Loss of a pregnancy can be a sad and distressing experience, but it is not uncommon. It is thought that possibly one in every two conceptions ends in miscarriage. Often the period is a few days late and more heavy and painful than usual. In this situation, a woman may not even think of a pregnancy. Over one in six recognised pregnancies ends in miscarriage and almost a quarter of women will experience a miscarriage in their lifetime.
The information given in this leaflet may help you to cope with the loss of your pregnancy at this difficult time. We have tried to provide answers to some of the questions you are likely to have.
Why did I miscarry?
Miscarriages are very common. It is usually difficult to give a definite answer as to what caused a miscarriage. It is extremely unlikely that anything you did caused your miscarriage. Woman and their partners may blame themselves for a miscarriage, but it is very seldom anything they have done, or not done, that causes the loss. At least 2/3 of all miscarriages occur because of a chromosome abnormality.
What happens now? Does anything need to be done?
Following some miscarriages, you may have already passed all of the pregnancy and therefore nothing further needs to be done. Blood loss, like a period, may continue for several days until the lining of the womb is all shed. Following other miscarriages, some or all of the pregnancy may still be within the womb. In many circumstances nature will take its course and you will pass all of the pregnancy. However there are other options like using medicines to help empty the womb. In some situations a small operation is required. The staff in Early Pregnancy Assessment Unit (EPAU) will have advised you and helped you to make a decision about what to do. You will find some more detailed information regarding these management options below.
Option A: “Wait and see” approach to miscarriage
Don’t I need an operation?
In the past an operation was routinely performed in all cases of miscarriage as there was no way to know how much tissue, if any, was still left behind in the womb. With modern ultrasound it has become possible to adopt a “wait and see” approach. Not all sorts of miscarriage are suitable for a “wait and see” approach. The staff in EPAU will have advised you as to whether or not this choice is suitable for you.
If I decide to wait how long will it take for me to miscarry?
Although the length of time taken for a miscarriage to be complete can vary, in the majority of cases a pregnancy will miscarry within two to three weeks.
Do I need to come back to the hospital?
We will ring you in about a week to see what is happening and how you are coping. In order to check if all the tissue has come away naturally, we will give you an appointment for a repeat scan for 2 weeks time. However, if you are bleeding heavily, have significant pain or are worried, please make contact with us sooner.
Is there any danger if I decide to wait?
All miscarriages can potentially be complicated by significant pain or heavy bleeding. Miscarriages managed with a “wait and see” approach carry a very small risk of infection and are not always successful. If unsuccessful then you may need to consider surgical management for your miscarriage. If you have any of the following symptoms you should contact your doctor or the EPAU:
- excessive bleeding
- unpleasant discharge
- lasting pain
- high temperature—fever.
Option B: Medical management of miscarriage
The Miscarriage Study
What is medical management?
Medical Management involves giving a medication (called Misoprostol) to promote complete miscarriage without the need for surgery. It has been proven to be an effective treatment in 80 – 90% of cases when the miscarriage occurs before 13 weeks of pregnancy. This form of treatment is still being developed clinically. Unfortunately, there is no agreement on the most effective dose to be used—this provides the focus of the current study. Medical management can now be offered to women who agree to participate in The Miscarriage Study.
Do I have to be involved in the study to have medical management?
Medical management is only available for women participating in the Miscarriage Study. Surgery or expectant management will be offered as standard care options to women who choose not to participate.
Is Misoprostol a recognised treatment of miscarriage?
Yes. Misoprostol has been demonstrated as an effective treatment of early miscarriage in clinical studies. It compares favourably to both expectant and surgical management. Furthermore, Misoprostol is listed in the Standard Drug List of Queensland Hospitals for use in miscarriage and is currently used in this hospital for the treatment of other pregnancy complications.
Misoprostol is not registered by its manufacturer for use in pregnancy, and hence the Therapeutic Goods Administration has not approved its use in pregnancy in Australia. However, there is strong support for its use in the treatment of miscarriage from both Queensland Health and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.
What is involved for me if I participate in this study?
The Miscarriage Study is a randomised controlled trial. Randomised controlled trials are the best way to compare alternative forms of care. Randomisation is like flipping a coin. If you agree to participate in the study, you will be allocated to receive one of two treatment options by chance—either the standard dose of Misoprostol (800 micrograms) which is most often used in other studies or the lower dose (400 micrograms). Participants will not be told what their allocated Misoprostol dose is. For both groups Misoprostol will be administered via the vagina. Giving medication via the vagina is commonly used in the treatment of pregnancy conditions; it should involve minimal discomfort. Before being discharged home, you will have some observations done and blood tests will be performed (this is standard care).
You will then be followed up in the EPAU the next day (Day 1). If miscarriage is not completed, then a repeat dose of Misoprostol will be given. On the third day after treatment commenced you will be phoned by the EPAU staff. At one week you will need to return to EPAU when an ultrasound scan will be performed and another blood test taken. If miscarriage has not been completed by one week or there are any other concerns, surgery would then be performed. You will be followed up again at six weeks. This follow-up plan is considered “standard care” for women undergoing conservative management. You will be asked to complete brief medical questionnaires at the day three and week six visits.
What are the risks of the study? What are the side-effects of Misoprostol?
Misoprostol is usually well-tolerated. Side-effects may include nausea, vomiting, diarrhoea and fever. Allergy to Misoprostol is uncommon. Misoprostol should not be used by women with a history of severe asthma or porphyria.
Bleeding and period-like pain will start soon after the first dose of Misoprostol is given. This occurs as the miscarriage is completed and may last for up to 24-72 hours before the pregnancy is lost. Period-like bleeding will then occur over the next week or so. Bleeding and pain may be excessive in approximately 10% of cases—a visit to your doctor or the hospital, and possibly surgery, may then be required. In a large recent study, hospitalisation for heavy bleeding or infection occurred in less than 1% of women.
Can I take something for pain?
It is safe to use simple painkillers containing paracetamol (eg Panadol; Herron paracetamol; Panadeine; other brands), or non-steroidal anti-inflammatory drugs (eg Brufen; Nurofen; Naprogesic; aspirin), for the treatment of this pain according to directions outlined on the package.
What are the aims of the study?
The Miscarriage Study aims primarily to determine the most effective dose of Misoprostol to be used in the medical management of miscarriage. We hope to determine if a smaller dose will be as effective in completing miscarriage within seven days of treatment with fewer side-effects.
What are the benefits of taking part in this study?
The major benefit of participation in this study is the chance to avoid surgery. Furthermore, the information learned from this study will promote options for women in the management of miscarriage.
What are the costs of participation?
Taking part in the study will not lead to any added costs for the participant.
What about confidentiality and my rights as a participant?
Participation in this study is entirely voluntary. Some basic information will be recorded about all patients attending the EPAU. This information will be kept confidential and its collection has been approved by the Human Research Ethics Committee at Mater Hospital. You are not obliged to participate and if you do participate you can withdraw at any time. If a participant does withdraw, we will arrange ongoing care through the Department of Gynaecology at Mater Hospital. In this case we would request to use any information you were willing to provide about your experience with the study so we can learn more about this treatment, but you have a right to refuse this.
All aspects of the study, including results, will be strictly confidential and only the investigators named above will have access to information on participants. A report of the study may be submitted for publication, but individual participants will not be identifiable in such a report.
Should you have any concerns after reading this information please do not hesitate to ask for further clarification from your doctor or the Local Principal Trial Investigator, Dr Scott Petersen. You may contact Mater Research Secretariat on 07 3163 1585 should you have any complaints about the conduct of the research, or wish to raise concerns. The Research Secretariat may contact the Patient Representative or Hospital Ethicist at its discretion.
Option C: Surgical management of miscarriage
What does the operation involve?
The operation following a miscarriage is sometimes called a “curette” or a “D&C” (which stands for a dilatation and curettage). It is also known as an ERPOC (which stands for the evacuation of retained products of conception). This is the traditional method carried out under a general anaesthetic in the operating theatre. Instruments are used to ensure the inside of the womb is empty. The operation usually takes about 5-10 minutes. It is done vaginally and you will have no cuts/stitches. Sometimes a D&C is the best choice but often other options (like using medicines or letting nature take its course) are preferable.
Are there any risks?
Like all operations, small anaesthetic and surgical risks are involved. There is a small risk of infection or injury to the womb or cervix. Injury to the womb occurs about once every 200-500 operations. The injury is usually small and of little consequence. Very rarely this injury may be more significant requiring further surgery at the time to repair the damage. Surgical management of miscarriage is nearly always successful (94%-100%). Uncommonly, however, surgery may need to be repeated to ensure the womb is empty.
Will the method of treatment I choose affect my chances of becoming pregnant again?
No. Generally your chances of having a successful pregnancy in the future are just as good regardless of what method you choose.
How long will I bleed for after a miscarriage?
The bleeding is usually less than a period and stops by about a week. If you are still bleeding on the tenth day, or if the loss increases, becomes heavier than your normal period or starts to smell offensive, you should contact EPAU or your GP. Whilst the bleeding continues, it is best to use sanitary pads instead of tampons, as this will reduce the risk of infection. Baths or showers can be taken as required.
What else should I expect after having a miscarriage?
If you have an anaesthetic, you will probably feel tired during 24-hour period after your anaesthetic and you should not drink alcohol, drive or operate any dangerous machinery.
After a miscarriage you may have a dull ache in your lower tummy—this is normal for a few days.
Your breasts may be tender for several days and you may even leak milk. In this case wear a good fitting bra, day and night, to provide adequate support until your breasts are comfortable. This may be necessary for a couple of weeks, but will settle on its own. If painful, mild painkillers such as paracetamol can be used. Testing to see if there is milk causes a reflex stimulation of milk production and should be avoided.
Going back to work?
If you have had an operation, you are unlikely to feel fit enough for work as soon as you leave hospital—so make sure you rest. One week's absence is usually enough but the decision to go back to work is up to you. In all cases, a sick leave certificate can be obtained on discharge from hospital.
Will I miscarry again?
Fortunately most couples go on to have normal, healthy, full term babies. The chance of another miscarriage following one miscarriage is not significantly changed. Even after several miscarriages, there is a good chance of a successful pregnancy.
What can I do to stop having a miscarriage?
There is no magic formula for success, but the emotional and physical well being of both mother and father in the months before pregnancy will help to give your baby the best possible start. Please remember these are only suggestions—the most important thing is to decide how you both feel about being pregnant again, and to prepare in whatever way feels right for you.
Check up on your health
After a miscarriage, it is worth while asking your GP for a general health check. Your doctor may be able to pick up or sort out problems that may affect a future pregnancy. If you have a disability or long term condition such as diabetes, epilepsy or high blood pressure, talk to your doctor about your plans to fall pregnant. Ask how your condition will affect your pregnancy and what extra care may be needed to reduce any risk to the baby. If there is a genetic disorder in your own or your partner's family, and you are worried that it may be passed on to your own children, ask your doctor about seeing a genetic counsellor who can advise you about the likely risk.
Drugs or Medicines
Don't take drugs or medicines unless you have checked with your doctors or pharmacist that they are safe to take during pregnancy. Common drugs such as alcohol, tobacco, caffeine (in tea, coffee and cola drinks) and tranquillisers can all affect the body's chemistry. Illegal drugs such as cannabis, heroin and cocaine may affect fertility and increase the risk of premature or low birth weight babies, or cause damage to the developing fetus. The safest course of action is to avoid using any of these drugs before and during pregnancy.
Smoking can make a man less fertile and produce damaged sperm and a woman who smokes runs a greater risk of miscarriage. Smoking during pregnancy affects the baby's growth and a small baby is more susceptible to health problems in the early weeks of life. If your partner smokes but you do not, you are still affected by breathing in smoke. Heavy drinking reduces the number of sperm a man produces and it can also damage sperm. For women, heavy drinking reduces fertility and increases the risk of miscarriage. It can also affect the baby's development during pregnancy. As the risk is highest in the earliest stages of pregnancy (including the time before a period is even missed) it is advisable that you both cut out or at least cut down on drinking if you are planning a pregnancy. If you choose to drink, you should have no more than seven standard drinks in a week, and no more than two standard drinks (spread over at least two hours) on any one day. (One standard drink = 100ml wine or one glass of beer (285 ml 'heavy', 375ml 'mid strength' or 425ml 'light') or 60 ml fortified wine/port OR 30 ml spirits a glass of wine).
Protect your baby
Certain infections may increase the risk of miscarriage or damage to your baby during pregnancy. Rubella (German measles) can seriously damage your baby if you catch it in the first few months of pregnancy. Even if you think you are immune, ask your doctor for a blood test to check. You can be vaccinated against rubella, but it is best to wait three months after the injection before getting pregnant.
A well balanced diet is the basis of good health. A good diet will help to provide the best possible conditions for a baby to grow. A healthy variety of foods includes vegetables and fruit, meat, fish, dried beans or pulses, eggs, milk, cheese, cereals and bread (wholemeal bread and wholegrain cereals such as muesli, porridge and wheat biscuits).
Folic Acid Supplements
Recent research has shown that a daily dose (400mcg tablet once a day) of Folic Acid appears to reduce the risk of spina bifida when taken in the pre-conception period and during the early weeks of pregnancy. High doses of certain vitamins and minerals can be harmful and so it is advisable to obtain advice from your doctor before taking any supplements.
How long should I wait before trying for another baby?
When the bleeding stops, it is usually safe to start having sexual intercourse again. You may need a few weeks for your body to recover and then it depends on how you and your partner feel. You may not feel like having intercourse for a while or your sex drive might decrease. Your feelings and those of your partner need to be respected on this—be loving and understanding to each other. You may ovulate unpredictably after a miscarriage and hence the time of your next period may be less certain. You may try again when you feel ready, however it is sometimes better to wait a few months before trying again for a baby.
Will I get a follow-up appointment after the miscarriage?
Not always, unless there is a specific reason. We will ring you in the next week or so to see how you are going. You are very welcome to ring us at anytime if things are not right. It is natural to feel low and depressed. Give yourself and your body time to recover. It may help to talk over things with your partner, friends and other members of the family. We will have also provided you today with a brochure regarding support following a miscarriage which you may find helpful.
For further information, please contact:
Natural Fertility Services
5th Floor Mater Mothers' Hospital
South Brisbane Qld 4101
Ph 07 3163 8437
Fax 07 3163 1830
Early Pregnancy Assessment Unit
Level 7, Mater Mothers' Hospitals
South Brisbane Qld 4101
Ph 07 3163 5132
© 2010 Mater Misericordiae Ltd. ACN 096 708 922
Mater acknowledges consumer consultation in the development of this patient information.
Last modified 11/11/2015.