Second trimester loss: late miscarriage
Most miscarriages happen in the first 12 weeks of pregnancy. Loss after the first trimester is less common but can be especially devastating because the pregnancy is more established and expectations for the baby may be higher.
Second trimester loss is usually used to describe when the baby dies between 14 and 24 weeks of pregnancy. This is sometimes called a late miscarriage.
You might have just received this news, perhaps with no warning, or your loss might already have happened. You might be somewhere in between those points, having to make decisions or waiting for treatment or for the loss to happen naturally.
“My daughter was a baby. My baby died. I held her, I had a funeral for her. I hate that I can’t register her, that nobody will know she existed.”
What people prefer their loss to be called
You may find it hard to understand why a very late pregnancy loss or baby loss is called a miscarriage and not a stillbirth – particularly as it means that there is no birth or death certificate for the baby. This is because 24 weeks of pregnancy is the legal age of viability – the stage at which a baby is thought to stand a good chance of surviving if born alive.
Causes of second trimester loss
You may never know what caused your loss, but it’s important to know that it is very unlikely to be due to anything you did or didn’t do. Most miscarriages, at whatever stage, happen because of a problem in the baby’s development.
A baby’s chromosomes are formed when the egg and sperm meet at conception. The baby receives half its chromosomes from each parent. Sometimes things can go wrong which results in the baby having the wrong number of chromosomes, or an individual chromosome may be too long or too short.
This can cause an abnormality which may cause an early miscarriage, but sometimes the baby dies later in pregnancy or shortly after birth. However, some babies with genetic or chromosome abnormalities survive.
Examples of chromosome or genetic abnormalities are Downs Syndrome, Patau Syndrome, Edwards Syndrome and Turner Syndrome.
If a chromosome abnormality is suspected as a cause of a loss, it may be possible to confirm this, or rule it out, by checking the baby’s chromosomes from blood, skin or the placenta.
In most cases a chromosome or genetic abnormality occurs by chance, but occasionally it is inherited from a parent. It is possible to check the parents’ chromosomes through blood tests. This information can help identify the risk of a similar problem happening again.
If there is an increased risk, you may be referred to a specialist to have tests and perhaps given advice about future pregnancies.
The placenta is the organ that provides the baby with oxygen and nutrients. It’s attached to the lining of the womb and is connected to the baby by the umbilical cord. Problems with the placenta can be due to a blood clotting problem such as Antiphospholipid Syndrome (APS), which can affect the blood flow through the placenta and cord to the baby. Other times, it can be that the placenta isn’t working properly or well, this stops the baby getting all the nutrients and oxygen that they need to grow normally
These are problems in the baby’s body, for example spina bifida or a congenital heart defect, (when the heart doesn’t form correctly). These are sometimes seen on an ultrasound scan, but sometimes they are only discovered after the baby is born.
If your baby is found to have this kind of problem, you should be offered genetic counselling so that you can find out more about the chances of it happening again.
An unusually shaped womb (uterus) can cause a late loss. Doctors sometimes suggest an operation to correct the shape of the womb but this isn’t always possible or recommended.
Problems with the cervix (the neck of the womb) can also cause late loss. The cervix should stay tightly closed during pregnancy. But if it is weakened or damaged for some reason, it may open as the baby grows bigger, causing a very early birth.
If your doctor thinks this might be the reason for your loss, they may suggest that you have a strengthening stitch, called a cervical stitch, in your next pregnancy. This is usually done under a general anaesthetic at 13 or 14 weeks of pregnancy.
More information on this from The Royal College of Obstetricians & Gynaecologists can be found here.
Some infections can cause a second trimester loss, either by infecting the baby or by infecting the amniotic fluid (the liquid around the baby).
Infections directly affecting the baby include parvovirus, cytomegalovirus (CMV), listeria and toxoplasmosis. Infections like these in one pregnancy do not increase the risk of them happening in a future pregnancy.
Infections of the amniotic fluid can happen when bacteria (germs) that normally live in the vagina get into the womb. One example is bacterial vaginosis (BV), a common infection which has been associated with premature (early) labour.
This is a blood clotting disorder, sometimes called ‘sticky blood syndrome’. It happens when your immune system makes abnormal antibodies that can cause blood clots in the placenta or stop the embryo from implanting properly, causing an early miscarriage.
APS can also cause problems in later pregnancy, including the baby not growing enough, pre-eclampsia or stillbirth. It also increases your risk of developing blood clots.
If you are found to have APS, you will be treated with low dose aspirin tablets and heparin injections. Together, these make your blood less likely to clot and can increase your chance of having a live baby.
You should not start taking aspirin unless it has been prescribed by your doctor.
Signs & symptoms
The main symptoms of second trimester loss are vaginal bleeding, painful cramps in your abdomen or waters breaking or leaking from around the baby.
For some people these symptoms may go on a long time, with repeated visits or stays in hospital.
For others it may be a very quick process, and they gave birth to their baby within a few hours of their first symptoms.
Some people notice that their baby’s movements have slowed down or changed, or they haven’t felt any movements for a while. Often there is no set pattern to movements before 24 weeks of pregnancy, so it can be difficult to know if this is normal or not.
Sometimes there are no obvious signs at all. Some people may have no idea that anything is wrong with the pregnancy and only find out that the baby has died during a routine scan or appointment.
“When they told me they couldn’t find a heartbeat, I think my heart stopped, too. I was full of the joys of being pregnant only to feel I had been hit by a train head on.”
Tests and investigations
After a second trimester loss, most hospitals offer tests for you, the baby, and sometimes your partner. Some tests might include:
Post-mortem
A post-mortem may be able to identify why your baby died and may also help your doctor to care for you in a future pregnancy.
A partial post-mortem will involve a detailed external examination of your baby and perhaps x-rays or scans, but can also include taking small samples of blood or skin.
A full post-mortem will include an internal examination of your baby, their organs and tissue. Any tissue removed at the post-mortem will be examined in a laboratory. This can take some time and it may be several weeks before you can be given results.
If your baby has to be transferred to another hospital for the examination, it may be up to eight weeks before they are returned. You may be able to see your baby again afterwards and you can talk this through with the pathologist or other staff.
If you decide not to have a full post-mortem, you can still ask for the placenta to be examined and for an external examination of your baby.
After the post-mortem examination, you would normally be invited for a follow-up consultation with your consultant to discuss the results. This would usually be your named consultant obstetrician but depending on local services, it may be the pathologist or your GP who explains the results.
For some parents, understanding why the baby died can help with the grieving process. However, a post-mortem does not always provide a reason. For some parents this is sad and frustrating. Others are comforted by the thought that there was nothing obviously wrong that might affect a future pregnancy.
How can I decide?
Deciding whether or not to have a post-mortem for your baby can be very difficult.
“When you are in such a cloud of deep grief you simply cannot retain information, think clearly or make decisions. Grief and the shock of it all massively affected me and made it hard to make decisions. It was helpful to have 24hrs between the loss and the start of the physical process to also think about all these decisions as a couple.”
To help you decide, you should have the chance to talk about it with someone who understands the process, either in the hospital or with your GP.
“We finally agreed on an external examination and a look at the chromosomes. The results were normal, which we found reassuring even though we still had no explanation as to why we lost our baby.”
Follow-up
You should be offered a follow-up appointment with your hospital consultant or a member of their team a few weeks after your loss.
This is the opportunity to get the results of any investigations, to ask any questions you have and to find out about any treatment that might help now or in another pregnancy.
You may not get answers to all your questions – and that might be because there sadly isn’t an answer. But it could be that the appointment felt rushed or the doctor did not seem well prepared, and you are worried that you haven’t received enough information.
It may help to talk to your GP, who might be able to find out more for you. GPs aren’t always sent this information from the hospital, so allow time for them to chase it up if necessary.
Whoever you see, it can be useful to take a written list of questions with you, as it’s easy to forget once you are there.
You might want to make notes of the information you are given, as there may be too much to take in and remember at the time.
What happens to my baby?
When a baby dies before 24 weeks of pregnancy, there is no legal requirement to have a burial or cremation. However, your hospital may offer to arrange for your baby to be buried or cremated or you may decide to arrange this yourself.
The hospital staff should give you time to think about what you want to do. You may feel too shocked to be able to make a decision right away. This is a decision you probably never imagined that you would have to make.
Can I have a certificate for my baby?
There are no formal certificates for babies miscarried before 24 weeks but there are some options for certificates of loss. These are not legal documents, but you may still find it comforting to have one. Optional certificates of loss are now available in England and Scotland. It is hoped that similar schemes will follow in Wales and Northern Ireland soon. Your hospital may offer a certificate of loss and/or may also have a memorial book where you can record your baby’s details. And we have a set of memorial certificates that you can choose from in our online shop.
Hospital arrangements
Hospital policies around burial and cremation differ. Your hospital may offer to arrange an individual burial or cremation for your baby, or they may offer collective burial or cremation.
In all cases the hospital staff should take time to explain to you what the hospital offers. They should give you written information as well, so that you can read and think about it after you go home.
“The bereavement unit at the hospital talked through all of these decisions with me, and contacted a friend to come into the hospital to be present for the discussions as well. They discussed the decisions with me sensitively and allowed me time to think through, and came back to discussions more than once if I requested.”
You may want to ask the hospital to keep your baby until you are ready to decide. They will let you know if there is any limit to the time you have for this, and what they do if they don’t hear from you by then. They should also understand if you feel you cannot make a decision at all.
“I was making funeral arrangements when all I wanted to do was to hold them in my arms and take them home forever.”
Making your own arrangements
You can make your own arrangements for a funeral and/or burial or cremation if you prefer. You could talk to a funeral director or a minister of your own faith.
“I was amazed by how helpful and sensitive the funeral directors were in organising my baby’s burial.”
The hospital chaplaincy or spiritual care team may also be a good source of information, advice and support, even if you don’t have any religious beliefs.
“The hospital chaplain was also amazing. The cremation was organised by the hospital but she regularly kept in contact even before Olivia was returned from her post mortem, letting us know all the options we had etc. She made a beautiful order of service and was very caring.”
You might decide that you want to bury your baby yourself. There are guidelines about how and where this can be done.
“We made a little garden of remembrance in our garden and planted a raspberry bush and just buried the baby there (in a little box).”
How will I feel after the loss?
The physical impact of second trimester loss can vary widely and it can be particularly distressing if you don’t know what to expect. Do contact your GP, midwife or hospital team if you need any medical advice.
Pain and bleeding
Everyone is different, but after a second trimester loss, you are likely to have some bleeding and pain like a period. This might go on for several weeks, with the pain and bleeding gradually getting less and less over that time. If you normally have a regular cycle, you can expect your period to return after around 4-8 weeks.
It is worth asking your doctor or midwife for advice if:
- the bleeding or pain increases
- you have a vaginal discharge that looks or smells bad, or
- you are worried about any other physical symptoms.
Your midwife might offer to visit you at home to see how you are doing. Your doctor can also give you a sick note/fit note if you need one for work.
Your breasts
Your breasts may be tender and, depending on how many weeks pregnant you were, may produce milk, and you might find this very upsetting. You may find it helpful to talk to your midwife or doctor about this and about what can help. They may suggest tablets to reduce the production of milk.
“They were great and said I could let my breast milk come naturally if I wanted or have the tablets to stop it happening. I chose the tablets as I couldn’t face that.”
If your breasts are painful, you might need to take a mild painkiller such as paracetamol but if they are very painful or inflamed, it’s best to consult your doctor or midwife.
Some people decide to donate their milk to help other babies. You can find your nearest milk bank by visiting https://ukamb.org/ .
Time to recover
You may feel physically and emotionally exhausted for quite a long time after your loss and your body needs time to recover. If you are producing milk, that can be tiring too. Despite being tired, you may find it hard to sleep.
“I felt tired all the time and didn’t want to get out of bed. I had a constant pain in my chest and a heavy feeling all over.”
Try to give yourself time to recover. Sometimes the demands of home and work make that difficult and some employers may not understand your needs or their responsibilities.
At work
If you normally work, you are likely to need time off both during and after your loss. If you are an employee, you will be entitled to pregnancy-related sickness leave.
Pregnancy-related leave may or may not be paid – it depends on your work contract. But it must be recorded separately as pregnancy-related sickness. This means that your time off must not be used against you in any way (for example as a reason to discipline you, refuse promotion or make you redundant).
You should be able to self-certify that the leave is pregnancy-related for the first seven days. After this, you will need a GP or other medical practitioner to give you a sick/fit note to certify it is pregnancy-related.
If you are self-employed and/or do casual work, the rules might not apply, but Citizens Advice will be able to explain your rights.
You may feel that it’s best to return to work as soon as possible after your loss, perhaps because you’re not being paid, or because of pressure from your workplace. But you might want to be with colleagues and/or to have the routine of work to help you through.
“I have spent moments at work shedding tears in the bathroom, pushing my emotional limit to smile through baby showers and birth announcements, having the stress of the work place tire me out and just not wanting to be there.”
Sex
It is for you and your partner to decide when you feel ready to start having sex again, but it is advisable to wait until your bleeding has completely stopped. Some people may be advised to wait longer for medical reasons like infection.
It is possible to become pregnant before periods restart so if you want to avoid this, you may want to use contraception.
You or your partner may have mixed feelings about sex. You may have pain or discomfort, or one or both of you may feel less desire. You may associate intercourse with pregnancy and loss, and any sexual intimacy may just feel ‘wrong’.
How you look and feel
You might be upset if you still look pregnant or you may feel that getting back to your pre-pregnant shape is somehow forgetting or even betraying your baby. You might not want to let go of feeling pregnant.
You might feel that the sooner you get back to your usual routine, the quicker you’ll feel better. But you may just need more time.
The emotional impact of second trimester loss
Experiencing pregnancy or baby loss after 13 weeks can be deeply distressing.
Your feelings
There is no right way to feel after your loss. And however you feel, you may show those emotions clearly or you might prefer to keep them hidden.
You might be very sad and tearful a lot of the time. Or perhaps it doesn’t feel natural to cry, or you worry about upsetting other people. Maybe you worry that if you start crying, you won’t be able to stop.
Coming home from hospital, no longer pregnant and without your baby can be very difficult. It can be upsetting to see baby clothes or other things you have prepared for your baby, though you may find them comforting.
“My husband put all the baby things away, out of sight, before I came home. He thought they would upset me. I got out the littlest baby-grow and held it and I cried and cried. It was sort of comforting, in a way.”
Some people tell us that they feel:
- angry – sometimes at particular people and sometimes just at the unfairness of it all
- jealous – especially of pregnant women or people with small babies
- guilty – wondering if the miscarriage was somehow your fault
- lonely – especially if people around you don’t seem to understand
- empty – a physical ache for your baby
- exhausted – finding it hard to do anything, perhaps not sleeping or eating properly
- panicky – perhaps with flashbacks, nightmares or intrusive thoughts
- low (depressed/hopeless) – unable to find the motivation to look after yourself or to concentrate on normal tasks. Not wanting to see other people
- anxious – about yourself, your partner, other children (if you have them) and the future. Or even worrying about very small things that wouldn’t normally bother you.
There is no “normal” timeline for grief. You may find you continue to grieve for your baby for a much longer or shorter time than you, or other people, expect. It may be anything from weeks to years.
You may feel as though your feelings are out of control – sometimes easing and sometimes right back where you started.
There may be particular things or dates that trigger those difficult times. You may be expecting them, or they may come out of the blue.
For everyone the experience is different. While you may never forget your loss, these feelings may ease over time.
“It does get easier. When it first happens you feel like you are in a black hole that you can’t escape. You never forget your baby, but day to day life becomes more manageable.”
Talking to others
You may find it hard to talk about what happened or how you feel. Or you might need to talk, to go over what happened again and again.
Finding someone who will listen and try to understand can be really helpful, but that may not be easy. It can sometimes be difficult for other people to fully understand all that you have been through, how you feel and how long those feelings may last.
Sometimes family and friends say the wrong thing, perhaps hoping to make you feel better. Some might avoid talking about your loss altogether because they worry they may make you more upset. Some people, sadly, just won’t understand.
“To be honest, I haven’t had a lot of emotional support because I don’t think people are comfortable talking about it, or bringing it up in case it upsets me. I find that quite difficult.”
You may find it helpful to talk to others who have experienced second trimester loss, by joining one of our support groups or Facebook communities.
For some people, pregnancy or baby loss may have a significant impact on their mental health. They may be given a diagnosis, like post-traumatic stress disorder, anxiety or depression.
Others may not have a diagnosis but still experience symptoms that make life difficult for a long time.
Whatever you are feeling, you don’t have to experience it alone. Your midwife, the hospital bereavement midwife or your GP may be able to refer you for counselling or simply offer time to talk.