Miscarriage, or early pregnancy loss, is a common complication occurring in about one in every four pregnancies, and most often in the first trimester. It’s estimated that about 12 to 15 percent of women have experienced a miscarriage, but as a sensitive health topic, it’s not often discussed, and can be difficult for many to do so when it can bring up feelings of loss, grief and isolation.
In fact, miscarriage can lead to a 10 to 30 percent increased risk of experiencing anxiety, depression, and/or post-traumatic stress syndrome, post-loss. For this reason, it’s important to lean on your support system, and seek outside help, like counselling, if needed.
Why does a miscarriage happen?
A miscarriage happens when a pregnancy is no longer viable. It is either diagnosed by ultrasound (for example the fetus stopped developing or there is no longer a heartbeat detectable) or clinically (cramping, bleeding and eventually passing the pregnancy tissue).
The causes of a miscarriage are complex, and mainly unknown, but can be broken down to two categories. Either an abnormal embryo exists (typically referred to as a chromosomal issue) or, a normal embryo exists but implants into a suboptimal endometrial environment. For the latter, this can range from hormonal and metabolic issues (abnormal thyroid function, high insulin levels, obesity), to structural (fibroids, septate uterus (A.K.A. a two-cavity uterus)), to infectious, to immune-related, and so on. This is where the cause of a miscarriage may get murky.
As the age of the eggs increase, quality declines which translates to more abnormal embryos. As women age, the cause of miscarriage is more likely to be embryo-related, instead of an endometrial environment issue.
What are the signs and symptoms of a miscarriage?
The most common sign of a miscarriage is vaginal bleeding, but not all vaginal bleeding means that a pregnancy loss is happening. About 20 to 40 percent of women will experience bleeding or spotting during the first trimester of their pregnancy, but only about half of these are due to a miscarriage occurring.
In cases of vaginal bleeding where a miscarriage is not occurring, about one to two percent of cases will be due to an ectopic pregnancy (where the embryo implants in a fallopian tube instead of the uterus—remember, an ectopic pregnancy is never viable and requires medical intervention before it ruptures and can become a life-threatening situation), but the remainder are cases of normal endometrial (uterine lining) implantation. In rare situations, spotting or bleeding can be due to an infection or the presence of a uterine polyp.
When bleeding does occur due to a miscarriage, it’s not uncommon for it to be heaviest for the first few hours, with residual spotting lasting a week or two (you may notice bleeding becoming lighter in flow, darker in colour and thicker in consistency). Bleeding may be accompanied by cramping and discomfort, though this isn’t true all the time.
How long does a miscarriage last?
There are different ways that a miscarriage can occur, but in most cases it can take two to six weeks for your body to process and remove products of conception (POC). With medical intervention (medications that cause the uterus to contract, thus aiding in expelling the POC) this can be much shorter, but follow-up monitoring is still done about two weeks later to ensure there is no remaining tissue in the uterus. It’s important that the body remove all non-viable POC to reduce the risk of infections like endometritis. Retained POC can also cause prolonged bleeding and pain. If left too long, adhesions can form in the uterus and can interfere with future fertility.
While the physical process may take up to six weeks, there is no timeline for the mental and emotional healing following a pregnancy loss.
Types of miscarriages that can occur:
- Threatened miscarriage: When there is vaginal bleeding within the first 20 weeks of pregnancy, but the cause is still unknown. In this scenario the pregnancy is still viable, but the term “threatened” suggests there was an event that was concerning that may or may not lead to a miscarriage.
- Missed miscarriage: When an ultrasound shows a non-viable pregnancy but there has been no vaginal bleeding yet. There’s no way to know when bleeding will start, but it’s important to continue to follow-up with your doctor every seven to 14 days should medical treatment be needed to start the miscarriage process. Although bleeding and the passing of all POC is most often complete within two to six weeks, it could take longer for someone experiencing a missed miscarriage. If no bleeding or pain occurs within one to two weeks, your doctor will repeat your ultrasound and review your treatment options (either medical drug use, which can be done at home, or surgical treatment).
- Incomplete miscarriage: When there has been some bleeding and loss of tissue, but some POC have been retained in the uterus. Like a missed miscarriage, the process of passing all POC can take two to six weeks.
- Complete miscarriage: When all POC have been passed and are no longer retained.
When should you contact your doctor if you believe you are having a miscarriage?
Any spotting or bleeding during pregnancy can be concerning, but the vast majority of such episodes are harmless and the pregnancy will progress normally. However, it can be hard to know the difference at home, so connecting with your doctor makes sense. They will likely send you for a transvaginal ultrasound and a blood test for the pregnancy hormone hCG to determine the location (in the uterus or in the tube (making it ectopic)) and viability of the pregnancy. If there is any doubt regarding the results of these tests, your doctor will do them again in a few days or up to a week later.
Generally, you should have a follow-up with your doctor or medical team every two weeks until the miscarriage is complete (that is, when all pain and bleeding have stopped).
Do I need treatment for a miscarriage?
At the very least a miscarriage can be uncomfortable and at the worst, it could require emergent medical attention. We always recommend advocating for yourself, which might include making sure that you are prescribed adequate pain medications and a doctor’s note to take time off work to allow yourself time to recover physically and mentally, no matter what time of treatment you may require.
There are three types of management for early pregnancy loss:
1. Expectant management of miscarriage
When there are no other complications, waiting it out is recommended for one to two weeks. Seventy percent of the time, the physical process is complete within two weeks, and 81 percent of miscarriages are completed by six weeks. That said, about 10 to 30 percent will need some type of medical intervention.
2. Medical (at-home) treatment of miscarriage
Medications such as mifepristone (oral) and misoprostol (oral or vaginal) can be used to help pass POC and are typically used for pregnancy losses that occur in the first 12 weeks of gestation. The success rate of these medications used together is 88 to 97 percent in both incomplete and missed miscarriage. Five to 20 percent of patients managing a miscarriage at home with medication will need surgical assistance, also called curettage, to help remove all retained POC.
The benefit to pharmaceutical treatment is that it can be done in the privacy of your own home and you have some control on when to start the process—a plus if you decide to arrange time away from work or will need additional support as you recover. These medications cause the uterus to contract while dilating and softening the cervix, which can cause side effects of cramping, pain, diarrhea (the small bowels are smooth muscles and will also be contracting) and fever. Bleeding will start within two to four hours of taking the medication and can be strong for the first two hours. You may also notice clotting and thicker tissues passing. If your bleeding continues longer than two hours while soaking through more than two large pads in an hour, seek emergent hospital care (it might mean some tissue is stuck in the cervix, and until it passes or is removed by a doctor, the bleeding will persist).
3. Surgical treatment of miscarriage
The standard surgical procedure used to be dilatation and curettage (D+C) which uses a sharp spoon-like instrument to scrape and remove any remaining POC, but it is more common now for doctors to use gentle suction (vacuum aspiration) which results in less trauma to the endometrial tissue, as well as less blood loss and pain. It’s a same-day procedure, usually undertaken with some form of sedation and a relatively quick recovery, with minimal risk.
The success rate of these interventions is 97 to 98 percent, and they can be completed more quickly than expectant management or medical drug interventions. You will still need to follow up with your doctor about two to three weeks post-surgery to make sure there have been no complications and that the procedure was successful.
Surgical treatment is used when someone is experiencing major heavy bleeding, or if there is an infection present. Women can also choose to have surgical assistance with their miscarriage to reduce the amount of pain and bleeding experienced and to avoid prolonging the experience.
Blood type and RhoGAM during miscarriage
Your blood type is very important. If you’re experiencing a miscarriage and have a negative blood type (O-, A-, B- AB-) then you will require a medication called RhoGAM (administered with a needle) to prevent you from developing anti-D antibodies which might have implications for a future pregnancy with a baby that might a positive blood type. Make sure you know your blood type. (RhoGAM is given to any RH-negative pregnant person at around 28-weeks of pregnancy and postpartum, but if there is bleeding earlier in pregnancy, they will be given an additional shot.)
When should you seek out emergency medical help when experiencing a miscarriage?
If you experience heavy bleeding (saturating two large pads in an hour for two consecutive hours or more), start feeling lightheaded, faint or are experiencing chest pain, seek emergency care immediately. Excessive blood loss may require a transfusion, and any retained POC may need assistance to be removed. Again, advocate for yourself. If you are concerned or want to be reassured, its very reasonable to seek urgent care.
What does your doctor look for to confirm your miscarriage is over?
A follow-up with your doctor or medical team member will occur one to two weeks after your initial assessment and treatment for pregnancy loss. If pain and bleeding have both stopped, your doctor will likely repeat your blood hCG test to confirm levels are going down. If your pregnancy hormone levels are still high, your doctor may continue monitoring, or you may need to repeat an ultrasound scan to make sure there are no retained POC (which can cause the hCG to stay high).
When can you start TTC after a miscarriage?
The benefit to pharmaceutical treatment is that it can be done in the privacy of your own home and you have some control on when to start the process—a plus if you decide to arrange time away from work or will need additional support as you recover. These medications cause the uterus to contract while dilating and softening the cervix, which can cause side effects of cramping, pain, diarrhea (the small bowels are smooth muscles and will also be contracting) and fever. Bleeding will start within two to four hours of taking the medication and can be strong for the first two hours. You may also notice clotting and thicker tissues passing. If your bleeding continues longer than two hours while soaking through more than two large pads in an hour, seek emergent hospital care (it might mean some tissue is stuck in the cervix, and until itpasses or is removed by a doctor, the bleeding will persist). Your doctor may recommend that you wait at least one to three months after a pregnancy loss before trying to conceive again (the World Health Organization recommends at least six months). It’s worth noting, however, that the data to support these timelines is far from conclusive. In fact, the uterus may be more receptive earlier, compared to waiting three or more months, without any additional pregnancy risks.
Alongside physical recovery following a miscarriage, you also need to be emotionally and physically ready to try again. The fertility journey can be incredibly challenging on your physical and emotional health so it’s important to take the time to process and grieve your pregnancy loss.