Miscarriage

Overview

Miscarriage is the sudden loss of a pregnancy before the 20th week. About 10% to 20% of known pregnancies end in miscarriage. But the actual number is likely higher. This is because many miscarriages happen early on, before people realize they're pregnant.

The term miscarriage might sound as if something was amiss in the carrying of the pregnancy. This is rarely true. Many miscarriages happen because the unborn baby does not develop properly.

Miscarriage is a somewhat common experience — but that doesn't make it any easier. If you've lost a pregnancy, take a step toward emotional healing by learning more. Understand what can cause a miscarriage, what raises the risk and what medical care might be needed.

Symptoms

Most miscarriages happen during the first trimester of pregnancy, which is about the first 13 weeks.

The symptoms can include:

• Bleeding from the vagina with or without pain, including light bleeding called spotting.
• Pain or cramping in the pelvic area or lower back.
• Fluid or tissue passing from the vagina.
• Fast heartbeat.

If you have passed tissue from your vagina, place it in a clean container. Then, bring it to your health care professional's office or the hospital. A lab can examine the tissue to check for signs of a miscarriage.

Keep in mind that most pregnant people who have vaginal spotting or bleeding in the first trimester go on to have successful pregnancies. But call your pregnancy care team right away if your bleeding is heavy or happens with cramping pain.

Causes

Irregular genes or chromosomes

Most miscarriages happen because the unborn baby doesn't develop properly. About half to two-thirds of miscarriages in the first trimester are linked with extra or missing chromosomes. Chromosomes are structures in each cell that contain genes, the instructions for how people look and function. When an egg and sperm unite, two sets of chromosomes — one from each parent — join together. But if either set has fewer or more chromosomes than usual, that can lead to a miscarriage.

Chromosome conditions might lead to:

• Anembryonic pregnancy. This happens when no embryo forms. Or the embryo forms but is absorbed back into the body. The embryo is the group of cells that develops into an unborn baby, also called a fetus.
• Intrauterine fetal demise. In this situation, an embryo forms but stops developing. It dies before any symptoms of pregnancy loss occur.

• Molar pregnancy and partial molar pregnancy. With a molar pregnancy, a fetus doesn't develop. This most often happens if both sets of chromosomes come from the sperm. A molar pregnancy is linked with irregular growth of the placenta, the pregnancy-associated organ that gives an unborn baby oxygen and nutrients.

  With a partial molar pregnancy, a fetus may develop, but it can't survive. A partial molar pregnancy happens when there is an extra set of chromosomes, also called triploidy. The extra set is often contributed from the sperm but can also be contributed from the egg.

  Molar and partial molar pregnancies can't continue because they can cause serious health problems. Sometimes, they can be linked with changes of the placenta that lead to cancer in the pregnant person.

Maternal health conditions

In a few cases, having certain health conditions might lead to miscarriage. Examples include:

• Uncontrolled diabetes.
• Infections.
• Hormonal problems.
• Uterus or cervix problems.
• Thyroid disease.
• Obesity.

What does NOT cause miscarriage

Routine activities such as these don't cause a miscarriage:

• Exercise, as long as you're healthy. But talk with your pregnancy care team first. And stay away from activities that could lead to injury, such as contact sports.
• Sex.
• Arguments.
• Use of birth control pills before getting pregnant.
• Working, as long as you're not exposed to high doses of harmful chemicals or radiation. Talk with your health care professional if you're concerned about work-related risks.

Some people who've had a miscarriage blame themselves. They think they lost the pregnancy because they fell, had a bad scare or other reasons. But most of the time, miscarriage happens because of a random event that is no one's fault.

Risk factors

Various factors raise the risk of miscarriage, including:

• Age. If you're older than age 35, you have a higher risk of miscarriage than a younger person. At age 35, you have about a 20% risk. At age 40, the risk is about 33% to 40%. And at age 45, it ranges from 57% to 80%.
• Past miscarriages. If you've had one or more prior miscarriages before, you're at higher risk of pregnancy loss.
• Long-term conditions. If you have an ongoing health condition, such as uncontrolled diabetes, you have a higher risk of miscarriage.
• Uterine or cervical problems. Certain uterine conditions or weak cervical tissues, also called incompetent cervix, might raise the chances of a miscarriage.
• Smoking, alcohol, caffeine and illegal drugs. People who smoke have a greater risk of miscarriage than do nonsmokers. Heavy use of caffeine or alcohol use also raises the risk. So does using illegal drugs such as cocaine.
• Weight. Being underweight or being overweight has been linked with a higher risk of miscarriage.
• Genetic conditions. Sometimes, one of the partners may be healthy but carry a genetic problem that raises the risk of a miscarriage. For example, one partner could have a unique chromosome that formed when the pieces of two different chromosomes attached to each other. This is called translocation. If either partner carries a chromosome translocation, passing it to an unborn child makes a miscarriage more likely.

Complications

Sometimes, pregnancy tissue that stays in the uterus after a miscarriage can lead to a uterine infection about 1 to 2 days later. The infection is called a septic miscarriage. Symptoms include:

• Fever higher than 100.4 degrees Fahrenheit more than two times.
• Chills.
• Pain in the lower stomach area.
• Foul-smelling fluid called discharge from the vagina.
• Vaginal bleeding.

Call your health care professional's office or your local OB triage or emergency department if you have these symptoms. The illness can get worse fast and become life-threatening without treatment.

Heavy bleeding from the vagina, called a hemorrhage, is another miscarriage complication. Along with the bleeding, a hemorrhage often happens with symptoms such as:

• Fast heartbeat.
• Dizziness from low blood pressure.
• Tiredness or weakness due low red blood cells, also called anemia.

Get medical care at once. Some people who have a hemorrhage need blood from a donor or surgery.

Prevention

Often, there's nothing you can do to prevent a miscarriage. Instead, focus on taking good care of yourself and your unborn baby:

• Get regular prenatal care while you're pregnant and right after you give birth.
• Stay away from miscarriage risk factors — such as smoking, drinking alcohol and illegal drug use.
• Take a daily multivitamin.
• If you've had one or more prior miscarriages, ask your health care professional if you should take low-dose aspirin.
• Limit caffeine. Many experts recommend having no more than 200 milligrams per day while pregnant. This is the amount of caffeine in a 12-ounce cup of brewed coffee. Also, check food labels for amounts of caffeine. The effects of caffeine aren't clear for your unborn baby and higher amounts may include miscarriage or preterm birth. Ask your pregnancy care team what's right for you.

If you have a long-term health condition, work with your health care team to keep it under control.

Diagnosis

Your health care team might do a variety of tests:

• Blood tests. These can check the level of the pregnancy hormone, called human chorionic gonadotropin (hCG), in your blood. This level is often repeated after 48 hours. A low or falling level of hCG could be a sign of pregnancy loss. If the pattern of changes in your hCG level is irregular, your health care professional may recommend more blood tests or an ultrasound. Your blood type also might be checked. If your blood type is Rh negative, a medicine called Rh immunoglobulin (RhoGAM) will likely be recommended unless you are less than six weeks pregnant.
• Pelvic exam. Your health care professional might check to see if the lower end of your uterus, called the cervix, has begun to open. If it has, that makes a miscarriage more likely.
• Ultrasound. During this imagining test, your health care professional checks for a fetal heartbeat and figures out if the pregnancy is growing properly. If the result of the test isn't clear, you might need to have another ultrasound in about a week.
• Tissue tests. If you've passed what looks like tissue, it can be sent to a lab to confirm that a miscarriage has happened — and that your symptoms aren't tied to another cause.
• Chromosomal tests. If you've had two or more previous miscarriages, your health care professional may recommend blood tests for both you and your partner. The tests can help find out if your or your partner's chromosome make-up might be linked with increased risk for miscarriage.

If your test results show that you had a miscarriage or are at risk of having one, your health care professional might use one of the following medical terms to describe what happened:

• Threatened miscarriage. This means that you have bleeding from the vagina, but your cervix hasn't begun to open. So there is a threat of a miscarriage. Such pregnancies typically go on without any more problems.
• Inevitable miscarriage. This describes a miscarriage that can't be avoided because you're bleeding, cramping and your cervix is open.
• Incomplete miscarriage. This is when you pass pregnancy tissue but some remains in your uterus.
• Missed miscarriage. The placental and embryonic tissues remain in the uterus, but the embryo has died or was never formed.
• Complete miscarriage. This means you have passed all the pregnancy tissues. This is common for miscarriages that happen before 12 weeks.
• Septic miscarriage. This condition happens when you get an infection in your uterus after a miscarriage. This can be a life-threatening infection. You need medical care right away.

Treatment

Threatened miscarriage

If you have bleeding from the vagina early in your pregnancy, your health care team might recommend that you rest until your symptoms get better. Bed rest and other treatments haven't been proved to prevent miscarriage, but sometimes they're prescribed as a safeguard. Don't use tampons or have sex while you still have bleeding, because these could lead to an infection of the uterus.

In some cases, it's also a good idea to delay any traveling — especially to areas where it would be hard to get medical care quickly. Ask your health care team if you should put off any trips you've planned.

Miscarriage

If tests show that you're having or will have a miscarriage, your health care team might recommend one of the following treatment choices:

• Expectant management. If you have no symptoms of an infection, you might choose to let the miscarriage progress naturally. This often happens within a couple of weeks of finding that the embryo has died. But it might take up to eight weeks. This can be an emotional time. Most often, expectant management is used in the first trimester. If the pregnancy tissue isn't passed from the body on its own, you'll need treatment with medicines or surgery.
• Medical treatment. This helps the uterus pass pregnancy tissue out of the body. A combination of the medicines mifepristone (Korlym, Mifeprex) and misoprostol (Cytotec) is more effective than is misoprostol alone. Combined treatment has a higher rate of helping the body release all remaining pregnancy tissue. Mifepristone combined with misoprostol also is linked with a lower risk of needing surgery to complete treatment compared with misoprostol alone.
• Surgical treatment. Another option is a minor procedure called suction dilation and curettage (D&C). During this procedure, your health care team opens your cervix and removes tissue from the inside of your uterus. The procedure also is called uterine aspiration. Complications are rare, but they might include damage to the connective tissue of the cervix or the wall of the uterus. You need surgical treatment if you have a miscarriage along with heavy bleeding or signs of an infection.

After a miscarriage, if you are blood type Rh negative, you also may get a shot of medicine called Rh immunoglobulin. Ask your health care team about your blood type and need for Rh immunoglobulin. If you are RH positive, you will not need Rh immunoglobulin. The shot can help prevent problems with a future pregnancy. It's given to some people whose blood type is Rh negative, often depending on how many weeks they were pregnant. Rh negative means you don't have a protein in your blood called Rh factor. If you get pregnant again and the unborn baby is Rh positive — meaning its blood has the protein — that can lead to life-threatening anemia or other problems for the baby.

Physical recovery

In most cases, physical recovery from miscarriage takes only a few hours to a couple of days. In the meantime, call your health care professional if you have:

• Heavy bleeding, such as soaking through more than two menstrual pads an hour for more than two hours in a row.
• Fever.
• Chills.
• Belly pain.

Most people who have a miscarriage get their period about two weeks after any light bleeding or spotting stops. You can start using any type of birth control right after a miscarriage. But don't have sex or put anything in your vagina — such as a tampon — for 1 to 2 weeks after a miscarriage. This helps prevent an infection.

Future pregnancies

It's possible to become pregnant during the menstrual cycle right after a miscarriage. But if you and your partner decide to try again, make sure that your body and mind are ready. Ask your health care professional for advice about when you might try to conceive.

Keep in mind that miscarriage often happens just once. Most people who miscarry go on to have a healthy pregnancy after miscarriage. Only two percent of people have two miscarriages in row. And up to 1% have three miscarriages in a row.

If you have more than one miscarriage, think about getting tested to find any underlying causes. This can be especially helpful if you've had 2 to 3 pregnancy losses in a row. There's a chance tests could find conditions of the uterus, chromosome conditions, blood clotting problems or issues with the immune system. If the cause of your miscarriages can't be found, don't lose hope. It's still possible to have a healthy baby. Overall, people who've had three miscarriages still have a 60% to 80% chance of having a full-term pregnancy.

Coping and support

Emotional healing can take much longer than physical healing. Miscarriage can be a heart-wrenching loss that others around you might not fully understand. Your emotions might range from anger and guilt to despair. And your partner's emotions may seem different from your own. Give yourself time to grieve the loss of your pregnancy, and ask loved ones for help if you need it.

You might never forget your hopes and dreams surrounding this pregnancy, but in time acceptance might ease your pain. Talk to your health care professional if you feel ongoing sadness or stress. You might have a treatable condition such as anxiety, depression or post-traumatic stress disorder. Counseling sessions with a mental health professional may help. So might talking with people who've lost pregnancies in a miscarriage support group.

Preparing for an appointment

If you have symptoms of miscarriage, call your health care team right away. Depending on your situation, you might need urgent medical care.

Here's some information to help you get ready for your appointment and know what to expect.

What you can do

Before your appointment:

• Ask for any instructions. In most cases you'll be seen right away. If that's not the case, ask whether you should limit your activities while you wait for your appointment.
• Find a loved one or friend who can join you for your appointment. Fear and anxiety might make it hard to focus on what your health care team says. Take someone along who can help remember all the information.
• Write down questions for your health care professional. That way, you won't forget anything important that you want to ask.

Below are some basic questions to ask your doctor or other members of your health care team about miscarriage:

• What are the treatment options?
• What kinds of tests do I need?
• Can I keep doing my usual activities?
• What symptoms should prompt me to call you or go to the hospital?
• Do you know what caused my miscarriage?
• What are my chances for a successful pregnancy in the future?

Feel free to ask other questions during your appointment too — especially if you need more information or you don't understand something.

What to expect from your doctor

Your health care professional is likely to ask you some questions too. For example:

• When was your last menstrual period?
• Were you using any form of birth control at the time you likely became pregnant?
• When did you first notice your symptoms, and how often do you get them?
• Compared with your heaviest days of menstrual flow, is your bleeding more, less or about the same?
• Have you had a miscarriage before?
• Have you had any complications during a previous pregnancy?
• Do you have any other health conditions?
• Do you know your blood type?