Early Miscarriage

Miscarriage means the loss of a baby in the first 23 weeks of pregnancy, with early miscarriage being the loss of a baby in the first 12 weeks. Unfortunately, miscarriage is common: about 25% of all pregnancies (one in four) end in a miscarriage. Sadly early miscarriage can at times happen before you even know that you are pregnant with perhaps as many as three-quarters of all fertilised eggs lost in the very earliest days of pregnancy.

How can I tell if I am having a miscarriage?

When your baby has died, usually your body recognises the loss and your cervix (neck of the womb) opens. This is associated with vaginal bleeding and lower abdominal (tummy) pain, the most common symptoms of miscarriage. This process allows the pregnancy tissue including the baby (which may be called an embryo or fetus depending on the stage of the pregnancy); the placenta (afterbirth); and the sac around the baby to pass out of the womb. Some women have no symptoms (called a missed miscarriage which is explained below).

Vaginal bleeding with a miscarriage can vary from brown discharge to heavy bleeding with fresh red blood and clots. The pain with a miscarriage is often crampy and can be mild or severe. Some women also notice that they stop feeling pregnant, for example stopping experiencing early pregnancy symptoms such as feeling sick or having tender breasts. You may also notice a discharge of fluid from the vagina (if the sac around the baby bursts) or some pregnancy tissue. Not all women will be able to tell that they have passed their baby. Other pregnancy tissue can look like a spongy blood clot. It may be a different colour from the other clots you have passed. If you think you have passed any pregnancy tissue it is useful to keep it to show to a health professional, you can wrap it in a sanitary pad. If you think you have passed some tissue into the toilet you do not need to retrieve it.

Unfortunately, it can be difficult for you to tell if you are having a miscarriage. Vaginal bleeding and lower abdominal pain are common in early pregnancy and do not always mean you are having a miscarriage, for example it can be normal to have light bleeding (also called spotting) at the time of implantation when the baby attaches to your womb. However you should always report pain and bleeding to a health professional who will decide if you need further investigations. Abdominal pain and vaginal bleeding can also be due to an ectopic pregnancy (see medical terms). Early pregnancy symptoms can vary, so if you stop experiencing a particular symptom it does not necessarily mean you have had a miscarriage, but ask a health professional if you are concerned.

What should I do if I think I am having a miscarriage?

You should contact a health professional if you are pregnant and experience any of the symptoms of miscarriage. You can get help and advice from:

  • Your GP
  • Your community midwife
  • Accident and Emergency (also called casualty or the emergency department) at your local hospital
  • NHS 111
  • NHS Choices website
  • Your obstetrician or gynaecologist (if you have one)
  • Your local early pregnancy assessment service or out-of-hours gynaecology service
  • Your local maternity unit

What will happen next?

You may be referred to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) or you may be reviewed by a health professional first.

Whoever reviews you will ask you about your symptoms; your current and any previous pregnancies; and your medical history. You will usually be offered a urine pregnancy test. The health professional may ask to examine you which may involve having you pulse and blood pressure checked; an examination of your abdomen; and a vaginal examination. A vaginal examination will involve the professional inserting a speculum (an instrument to open up the vaginal walls) and looking at your cervix. This examination is to check where the bleeding is coming from; how much you are bleeding; and to see if your cervix has opened up at all. She / he may ask to take a swab to check for infections such as chlamydia. The professional may also ask to perform an internal vaginal examination to look for signs of an ectopic pregnancy. Having a vaginal examination is safe in early pregnancy and will not cause you to have a miscarriage. Usually a health professional will not be able to tell you whether or not you have had a miscarriage just from examining you but sometimes, if they are able to see pregnancy tissue, they may be able to tell that you have already had a miscarriage.

If you are more than six weeks pregnant (or you are unsure how many weeks pregnant you are) and you are bleeding or are in pain you will be referred to an early pregnancy assessment service or out-of-hours gynaecology service.

If you are less than six weeks pregnant, have vaginal bleeding but are not in pain you may not be referred but will be advised to repeat a urine pregnancy test after seven to 10 days and return if it is positive or if your symptoms get worse. If the repeat pregnancy test is negative, this means you have miscarried.

Referral to an early pregnancy assessment service

If you are referred to an early pregnancy assessment service or out-of- hours gynaecology service you will be offered a transvaginal ultrasound scan (either immediately or at the next available time) to check the location of the pregnancy (whether it is in your womb or if you may have an ectopic pregnancy); the size of the pregnancy and whether there is a heartbeat. This is an internal scan that examines your womb and pelvis through the vagina. It is more likely to diagnose miscarriage and ectopic pregnancy than an abdominal scan. An internal scan is safe in pregnancy and will not harm your baby or cause a miscarriage.

It may not be possible to diagnose miscarriage from one scan only so you may be advised to return for another scan. This is usually if the first scan shows a very early pregnancy and it is uncertain whether it is still growing or if you have miscarried. You will usually be asked to return after at least seven days. This is because it is not possible to diagnose a miscarriage with certainty in a shorter time, as pregnancies may grow at different rates and having a repeat scan too soon may suggest you have had a miscarriage when you have not. Waiting for a repeat scan will not affect whether or not you have a miscarriage but you should follow advice you are given about contacting the early pregnancy assessment service if your symptoms get worse in between.

Types of early pregnancy loss and medical terms

Threatened miscarriage

This is the medical term for when you have vaginal bleeding or abdominal pain but your pregnancy is continuing (referred to as viable on scan).

Incomplete miscarriage

This is the medical term for when you have started to have a miscarriage but there is still some pregnancy tissue in your womb. A health professional will discuss options for treatment with you (see below).

Complete miscarriage

This is the medical term for when you have passed all the pregnancy tissue and the womb is empty on scan. You may still have some bleeding that should settle over the next two weeks.

Missed miscarriage

This is the medical term for when your pregnancy has stopped developing but is still inside the womb. You may have no symptoms and this is diagnosed on scan.

Anembryonic pregnancy or empty sac

This is the medical term for when a pregnancy stops developing very early and only an empty pregnancy sac can be seen on scan.

Treatment options

Threatened miscarriage

If the ultrasound scan shows that you have a pregnancy inside of the womb and the baby has a heartbeat, you do not need any further investigations and should continue routine antenatal care. You should return if your bleeding gets worse or lasts for more than two weeks as this may mean you have gone on to have a miscarriage. There is no medical evidence to show that bed rest or anything else you can do will decrease your risk of miscarrying if you are bleeding. However, you should listen to your body and only do what you feel up to at this time.

Confirmed miscarriage

If an ultrasound scan confirms that you have had a miscarriage a health professional will discuss treatment options with you. You may decide what treatment you prefer immediately or you may need some more time to decide. It is usually safe to wait to make a decision unless you are bleeding heavily or have signs of an infection so the health professional will advise you about this.

Expectant management

Current guidelines recommend that most women should be offered expectant management for the first 7 to 14 days after miscarriage has been diagnosed. Expectant management involves having no active treatment and waiting for the miscarriage to complete naturally. This will involve delivering the baby and other pregnancy tissue at home. The size of the baby and the amount of pregnancy tissue, bleeding and pain you may experience will vary depending on how many weeks pregnant you were or how much tissue was seen on the scan if you had an incomplete miscarriage. You should ask the health professional looking after you what you are likely to expect. They will also provide you with information including whom to contact if you have any concerns or worries. Some units may ask you to take any pregnancy tissue you pass back to the hospital for examination (see above for a description of what you might see).

This is not recommended in current guidelines and you do not need to worry if you are unable to recognize any pregnancy tissue or if you think you have passed it into the toilet. If you want to take it back to the hospital you should wrap it in a sanitary pad and take it to the hospital as soon as possible as it may become infected. You should wash your hands after handling anything you think may be pregnancy tissue as well as before and after changing your pads.

Bleeding during expectant management can be heavy and you should contact the early pregnancy assessment service if you are soaking through pads or are worried. You should not use tampons as these may increase the risk of you getting an infection. Pain can vary from woman to woman. Some women experience milder crampy pain whereas others have pain similar to contractions. If you need to take pain relief you can take whatever over-the-counter pain relief you normally use. If you need stronger pain relief you will be able to get a prescription from the early pregnancy assessment service.

Most women will not need any further treatment following expectant management. If your bleeding and pain stop after 7 to 14 days this suggests that the miscarriage is complete and you may be asked to take a urine pregnancy test after three weeks. If this is negative this confirms the miscarriage is complete. If this is positive you need to contact the early pregnancy assessment unit to arrange further investigations and treatment incase you have persistent pregnancy tissue.

If after 7 to 14 days the pain and bleeding have not stopped or are getting worse (or if you have had a missed miscarriage and they have not started) you should contact your local early pregnancy assessment service for further advice. Routinely, they would advise you to attend the unit to be assessed and offer a repeat ultrasound scan. If the repeat scan shows you have an incomplete miscarriage, a health professional will discuss all treatment options (continued expectant management, medical management, and surgical management) with you. It is completely acceptable, if you prefer, to choose to continue expectant management and would not cause any harm to you or your womb. You may be asked to return for a routine review after another 14 days. If your symptoms worsen or you show signs of infection such as a high fever or smelly discharge, you should contact your local unit to be reviewed sooner.
Other treatment options will be explored with you if your medical history means that expectant management is not the best option for you or if you do not want to try expectant management.

Frequent risks of expectant management include:

  • Bleeding that lasts up to two weeks (up to all women)
  • Need for unplanned (emergency) treatment (35 per 100 women)
  • Pelvic infection (2-3 in 100 women)

Medical management

Medical management involves taking medication (either in the vagina or by mouth if you prefer) to hasten the process of the miscarriage. Side effects of the medications used can include pain, diarrhoea and vomiting. Prior to treatment, you would be advised whether you would need to stay in hospital or whether you could go home after you have taken the medication. You will also be given advice about pain relief, anti-sickness medication and whom to contact if you go home and have not started to bleed 24 hours after treatment, to plan your subsequent care.

You will deliver the baby and other pregnancy tissue following taking the medication. The time this takes is variable. The size of the baby and the amount of pregnancy tissue, bleeding and pain you may experience will also vary depending on how many weeks pregnant you were or how much tissue was seen on the scan, if you had an incomplete miscarriage. You should ask the health professional looking after you what you are likely to expect.

Both the amount of bleeding and pain can vary from woman to woman. Bleeding can be heavy and you should contact the early pregnancy assessment service if you are soaking though pads or are worried. Bleeding may last for up to 14 days following medical management. Some women experience milder crampy pain whereas others have pain similar to contractions.

If your bleeding and pain stop after medical management this suggests that your miscarriage is complete and you may be asked to take a urine pregnancy test after three weeks. If this is negative this confirms the miscarriage is complete. If this is positive you need to contact the early pregnancy assessment unit to arrange further investigations and treatment incase you have persistent pregnancy tissue.

Frequent risks of medical management include:

  • Bleeding that lasts up to two weeks (up to all women)
  • Need for unplanned (emergency) treatment (21 per 100 women)
  • Pelvic infection (2 in 100 women)

Surgical management

Surgical management involves a doctor emptying your womb while you are under an anaesthetic. This is usually under a general anaesthetic in an operating theatre, and looks to remove your baby and other pregnancy tissue, however some units may also offer a procedure called manual vacuum aspiration under local anaesthetic in an outpatient or clinic setting.

During surgical management, a surgeon will use an instrument to open up the neck of your womb (cervix) and then insert a plastic tube into the womb. Using suction she/ he will empty your womb. After surgical management you may still bleed for up to 14 days. If the bleeding becomes heavier, smells unpleasant or you experience any abdominal pain you should contact your care provider in case any pregnancy tissue has been left behind or you have an infection.

The Royal College of Obstetricians and Gynaecologists advises that serious risks from surgical management of miscarriage include:

  • Significant tear to the cervix (1 in 1000 to 1 in 10000 women)
  • Perforation of (make a hole in) the womb (up to 5 in 1000 women) which might require keyhole or open surgery to repair any damage
  • Heavy bleeding (1-2 in 1000 women)

Frequent risks include:

  • Bleeding that lasts up to two weeks (up to all women)
  • Need for a repeat procedure if some pregnancy tissue is not removed (up to 5 in 100 women)
  • Pelvic infection (3 in 100 women)

If you choose surgical management and your blood group is rhesus negative you will be offered an injection of anti-D.

Registering your loss

If your baby passes away before 24 completed weeks of pregnancy legally you cannot register the birth at a register office so you will not be given a birth certificate. However, some hospitals may give you a certificate to commemorate your baby.

Recovering after a miscarriage

Bleeding and pain

Whether you choose expectant, medical or surgical management, it is normal to have bleeding and crampy pain similar to a period for up to two weeks following a miscarriage. You should use sanitary pads rather than tampons (which may increase the risk of you getting an infection). You can take over-the-counter painkillers such as paracetamol or ibuprofen or ask your health professional if you think you need a stronger painkiller. You will have a period four to six weeks following the miscarriage. It is safe to use tampons again if you prefer.

Signs of infection

You should contact the early pregnancy assessment service; out-of-hours gynaecology service; the emergency department; or your GP if: your pain gets worse; your bleeding gets heavier than a period; you have a smelly or unusual discharge; or you have a fever. These may all be signs that you have an infection and may need urgent treatment with antibiotics.

Physical recovery

After you have miscarried, you may feel very tired. This is partly because of hormonal changes in your body combined with the effects of bleeding, being in pain and your emotional response to the miscarriage. Most women need to take some time off work to recover. It is up to you whether or not you tell your employer that you have miscarried.

If you feel dizzy or short of breath you should contact the early pregnancy assessment service, out-of-hours gynaecology service, or your GP as you may need a blood test to check if you are anaemic. If you are anaemic you will be given treatment with iron. Rarely, some women may need to consider a blood transfusion.

When can I have sex again?

You should wait until you have stopped bleeding before you have sex again. This is because there is an increased risk of infection passing through the cervix into your womb while the cervix is open.

Swimming

You should wait until you have stopped bleeding before you go swimming. This is because there is an increased risk of infection passing through the cervix into your womb while the cervix is open.

Bath and showers

You can bath and shower as normal but you should not douche as this may cause an infection.

Causes of miscarriage

In most cases, the cause of an early miscarriage is not known and there is nothing you could have done to prevent it. Early miscarriages usually happen because the embryo is not developing as it should. Chromosome problems are thought to be the most common cause. These problems usually happen for no reason and are unlikely to happen again.

To develop properly, a baby needs the right number of normal chromosomes. He’ll need 23 from his mother and 23 from his father. Chromosomal abnormalities can prevent a baby from developing. These abnormalities may happen because there are the wrong number of chromosomes, or because there are changes to a chromosome’s structure. In that case, the pregnancy will come to an end.

Further tests

You will usually only be offered further tests if you have had three or more miscarriages (called recurrent miscarriage) or if you have had a late miscarriage (after 12 weeks of pregnancy). This is because early miscarriage is common and usually no treatable cause would be found if these tests were performed. This means that paying for these tests privately, if they are not offered by the NHS, is unlikely to benefit you.
Recurrent miscarriage affects 1% of couples (1 in 100) and late miscarriage affects 1-2% of pregnancies (1-2 in 100). You can find more information about the sorts of tests and possible treatments you would be offered at www.rcog.org.uk/womens-health/clinical-guidance/recurrent-and-late-miscarriage.

When can I try to conceive again?

You can start trying to conceive again as soon as you feel ready. Health professionals may recommend that you wait until after your next period to help date a future pregnancy. The reason for this is that if you have not had a period it may be difficult to know when you were likely to have become pregnant. This can make interpreting any early scans in the next pregnancy more difficult.

However, there is no reason to wait longer than that unless you choose to. Research has shown that women who get pregnant again within six months of a miscarriage have a reduced risk of miscarriage, ectopic pregnancy and of complications during their next pregnancy.

Next pregnancy

If you are planning another pregnancy, there are a few things you can do to be as healthy as possible and which may reduce your risk of having another miscarriage:

  • Give up smoking
  • Do not drink alcohol
  • Do not use illegal drugs
  • Aim to be a healthy weight before getting pregnant (see your GP for help with this)
  • Eat a healthy balanced diet
  • Exercise regularly (but if you are already pregnant and did not exercise regularly before becoming pregnant you should consult your midwife or doctor before starting a new exercise plan)
  • Reduce the amount of caffeine you consume (for example in coffee, tea, energy drinks and chocolate)
  • Take 400 micrograms of folic acid from when you start trying to conceive until 12 weeks of pregnancy to reduce the risk of neural tube defects

Future pregnancies

Even if you have had a fallopian tube removed your chance of conceiving normally and going on to have a baby is high. In a future pregnancy you would be offered a scan between six and eight weeks of pregnancy to check that you do not have another ectopic pregnancy. The risk of having a further ectopic pregnancy is 7-10% (7 – 10 in 100).

Important Note:

All information on this website, and advice and support offered by the charity team is on a non-medical basis. The charity advises that anyone going through baby loss, medical treatment or health issues, should seek advice from their own GP, Consultant, Midwife or Healthcare Professional.

Download the Saying Goodbye Support Leaflet (PDF)

References

The information in this leaflet is based on the documents listed below. Website addresses are given so you can look at any of them yourself if you want more information.

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