Both bleeding and cramping abdominal pain in the early stages of pregnancy are common and do not necessarily mean that the fetus has been miscarried, but they are classic symptoms. In such a case, you should seek help from your doctor.
Diagnosis is usually made by ultrasound, either transvaginal (preferred) or transabdominal. Neither method increases or decreases the risk of miscarriage. In addition, blood tests, such as βhCG, may be requested. You will definitely need to undergo a gynecological examination. Sometimes the diagnosis is not certain and additional time may be required to confirm it with a subsequent ultrasound.
If the ultrasound shows that there are no traces of pregnancy remaining in the uterus, then the miscarriage is called a complete miscarriage and no further action is necessary. If, on the other hand, the presence of remnants of the pregnancy is confirmed, then the options are either to wait for nature to cause the complete miscarriage of the remnants, or to have a medical or surgical 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:
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.
Heavy or prolonged vaginal bleeding, smelly vaginal discharge and abdominal pain: 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.
If you have the above symptoms or a fever with flu-like symptoms, you may have an infection of the uterus (endometritis). It occurs in 2-3/100 women and requires antibiotic treatment.
If there is also a fever with loss of appetite, this may be due to damage to the uterus during surgery and requires hospitalization.
When you return to work depends on how you feel. It is a good idea to rest for a few days before starting your daily routine, but even returning in a day or two does not cause harm to your body. Most women return in 1 week. Sexual intercourse is allowed when bleeding and abdominal pain stop. The next pregnancy can be achieved according to your doctor’s instructions.
You should know that because you have had a miscarriage, you are not at increased risk for another one. However, if another one follows, then it should be investigated whether there is a specific cause that caused them.
It is a good idea to take 400mg of folic acid before the next pregnancy until at least the first 12 weeks of pregnancy, have a balanced diet, stop smoking and do not drink alcohol, as it increases the risk of miscarriage.
High-quality medical services from Obstetrician-Gynecologist Alexandros Mainas, in Komotini.