Loss of a pregnancy can be a sad and distressing experience. Sadly, approximately a third of all pregnancies do end in miscarriage. The information in this leaflet may provide answers to some of the many questions you are likely to have and help you to cope with the loss of your pregnancy.
Why did I miscarry?
Miscarriages are very common. It is usually difficult to give a definite answer as to what caused a miscarriage. It is extremely unlikely that anything you did caused your miscarriage. Women and their partners may blame themselves for a miscarriage, but it is very seldom anything they have done, or not done, that causes the loss. At least two-thirds of all miscarriages occur because of a chromosome abnormality. This is usually a random occurrence and does not necessarily mean that there are any problems with a couples ovum and sperm.
What happens now? Does anything need to be done?
Following some miscarriages, all of the pregnancy tissue may have been passed and so nothing further needs to be done. Blood loss, like a period, may continue for several days until the lining of the uterus is completely shed. Sometimes, following a miscarriage, pregnancy tissue may remain inside the uterus. Usually nature will take its course and all of the pregnancy will be passed. However, there are other options like using medicines to help empty the uterus. In some situations a minor operation is required.
Your treating doctor or nurse will discuss all of the management options available to you so that you may make an informed choice about which management to undergo—expectant, surgical or medical. This decision can be made in consultation with your partner and family, and treating doctor/nurse.
You will find some more detailed information regarding these management options below.
Don't I need an operation?
In the past an operation was routinely performed for all miscarriages as there was no way to know how much pregnancy tissue, if any, still remained in the uterus. Using modern ultrasound techniques, it has become possible to adopt an expectant management (wait and see) approach. Not all miscarriages are suitable for this management option–the staff in the Early Pregnancy Assessment Unit (EPAU) will advise you as to whether this choice is appropriate for you.
If I decide to wait, how long will it take for me to miscarry?
Although the length of time taken for a miscarriage to be complete is difficult to predict, in the majority of cases, a pregnancy will miscarry within two to three weeks.
Do I need to come back to the hospital?
We will telephone you weekly to see what is happening and how you are coping. If you have a heavy bleed which gradually decreases and stops, then the miscarriage is most likely complete. If you are still bleeding two weeks after the heavy bleeding commences, then we will arrange for you to have an ultrasound scan to check whether your miscarriage is complete. However, if you are bleeding heavily, have significant pain or are worried, please contact us sooner (if you are soaking a pad in 30–60 minutes, go straight to your nearest emergency department).
If you change your mind about this management option, you are welcome to call us and discuss one of the other management options.
Is there any danger if I decide to wait?
All miscarriages can potentially be complicated by significant pain or heavy bleeding. Miscarriages managed with a wait and see approach carry a very small risk of infection but this approach is not always successful. If unsuccessful, you will be advised to consider surgical or medical management for your miscarriage.
Medical management involves giving a medication called misoprostol to facilitate a complete miscarriage without the need for surgery. It has been proven to be an effective treatment for 80 to 85 per cent of women whose miscarriage occurs before 13 weeks of pregnancy.
Is misoprostol a recognised treatment of miscarriage?
Yes. Misoprostol has been demonstrated as an effective treatment of early pregnancy loss in clinical studies and it compares favourably to both expectant and surgical management.
Misoprostol is not registered by its manufacturer for use in pregnancy, and hence the Therapeutic Goods Administration has not approved its use in pregnancy in Australia. However, there is strong support for its use in the treatment of miscarriage from both Queensland Health and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG).
What is involved for me if I have misoprostol?
Misoprostol will be administered via the vagina. This method of giving medication is commonly used in the treatment of pregnancy conditions and should involve minimal discomfort. Before being discharged home, you will be observed over 30 minutes to ensure you do not have an allergic response to the medication.
The following day you have the option of returning to EPAU so you can be given a repeat dose of misoprostol or you can elect to take the second dose home and self-administer it the next day. The treating doctor or nurse will explain to you how to do this. This second dose is very important as it helps to ensure that the uterus is emptied and the miscarriage completed. Omitting this second dose can result in pregnancy tissue being left in the uterus and the possible need for a curette (operation).
What can I expect after being given misoprostol?
Bleeding and pain will start soon after the first dose of misoprostol is given (approximately two to four hours). This may last for up to 24–72 hours before the miscarriage is completed. Period-like bleeding will then occur over the next week or so.
Approximately 10 per cent of women may experience excessive pain or bleeding—a visit to your doctor or the hospital, and possibly surgery, may then be required. In a large recent study, hospitalisation for heavy bleeding or infection occurred in less than one per cent of women. It is safe to use simple pain medication such as paracetamol (e.g. Panadol) or non-steroidal anti-inflammatory drugs (e.g. Brufen, Nurofen) for the treatment of this pain, according to directions outlined on the package.
What are the risks and side effects of misoprostol?
Misoprostol is usually well-tolerated. Side-effects may include nausea, vomiting, diarrhoea and fever. Allergy to misoprostol is uncommon; however, misoprostol should not be used by women with a history of severe asthma or porphyria (a metabolic disorder).
Should you have any concerns after reading this information, please do not hesitate to ask for further clarification from your doctor or nurse.
Your follow up appointments
The EPAU Nurse will telephone you a week after the misoprostol was given to check on your progress. If the medication has not worked and nothing has happened, you will be given an appointment to return to EPAU and discuss further options. If the miscarriage has occurred then no further intervention is required. For most women, the bleeding will stop within two weeks from the initial heavy bleeding. However, if you are still bleeding after this time, please call EPAU to make an appointment and we will assess you to make sure the miscarriage is complete.
If your miscarriage has not been completed then you have the option to either give it more time, have another two doses of misoprostol or to have a surgical procedure called a curette. The EPAU nurse will continue to follow you up via telephone until the miscarriage is complete, regardless of which option you choose.
Option C: Surgical management of miscarriage
The operation following a miscarriage is called a Dilatation and Curettage (D&C) and involves opening up the cervix (dilatation) and removing the uterine contents (curettage).
How is a D&C performed?
The procedure is performed as day surgery under general anaesthetic and takes less than 15 minutes.
A catheter (tube) is inserted into your bladder to ensure it is completely empty. A speculum is used to hold open the vagina (just like during a Pap smear examination) so that the cervix can be dilated using metal rods called dilators. A suction catheter is passed into the uterus to remove any blood and clots. A spoon shaped instrument called a "curette" is then passed into the uterus so the lining (endometrium) can be gently scraped. The tissue that is removed (curettings) is sent to pathology to be examined under a microscope to make sure there are no abnormalities.
What are the risks or after effects with this type of operation?
D&C is a common operation and there are few risks; however, some women may experience one or more of the following.
How will I feel after the operation?
After the procedure you may have period-like crampy pains. If so please tell the nurse. At home it is safe to use simple pain medication such as paracetamol (e.g. Panadol), or non-steroidal anti-inflammatory drugs (e.g. Brufen; Nurofen) for the treatment of this pain, according to directions outlined on the package.
You will have some bleeding in the days after the procedure. The amount and duration of bleeding is different for each woman. However, many women describe having some bleeding for a day or two then stopping for a day or two and then having some light bleeding over the next few days. If you develop heavy bleeding (i.e. soaking a pad every 30–60 minutes) you need to go to your nearest Emergency Department.
It is important that you only wear sanitary pads while you are bleeding; the use of tampons can cause infection. You may have a bath or a shower, as usual.
The general anaesthetic might make you feel drowsy and nauseated. You might feel thirsty but you are not able to drink straight away. You may be given some ice to suck instead.
You may feel sad—please let the nurse know if you would like to see a pastoral care worker while you are in hospital.
If you are feeling sad or depressed when at home, you have a few options for help:
You should wait two weeks, or until any bleeding has stopped, after a D&C (or any type of miscarriage) before resuming intercourse.
You must return to see a doctor if:
How long will I bleed for after a miscarriage?
Once the heavy bleeding has occurred and the pregnancy tissue has been passed, the bleeding gradually decreases then stops over the following week. You should contact EPAU or your GP if:
What else should I expect after having a miscarriage?
Tiredness - If you have a general anaesthetic, you will probably feel tired during the 24-hour period after your anaesthetic; you should not drink alcohol, drive or operate any dangerous machinery during this time.
Pain - After a miscarriage you may have a dull ache in your lower abdomen–this is normal and may last for a few days.
Breasts - Your breasts may be tender for several days and you may even leak milk. If this occurs wear a firm fitting bra, day and night, to provide adequate support until your breasts are comfortable. This may be necessary for a couple of weeks, but will settle on its own. If painful, mild pain medication such as paracetamol can be used.
Going back to work?
One week's absence is usually enough but the decision to go back to work is up to you. In all cases, a sick leave certificate can be obtained on discharge from hospital.
Will the method of treatment I choose affect my chances of becoming pregnant again?
No. Generally your chances of having a successful pregnancy are just as good regardless of what method you choose. However, the surgical option carries a slightly higher risk of fertility problems.
How long should I wait before trying for another baby?
When the bleeding stops, it is usually safe to start having sexual intercourse again. You may need a few weeks for your body to recover and then it depends on how you and your partner feel. You may not feel like having intercourse for a while or your sex drive might decrease. Your feelings and those of your partner need to be respected on this. You may ovulate unpredictably after a miscarriage and hence the time of your next period may be less certain. You may try for another pregnancy again when you feel ready; however, we recommend you wait until after one period before trying for another pregnancy. Your period should return within four to six weeks of the miscarriage. If it does not, then please see your doctor for a check-up.
Will I miscarry again?
Fortunately most couples go on to have normal, healthy, full term babies. The chance of another miscarriage following one miscarriage is not significantly changed. Even after several miscarriages, there is a good chance of a successful pregnancy.
There is no magic formula for success, but the emotional and physical wellbeing of both mother and father in the months before pregnancy will help to give your baby the best possible start. Please remember these are only suggestions—the most important thing is to decide how you both feel about being pregnant again, and to prepare in whatever way feels right for you.
Check up on your health
After a miscarriage, it is worthwhile asking your GP for a general health check. Your doctor may be able to identify or resolve any problems that may affect a future pregnancy. If you have a disability or long term condition such as diabetes, epilepsy or high blood pressure, talk to your doctor about your plans to fall pregnant. Ask how your condition will affect your pregnancy and what extra care may be needed to reduce any risk to the baby. If there is a genetic disorder in your own or your partner's family, and you are worried that it may be passed on to your own children, ask your doctor about seeing a genetic counsellor who can advise you about the likely risk.
Drugs or Medicines
Don't take drugs or medicines unless you have checked with your doctors or pharmacist that they are safe to take during pregnancy. Common drugs such as alcohol, tobacco, caffeine (in tea, coffee and cola drinks) and tranquillisers can all affect your body's chemistry. Illegal drugs such as cannabis, heroin and cocaine may affect fertility and increase the risk of premature or low birth weight babies, or cause damage to the developing fetus. The safest course of action is to avoid using any of these drugs before and during pregnancy.
Smoking can make a man less fertile and may result in the production of damaged sperm; a woman who smokes has an increased risk of miscarriage.
Heavy drinking reduces the number of sperm a man produces and can also damage sperm. For women, heavy drinking reduces fertility and increases the risk of miscarriage. It can also affect the baby's development during pregnancy. As the risk is highest in the earliest stages of pregnancy (including the time before a period is even missed) it is advisable that you both stop drinking if you are planning a pregnancy and during pregnancy.
Protect your baby
Certain infections may increase the risk of miscarriage or abnormality to your baby during pregnancy. Rubella (German measles) can lead to serious disability for your baby if you have it in the first few months of pregnancy. Even if you think you are immune, ask your doctor for a blood test to check. You can be vaccinated against rubella, but it is best to wait three months after the injection before becoming pregnant.
A well balanced diet is the basis of good health. A good diet will help to provide the best possible conditions for your baby to grow.
Folic Acid Supplements
Recent research has shown that a daily dose of folic acid (400 mcg tablet once a day) appears to reduce the risk of spina bifida when taken in the pre-conception period and during the early weeks of pregnancy. High doses of certain vitamins and minerals can be harmful, so it is advisable to obtain advice from your doctor before taking any supplements.
Will I get a follow-up appointment after the miscarriage?
Not always, unless there is a specific reason. We will ring you in the next week or so to see how you are going. You are very welcome to ring us at any time if you have any concerns. It is natural to feel low and depressed. Give yourself time to recover. It may help to talk over things with your partner, friends and close family members.
For further information, please contact:
Early Pregnancy Assessment Unit
Level 7, Mater Mothers' Hospitals
South Brisbane Qld 4101
Ph 07 3163 5132
Fertility Services at Mater
Level 7, Mater Mothers' Hospital
South Brisbane Qld 4101
Ph 07 3163 8437
Fax 07 3163 1830
Day Surgery Unit
Level 5, Mater Hospital Brisbane
South Brisbane Qld 4101
Phone 07 3163 8701