplete or complete miscarriage. Ectopic pregnancy and molar pregnancy are also types of early pregnancy loss.

● Chemical pregnancy – A very early pregnancy loss. A pregnancy test is positive, but the pregnancy ends before it can be seen on an ultrasound scan.

● Missed miscarriage – The pregnancy has ended, but there are no symptoms such as bleeding or pain.

● Incomplete miscarriage – A miscarriage starts, but some pregnancy tissue remains in the womb.

● Complete miscarriage – All of the pregnancy tissue has passed from the womb.

● Ectopic pregnancy – The pregnancy develops outside of the womb, usually in the fallopian tube.

● Molar pregnancy – Abnormal tissue grows in the womb instead of a healthy pregnancy.

Signs of a miscarriage

Symptoms of a miscarriage include vaginal bleeding. You may also experience cramping and pain in your lower abdomen. Bleeding can vary from light spotting or brown discharge to a heavier bleed. This may be heavier than your normal period.

Other signs of miscarriage include a gush of fluid from your vagina. You might also pass tissue from your vagina, which may look lumpy or stringy.

A sudden loss of pregnancy symptoms, such as feeling sick and tender breasts, can also be a sign. It is worth remembering this can also be normal, as symptoms can gradually get better or disappear as you move into your second trimester.

Continuous low abdominal pain or backache that is not relieved by normal pain relief is a reason to contact your midwife. If your symptoms are severe, you should go to the Accident and Emergency department (A&E).

Diagnosing miscarriage

If you have any bleeding during your pregnancy, contact your GP or midwife straight away. If you have symptoms of a miscarriage, you will usually be referred to a hospital for tests.

An ultrasound scan can often check if you are having a miscarriage. The most accurate scan is an internal one, where a small probe is placed inside your vagina (a transvaginal scan). You may also be offered blood tests. If these tests don't give a clear answer, they may be repeated after a couple of weeks.

Understanding scan results

Sometimes, a pregnancy cannot be seen on an ultrasound scan, even with a positive pregnancy test. This is called a pregnancy of unknown location (PUL). The pregnancy could be in the right place but very small/early. It might also be an ectopic pregnancy growing outside the womb. Or, the miscarriage may have already finished.

To find out what has happened, further tests are carried out. Blood tests may be done 48 hours apart to look for changes in pregnancy hormones. If a miscarriage is confirmed, you will discuss your management options with your doctor or midwife.

Your options for care and management

You have three main options for your care after a miscarriage is confirmed. These are expectant, medical, or surgical management.

Expectant management

Expectant management means waiting for a miscarriage to happen naturally. You do not need to stay in hospital for this.

This option may be suitable if you prefer to avoid medicine or have surgery. It may also suit you if you are comfortable with some waiting and uncertainty.

Expectant management may not be recommended if you have a higher risk of heavy bleeding. This might be the case if you've had a heavy bleeding in a previous pregnancy, or if you cannot have a blood transfusion. It is also not recommended if you have signs of infection.

What to expect with expectant management

There is no way to know exactly when the pregnancy tissue will pass. If nothing has happened after 14 days, you will usually be asked to return to the hospital or Early Pregnancy Assessment Unit (EPAU).

When the miscarriage starts, you will usually have pain and cramping. This can be stronger than period pain. Some women describe it as similar to early labour pain or contractions.

You will have vaginal bleeding, which can be heavy. You may also pass large blood clots and tissue. Passing the pregnancy tissue can be upsetting, especially if you are not expecting it.

Expectant management is successful for about half of women. This means that for about half of women, the miscarriage doesn't complete on its own. They will then be offered another type of management.

About 1 to 3 in 100 women who have expectant management will develop an infection. About 2 in 100 women will have heavy bleeding and may need an emergency treatment.

Medical management

Medical management uses medicine to help the pregnancy tissue leave your womb. The tissue passes through the cervix and vagina. This is the same process as a natural miscarriage.

This option may be preferred if you do not want to wait for the miscarriage to happen naturally, and if you want to avoid surgery. Doctors may suggest medical management if the miscarriage has not completed after 14 days of expectant management.

It can also be an option for an incomplete miscarriage, where some tissue remains. If you have an incomplete miscarriage, you will be given misoprostol. This is usually given as vaginal or oral tablets. This medicine helps the neck of the womb (cervix) to open. This allows the pregnancy tissue to come away.

For a missed miscarriage, some hospitals will recommend giving an oral tablet called mifepristone first. Misoprostol is given 48 hours later as a vaginal pessary. Combining these medicines makes the treatment more likely to work.

What to expect during medical management

Bleeding will usually start a few hours after taking the medicine. You will feel pain and cramping, sometimes stronger than period pain. The pain can sometimes feel stronger than with expectant management, so it's a good idea to talk to your care team about pain relief options.

As with expectant management, you may have heavy bleeding and you should pass the pregnancy tissue vaginally.

Medical management is successful for about 85 in 100 women. About 1 to 3 in 100 women who have medical management will develop an infection. About 2 in 100 women will have severe bleeding (a haemorrhage) and may need an emergency operation. If the treatment does not work, you will be offered an operation.

Surgical management

Surgical management involves surgery to remove the pregnancy tissue. This is done through your cervix using a suction device. This is usually a planned operation. It can be done under general anaesthetic, where you are asleep. It can also be done using local anaesthetic, where you are awake.

Surgery may be advised if you are bleeding heavily and continuously. It may also be advised if there are signs of infection, or if medical treatment has been unsuccessful.

During the operation, your cervix will be gently opened. The pregnancy tissue will then be removed.

Surgical management works for 95 out of 100 women. If it does not work, you may need a second surgery.

Risks of surgical management

Surgical management is a safe procedure for most women. Like all surgery, it has some risks, though these are uncommon. Your doctor will explain them before the operation. There is also a small extra risk from having a general anaesthetic.

Out of every 100 women who have this surgery:

● Around 95 women will not need further management.

● Around 5 women will need a second surgery because the first is not fully successful.

● Between 1 and 3 women will develop an infection.

● Between 16 and 18 women will have some scar tissue (intrauterine adhesions) in their womb.

● Around 2 women will have severe womb scarring.

● Around 1 in 1000 women will have an accidental hole (perforation) made in their womb.

● Around 5 in 1000 women will have an injury to the cervix, which is the entrance to the womb.

● Between 1 and 2 in 1000 women will need a blood transfusion.

Investigations for recurrent miscarriage

Having three or more early miscarriages is known as recurrent miscarriage. This applies even if you have had successful pregnancies in between. The NHS generally refers you to a miscarriage specialist after three early miscarriages or one late miscarriage.

Tests are available to try and find out why you have had multiple pregnancy losses. However, these tests may not always find a reason. Sadly, most cases of recurrent miscarriage are unexplained.

What tests are done?

If you have had recurrent miscarriages, you may be offered tests on the pregnancy tissue.

These tests check for abnormalities in the fetal chromosomes. Chromosomes carry genetic information. These changes can help explain why miscarriages happen.

If an abnormal result is found, it may have happened by chance, rather than being inherited from either parent. If there is a chance it was inherited, you may be offered further testing. This is called parental karyotyping. It checks the chromosomes of both parents.

Further diagnostic tests

A transvaginal ultrasound can check your womb for any structural abnormalities. This scan uses a small probe placed inside the vagina.

This scan may also be offered after a later pregnancy loss, such as in the second trimester or after a previous preterm birth. This scan checks the cervix in future pregnancies. A short cervix may increase the risk of pregnancy complications. If needed, treatment options may involve a medicine called progesterone or a cervical stitch.

What to expect during and after a miscarriage

Bleeding

Most women have vaginal bleeding during a miscarriage. The amount often depends on how many weeks pregnant you were. It can be very heavy at first.

Bleeding is usually heaviest for the first few days. It then normally becomes lighter, and stops within 2 to 3 weeks.

You may pass blood clots and pregnancy tissue. Bleeding can last 1 to 4 weeks after the pregnancy has passed. It should become lighter and may become brown before stopping.

Your period may return within 4 to 6 weeks.

Use sanitary towels or period pants instead of tampons or menstrual cups. This helps to reduce the risk of infection.

Pain and cramping

You will likely have some cramps in your lower abdomen. These can feel like strong period pain. This is from the womb contracting to help the tissue pass. Simple pain relief such as paracetamol and ibuprofen can help.

When to seek urgent help

Contact your Early Pregnancy Assessment Unit (EPAU) or A&E in the following situations:

● The bleeding makes you feel unwell, dizzy, or faint.

● You are soaking through more than two heavy sanitary pads per hour for over three hours.

● You develop a fever.

● You experience severe pain or cramping that is not controlled with pain relief.

● You have heavy, long-lasting, or smelly vaginal bleeding. This may be a sign of infection, especially if you also have a fever or flu-like symptoms.

● Worsening abdominal pain, as this may be a sign of a womb injury, especially accompanied by a fever, loss of appetite, or vomiting.

● You experience burning and stinging when you pass urine, or need to pass urine more frequently. This could be a urine infection, which may need antibiotics.

● Your leg becomes painful, red, swollen, hot, or you have difficulty standing. This could be a deep vein thrombosis (DVT).

Physical and emotional recovery

Supporting your physical recovery

Generally, your physical recovery depends on your health before the miscarriage. Looking after your general health can help your body to recover.

Gentle self-care, like eating a balanced diet, can help your body heal. If you smoke, getting support to stop can also help your body to recover.

You may find it helpful to ask for support from family and friends. This could include help with shopping, cleaning and cooking.

You can return to exercise when you feel ready. Listen to your body and stop and rest if you experience pain.

Emotional recovery

A miscarriage can be a very difficult experience. You may feel a mix of emotions. These can include sadness, shock, and grief. You might also feel guilt, anger, or resentment.

Hormone changes after a miscarriage can also affect your mood. Everyone experiences loss differently, and there is no right or wrong way to feel.

Grief is a normal human response after a loss. Allow yourself time to process what has happened. You and your partner may grieve in different ways. Some people want to talk about their feelings. Others find it difficult to express how they feel.

Some people find it comforting to create memories of their pregnancy. Others find it helpful to talk about the loss, write in a journal or connect with support groups.

If your feelings become overwhelming, extra support may help.

Seeking support for emotional recovery

If you have a partner, try to support each other. Remember that you may have different feelings and ways of coping.

Support is available through online communities, support groups, and helplines. Professional counselling can also help, either alone or as a couple. Your GP can discuss local support services and referral options.

Emotional stress can leave you feeling very tired and may affect your sleep. Speak to your GP if you are struggling to sleep, or are finding it difficult to cope.

Practical support

More workplaces are recognising the need for support after a miscarriage. You may feel ready to return to work quickly, or you may need time off to recover.

Some employers have specific miscarriage policies. These may include paid leave or other support. Speak to your manager or HR to find out what is available.

If your workplace does not have a specific policy, you may still be entitled to take sick leave. Any leave taken after a miscarriage should be recorded as pregnancy-related leave, which is separate from other sickness leave. A doctor can provide a fit note if needed.

The Equality Act 2010 protects women against discrimination related to pregnancy. If you feel you have been treated unfairly, seek advice as soon as possible.

Returning to work and relationships

Give yourself time to adjust to being back at work. You may feel tired, or find it difficult to concentrate. Grief can change from day to day.

Some people find a phased return helpful. Others may prefer temporary changes to their duties or working pattern, such as working from home.

Certain situations at work may feel challenging after a miscarriage. If you feel comfortable, discussing any concerns with your manager or HR could be helpful.

Losing a pregnancy can put pressure on your relationship. It may take time for you or your partner to be ready for intimacy again. Talking together and being kind to each other can help.

You and your partner might want to wait for any test results before making decisions about the future. When you feel ready, some resources can offer personalised information and support. For example, the Tommy's Miscarriage Support Tool provides personalised information based on your history.