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What is a miscarriage?
Miscarriage is the loss of a pregnancy in the first 20 weeks. (In medical articles, you may see the term "spontaneous abortion" used in place of miscarriage.) About 10 to 20 percent of known pregnancies end in miscarriage, and more than 80 percent of these losses happen before 12 weeks.
This doesn't include situations in which you lose a fertilized egg before a pregnancy becomes established. Studies have found that 30 to 50 percent of fertilized eggs are lost before or during the process of implantation – often so early that a woman goes on to get her period at about the expected time.
Spotting the signs of a miscarriage
If you have these signs of miscarriage, call your doctor or midwife right away so she can determine whether you have a problem that needs to be dealt with immediately:
- Bleeding or spotting. Vaginal spotting or bleeding is usually the first sign of miscarriage. Keep in mind, though, that up to 1 in 4 pregnant women have some bleeding or spotting (finding spots of blood on your underpants or toilet tissue) in early pregnancy, and most of these pregnancies don't end in miscarriage.
- Abdominal pain. Abdominal pain usually begins after you first have some bleeding. It may feel crampy or persistent, mild or sharp, or may feel more like low back pain or pelvic pressure.
If you have both bleeding and pain, the chances of your pregnancy continuing are much lower. It's very important to be aware that vaginal bleeding, spotting, or pain in early pregnancy can also signal an ectopic or a molar pregnancy.
Also, if your blood is Rh-negative, you may need a shot of Rh immune globulin within two or three days after you first notice bleeding, unless the baby's father is Rh-negative as well.
Some miscarriages are first suspected during a routine prenatal visit, when the doctor or midwife can't hear the baby's heartbeat or notices that your uterus isn't growing as it should be. (Often the embryo or fetus stops developing a few weeks before you have symptoms like bleeding or cramping.)
If your practitioner suspects that you've had a miscarriage, she'll order an ultrasound to see what's going on in your uterus. She may also do a blood test.
What causes a miscarriage
Between 50 and 70 percent of first-trimester miscarriages are thought to be random events caused by chromosomal abnormalities in the fertilized egg. Most often, this means that the egg or sperm had the wrong number of chromosomes, and as a result, the fertilized egg can't develop normally.
Sometimes a miscarriage is caused by problems that occur during the delicate process of early development. This would include an egg that doesn't implant properly in the uterus or an embryo with structural defects that prevent it from developing.
Since most healthcare practitioners won't do a full-scale workup of a healthy woman after a single miscarriage, it's usually impossible to tell why the pregnancy was lost. And even when a detailed evaluation is performed – after you've had two or three consecutive miscarriages, for instance – the cause still remains unknown half the time.
When the fertilized egg has chromosomal problems, you may end up with what's sometimes called a blighted ovum (now usually referred to in medical circles as an early pregnancy failure). In this case, the fertilized egg implants in the uterus and the placenta and gestational sac begin to develop, but the resulting embryo either stops developing very early or doesn't form at all.
Because the placenta begins to secrete hormones, you'll get a positive pregnancy test and may have early pregnancy symptoms, but an ultrasound will show an empty gestational sac. In other cases, the embryo does develop for a little while but has abnormalities that make survival impossible, and development stops before the heart starts beating.
If your baby has a normal heartbeat – usually first visible on ultrasound at around 6 weeks – and you have no symptoms like bleeding or cramping, your odds of having a miscarriage drop significantly and continue to decrease with each passing week.
What puts you at a higher risk for miscarriage
Though any woman can miscarry, some are more likely to miscarry than others. Here are some risk factors:
- Age: Older women are more likely to conceive a baby with a chromosomal abnormality and to miscarry as a result. In fact, 40-year-olds are about twice as likely to miscarry as 20-year-olds. Your risk of miscarriage also rises with each child you bear.
- A history of miscarriages: Women who have had two or more miscarriages in a row are more likely than other women to miscarry again.
- Chronic diseases or disorders: Poorly controlled diabetes and certain inherited blood clotting disorders, autoimmune disorders (such as antiphospholipid syndrome or lupus), and hormonal disorders (such as polycystic ovary syndrome) are some of the conditions that could increase the risk of miscarriage.
- Uterine or cervical problems: Having certain congenital uterine abnormalities, severe uterine adhesions (bands of scar tissue), or a weak or abnormally short cervix (known as cervical insufficiency) up the odds for a miscarriage. The link between uterine fibroids (a common, benign growth) and miscarriage is controversial, but most fibroids don't cause problems.
- A history of birth defects or genetic problems: If you, your partner, or family members have a genetic abnormality, have had one identified in a previous pregnancy, or have given birth to a child with a birth defect, you're at higher risk for miscarriage.
- Infections: Research has shown a somewhat higher risk for miscarriage if you have listeria, mumps, rubella, measles, cytomegalovirus, parvovirus, gonorrhea, HIV, and certain other infections.
- Smoking, drinking, and using drugs: Smoking, drinking alcohol, and using drugs like cocaine and MDMA (ecstasy) during pregnancy can all increase your risk for miscarriage. Some studies show an association between high levels of caffeine consumption and an increased risk of miscarriage.
- Medications: Some medications have been linked to increased risk of miscarriage, so it's important to ask your caregiver about the safety of any medications you're taking, even while you're trying to conceive. This goes for prescription and over-the-counter drugs, including nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and aspirin.
- Environmental toxins: Environmental factors that might increase your risk include lead; arsenic; some chemicals, like formaldehyde, benzene, and ethylene oxide; and large doses of radiation or anesthetic gases.
- Paternal factors: Little is known about how the father's condition contributes to a couple's risk for miscarriage, though the risk does rise with the father's age. Researchers are studying the extent to which sperm could be damaged by environmental toxins but still manage to fertilize an egg. Some studies have found a greater risk of miscarriage when the father has been exposed to mercury, lead, and some industrial chemicals and pesticides.
- Obesity: Some studies show a link between obesity and miscarriage.
- Diagnostic procedures: There's a small increased risk of miscarriage after chorionic villus sampling and amniocentesis, which may be performed for diagnostic genetic testing.
Your risk of miscarriage is also higher if you get pregnant within three months after giving birth.
What to do if you think you might be having a miscarriage
Call your doctor or midwife immediately if you ever notice unusual symptoms such as bleeding or cramping during pregnancy. Your practitioner will examine you to see if the bleeding is coming from your cervix and check your uterus. She may also do a blood test to check for the pregnancy hormone hCG and repeat it in two to three days to see if your levels are rising as they should be.
If you're having bleeding or cramping and your practitioner has even the slightest suspicion that you have an ectopic pregnancy, you'll have an ultrasound right away. If there's no sign of a problem but you continue to spot, you'll have another ultrasound at about 7 weeks.
At this point, if the sonographer sees an embryo with a normal heartbeat, you have a viable pregnancy and your risk of miscarrying is now much lower, but you'll need to have another ultrasound later if you continue to bleed. If the sonographer determines that the embryo is the appropriate size but there's no heartbeat, it means the embryo didn't survive.
If the sac or the embryo is smaller than expected, the absence of a heartbeat might just mean that your dates are off and you're not as far along as you thought. Depending on the circumstances, you may need a repeat ultrasound within one to two weeks and some blood tests before your caregiver can make a final diagnosis.
If you're in your second trimester and an ultrasound shows your cervix is shortening or opening, your doctor may decide to perform a procedure called cerclage, in which she stitches your cervix closed in an attempt to prevent miscarriage or premature delivery. (This is assuming your baby appears normal on the ultrasound and you have no signs of an intrauterine infection.) Cerclage isn't without risk, and not everyone agrees on what makes you a good candidate for it.
If you're showing signs of a possible miscarriage, your doctor or midwife may prescribe bedrest in hopes of reducing your chances of miscarrying – but there's no evidence that bedrest will help. She may also suggest that you not have sex while you're having bleeding or cramping. Sex doesn't cause miscarriage, but it's a good idea to abstain if you're having these symptoms.
You may have light bleeding and cramping for a few weeks. You can wear sanitary pads but no tampons during this time and take acetaminophen for the pain. If you are miscarrying, the bleeding and cramping will likely get worse shortly before you pass the "products of conception" – that is, the placenta and the embryonic or fetal tissue, which will look grayish and may include blood clots.
If you can, save this tissue in a clean container. Your caregiver may want to examine it or send it to a lab for testing to try to find out why you miscarried. In any case, she'll want to see you again at this point, so call her to let her know what's happened.
What happens if you don't pass the tissue
There are different ways of handling this, and it's a good idea to discuss the pros and cons of each with your caregiver. If there's no threat to your health, you may choose to wait and let the tissue pass on its own. (More than half of women spontaneously miscarry within a week of finding out that the pregnancy is no longer viable.) Or you may decide to wait a certain amount of time to see what happens before having a procedure to remove the tissue.
In some cases, you can use medication to speed up the process, although there may be side effects such as nausea, vomiting, and diarrhea. If you choose to wait or take medication to try to speed it up, there's a chance you'll end up needing to have the tissue surgically removed anyway.
On the other hand, if you find that it's too emotionally trying or physically painful to wait for the tissue to pass, you may decide to just have it removed. This is done by suction curettage or dilation and curettage (D&C).
You'll definitely need to have the tissue removed right away if you have any problems that make it unsafe to wait, such as significant bleeding or signs of infection. And your practitioner may recommend the procedure if this is your second or third miscarriage in a row, so the tissue can be tested for a genetic cause.
Suction curettage and traditional D&C
The procedure doesn't usually require an overnight stay unless you have complications. As with any surgery, you'll need to arrive with an empty stomach – no food or drink since the night before.
Most obstetricians prefer to use suction curettage (or vacuum aspiration) because it's thought to be slightly quicker and safer than a traditional D&C, though some will use a combination of the two. For either procedure, the doctor will insert a speculum into your vagina, clean your cervix and vagina with an antiseptic solution, and dilate your cervix with narrow metal rods (unless your cervix is already dilated from having passed some tissue). In most cases, you'll be given sedation through an IV and a local anesthetic to numb your cervix.
For suction curettage, the doctor will pass a hollow plastic tube through your cervix and suction out the tissue from your uterus. For a traditional D&C, she'll use a spoon-shaped instrument called a curette to gently scrape the tissue from the walls of your uterus. The whole thing may take about 15 to 20 minutes, though the tissue removal itself takes less than ten minutes.
Finally, if your blood is Rh-negative, you'll receive a shot of Rh immune globulin unless the baby's father is Rh-negative, too.
What happens after a miscarriage
Whether you pass the tissue on your own or have it removed, you'll have mild menstrual-like cramps afterward for up to a day or so and light bleeding for a week or two. Use pads instead of tampons and take ibuprofen or acetaminophen for the cramps. Avoid sex, swimming, douching, and using vaginal medications for at least a couple of weeks and until your bleeding has stopped.
If you begin to bleed heavily (soaking a sanitary pad in an hour), have any signs of infection (such as fever, achiness, or foul-smelling vaginal discharge), or feel excessive pain, call your practitioner immediately or go to the emergency room. If your bleeding is heavy and you begin to feel weak, dizzy, or lightheaded, you may be going into shock. In this case, call 911 right away – don't wait to hear from your caregiver, and don't drive yourself to the ER.
The chance of having another miscarriage
It's understandable to be worried about the possibility of another miscarriage, but fertility experts don't consider a single early pregnancy loss to be a sign that there's anything wrong with you or your partner.
Some practitioners will order special blood and genetic tests to try to find out what's going on after two miscarriages in a row, particularly if you're 35 or older or you have certain medical conditions. Others will wait until you've had three consecutive losses. In certain situations, such as if you had a second-trimester miscarriage or an early-third-trimester premature birth from a weakened cervix, you might be referred to a high-risk specialist after a single loss so your pregnancy can be carefully managed.
Conceiving again after a miscarriage
You may have to wait a bit. Whether you miscarry spontaneously, with the help of medication, or have the tissue removed, you'll generally get your period again in four to six weeks.
Some practitioners say you can start trying to conceive again after this period, but others recommend that you wait until you've been through another menstrual cycle so that you have more time to recover physically and emotionally. (You'll need to use birth control to prevent conception during this time, because you may ovulate as early as two weeks after you miscarry.)
How to cope after a miscarriage
Though you may be physically ready to get pregnant again, you may not feel ready emotionally. Some women cope best by turning their attention toward trying for a new pregnancy as soon as possible. Others find that months or more go by before they're ready to try to conceive again. Take the time to examine your feelings, and do what feels right for you and your partner. For more information see our article on coping with pregnancy loss.
You may find help in a support group (your caregiver can refer you to one) or in our Community's miscarriage support discussions.
If you're feeling overwhelmed by your sadness, call your caregiver. She can put you in touch with a therapist who can help.
If you're wondering how to explain a pregnancy loss to your child, read about how to talk to your preschooler about pregnancy loss.