The purpose of this information is to:
- describe what miscarriages are, and why they occur
- explain what treatment options are available
- describe expectant management in detail
- explain what can be expected during your recovery from a miscarriage
- discuss future pregnancies
Separate information is available on medical management of miscarriage, surgical management of miscarriage under general anaesthetic, and surgical management using local anaesthetic.
A miscarriage is the loss of a pregnancy before 24 weeks of pregnancy. Miscarriages are classed as early miscarriages (before 12 weeks) or late miscarriages (between 12 to 24 weeks).
Sadly, early miscarriages are common, affecting between 1 out of every 5 pregnancies, and 1 out of every 2 pregnancies, depending on the age of the pregnant woman. Late miscarriages are less common, affecting 1 out of every 100 pregnancies. In general, the risk of miscarriage decreases as the pregnancy develops.
Symptoms of miscarriage vary. The most common symptom is vaginal bleeding. This is usually accompanied by period-like cramping pain. Sometimes women with healthy pregnancies can experience some bleeding and pain, but heavy bleeding is more likely to indicate a miscarriage.
Some women may not experience any symptoms until after they are diagnosed with a miscarriage at a routine ultrasound scan.
Some bleeding and discomfort are unfortunately inevitable during a miscarriage, regardless of how it happens or is treated. Most of the time these symptoms are manageable at home with simple painkillers that you can buy over the counter, rest, and the support of family or friends.
However, if at any stage:
- the pain is unmanageable at home
- you are bleeding very heavily (changing a large pad more than once an hour for two consecutive hours, or you are feeling dizzy)
- you develop a high temperature or
- you are frightened or feel unable to cope
then you should go to your nearest Accident and Emergency department. This is because occasionally women need additional medical support or an emergency operation.
Most importantly, miscarriage is not your fault, and it is very unlikely that you could have done anything differently to prevent it from happening.
More than half of early miscarriages are caused by genetic abnormalities in the egg, sperm, or early pregnancy. We do not fully understand why these genetic changes happen. However, very often they mean that the pregnancy could not progress into a healthy baby, and a miscarriage is the body recognising this.
We know that the risk of miscarriage is higher as you get older. For example, at the age of 30, the risk of a woman experiencing a miscarriage is 1 out of every 5 pregnancies; over the age of 40, the risk of miscarriage is 1 out of every 2 pregnancies. We also know that certain lifestyle factors, such as smoking, being overweight or heavy drinking of alcohol, may increase your risk of miscarriage.
Rarely early miscarriages can occur for other reasons, such as
- clotting abnormalities (antiphospholipid syndrome)
- an inheritable genetic pattern in either parent
Because these problems are uncommon, we would normally only perform further investigations in women who have had three or more miscarriages.
There are three different types of miscarriage:
- Early embryonic demise is when the pregnancy has stopped developing but remains within the womb. You may also hear this referred to as a ‘missed miscarriage’ or ‘delayed miscarriage’
- Incomplete miscarriage is when some of the pregnancy tissue has already passed, but some tissue is still inside the womb
- Complete miscarriage is when all the pregnancy has passed and the womb is empty
The best method to diagnose a miscarriage is an internal (transvaginal) ultrasound scan. This type of scan allows a much more detailed view of the pregnancy and the womb than scans performed on the tummy.
It may not be possible to diagnose a miscarriage during the first scan. If this is the case, a repeat scan will be arranged after one to two weeks.
The options for treatment are:
1. Expectant management – waiting for the pregnancy to pass on its own
2. Medical management – giving tablets to start the process of miscarriage
3. Surgical management – an operation to remove the pregnancy from the womb
Studies have shown that there appears to be no difference in women’s long-term health, ability to become pregnant, or carry future pregnancies, depending on the choice of treatment. As a result, women are usually able to choose the management option they prefer. However, in some situations, especially if you are (or are at risk of) bleeding heavily, or if there is evidence of infection, surgical management is safer: your doctor will explain if this is the case.
People often don’t feel ready to make a decision about treatment at the time their miscarriage is diagnosed. Please do not worry if this is the case. You can contact the early pregnancy unit if you would like to re-discuss your options, or proceed with medical or surgical management.
1. Expectant management
This means waiting for the miscarriage to happen naturally. This is successful in about one out of every two women who choose this option.
Unfortunately, we are unable to accurately predict when the process of a miscarriage will start, and sometimes this uncertainty is difficult. When the miscarriage occurs, you are likely to have heavy bleeding with clots and strong cramping pains. We recommend that you have painkillers (such as paracetamol and ibuprofen, if you are able to take them) at home, which you can take according to the instructions on the packet, to treat these cramping pains. We can also provide some stronger painkillers if you are likely to need them.
We recommend that you contact the department after two weeks if heavier bleeding (suggesting that pregnancy tissue is passing) has not started, so that we can re-discuss other management options with you (though you may still choose to wait longer). You may also wish to contact us sooner if you change your mind, and wish to proceed with medical or surgical management.
We also suggest that you contact us if bleeding does not stop within two weeks of starting, so we can organise a further scan.
2. Medical management
This involves putting tablets into the vagina (misoprostol), and sometimes also taking a tablet by mouth (mifepristone), to bring on the process of a miscarriage. We generally only offer medical management to women with early embryonic demise. This is because it is no more effective than waiting if you have an incomplete miscarriage. It is successful for eight to nine out of every ten women with early embryonic demise.
Please see our information on “medical management of miscarriage” for more details.
3. Surgical management
Surgical management involves emptying the womb using a suction device. We may recommend this for larger pregnancies, or if there are other reasons you may bleed more heavily.
Surgical management of miscarriage is performed through the vagina, and does not usually involve any cuts of stitches. You may be given the choice whether to have the procedure under general anaesthetic (when you are asleep) or using local anaesthetic (you are awake, but with a numbing injection into the neck of the womb, and gas and air to breath if you need it). If your pregnancy is further developed or you are at higher risk of bleeding we will recommend a general anaesthetic.
If you choose to have the procedure awake, your recovery may be faster, and you are likely to be in hospital for less time. The level of pain women may experience varies from person to person. However, some women experience strong cramping pains during the procedure, and other women may find it stressful or upsetting to be awake: it is up to you if you would prefer to be under general anaesthetic.
More information about surgical management is available under “Surgical management of miscarriage under general anaesthetic” and “Surgical management of miscarriage with local anaesthetic”.
Sometimes a natural miscarriage happens while waiting for a booked surgical procedure. If you experience heavy bleeding, please contact the Early Pregnancy Unit the following day to organise another scan to check whether the operation is still needed.
All treatments and procedures have risks, and we will talk to you about the risks of each option. Overall the risk of serious complications is low.
Heavy bleeding
Whichever treatment you choose, there is a risk of heavy bleeding during a miscarriage.
If you lose a lot of blood, you may need to have a blood transfusion (donated blood given to you directly into your vein). If you have expectant or medical management, or start to bleed prior to a booked surgical procedure, occasionally the bleeding is so heavy that you will need to come into hospital as an emergency.
The risk of bleeding is lowest from a booked surgical procedure, and if you do bleed at the time of the procedure, we can usually treat it very quickly. If you bleed heavily during expectant or medical management, you may be recommended to have an emergency surgical procedure.
Infection
Uncommonly, miscarriage can be associated with infection. Sometimes infection may be introduced by a surgical procedure.
If you develop signs of infection (fever, chills, worsening tummy pain, or discharge with a strong, unpleasant smell), you should contact the early pregnancy unit or attend A&E. If infection occurs, you will need antibiotics, and you may require admission to hospital.
Injury to the womb (perforation)
A risk of surgical management is perforation of the womb. This is where a small hole is accidentally caused with an instrument used during surgery. We many need to admit you to hospital overnight and give you some antibiotics. Very uncommonly you may need surgery via a cut in the abdomen (usually a keyhole procedure), to repair the perforation or damage to other organs.
Intrauterine adhesions
Generally the lining of the womb heals very well after miscarriage. Adhesions is the term for scar tissue that can form within the womb. Although mild scarring is commonly seen after miscarriage (including miscarriage managed without surgery), it rarely has any implications for the future. Severe adhesions are uncommon, but may result in difficulty getting pregnant in the future. We do not fully understand what causes some women to develop severe adhesions, and others not to.
Severe adhesions may present with absent or very light periods. If you have not had a period within six weeks of your surgery, or your period is very light, we may suggest a repeat scan or camera test (hysteroscopy) to look inside the womb and check for these.
Unsuccessful treatment
There is a risk of some tissue being left within the womb after expectant, medical or surgical management. The risk is lowest after surgical management (1 in every 20 patients). If there is tissue left within the womb, sometimes it will pass by itself as you bleed, but it may require a surgical procedure.
If you miscarry at home, the pregnancy will often pass on the toilet and it often happens that it is flushed away. Alternatively, you may decide to bury the pregnancy tissue.
You may prefer for the hospital to handle the pregnancy remains, in which case you should contact the early pregnancy unit nurses (see contact details below) to arrange to bring it in to us in a container that you are happy for us to keep.
Pregnancy tissue that is removed during a surgical procedure, or passes in hospital, is handled sensitively, and in accordance with your wishes. We recommend histology examination (where the tissue is examined under a microscope) to confirm pregnancy tissue was removed, and to exclude a molar pregnancy (a rare cause of miscarriage, which requires further follow-up). We do not write to you with these results unless they are abnormal. For some women with recurrent miscarriage, cytogenetic testing is recommended, and this will be discussed further with you.
After testing, many women then choose for the hospital to handle the pregnancy tissue by communal cremation. Other women prefer to take the pregnancy away with them. We need to discuss your options with you, and ask you to sign a form about your choices. More information about your options for handling pregnancy tissue at home or in hospital can be found under ‘Sensitive arrangements for pregnancy tissue after miscarriage and/or surgical management’.
You can also discuss your options with the bereavement midwife on 07539 215 484.
We do not organise routine follow-up following miscarriage management. However, we would recommend making a follow- up appointment in the Early Pregnancy Unit, if:
- Bleeding continues for more than two weeks
- Your next menstrual period has not started within six weeks of the bleeding stopping
- You have developed symptoms of infection (abnormal vaginal discharge or fevers)
A follow-up can be organised by calling the Early Pregnancy Unit nurses on 020 3447 6515.
We would recommend attending your local A&E department if the bleeding is extremely heavy, you are in severe pain or have symptoms of severe infection (high fevers, abnormal vaginal discharge).
During the first two weeks following a miscarriage while you are bleeding you should avoid having sex, swimming or using tampons to reduce the risk of infection.
It can take up to three weeks following a miscarriage for your pregnancy hormones to clear, during which time a pregnancy test can still read positive.
When you return to work depends on you and how you feel. If you have an operation, it is advisable to rest for a day after.
Although you may physically feel back to normal quickly after a miscarriage, many women find they need longer to recover emotionally. You can ask your doctor for a sick note from EPU, or on the day of a surgical procedure. If you need longer than two weeks, you should see your GP.
You will usually get your next period 4-6 weeks after a miscarriage. If you feel physically and emotionally ready, you can start trying for a pregnancy after this period. It is possible and safe to get pregnant even before this first period, but our advice is generally to use contraception in this time. This is so, when you do get pregnant, you will know how far along you are (which helps us know what to expect on scan), and also to make sure you are healthy for a new pregnancy.
Some women and couples may need more time to recover emotionally and physically before trying again. The best time to start trying again is when you and your partner feel ready to do so.
The risk of miscarriage is slightly increased in women who have had a previous miscarriage, though your chances of a healthy pregnancy are likely to be higher than your chance of miscarriage. The Tommy’s Miscarriage Support Tool can calculate your personalised risk of a repeat miscarriage.
There are several things you can do to increase your chance of having a healthy pregnancy:
- Take folic acid supplements
- Reduce alcohol intake
- Stop smoking
- Eat a healthy, balanced diet
If you become pregnant again, we offer a reassurance scan at around 7 weeks’ gestation, or earlier if you experience pain or bleeding. You can attend the walk-in clinic for this scan. If you develop bleeding in any future pregnancies, then we would offer you progesterone treatment to reduce the risk of a miscarriage.
It is common to experience profound sadness and grief after a miscarriage. Some women and their partners find that these feelings persist for a long time. Other people experience anxiety, depression, and post-traumatic stress after a miscarriage. If you are struggling emotionally, it is important that you discuss this with your healthcare professional in hospital and your GP.
You may find some of the support organisations listed at the end of this leaflet helpful. You may also need more formal support or treatment, for which your GP can help or refer you.
You can also self-refer to your local counselling service, via “NHS Talking Therapies”.
There are also books which can be helpful:
- Miscarriage: Women’s Experiences and Needs, Christine Moulder
- The Baby Loss Guide, Zoe Clark Coates Pregnancy After Loss, Zoe Clark Coates
PALS
The Patient Advice and Liaison Service (PALS) is a service that offers general support, information and assistance to patients, relatives and visitors. The PALS office is located on Ground Floor Atrium.
- Telephone: 020 3447 9975
- Email: PALS
@uclh.nhs.uk - Address: PALS, Ground Floor Atrium, University College Hospital, 235 Euston Road, London NW1 2BU
Early Pregnancy Unit
Direct line: 020 344 76515 (please leave a voicemail)
Email: uclh.
Opening Times:
Monday- Friday 09:00 – 12:30 and 14:00 – 15:00
Saturday and Sunday 09:00-12:30 (A&E referrals only)
The EPU is located on the lower ground floor of the Elizabeth Garrett Anderson Wing. Follow signs to Clinic 3.
Page last updated: 10 May 2024
Review due: 01 May 2025