Miscarriage

Types of miscarriage

Ectopic pregnancy, a pregnancy outside the uterus, is a different and potentially dangerous condition that can also cause bleeding and pain.

Symptoms

• vaginal bleeding, from spotting to heavy bleeding with clots
• cramping or pain in the lower belly or lower back
• passing tissue or grayish material
• a sudden loss of pregnancy symptoms, such as nausea or breast tenderness (this alone is not a reliable sign)

Bleeding in early pregnancy is common, occurring in about a quarter of pregnancies, and many continue normally. Ultrasound is the only way to know.

Causes

• Chromosomal abnormalities: about half or more of first-trimester miscarriages, usually random events at conception.
• Older age: risk rises from about 10 to 15% under 35 to about 50% by age 45, due to egg quality.
• Uterine problems: a septum, large fibroids, scar tissue.
• Hormonal and medical conditions: uncontrolled diabetes or thyroid disease, antiphospholipid syndrome, polycystic ovary syndrome.
• Infections: some, such as listeria.
• Smoking, heavy alcohol use, drugs and very high caffeine intake.
• Some medicines, such as isotretinoin and methotrexate.

Normal exercise, sex, working, lifting usual loads, mild stress, morning sickness and flying do not cause miscarriage.

Diagnosis

• Transvaginal ultrasound: checks for a gestational sac, embryo and heartbeat, and for remaining tissue.
• hCG blood tests: levels that fall or rise abnormally over 48 hours.
• Pelvic exam: whether the cervix is open.
• Blood type and Rh factor.

Sometimes a repeat ultrasound 1 to 2 weeks later is needed before confirming a loss, especially very early.

Treatment options

Options are equally safe for most people with an early pregnancy loss, and you can usually choose:

• Expectant management: waiting for the body to pass the tissue naturally. This works in most cases within 2 weeks, though it may take longer.
• Medication: mifepristone followed by misoprostol, taken by mouth or vaginally, which completes the miscarriage within hours to days in most people.
• Uterine aspiration (vacuum aspiration or D&C): a short procedure in the office or operating room that removes the tissue. It is quicker and more predictable, and is advised for heavy bleeding or infection.

Other care:

• Rh immune globulin for Rh-negative people in some situations, to prevent problems in future pregnancies (see Rh disease).
• Pain relief: ibuprofen or acetaminophen (paracetamol) at the label dose, and a heating pad.

Recovery

• Bleeding usually lasts 1 to 2 weeks; cramping eases in a few days.
• Avoid tampons and vaginal sex until bleeding stops, or as advised.
• A period usually returns in 4 to 6 weeks.
• Ovulation can occur within 2 weeks, so use contraception if you do not want to conceive.
• Trying again: there is usually no medical need to wait more than one cycle unless your provider advises otherwise.

Emotional recovery

Grief, sadness, guilt, anger and anxiety are common, for partners as well. Some people experience depression or anxiety that lasts. Talk to people you trust, consider pregnancy loss support groups or counseling, and tell your provider if low mood persists. See grief for more on coping.

Recurrent miscarriage

After two or more losses, testing may include parental chromosomes, uterine imaging, thyroid and diabetes tests, and antiphospholipid antibodies. A cause is found in about half. Even after several miscarriages, most people have a successful pregnancy in the future.

Frequently asked questions

What are the first signs of a miscarriage?

The most common first signs are vaginal bleeding or spotting and cramping in the lower belly or back. Some people pass tissue. Others have no symptoms, and the loss is found on ultrasound. Bleeding does not always mean miscarriage, so contact your provider.

What causes a miscarriage?

Most early miscarriages are caused by random chromosomal problems in the developing embryo. Other causes include uterine abnormalities, uncontrolled diabetes or thyroid disease, clotting disorders, infections and smoking. Everyday activities like exercise, sex and work do not cause miscarriage.

What does a miscarriage look like?

Bleeding can range from spotting to heavy bleeding with clots, often heavier than a period. Tissue may look like large clots or grayish material. In very early pregnancy, it may look like a heavy, crampy period.

How long does a miscarriage last?

Physical symptoms vary. A natural miscarriage may take hours to several days to pass, and bleeding often continues for 1 to 2 weeks. With medication or a procedure, the process is usually quicker. Emotional recovery can take much longer.

Can I get pregnant after a miscarriage?

Yes. Most people who have a miscarriage go on to have a healthy pregnancy. You can ovulate within 2 weeks. Many providers say it is safe to try again after one normal period or when you feel emotionally ready.