Miscarriage
Miscarriage is the most common kind of pregnancy loss. Around one in five pregnancies ends this way. Common does not mean easy, and it never means insignificant.
People come to this information at many different points: when something doesn’t feel right, after a loss has been confirmed, or while trying to make sense of what has already happened. However you arrive here, your experience matters.
A miscarriage is when a pregnancy ends before 24 weeks. In the UK, losses up to 23 weeks and 6 days are defined as miscarriage, while losses from 24 weeks are legally described as stillbirth. These definitions exist for medical and legal reasons, but they don’t always reflect how a loss feels, especially if your baby died later in pregnancy. Many people find these distinctions painful or confusing, and it’s okay if they don’t sit comfortably with you.
Why miscarriage happens
Even though miscarriage is so common, there is still a great deal we don’t know about why it happens. Many people never receive a clear explanation for their loss, even after medical tests.
Not knowing can be deeply unsettling. Without answers, it’s easy to question your body, your choices, or something you think you should or shouldn’t have done. Miscarriage is very unlikely to have been caused by anything you did or didn’t do.
Where causes are identified, they may include:
- Genetic changes, where the pregnancy cannot develop as it should
- Hormonal factors, which can affect implantation and early development
- Blood-clotting conditions, which affect how the placenta forms
- Infections associated with high fever or specific illnesses
- Anatomical differences, such as changes to the uterus or cervix
Often, no single cause is found.
Symptoms and Diagnosis
Miscarriage can happen with different signs, or sometimes with no symptoms at all. Common experiences include vaginal bleeding, which may be light or heavy, and abdominal or back pain. Some women notice cramping, passing of clots, or changes in discharge.
Not all bleeding or pain means miscarriage. Some pregnancies continue normally despite symptoms. But if you experience severe abdominal or shoulder pain, heavy bleeding, or feel faint, seek medical attention immediately.
Diagnosis usually involves a combination of medical history, pregnancy tests, and ultrasound scans. Sometimes, multiple scans are needed to understand what is happening. Each person’s experience can be different, and uncertainty can be very stressful.
The Physical Process
Miscarriage can occur in different ways. Some people experience cramping, bleeding, and passing of tissue naturally, while others may need medical or surgical intervention.
You should be able to choose what treatment to have and be given information to guide your decision. Unless you need emergency treatment, you should be given time to choose the right way forward for you. These can be difficult choices to have to make at a distressing time.
Also called ‘expectant’ or ‘conservative’ management. Some prefer to wait and let the miscarriage happen naturally. Doctors often recommend this, especially in the first eight or nine weeks of pregnancy. National (NICE) guidance also states that natural management should be the first method to consider.
What happens?
This can vary a lot depending on the size of the pregnancy and the findings of the ultrasound scan. It can take anything from days to weeks before the miscarriage begins. Once it does, you are likely to have strong cramps and bleeding. The bleeding may go on for 2-3 weeks; or the small pregnancy sac in the womb may be reabsorbed without much bleeding at all. It can be very difficult to predict exactly what will happen and when. You will probably be asked to visit or contact the hospital over the next few weeks. You may be offered a scan to check whether the uterus has emptied.
Or you may be asked to do a pregnancy test at home and come back if it is still positive after 2-3 weeks. At this point you may be offered medical or surgical management.
Does it hurt?
Most women have cramps and these can be extremely painful, especially when the pregnancy tissue is being pushed out. This is because the uterus is tightly squeezing to push its contents out, much like it does in labour. You are also likely to bleed very heavily and pass clots. These can be as big as the palm of your hand. You may see the pregnancy sac, which might look different from what you expected. You may – especially after 10 weeks – see an intact fetus. The hospital team should prepare you for what to expect and provide or advise you about pain relief.
What are the risks?
Infection
This affects about 1 in 100 women, so some hospitals give antibiotics routinely to prevent it. Signs include:
- a raised temperature and flu-like symptoms
- vaginal discharge that is a different colour, thickness or smell to usual
- abdominal pain that gets worse rather than better
- bleeding that gets heavier rather than lighter.
Treatment is with antibiotics. You may need an operation to remove any remaining pregnancy tissue. It is always advised to use pads rather than tampons for the bleeding and not to have sex until it has stopped.
Haemorrhage (extremely heavy bleeding)
About 2 in 100 women have bleeding bad enough to need a blood transfusion. Some of them need emergency surgery to stop the bleeding. If you are bleeding very heavily – or feel otherwise unwell or unable to cope – it is best to contact the hospital where you were treated or your nearest Accident & Emergency department.
Retained tissue
Sometimes a natural miscarriage doesn’t complete itself properly – even after a few weeks – and some pregnancy tissue remains in the uterus. You may need an operation to remove it. In rare cases, pregnancy tissue gets stuck in the cervix (neck of the uterus2) and needs to be removed during a vaginal examination. This can be very painful and distressing.
What are the benefits of natural management?
The main benefit is avoiding invasive treatment. You may want your miscarriage to be as natural as possible and to be fully aware of what is happening. You may also find it easier to say goodbye to the pregnancy if you see the tissue and maybe the fetus as it passes.
What are the disadvantages?
- You may find it difficult not knowing when or where the miscarriage might happen. This can take anything from days to weeks. You may worry about starting to bleed heavily in public when you are least prepared – although wearing period pads as a precaution can help
- You may be anxious about how you will cope with pain and bleeding, especially if you are not within easy reach of a hospital
- You may be frightened about seeing the remains of your baby
- You may find it upsetting or difficult to have follow-up calls or appointments to check on progress – although some women find this reassuring
- You might be too upset to wait for the miscarriage to happen naturally once you know your baby has died.
This means treatment with medication and/or vaginal tablets (pessaries) to start or speed up the process of a missed or incomplete miscarriage. However, it isn’t suitable for women with some health conditions.
What happens?
The exact treatment your hospital offers will depend on current practice and individual patient assessment. You might have some or all of your treatment in hospital, or you might be given some or all of the medication to use at home.
If you have a missed or delayed miscarriage or an anembryonic pregnancy, you are likely to be given tablets that block pregnancy hormones and help break down the lining of the uterus. You will be asked to return two days later for the next stage of treatment, unless you have already miscarried. The next stage means having tablets or pessaries to make your uterus contract and push out the pregnancy tissue.
If you have had an incomplete miscarriage, you will start with this second stage treatment. You may need more than one dose of the medication before the miscarriage happens.
The medication may make you feel sick and can cause diarrhoea and flu-like symptoms. The hospital team should provide you with anti-sickness tablets.
Does it hurt?
Most women have cramps that can be extremely painful, especially when the pregnancy tissue is being pushed out. This is because the uterus is tightly squeezing to push its contents out, much like it does in labour.
You are also likely to bleed very heavily – more than with a normal period – and pass clots. These can be as big as the palm of your hand. You may need to use extra-absorbent pads, possibly even more than one at a time. You may see the pregnancy sac, which might look different from what you expected. You may – especially after 10 weeks – see an intact fetus.
The hospital team should prepare you for what to expect. They should provide you with strong painkillers or advise what you can use and should also give you emergency contact numbers in case you need help or advice. You will be advised to take a pregnancy test three weeks after your treatment. If it is still positive, you will be asked to return to the hospital for further assessment.
What are the risks?
Infection affects about 1-4 women in every 100. Haemorrhage affects about 2 in 100 – the same as for natural miscarriage. Medical management is effective in 80-90 per cent of cases. If it is not, or if you have an infection, you may be advised to have surgical management to complete the miscarriage.
What are the benefits?
The main benefit is avoiding an operation and the anaesthetic (general or local) that goes with it. Some women see medical management as more natural than having an operation, but more controllable than waiting for nature to take its course. As with natural management, you may prefer to be fully aware of what is happening, to see the pregnancy tissue and perhaps the fetus.
And the disadvantages?
- You may find the process painful and frightening, although good information about what to expect can help.
- You may be anxious about how you will cope with pain and bleeding, especially if you are not in hospital at the time.
- You may be frightened about seeing the remains of your baby.
- Bleeding can continue for up to three weeks after the treatment and you may need several follow-up scans to check on progress
- Some women end up having an operation anyway.
This is a procedure to remove the pregnancy tissue. It may be done under general anaesthetic, so you are asleep, in this case you might hear it called a D&C. It can also be completed with local anaesthetic, where you stay awake, in this case you will hear it called an MVA.
Surgical management under general anaesthetic
This used to be called called ERPC or ERPoC, which stands for Evacuation of Retained Products of Conception. You might hear it called a D & C, but that is a slightly different procedure, usually carried out for women with period problems. Both of these terms are still used occasionally.
What happens?
The cervix (neck of the uterus) is dilated (stretched) gradually. This is usually done under anaesthetic but you might be given me3dication or vaginal pessaries before the operation to soften the cervix. A narrow suction tube is then inserted into the uterus to remove the remaining pregnancy tissue. This takes about 5-10 minutes.
A sample of the tissue removed is usually sent to the pathology department to check that it is normal pregnancy tissue. It is not usually tested further unless you are having investigations after recurrent miscarriage.
Does it hurt?
If you are given tablets or vaginal pessaries before the operation, you may have cramping pain and perhaps some bleeding as the cervix opens. Having a general anaesthetic means you will not feel anything during the operation itself; and there are no cuts or stitches. You may have some abdominal cramps (like strong period pain) when you wake up and for a few days afterwards.
You may bleed for up to 2-3 weeks after the operation. Bleeding may stop and start but should gradually tail off. If it stays heavy, gets heavier than a period or makes you worried, it is best to contact your GP or the hospital.
What are the risks?
- About 2-3 women in every hundred get an infection.
- Rarely – less than 1 in 200 cases – the operation can perforate (tear) the uterus; damage to other organs is rarer still.
- There is a very low risk of adhesions. Adhesions is the term for scar tissue that can form within the womb. Mild scarring can be common after miscarriage (including miscarriage managed without surgery), and rarely causes any problems that may impact your future fertility. Very rarely, someone may experience severe adhesions (known as Asherman’s syndrome) that 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.
- Haemorrhage (extremely heavy bleeding).
- Very occasionally – in around 5 in 100 cases – some pregnancy tissue remains in the uterus and a second operation is needed to remove it.
- Very rarely, the general anaesthetic can cause a severe allergic reaction (about 1 in 10,000 cases) or even death (fewer than 1 in 100,000 cases).
- Very rarely (less than 1 in 30,000 cases) it can result in a hysterectomy (removal of the uterus); this would only be if there is uncontrollable bleeding or severe damage to the uterus.
What are the benefits?
With surgical management you know when the miscarriage will happen and can plan around that. With a general anaesthetic you won’t be aware of what’s going on. It may be a relief when the miscarriage is ‘over and done with’ and you can begin to move on.
And the disadvantages?
Some women are frightened of anaesthetics, surgery and staying in hospital. Some prefer to let nature take its course and to remain aware of the miscarriage process. The anaesthetic might make you feel groggy or unwell for a few days. Some women refuse surgery because they worry that the diagnosis might be wrong and their baby is still alive. If this is a concern, don’t be afraid to ask for another scan just to be sure.
Surgical Management under local anaesthetic
This is also sometimes called MVA, which stands for Manual Vacuum Aspiration. It may be carried out in a hospital ward, a day surgery unit or an out-patient clinic.
What happens?
You may be given tablets or vaginal pessaries before the operation to soften the cervix, along with pain relief. A local anaesthetic is injected into your cervix, or the cervix may be numbed with a gel, and the cervix is then dilated (stretched) gradually. A narrow suction tube is then inserted into the uterus to remove the remaining pregnancy tissue.
You should be offered further pain relief during the procedure and may have a scan afterwards. This usually takes about ten minutes. Afterwards you will probably be advised to wait for an hour or two to make sure you are well enough to go home. A sample of the tissue removed may be tested afterwards to check that it is normal pregnancy tissue.
Does it hurt?
Most women feel some pain during the procedure, which can range from mild discomfort to a very intense cramping pain. The injection of local anaesthetic into your cervix might feel uncomfortable, but it only lasts for a few seconds.
It’s likely you’ll then feel some pain or cramping as the tissue is removed and the uterus contracts. You can be given additional pain relief, such as nitrous oxide (gas and air). We recommend you speak to your healthcare professional before the procedure to discuss how they will help you manage any pain, and what your options are if you find it too uncomfortable.
Know that you can ask for the procedure to be stopped if you need to. You will usually have the option of then having the procedure under general anaesthetic, but often you may have to wait some time for this, depending on when you last ate, and what else is happening in your hospital.
You should expect some light vaginal bleeding and cramping afterwards. You may be given painkillers to take home or be advised to take some over-the-counter medication. If the bleeding becomes heavy, it is important to contact the team that treated you.
Are there any risks?
These are mostly the same as for management under general anaesthetic. There is a very small risk of having a reaction to the local anaesthetic.
What are the benefits?
You will know when the miscarriage will happen and may then feel you can begin to move on. The procedure is quick and you will recover more quickly than from a general anaesthetic. You may actually prefer to be awake and aware of what is happening.
Disadvantages
Some women prefer not to be aware of the process. And you may worry about coping with pain or anxiety.
The emotional impact
Miscarriage is not only a physical event. For some, it brings shock, grief, anger, guilt, and fear, and sometimes all at once. It can feel isolating, especially when others don’t know what to say or minimise the loss because it happened “early”.
There is no right way to respond, and no timetable for recovery. What you’re feeling is valid.
After Miscarriage
The end of a pregnancy can leave a mixture of grief, relief, confusion, and guilt. Recovery is both physical and emotional, and each person moves at their own pace.
You may notice ongoing physical symptoms such as cramping or bleeding, and it’s important to contact a healthcare professional if symptoms are heavy or worrying. Emotionally, it’s normal to feel sadness, anger, or anxiety, and support from friends, family, or counselling can help.