Miscarriage

Miscarriage is the loss of a pregnancy in its first half, before the point at which a baby could be brought through; exactly where that line falls is set differently from country to country, usually around the twenty-second week. It happens far more often than people assume: roughly one in six to eight pregnancies that a woman knows about ends in loss. Three losses in a row or more are uncommon, affecting about one woman in a hundred. And almost never is there anything behind it that the woman did or failed to do.

Signs that mean seeing a doctor

The commonest sign is vaginal bleeding. It varies widely, from brown spotting on underwear to bright red blood with clots, and it may stop and start again over several days. The second complaint is cramping pain low in the abdomen and in the lower back, like period pain but stronger.

There are other signs: fluid leaking away, tissue being passed, and the sudden disappearance of pregnancy symptoms — breasts that stop being tender, sickness that lifts. Separate from all this is missed miscarriage: there are no symptoms at all, and it is discovered at a routine scan.

It is worth knowing the other side too: light spotting in the early weeks is common, and in many women the pregnancy goes on perfectly well afterwards. Bleeding is not a verdict; it is a reason to be examined. With any bleeding or pain, get in touch the same day, and if you are already under care, ring your midwife or unit directly rather than waiting for the next scheduled appointment.

When it counts in hours

Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine, single number 112) if a pregnant woman has:

• heavy bleeding — a pad soaked through in an hour or less, bright red blood and large clots;
• severe abdominal pain, usually on one side, that stops her straightening up or doing anything at all;
• pain at the tip of the shoulder or under the shoulder blade, a sign of blood in the abdomen;
• sudden weakness, dizziness, pallor, cold sweat or fainting;
• a temperature above 38 degrees, chills and offensive discharge, particularly if a miscarriage has already begun.

Behind the first four points may lie an ectopic pregnancy, where the fertilised egg has implanted outside the womb, usually in a fallopian tube. It shows itself between five and fourteen weeks and is dangerous because of internal bleeding, so here nobody waits for morning or drives themselves. The last point signals infection in the womb, which also needs help immediately. If you have already lost three pregnancies, or had an ectopic pregnancy or a molar pregnancy, in a new pregnancy you will be assessed on first contact, without waiting for a referral.

Why it happens — and what has nothing to do with it

Three out of four miscarriages occur in the first three months, and the reason is nearly always the same: a chance fault in the embryo's set of chromosomes. The cells end up with one chromosome too many or one too few, the embryo cannot develop further, and the pregnancy stops of its own accord. It is chance, it almost never repeats, and it does not mean anything is wrong with either parent. Less often the fault lies in how the placenta develops. Such errors grow commoner with age: under thirty about one pregnancy in ten is lost, and by forty nearly half. That is a property of eggs, not of lifestyle.

Losses in the second half work differently. Behind them more often stands the mother's own condition: poorly controlled diabetes, severe high blood pressure, untreated thyroid disease, lupus, antiphospholipid syndrome, kidney disease. Infections can play a part — rubella, cytomegalovirus, listeriosis, toxoplasmosis, malaria, or any severe illness with a high fever. Another group of causes is the shape of the womb: fibroids that distort the cavity, congenital septa, and a weak cervix that opens early and silently, without contractions. Smoking, alcohol, recreational drugs and marked obesity all raise the risk. Some medicines are contraindicated in pregnancy — methotrexate, retinoids, misoprostol, non-steroidal anti-inflammatory drugs — so check anything you take with a doctor.

And here is what does not raise the risk, though it is precisely what women blame themselves for: stress, a fright or bad news; work, including standing jobs; sport and sex; carrying a bag; flying; spicy food; the cup of coffee drunk before you knew you were pregnant.

How it is confirmed

The main test is ultrasound, usually through the vagina: in the early weeks a small probe gives a far clearer picture than scanning through the abdomen, and it is safe in pregnancy. The doctor looks for a pregnancy sac in the womb, whether the embryo matches the dates, whether there is a heartbeat, and whether tissue remains if the loss has already begun.

The second test is a blood test for human chorionic gonadotrophin, the pregnancy hormone. What matters is the trend: blood is taken twice about forty-eight hours apart to see whether the level is rising or falling. A single measurement says almost nothing.

Often nothing can be said at the first attempt, especially before six or seven weeks when the embryo is still tiny. The scan is then repeated in a week to ten days. The wait is hard but necessary: a diagnosis of a pregnancy that has stopped is not made on one doubtful image. At the same time your blood group and rhesus status are checked, which will matter later.

What happens next

If the womb has already emptied completely, no treatment is needed. If tissue remains, there are three equally valid paths, and the choice is largely yours.

• Waiting. In most cases everything passes on its own within a week or two. This suits anyone who would rather avoid any intervention and can live with the uncertainty.
• Medicines. Drugs that open the cervix and make the womb contract; some are given vaginally. They begin to work within hours, and the sensation is like a very heavy, painful period.
• Aspiration. A short procedure in which the contents of the womb are removed by suction, under local or general anaesthetic. It is offered straight away with heavy bleeding, with signs of infection, and when the first two options have not worked.

Complications are rare with all three. Seek help at once if the bleeding becomes very heavy, a fever develops or sharp pain appears. Light bleeding may continue for up to three weeks; while it lasts, avoid tampons and do not swim in pools or open water, which lowers the risk of infection. After three weeks take a home pregnancy test: if it is still positive, see a doctor. And ask about your rhesus status — women who are rhesus negative are given anti-D immunoglobulin in certain circumstances to protect future pregnancies.

Recovery and the next pregnancy

The body recovers sooner than people expect. Periods usually return within four to eight weeks, though it may take several months for the cycle to settle. Ovulation can happen as early as two weeks, before that first period, so if pregnancy is not wanted now, contraception starts straight away. Sex resumes once the bleeding has stopped and you want to; there are no rigid timescales. Tiredness and poor concentration last for weeks, and that is normal.

There is no medical reason to wait six months before trying again: the usual advice is to wait for at least one period so that dating is easier, and then to go by how ready you feel, physically and emotionally. It is worth starting folic acid beforehand and reviewing long-term conditions and regular medicines with a doctor. And most importantly: after one miscarriage the chances of a pregnancy that goes to term remain high, and most women carry the next one without complications.

What people feel afterwards

This is real grief, even if the pregnancy was very short and nobody else knew. Numbness, tears, anger — including at friends with pushchairs — guilt, sleeplessness, an inability to concentrate at work. It may arrive not immediately but weeks later, once the rush has passed; and it hurts separately on the due date and on the anniversary.

A partner grieves too, only often in silence: men frequently feel their role is to hold together and support, and put their own loss aside. It is worth saying these things out loud, or each retreats into a private silence. Grieving at different speeds is normal, not a sign of indifference. If you want to mark the memory somehow — a name, a date, a small ritual — that is entirely legitimate and needs no explaining to anyone; what is possible by way of a farewell depends on the stage of pregnancy and on the practice of the particular unit, so ask your team.

Ask for help if things are no easier after several weeks, if you cannot sleep or eat, if anxiety is taking over, or if the thought returns that there is no point in going on. That is not weakness: psychologists and psychotherapists work with grief, and support groups for people who have been through a loss exist almost everywhere.

When the cause is looked for: repeated losses

After a single loss the cause is not usually investigated: the odds that it was chance are simply too high. Testing is offered after several losses in a row — in most countries after three, and sooner if they were late or known risk factors are present.

What is generally checked: blood for antiphospholipid antibodies and lupus anticoagulant, twice, several weeks apart and outside pregnancy; thyroid function; the shape of the womb on ultrasound, to find a septum or a fibroid distorting the cavity. The couple's chromosomes and, where possible, tissue from the lost pregnancy are studied separately by karyotyping; if anything is found, genetic counselling is offered.

In about half of cases no cause is found, and that is not a sentence: even without an explanation, most such couples eventually have a healthy baby. Where the cause is clear there is something to be done: antiphospholipid syndrome is treated with low-dose aspirin together with blood-thinning medicines, thyroid problems are corrected, a weak cervix is supported with a stitch or with progesterone, and a septum in the womb is removed surgically. In these cases the next pregnancy is followed with an early scan and frequent checks.

Online consultation

A remote conversation earns its place in two situations. The first is when something is happening right now and it is unclear how urgent it is: from a description of the bleeding, the pain and the dates, a doctor will say whether to go in immediately, arrange a scan today, or simply watch. The second is afterwards: going through the scan report and blood results, understanding the difference between the three ways of completing a miscarriage and what "incomplete miscarriage" means, whether you need anti-D immunoglobulin, and why a test still shows two lines.

Later come other questions: when it is reasonable to try again, which tests are worth having before conceiving, what to do about long-term medicines, and whether it is worth being investigated after a second loss. The limits of the format are obvious: examining, scanning and taking blood cannot be done through a screen, and with heavy bleeding, severe one-sided pain, shoulder-tip pain or fainting what is needed is not a call but an ambulance.

This material is for information only and does not replace medical advice.