EARLY MISCARRIAGE

Vaginal bleeding and/or cramping pain in the early stages of pregnancy are common and do not always mean that there is a problem. However, bleeding and/or pain can be a sign of a miscarriage.
If you have any bleeding and/or pain, you can get medical help and advice.

An early miscarriage is usually diagnosed by an ultrasound scan. You may be advised to have either a transvaginal scan (where a probe is gently inserted in your vagina) or a transabdominal scan (where the probe is placed on your abdomen) or occasionally both. A transvaginal scan may be recommended as it gives a clearer image. Neither scan increases your risk of having a miscarriage.
You may be offered blood tests that could include checking the level of your pregnancy hormone (βhCG).

If the ultrasound examination shows that there are retained products of gestation within the uterus, then the miscarriage is defined as complete and no further actions are necessary. If, however, the presence of retained products of gestation is confirmed, then the options are, either to wait so that nature itself provokes the complete removal of the retained products, or perform a pharmacological or surgical ablation (curettage).

This is successful in about 50 out of 100 women who choose this option. It can take some time before the bleeding starts and this may continue for up to 3 weeks. It may be heavy and you may experience cramping pain. If you have severe pain or very heavy bleeding, you may need to be admitted to hospital.
You should be given a follow-up appointment about 2 weeks later:
If the bleeding and pain has settled by then, it is likely that all the pregnancy has come away. You will be advised to do a urine pregnancy test 1 week after this. If it is still positive, you should contact your local hospital.
If bleeding fails to start within 7–14 days or is persisting or getting heavier, you will be offered a further ultrasound scan. The options of continuing expectant management, medical treatment or having an operation will then be discussed with you.

This is successful in 85 out of 100 women and avoids an anaesthetic.
You will be given medication called misoprostol, usually as vaginal pessaries although tablets to swallow may be taken if you prefer. The medication helps the neck of the womb (cervix) to open and lets the remaining pregnancy come away. It will take a few hours and there will be some pain with bleeding or clotting (like a heavy period). You will be offered pain relief and anti-sickness medication. Some women may experience diarrhoea and vomiting.
If bleeding has not started 24 hours after treatment, you should contact your Early Pregnancy Assessment Service or hospital.
After the treatment, you may bleed for up to 3 weeks. If the bleeding is heavy, you should contact your local hospital.
You will be advised to do a pregnancy test 3 weeks later. If this is positive, you should contact your Early Pregnancy Assessment Service to arrange a follow-up appointment. If the treatment has not worked, you will be given the option of having an operation.

The operation may be carried out under general or local anaesthetic. It is successful in 95 out of 100 women.
The pregnancy is removed through the cervix. You may be given tablets to swallow or vaginal pessaries before the operation to soften your cervix.
Surgery will usually take place within a few days of your miscarriage but you may be advised to have surgery immediately if:

• you are bleeding heavily and continuously
• there are signs of infection
• medical treatment to remove the pregnancy has been unsuccessful.

The operation is safe but there is a small risk of complications including heavy bleeding, infection or damage to the womb. A repeat operation is sometimes required. The risk of infection is the same if you choose medical or surgical treatment.
Some tissue removed at the time of surgery may be sent for testing in the laboratory. The results can confirm that the pregnancy was inside the womb and not an ectopic pregnancy (when the pregnancy is growing outside the womb). It also tests for any abnormal changes in the placenta (molar pregnancy).
Some women who miscarry at home choose to bring pregnancy remains to the hospital so that they can be tested.
Options for disposal of the remains will be discussed with you and your partner.

You can expect to have some vaginal bleeding for 1–2 weeks after your miscarriage. This is like a heavy period for the first day or so. This should lessen and may become brown in colour. You should use sanitary towels rather than tampons, as using tampons could increase the risk of infection.
If you normally have regular periods, your next period will usually be in 4–6 weeks’ time. Ovulation occurs before this, so you may be fertile in the first month after a miscarriage. Therefore, if you do not want to become pregnant, you will need to use contraception.

You can expect some cramps (like strong period pains) in your lower abdomen on the day of your miscarriage. You may get milder cramps or an ache for a day or so afterwards. If the discomfort is not relieved by simple painkillers from the pharmacy and you experience the following symptoms, you should seek medical advice from your doctor.

If you also have a raised temperature (fever) and flu-like symptoms, you may have an infection of the lining of the womb (uterus). This occurs in two to three out of 100 women. It can be treated with antibiotics. These symptoms can also indicate that some tissue remains from the pregnancy (see above).

Increasing abdominal pain and you feel unwell: If you also have a temperature (fever), have lost your appetite and are vomiting, this may be due to damage to your uterus. You may need to be admitted to hospital.

When you return to work depends on you and how you feel. It is advisable to rest for a few days before starting your routine activities but returning to work within a day or two will not cause you harm if you feel well enough. Most women will return to work in a week, but you may need longer to recover emotionally. If so, it may be helpful to talk with your GP or occupational health adviser.

You can have sex as soon as you both feel ready. It is important that you are feeling well and that any pain and bleeding has significantly reduced.
When can we try for another baby?
You can try for a baby as soon as you and your partner feel physically and emotionally ready.
Am I at higher risk of a miscarriage next time?
You are not at higher risk of another miscarriage if you have had one or two early miscarriages. Most miscarriages occur as a one-off event and there is a good chance of having a successful pregnancy in the future.
A very small number of women have a condition that makes them more likely to miscarry. If this is the case, medication may help.
Is there anything else I should know?
Like anyone else planning to have a baby, you should:
take 400 micrograms of folic acid every day from when you start trying until 12 weeks of pregnancy to reduce the risk of your baby being born with a neural tube defect (spina bifida)
be as healthy as you can – eat a balanced diet and stop smoking
not drink alcohol as this may increase your chance of miscarriage.