1. You get bright red blood loss and abdominal cramps. If the blood loss persists, becomes more severe and is accompanied by severe labour pains, it probably indicates an imminent miscarriage or a miscarriage already happening. Your body is working on expelling the foetus. If you have given birth in the past, you will recognise the abdominal cramps as contractions.
2. Sometimes it appears as if nothing is wrong. You do not have any blood loss and your pregnancy feels normal. The ultrasound scan does not show any heart activity in the foetus. It is very probable that the foetus stopped growing earlier, but has not been expelled yet. This is called a missed abortion.
3. Sometimes the ultrasound only shows an amniotic sac (but no foetus). This means things went wrong very early in the pregnancy, even before the embryo was formed.
In about 20% of all pregnancies, vaginal blood loss occurs in the period up to the 16th week of the pregnancy. This could indicate an imminent miscarriage. In about half of these cases, the pregnancy will remain intact, a miscarriage will occur in the other half. If you have just a bit of blood loss but no abdominal pains or cramps, chances are very slim something will go wrong and you can wait to see if anything happens. At that time, no one can tell you whether your pregnancy will continue as expected or not. When you have severe blood loss, you should always contact us.
A miscarriage often occurs because something went wrong when the cells replicated and/or because of the genetic material. The pregnancy does not have a healthy chance and can be aborted naturally. Most miscarriages occur because of chromosomal abnormalities. Chances of repetitions are often small. The cause of the abnormality in the chromosomal pattern in the embryo can rarely be found in (one of) the parents.
If you have been given the sad news that the pregnancy is not going well, it is important to stay calm and take your time to think about the various options. There are three options if you know you are about to miscarry.
If it is medically responsible, you can wait a few weeks to see if the miscarriage starts spontaneously. This is an uncertain period, because you do not know how and when it will start. Most miscarriages are spontaneous and without complications, so medical intervention will not be necessary. After the initial blood loss, the miscarriage starts within a few days, although it sometimes takes longer, at most a few weeks. The blood loss lasts for a few days, and then turns into heavy blood loss and cramping pains. When your womb is expelling the foetus, you will have contractions to open the cervix up a bit more. This can be very painful. The moment of expulsion can be accompanied by heavy blood loss. If you are not prepared for this, it can be quite frightening. The blood loss can be so heavy for a while, sanitary towels might not be enough; it is really flowing out of you. Soon after this, the cramps will be at their most painful, and you will feel ‘something’ leaving your womb. That is the foetus. After the foetus has been expelled, the pain will diminish, and the blood loss will decrease to the level of a regular menstruation. The blood loss will last for a few more days. The bleeding can last until up to three weeks after the miscarriage. If you are in pain, you can take paracetamol or ibuprofen. A few weeks after you’ve miscarried, your menstruation will become normal again. Very rarely, the bleeding will not stop, and the miscarriage turns out not to have been complete. In that case you will be referred to a gynaecologist for a curettage (the womb will be cleaned). If you decide to wait, we will explain things and give
instructions for when to call. Sometimes, nothing happens in the time period agreed upon, and in that case we will discuss with you what happens next. After the miscarriage, you have the option to find out if the miscarriage was complete by means of an ultrasound scan. This is always done in consultation with you.
A second option is to remove foetal tissue from the womb by means of medication. If a miscarriage does not spontaneously start, or if you prefer not to wait, the miscarriage can be induced with medication (Misoprostol). These are tablets that have to be inserted vaginally, and these will cause the womb to contract and the cervix to open. In this case, we will refer you to a gynaecologist for a consult. In consultation with your gynaecologist you decide when to take the tablets. You will then be given the medication so you can take them in the comfort of your own home. The next step is to wait for the miscarriage, which usually happens within two days after taking the medication. Misoprostol is effective in 75% of the cases. If it is not effective, a curettage will be scheduled.
When you choose to have a curettage, we will refer you to a gynaecologist for a consult. When you have a curettage, the gynaecologist removes the foetal tissue from the uterus using a slim tube (vacuum curettage) or a curette. The procedure takes approximately five to ten minutes, and is done on an outpatient basis. You will get a light anaesthetic or an epidural. Another option is to be under a general anaesthetic when the curettage is done. It is understandable that this is never a doctor’s first choice. It is a relatively simple procedure, and anaesthetic always comes with a risk, no matter how minimal. Do not be too hasty when deciding on a curettage. When you come in for your first ultrasound, and you get the news that your pregnancy is not well (a missed miscarriage), a lot of couples tend to immediately choose to have a curettage. This is a logical response. However, experience shows that you will later feel as if it has all passed you by. After all, you went for your first ultrasound scan unsuspectingly and with high hopes, and then everything changed. It takes a while before you are fully aware of what happened. All three options have advantages and disadvantages. Your decision depends on your personal preference. Take a few days to decide, and feel free to talk to us, if you need it. Taking time to process this makes you aware of the fact that you are saying goodbye to your pregnancy.
The physical recovery after a spontaneous miscarriage or a curettage is usually quick. During one to six weeks, you could have some blood loss and brownish discharge. It is best to wait until the blood loss stops before having intercourse. Your next menstruation starts after approximately four to six weeks, although this could take longer. After a miscarriage, you have the same chance of becoming pregnant as before the miscarriage. The chance of having another miscarriage is not higher. There are no medical reservations to becoming pregnant again. Start taking folic acid before you become pregnant again. Please refer to the Dutch website strakszwangerworden.nl for tips on becoming pregnant healthily.
After a miscarriage, it is normal to need time to recover emotionally as well. The loss can be profound for you and your partner. Sad feelings are most intense during the first four to six weeks, and they often start to fade after three or four months. This could also take longer, though. Besides grief, you can feel anger, guilt, disbelief or a feeling of emptiness, a failure of your own body or jealousy towards other pregnant women. These feelings are likely to occur at first, and they are
very understandable; it takes time to accept them. You might dwell on the question why this happened or why it went wrong. As said before, a miscarriage is often caused by a defect in development. This could not have been prevented by a healthier lifestyle, less stress or more rest, although it is true that smoking, drugs and alcohol can increase the risk of a miscarriage. If you want, you can make a follow-up appointment with us.