Miscarriage

Topic Overview

What is a miscarriage?

A miscarriage is the loss of a pregnancy during the first 20 weeks. It is usually your body's way of ending a pregnancy that has had a bad start. The loss of a pregnancy can be very hard to accept. You may wonder why it happened or blame yourself. But a miscarriage is no one's fault, and you can't prevent it.

Miscarriages are very common. About 1 in 4 pregnancies end in a miscarriage.¹ It is also common for a woman to have a miscarriage before she even knows that she is pregnant.

What causes a miscarriage?

Most miscarriages happen because the fertilized egg in the uterus does not develop normally. A miscarriage is not caused by stress, exercise, or sex. In many cases, doctors don't know what caused the miscarriage.

The risk of miscarriage is lower after the first 12 weeks of the pregnancy.

What are the common symptoms?

Common signs of a miscarriage include:

• Bleeding from the vagina. The bleeding may be light or heavy, constant or off and on. It can sometimes be hard to know whether light bleeding is a sign of miscarriage. But if you have bleeding with pain, the chance of a miscarriage is higher.
• Pain in the belly, lower back, or pelvis.
• Tissue that passes from the vagina.

How is a miscarriage diagnosed?

Call your doctor if you think you are having a miscarriage. If your symptoms and a pelvic exam do not show whether you are having a miscarriage, your doctor can do tests to see if you are still pregnant.

How is it treated?

No treatment can stop a miscarriage. As long as you do not have heavy blood loss, a fever, weakness, or other signs of infection, you can let a miscarriage follow its own course. This can take several days.

If you have Rh-negative blood, you will need a shot of Rhogam. This prevents problems in future pregnancies. If you have not had your blood type checked, you will need a blood test to find out if you are Rh-negative.

Many miscarriages complete on their own, but sometimes treatment is needed. If you are having a miscarriage, work with your doctor to watch for and prevent problems. If the uterus does not clear quickly enough, you could lose too much blood or develop an infection. In this case, medicine or a procedure called a dilation and curettage (D&C) can more quickly clear tissue from the uterus.

A miscarriage doesn't happen all at once. It usually takes place over several days, and symptoms vary. Here are some tips for dealing with a miscarriage:

• Use pads instead of tampons. You will probably have vaginal bleeding for a week or so. It may be like or slightly heavier than a normal period. You may use tampons during your next period, which should start in 3 to 6 weeks.
• Take acetaminophen (Tylenol) for cramps. Read and follow all instructions on the label. You may have cramps for several days after the miscarriage.
• Eat a balanced diet that is high in iron and vitamin C. You may be low in iron because of blood loss. Foods rich in iron include red meat, shellfish, eggs, beans, and leafy green vegetables. Foods high in vitamin C include citrus fruits, tomatoes, and broccoli. Talk to your doctor about whether you need to take iron pills or a multivitamin.
• Talk with family, friends, or a counselor if you are having trouble dealing with the loss of your pregnancy. If you feel very sad or depressed for longer than 2 weeks, talk to a counselor or your doctor.
• Talk with your doctor about any future pregnancy plans. Most doctors suggest that you wait until you have had at least one normal period before you try to get pregnant again. If you don't want to get pregnant, ask your doctor about birth control options.

After a miscarriage, are you at risk for miscarrying again?

Miscarriage is usually a chance event, not a sign of an ongoing problem. If you have had one miscarriage, your chances for future successful pregnancies are good. It is unusual to have three or more miscarriages in a row. But if you do, your doctor may do tests to see if a health problem may be causing the miscarriages.

Frequently Asked Questions

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	Should I have medical, surgical, or no treatment to complete a miscarriage?

Symptoms

Symptoms of a miscarriage include:

• Vaginal bleeding that may be light or heavy, constant or irregular. Although bleeding is often the first sign of a miscarriage, first-trimester bleeding may also occur with a normal pregnancy. But bleeding with pain is a sign that miscarriage is more likely.
• Pain. You may have pelvic cramps, abdominal pain, or a persistent, dull ache in your lower back. Pain may start a few hours to several days after bleeding has begun.
• Blood clots or grayish (fetal) tissue passing from the vagina.

It is not always easy to tell whether a miscarriage is taking place. A miscarriage often does not occur as a single event but as a chain of events over several days. One woman's physical experience of a miscarriage can be very different from another woman's experience.

Risk factors for miscarriage

Factors that may increase your risk of miscarriage include:

• Your age , especially at age 35 and older.
• A history of recurrent miscarriage (three or more).
• A history of miscarriages on your mother's side of the family.
• Polycystic ovary syndrome, which can cause ovulation problems, obesity, increased male hormone levels, and an increased risk of diabetes.
• A poorly controlled ongoing disease (such as diabetes or an autoimmune disease).
• Certain bacterial or viral infections during pregnancy.
• A blood-clotting disorder such as antiphospholipid antibody syndrome.
• Problems with the structure of the uterus (such as a T-shaped uterus).
• A history of pregnancy with a birth defect.
• A physical injury.
• Exposure to dangerous chemicals, such as benzene, arsenic, or formaldehyde, before or during pregnancy.
• The father's age, especially beyond age 35.²

Other factors that may slightly raise miscarriage risk include:

• Nonsteroidal anti-inflammatory drug (NSAID) use (such as ibuprofen or naproxen) at the time of conception or during early pregnancy.³
• Alcohol use during pregnancy.⁴
• Cigarette smoking during pregnancy.⁵
• Cocaine use during pregnancy.⁵
• A snakebite.⁶
• Caffeine use during pregnancy.
• A chorionic villus sampling (CVS) or amniocentesis to test for birth defects or genetic problems. When done by a highly trained provider, one study showed that these tests have a risk of miscarriage of about 1 in 400. ⁷ Some studies have shown higher risks, between 2 and 4 in 400.⁸ This greater risk may be more likely in medical centers with less experienced providers, especially for CVS.

There are also known factors that do not increase the risk of miscarriage, such as exposure to computer monitors or electric blankets, sexual intercourse, and exercise.

Exams and Tests

A miscarriage is diagnosed with:

• A pelvic exam, which allows the health professional to see whether the cervix is opening (dilating) or whether there is tissue or blood in the cervical opening or the vagina.
• A blood test, which checks the level of the pregnancy hormone called human chorionic gonadotropin (hCG). Your health professional may take several measurements of hCG levels over a period of days to learn whether your pregnancy is still progressing.
• An ultrasound, which helps to determine whether the amniotic sac is intact, detect a fetal heartbeat, and estimate the age of the fetus.

If you have not had one before, you may have a blood test to see if you have Rh-negative blood.

Recurrent miscarriage. If you have three or more miscarriages, your health professional can test for possible causes, including:^{9, 10}

• Testing your blood for antibodies to check for antiphospholipid antibody syndrome.
• Using a karyotype to test your blood for parental chromosome abnormalities.
• Testing hormone levels to check for polycystic ovary syndrome.
• Using hysteroscopy or pelvic ultrasound to check for problems with uterine structure.

Treatment Overview

There is no treatment that can stop a miscarriage. As long as you do not have heavy blood loss, fever, weakness, or other signs of infection, you can let a miscarriage follow its own course. This can take several days.

If you have an Rh-negative blood type, you will need a shot of low-dose Rhogam. This prevents problems in future pregnancies. Your doctor can do a blood test to see if you are Rh negative.

If a miscarriage is causing intense pain or bleeding or is taking longer than you are comfortable with, talk to your health professional about using medicine or surgery (such as a procedure called dilation and curettage, or D&C) to clear the uterus.

An obstetrician, a family medicine doctor, or a certified nurse-midwife can manage a miscarriage.

Should I have medical, surgical, or no treatment to complete a miscarriage?

Threatened miscarriage

If you have vaginal bleeding, but tests suggest that your pregnancy is still progressing, your health professional may recommend:

• Resting. You will be advised to temporarily avoid sexual intercourse (pelvic rest) and heavy activity. Your health professional may recommend bed rest. But most research shows that bed rest does not prevent miscarriage.¹¹
• Taking progesterone. You may be treated with the hormone progesterone to help maintain the pregnancy. However, this treatment may serve only to delay a miscarriage and has not been proven effective for preventing a miscarriage.¹² (Progesterone has only shown promise for preventing preterm birth later in a high-risk pregnancy.¹³)
• Avoiding NSAIDs. You will be advised to avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Use only acetaminophen, such as Tylenol, for nonprescription pain relief.

Incomplete miscarriage

Sometimes all or some of the fetal tissue stays in the uterus after a pregnancy miscarries. This is called an incomplete miscarriage (incomplete or missed spontaneous abortion). If your health professional determines that you have had an incomplete miscarriage, you will have one or more treatment options:

• Watchful waiting. This period of waiting, called expectant management, allows the miscarriage to end naturally while your health professional watches for and treats any complications.
• Medicine. Mifepristone and/or misoprostol cause the uterus to empty.
• Dilation and curettage (D&C). This surgical procedure clears the uterus of tissue. A D&C offers the quickest treatment for a miscarriage.

Should I have medical, surgical, or no treatment to complete a miscarriage?

Additional treatment concerns

If you are bleeding heavily, you will be tested for anemia and treated if necessary.

If your blood is Rh-negative, you will need Rh immune globulin (RhoGAM) after the miscarriage. This protects a future pregnancy against Rh sensitization. For more information, see the topic Rh Sensitization During Pregnancy.

In very rare cases, removal of the uterus (hysterectomy) is needed for women who have severe, uncontrollable bleeding or a severe infection that is not cured with antibiotics.

After a miscarriage

If you plan to become pregnant again, check with your health professional. Most doctors and nurse-midwives recommend waiting until you have had at least one normal menstrual period before attempting to become pregnant.

Your chances of having a successful pregnancy are good, even if you've had one or two miscarriages.

If you have had three or more miscarriages (recurrent miscarriage), your health professional may suggest further testing to help find the cause. In up to 75% of couples who are tested, no obvious cause is found for recurrent miscarriage. But studies have shown that up to 70% of couples with unexplained recurrent miscarriages go on to have a baby without treatment.¹⁰

What To Think About

Researchers suspect that a small number of miscarriages are related to a woman's immune system response against the pregnancy. But experimental immunotherapies used to prevent this have no proven benefit.¹⁴

Home Treatment

There is nothing you can do to prevent a miscarriage. It is usually the body's way of ending a pregnancy that has had a bad start, often at the earliest stage of cell division.

It is important to be alert to the symptoms of a miscarriage so that you can seek medical evaluation. If you are having symptoms of a miscarriage, avoid sexual activity (called pelvic rest) and strenuous activity until your symptoms have been evaluated by a health professional.

Call 911 or other emergency services immediately if you are pregnant and you have severe vaginal bleeding AND signs of shock. Early signs of shock include:

• Lightheadedness or a feeling that you are about to pass out.
• Restlessness, confusion, or signs of fear.
• Shallow, rapid breathing.
• Moist, cool skin or possibly profuse sweating.
• Weakness.
• Thirst, nausea, or vomiting.
• Abnormal increase in heart rate.

Call your health professional immediately if you are pregnant and you have any vaginal bleeding or cramping pain in your abdomen, pelvis, or lower back.

Your health professional may ask you to collect any expelled clots or tissue, if possible, in a clean container. The clots may be examined to determine whether you have passed fetal tissue.

After a miscarriage

The most common miscarriage complications are excessive bleeding and infection, which affect up to 10% of women who miscarry.¹⁵

It is normal to have mild or moderate vaginal bleeding for up to 14 days after a miscarriage. But the bleeding should not be severe.

Call 911 or other emergency services immediately if you have recently been treated for a miscarriage and you have severe vaginal bleeding AND signs of shock.

Call your health professional immediately if you have recently been treated for a miscarriage and you are experiencing:

• Severe vaginal bleeding without signs of shock. If your health professional does not respond immediately, or if you do not have a health professional, have someone drive you to the nearest emergency room.
• Symptoms of infection. These symptoms include:
  • Fever of 100.4 °F (38 °C) or higher.
  • Moderate to severe abdominal pain or cramping.
  • Smelly vaginal discharge.

Coping with a miscarriage

It is normal to go through a grieving process after a miscarriage, regardless of the length of your pregnancy. Guilt, anxiety, and sadness are common and normal reactions after a miscarriage. It is also normal to want to know why a miscarriage has happened. In most cases a miscarriage is a natural event that could not have been prevented.

To help you and your family cope with your loss, consider meeting with a support group, reading about the experiences of other mothers, and talking to friends or a counselor or member of the clergy. For more information, see the topic Grief and Grieving.

Your local bookstore or library may have books on coping with miscarriage. Also, your health professional will be able to address your questions and concerns about the miscarriage.

The intensity and duration of the grief varies from woman to woman, but most women find that they can return to the daily demands of life in a fairly short time. It is important to call your health professional if you have symptoms of depression that last for more than 2 weeks.¹⁶ The loss and the hormonal swings that result from a miscarriage can cause symptoms like postpartum depression.

A healthy, full-term pregnancy is possible for most women who have had a miscarriage, and even after having repeated miscarriages. If you want to become pregnant again, check with your doctor or nurse-midwife. Most health professionals recommend waiting until you have had at least one normal menstrual period before attempting to become pregnant after a miscarriage.

Other Places To Get Help

Organizations

Related Information

• Ectopic Pregnancy
• Grief and Grieving
• Molar Pregnancy
• Pregnancy
• Preterm Labor
• Rh Sensitization During Pregnancy

References

Citations

1. Creinin MD, et al. (2001). Early pregnancy failure-Current management concepts. Obstetrical and Gynecological Survey, 56(2): 105-113.

2. Kleinhaus K, et al. (2006). Paternal age and spontaneous abortion. Obstetrics and Gynecology, 108(2): 369-377.

3. Li D, et al. (2003). Exposure to non-steroidal anti-inflammatory drugs during pregnancy and risk of miscarriage: Population-based cohort study. BMJ, 327(7411): 368-372.

4. Cunningham FG, et al. (2005). Abortion. In Williams Obstetrics, 22nd ed., pp. 231-251. New York: McGraw-Hill.

5. Ness RB, et al. (1999). Cocaine and tobacco use and the risk of spontaneous abortion. New England Journal of Medicine, 340(5): 333-339.

6. Lewis LM, et al. (2006). Bites and stings. In DC Dale, DD Federman, eds., ACP Medicine, section 8, chapter 2. New York: WebMD.

7. Caughey AB, et al. (2006). Chorionic villus sampling compared with amniocentesis and the difference in the rate of pregnancy loss. Obstetrics and Gynecology, 108(3): 612-616.

8. Seeds JW (2004). Diagnostic mid trimester amniocentesis: How safe? American Journal of Obstetrics and Gynecology, 191: 608-616.

9. Reindollar RH (2000). Contemporary issues for spontaneous abortion: Does recurrent abortion exist? Obstetrics and Gynecology Clinics of North America, 27(3): 541-554.

10. American College of Obstetricians and Gynecologists (2001, reaffirmed 2005). Management of recurrent early pregnancy loss. ACOG Practice Bulletin No. 24. Obstetrics and Gynecology, 97(2): 1-12.

11. Sotiriadis A, et al. (2004). Threatened miscarriage: Evaluation and management. BMJ, 329(7458): 152-155.

12. Oates-Whitehead RM, et al. (2006). Progestogen for preventing miscarriage. Cochrane Database of Systematic Reviews (1). Oxford: Update Software.

13. American College of Obstetricians and Gynecologists (2003, reaffirmed 2006). Use of progesterone to reduce preterm birth. ACOG Committee Opinion No. 291. Obstetrics and Gynecology, 102(5): 1115-1116.

14. Scott JR (2006). Immunotherapy for recurrent miscarriage. Cochrane Database of Systematic Reviews (1). Oxford: Update Software.

15. Ballagh SA, et al. (1998). Is curettage needed for uncomplicated incomplete spontaneous abortion? American Journal of Obstetrics and Gynecology, 179(5): 1279-1282.

16. Brier N (1999). Understanding and managing the emotional reactions to a miscarriage. Obstetrics and Gynecology, 93(1): 151-155.

Other Works Consulted

• American College of Obstetricians and Gynecologists (2005). Antiphospholipid syndrome. ACOG Educational Bulletin No. 68. International Journal of Gynaecology and Obstetrics, 106(5, Part 1): 1113-1121.

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