A miscarriage can be a devastating experience. Sadly, they are more common than people realise. Here we discuss how to recognise if you are having an early miscarriage and how to get help.

What is a miscarriage?

A miscarriage is any spontaneous loss of pregnancy up to 23 weeks and 6 days. From 24 weeks, the loss of the pregnancy is called a stillbirth.

If a miscarriage happens in the first 12 weeks of pregnancy it is called a first trimester miscarriage, with any pregnancy loss occurring after 12 but before 23+6 weeks termed a second trimester miscarriage.

Three or more consecutive miscarriages are referred to as “recurrent miscarriage” and while this is uncommon, affecting approximately 1% of couples, it usually warrants referral to specialist services for investigation.

How common is miscarriage?

Sadly miscarriage is the most common complication of early pregnancy, affecting up to 15% of all pregnancies, in many cases before a woman even knows she is pregnant. The majority of miscarriages occur in the first trimester, with the incidence of second trimester miscarriage being much less common, affecting between 1-2% of pregnancies.

What are the causes or risk factors for miscarriage?

In most cases the specific cause of a miscarriage is unknown. There is also nothing that can be done to prevent miscarriage.

The majority of early pregnancy loss is thought to occur as a result of genetic abnormalities in the developing fetus. This occurs at random and is unlikely to happen again. However, there are some risk factors known to affect the chances of having a miscarriage, some of which are considered modifiable.

Modifiable risk factors

Alcohol

Alcohol consumption, both pre-conception and in the first three months of pregnancy, has been shown to increase the risk of miscarriage, with the overall risk related to the amount of alcohol consumed. Women who drink over four units a week are nearly three times more likely to miscarry than those who are not drinking at all.

Extremes of BMI

Being either under or overweight can affect both your chances of getting pregnant and your risk of miscarriage. Women with a BMI of over 30 are 5% more likely to miscarry than women with a BMI in the normal range (20-25).

Non modifiable risk factors

Chronic medical conditions

Medical conditions such as diabetes, epilepsy, thyroid disease and cystic fibrosis are all associated with an increased risk of miscarriage. However, with appropriate treatment and good control this risk is reduced. Women with any chronic medical condition are encouraged to meet with their specialist team prior to considering pregnancy, as optimisation of their care pre-conception is known to increase the chances of a successful pregnancy. In addition, this also provides a good opportunity to review any medications as sometimes these may need to be changed prior to trying to conceive.

High maternal/paternal age

Increasing maternal age is associated with an increased risk of first trimester miscarriage, with an incidence of 51% in women aged 40-44 years, compared with 9% in women aged 20-24. This increased risk is largely due to the higher incidence of chromosomal abnormalities in the fetus with rising maternal age. This risk is also affected by rising paternal age, on account of the increasing incidence of genetic abnormalities in the sperm.

Uterine malformations

Major uterine malformations, for example a septate uterus, have been shown to increase the risk of first trimester miscarriage by up to three times. Minor abnormalities, although sometimes associated with recurrent miscarriage, are not thought to increase the general risk of miscarriage.

Infection

Any infection that makes women unwell has the potential to cause miscarriage, however this is usually associated with severe infections in the second trimester. Minor illnesses such as coughs and colds are not associated with miscarriage.

Things that do not increase your risk of miscarriage

Unfortunately there are still many myths surrounding the causes of miscarriage. None of the list below have been proven to increase the risk of miscarriage.

• Sex
• Exercise
• Flying
• Working
• Stress
• Normal caffeine intake (although excessive caffeine — i.e. >7 cups a day — is associated with miscarriage)

What are the signs and symptoms of miscarriage?

Miscarriage most commonly presents with bleeding in early pregnancy and is often associated with cramp-like lower abdominal pain. Any bleeding in early pregnancy is termed a “threatened miscarriage” as not all bleeding will definitely be due to miscarriage. In some cases, miscarriage can occur with no symptoms at all and only be identified at the time of an ultrasound scan. This event is termed a “missed miscarriage”.
Bleeding may range from light spotting, visible on your underwear/clothes or just on wiping, to heavy loss with clots. It may be continuous or intermittent and blood may be fresh red or old and brown in colour. Likewise, pain can vary from mild discomfort to significant pain and cramping.

Any combination of pain and bleeding in early pregnancy merits a discussion with your GP or early pregnancy unit. Very heavy bleeding (filling a sanitary pad every 30 minutes) or feeling faint due to blood loss means you should attend A&E so you can be seen urgently by a gynaecologist. If the pain is one sided, or you feel dizzy or faint you should also seek medical advice urgently as this may be a sign of an ectopic pregnancy.

I am bleeding in early pregnancy — does this mean I am having a miscarriage?

Not always.

Bleeding in early pregnancy is very common and although never considered “normal” it does not always equate to miscarriage. See vaginal bleeding in pregnancy.

If the bleeding has been pain-free, minimal and has settled, patients are usually advised to keep an eye on things and see what happens. However, if the symptoms have been more severe it is usually advisable to discuss them with your GP or early pregnancy unit.

Advice will very much depend on the individual situation, however health professionals working within early pregnancy know how stressful and frightening bleeding is and will always try to give you some idea of what is happening. That said, a lot of times there will be no clear answer and often the only option is to wait.

How is a miscarriage diagnosed?

If you think you are having a miscarriage, you should see your GP or self-refer to an early pregnancy unit. Depending on how far along you are and how heavy the bleeding is, a scan may be arranged to check the viability of the pregnancy. Most units will only offer scans during “office hours”. If you are more than 7 weeks this can usually be done by checking the heartbeat. Miscarriages earlier than 7 weeks may be harder to diagnose, so you may need to return for a further scan 7-10 days later to see if things are progressing or not. If you are very early in pregnancy, then a scan may not be any use as it is too early to be able to see a pregnancy.

In the case of a complete miscarriage, there will be no visible pregnancy tissue left in the womb. You may need to have a few blood tests to check hCG levels (the pregnancy hormone) are falling. If the bleeding was very heavy and stopped, you may only need to repeat a pregnancy test in 2-3 weeks.

Can I prevent miscarriage?

Unfortunately, the majority of cases of miscarriage cannot be prevented and there is nothing that can be done to guarantee a healthy pregnancy. However, there are certain things that you can do to minimise your risk of pregnancy loss:

• Not smoking
• Not drinking alcohol
• Not taking illegal drugs
• Eating a healthy balanced diet and maintaining a healthy weight
• Trying to lose some weight pre pregnancy if your BMI is above 25
• Staying active

Is miscarriage my fault?

No.

The most important thing to understand after experiencing a miscarriage is that it is not your fault. Even if you have risk factors that give you a higher chance of having a miscarriage, this does not mean that this was the cause.

In many cases the cause of miscarriage will be unknown, which is frustrating and can make coming to terms with the event harder. However, it is important to remember that miscarriage is very common, and most couples who suffer a miscarriage will go on to have a successful pregnancy afterwards.

What are the treatment options for managing miscarriage?

Not all miscarriages require treatment. In many cases all of the pregnancy tissue passes naturally and things settle on their own. This is what is called a “complete miscarriage”. It can take anywhere from a few days to a fortnight.

In other cases, the miscarriage may either have started but not finished (there is remaining pregnancy tissue in the womb). This is termed an “incomplete miscarriage” or may have occurred without symptoms and only have been identified at the time of scan, a “missed miscarriage”. If there is still pregnancy tissue in the womb, you may notice ongoing bleeding.

In this situation there are various options about what to do next. These depend on the stage of pregnancy at which the miscarriage occurred as well as the individual patient’s preference. In some cases — for example, if there is concern about significant blood loss — one treatment option may be recommended above another based on patient safety. However, the team should always go over the full range of options and the specific risk/benefit of each.

Expectant management

Expectant management refers to waiting for the miscarriage to happen naturally and is usually recommended as a first option, avoiding the need for any specific intervention. This reduces the risk of any potential side effects. However, it can take up to several weeks to occur and is only successful in about 50% of cases.

Expectant management will not be recommended as a safe option if there is any concern about:

• Current heavy bleeding or an increased risk of heavy bleeding
• Increased risk of the effects of heavy bleeding (for example, if the patient is currently anaemic or is unsuitable for blood transfusion etc.)
• Current infection

As the miscarriage starts, pain and bleeding will occur. This is often heavier than a normal period and patients are advised to take simple analgesia. The time taken for this to happen varies but it can take a few weeks for the bleeding to start. The miscarriage bleeding itself can last anywhere from a few days to a few weeks. Once the miscarriage is complete the pain and bleeding will stop.

Early pregnancy units vary in their advice but commonly patients are asked to take a pregnancy test in 2-3 weeks’ time and should notify the unit if the test is still positive, as this may mean not all of the pregnancy tissue has passed.

Likewise, patients are advised to contact their early pregnancy unit if their bleeding is very heavy (soaking through pads regularly or onto their clothes), if they feel unwell or if they develop any signs of infection such as a temperature or smelly discharge.

The most common risks associated with expectant management are:

• The need for further intervention (approximately 50%)
• Infection
• Heavy bleeding

Some patients prefer the situation to be dealt with at once and do not wish to wait for expectant management. In these situations the alternative is either medical or surgical management.

Medical Management

Medical management refers to taking medication to help the pregnancy tissue to pass more quickly and is usually offered if expectant management has been unsuccessful or if patients would prefer it as a first option. Medical management is successful in 85% of cases.

The medication used is called misoprostol and it is usually given either as a tablet, a spray under the tongue or as a vaginal pessary. It works by helping the cervix (neck of the womb) to open and the pregnancy tissue to pass. It usually takes a few hours for the bleeding to start and again it can take up to a couple of weeks for the pregnancy tissue to pass. If no bleeding happens within a certain time-frame the dose is often repeated.

Most women will be suitable to take this medication at home; however, those who are at increased risk of bleeding may be advised to stay in hospital until the pregnancy tissue has passed.

Some women find misoprostol makes them feel sick, so patients are usually given anti-sickness tablets to take with it. It is also common to experience some diarrhoea.

The most common risks associated with medical management are:

• The need for further intervention (approximately 15%)
• Infection
• Heavy bleeding

Surgical Management

Surgical management refers to having an operation or procedure to remove the pregnancy tissue from within the uterus or womb. This is usually done with a suction catheter that is passed vaginally through the cervix into the cavity of the womb. Options for this vary depending on the hospital, however generally it can be done under either local or general anaesthetic.

Manual Vacuum Aspiration (MVA) uses a very narrow suction catheter passed up the vagina and into the womb. It is done with local anaesthetic injected into the cervix and with the patient awake. This avoids the need for a general anaesthetic, which may not be suitable or safe for everyone. This is usually best suited to earlier first trimester miscarriage where the size of the pregnancy tissue is smaller.

Alternatively, this process can be done under general anaesthetic. In a very similar procedure, the cervix is dilated using special instruments and the pregnancy tissue removed again using a suction catheter. Sometimes a scan is performed at the same time to ensure that all of the pregnancy tissue is removed.

While some people prefer the surgical options, they do tend to come with a slightly higher risk. In part this relates to the risk of the anaesthetic, however, along with the risk of bleeding and infection, there is also the additional risk of potential damage to the cervix or the inside of the womb. These risks are very small but can be significant.

Where can I find more information or support?

Miscarriage can be a devastating experience for both women and their partners and it is important to allow yourselves time to come to terms with it. Everyone copes differently and there is no right or wrong way to manage your emotions.

While it can be a very useful resource, searching the internet for answers may not always provide reliable and up-to-date information. The two websites below provide plenty of accurate and useful advice.

• The Miscarriage Association
• The NHS

Can I have a memorial for my baby?

For pregnancy loss under 24 weeks there is no legal requirement to have a burial or cremation, however some families wish to do this. Many hospitals offer a shared cremation for all pregnancy loss, but this may vary from hospital to hospital and NHS trust to NHS trust. At the very least all hospitals should discuss your options with you and seek your advice on what you want to happen.
While it can be a difficult thing to talk about, if you have specific requests you should discuss your options with the team taking care of you.

When can I try for another pregnancy?

The decision as to when to try for another baby is a very personal one and there is no right or wrong answer. It is generally advised that you wait until all the symptoms of the miscarriage, such as pain or bleeding, have gone before having sex again and in the majority of cases there is no medical reason why couples cannot try again after the first normal period following miscarriage has occurred, usually 4-6 weeks later. However emotionally, things may take longer to heal and it is important to take things at your own pace. Some couples may feel ready to try again immediately, others may never want to.

In some cases, for example if the miscarriage may be attributable to an infection or suboptimal control of a chronic medical condition (for example, diabetes), then it is worth waiting to speak to your doctor before trying again as there may be some things that can be done to help improve the chance of success next time.

Having one miscarriage does not increase your chance of having another miscarriage, but sadly the risk is again around 15% and may be higher if you are older.

Main points

• A miscarriage is a spontaneous loss of pregnancy up to 23 weeks and 6 days. A first trimester miscarriage happens before 12 weeks.
• Miscarriage is very common, affecting 15% of pregnancies, but is more likely to occur with advancing age.
• Often the cause of a miscarriage is not known. There is nothing that can be done to prevent a miscarriage and it is definitely no one’s fault.
• Most commonly miscarriages present with bleeding and cramping, though not all bleeding in early pregnancy is due to miscarriage.
• Sometimes a miscarriage may only be seen on a routine antenatal scan “missed miscarriage”.
• If you have any bleeding or cramping in pregnancy, then seek advice from your GP or early pregnancy unit. Heavy bleeding warrants attendance to an urgent care centre or A&E.
• Your early pregnancy unit will assess you over the phone or in person and make a plan based on your individual situation. This may involve having an ultrasound scan.
• Treatment of miscarriage can be expectant (letting nature take its course), medical (using medication to speed up the natural process) or “surgical” (a suction procedure via the vagina and cervix to remove pregnancy tissue).
• Miscarriage can be a devastating experience and it is important to be kind to yourself, give yourself time to heal and seek support.
• Most couples go on to have successful pregnancies following a miscarriage. Having a miscarriage does not increase your chance of having a miscarriage the next time.

References:

NICE guideline 126: Ectopic pregnancy and miscarriage: diagnosis and initial management. 2019

www.rcog.org.uk

www.miscarriageassociation.org.uk

www.tommys.org.uk/pregnancy-complications/baby-loss/miscarriage

www.nhs.uk/conditions/Miscarriage