If you lose a baby before 22 weeks of pregnancy, it is called a miscarriage. If this happens in the first 3 months of pregnancy, it is known as an early miscarriage. It may be accompanied by vaginal bleeding and pain.

Many early miscarriages occur before a woman has missed her first period or before her pregnancy has been confirmed. Once you have had a positive pregnancy test, there is around a one in five (20%) risk of having a miscarriage in the first three months. Most miscarriages occur as a ‘one-off’ (sporadic) event and there is a good chance of having a successful pregnancy in the future.

Late miscarriages, after 3 months of pregnancy but before 22 weeks, are less common: 1–2 in 100 (1–2%) pregnancies end in a late miscarriage.

When a miscarriage happens three or more times in a row, it is called a recurrent miscarriage. Recurrent miscarriage affects 1 in 100 (1%) couples trying to have a baby.

How is a miscarriage diagnosed?

Ultrasound is used for the diagnosis. We may need to repeat the ultrasound in 1-2 weeks to confirm the diagnosis.

Why do miscarriages occur?

Much is still unknown about why early miscarriages occur. The most common cause is chromosome problems. In order to grow and develop normally, a baby needs a precise number of chromosomes. If there are too few or too many chromosomes, the pregnancy may end in a miscarriage.

What is the risk of having a miscarriage?

The risk of miscarriage is increased by:

• A woman’s age – the risk of early miscarriage increases with age. At the age of 30, the risk of miscarriage is one in five (20%). At the age of 42, the risk of miscarriage is one in two (50%).
• Blood-related marriages increase the risk of chromosomal and genetic problems and hence increases the risk of miscarriage.
• Health problems – as an example, poorly controlled diabetes or thyroid disorder, can increase the risk of a miscarriage.
• Lifestyle factors – smoking and alcohol are linked with miscarriage.

• There is no scientific evidence to show that stress causes a miscarriage.
• Sex during pregnancy is not harmful and is not associated with early miscarriage.
• There is no treatment to prevent a miscarriage.

Causes of late miscarriage (> 3 months and <22 weeks)

• The weakness of the cervix is known to be a cause of miscarriage from 14 to 22 weeks of pregnancy. This can be difficult to diagnose when you are not pregnant. It may be suspected if in a previous pregnancy your water broke early, or if the neck of the womb opened without any pain.
• Conditions which causes the blood to clot more can cause recurrent and late miscarriage and tests can help us treat the condition before planning the next pregnancy.

What happens if it is a miscarriage in the first 3 months of pregnancy?

If the miscarriage has completed, you will not need any further treatment.

If the miscarriage has not completed, there is a range of options available.

What are my choices?

You may choose to have an operation, or you may prefer to let nature take its course or take tablets to start the process.

Letting nature take its course (expectant management)

Expectant management is successful in 50 out of 100 women (50%). It can take time before bleeding starts and it is normal for the bleeding to continue for up to three weeks. Bleeding may be heavier than normal and you may experience cramping pain. Very occasionally, emergency admission for heavy bleeding or severe pain is necessary. If bleeding does not start or the miscarriage has not completed, you will be offered the option of taking tablets or having an operation.

Taking tablets (medical treatment)

You will either be given tablets to swallow, dissolve under the tongue, or medication to insert into the vagina, which allows the entrance of the womb (cervix) to open and pass the pregnancy. This usually takes a few hours and there is some pain with bleeding or clotting (like a heavy period). You can take pain-relieving drugs. After the treatment, you may bleed for up to three weeks. If treatment does not work, or the miscarriage has not completed, you will be given the option of having an operation. Medical treatment is successful in 85 out of 100 women (85%) and avoids a general anesthetic. You will often only need to be in the hospital for a few hours and can then go home. However, there is a risk of heavy bleeding and the need for emergency admission to hospital.

Having an operation (surgical treatment)

The operation is usually carried out under general anesthetic, Surgery is usually arranged as a planned operation, usually within a few days. Surgical treatment is successful in 95 out of 100 women (95%).
You may be advised to have surgery immediately if:

• you are bleeding heavily and continuously
• the miscarriage is infected
• expectant or medical management is unsuccessful.

The cervix is gently opened and the pregnancy tissue removed by the use of a suction device. You may be given tablets to swallow or vaginal pessaries before the operation to soften the cervix and make the operation easier and safer. This operation is called D&C (dilatation and curettage).

The operation is safe, but there is a small risk of complications. These complications do not happen very often. They can include heavy bleeding (hemorrhage), infection, a repeat operation if not all the pregnancy tissue is removed and, less commonly, perforation (tear) of the womb that may need repair. The risk of infection is the same if you choose medical or surgical treatment.

What can I expect after this operation?

Length of stay in hospital

This operation is done as a day case, which means that you can go home on the same day. Most modern anesthetics are short-lasting. You should not have, or suffer from, any after-effects for more than a day after your operation. During the first 24 hours, you may feel more sleepy than usual and your judgment may be impaired. If you drink any alcohol, it will affect you more than normal. You should have an adult with you during this time and you should not drive or make any important decisions. The adult should be above 18 years of age.

Vaginal bleeding

You can expect to have some vaginal bleeding for one to two weeks after your operation. This may be like a heavy period for the first day or so. This should lessen and may become brown in colour.

Discomfort

You can expect some cramps (similar to strong period pains) in your lower abdomen on the day of the operation. You may get milder cramps or an ache for a day or so afterwards. When leaving the hospital, you should be provided with painkillers to reduce any discomfort.

When should I come to the hospital?

You should attend the Women’s Urgent Care Clinic if you:

• are worried about the amount of bleeding
• are worried about the amount of pain you are in and the pain-relieving drugs are not helping
• have a smelly vaginal discharge
• get shivers or flu-like symptoms
• are feeling faint
• have pain in your shoulders.
• painful heavy hot leg, difficulty bearing weight
• burning or stinging in urine

Burial

If you pass the fetus spontaneously and there are any features of a baby, which can be identified, a burial will be arranged, however, when a surgical procedure like D&C is done, the fetus is not identifiable and the parents are not shown anything.

Are there any tests?

It may be required for some tissue removed at the time of surgery to be sent for analysis in the laboratory. The results may confirm that the pregnancy was inside the womb and not an ectopic pregnancy (when the pregnancy is growing outside the womb). It also tests for any abnormal changes in the placenta (molar pregnancy). You may miscarry at home. In this situation, some women choose to bring any tissue to the hospital so that it can be analyzed.

Will the tests find out the reason for the miscarriage?

Further tests to find out if there is a treatable cause for the miscarriage are not routine unless you have had three miscarriages in a row or a miscarriage after 12 weeks.

What happens next?

To reduce the chance of infection, sanitary towels are advised rather than tampons until the bleeding has stopped. You may also be advised to wait until you have stopped bleeding before you have sex. Your next period will be in four to six weeks time. Ovulation occurs before this, so you are fertile in the first month after a miscarriage. If you do not want to become pregnant, you should use contraception. Waiting for a period allows for better dealing of the pregnancy if you do get pregnant and gives you some time to come to terms with the loss. Making sense of what has happened can take time. You and your partner should be offered a follow-up appointment with a member of the healthcare team.

When can we try for another baby?

The best time to try again is when you and your partner feel physically and emotionally ready. In some cases, it may be best to wait 6 months (ex: late miscarriage).

How will I feel?

Losing a pregnancy is a deeply personal experience that affects everyone differently. It can affect the woman, her partner, and others in the family. Many women grieve, but come to terms with their loss. Other women feel overwhelmed and find it difficult to cope. Physical symptoms such as fatigue, loss of appetite, difficulty concentrating and trouble sleeping can be signs of emotional distress. Some women feel fine initially and only later do they experience difficulties. Many men feel similar distress.

Many women experience a profound sense of loss and disappointment. They experience feelings of shock and sadness and anger and can find it difficult to accept their loss. Other women experience a sense of relief. These emotions are common and will pass with time and good support. Other women experience feelings of guilt, blaming themselves for what they did or did not do. Some women find it hard to move on without knowing the exact cause of their miscarriage. Others are consoled by the fact that their miscarriage was a chance event and once the process had started, nothing could have been done to prevent it. Some women want to talk about their experience. Others find this too painful. You should be given all the time you need to grieve. Talking about how you feel with your healthcare professional can help.