Spotting (finding spots of blood on your underpants or toilet tissue after urinating) or bleeding is sometimes the first sign of miscarriage. Keep in mind, though, that spotting is common early in pregnancy and may or may not be a sign of a problem with the baby. However, 50% of the time it is actually a symptom of a serious problem such as a miscarriage, an ectopic pregnancy or in very rare cases a molar pregnancy.
If you have any spotting or bleeding, call your doctor or midwife right away so she can determine whether your spotting indicates a potential problem.
You may also have abdominal pain, which can feel crampy or persistent as well as mild or sharp.
Or you may just feel low back pain or pelvic pressure.
The bleeding and cramping may get worse shortly before you pass the “products of conception” – that is, the placenta and the embryonic or fetal tissue, which will look greyish and may include blood clots. If you can, save this tissue in a clean container because your doctor may want to examine it or send it to a laboratory for testing.
Sadly in this terrible time, you may not always find yourself in your home environment or hospital. You may feel frightened and terribly upset. Some may pass blood clots or tissue-like material. Other unfortunate women may find tiny arms and legs, which can be horrific and shocking.
Some miscarriages are discovered only during a routine antenatal clinic or scan visit.
What does the doctor do?
An abdominal examination is usually combined with an internal (pelvic) examination.
In this way, it is possible to determine if the bleeding is a sign of a pregnancy that is destined to miscarry or one that may continue.
An ultrasound scan is the most useful investigation. This is performed through the abdomen or through the vagina and gives precise information about whether the pregnancy is continuing or not.
If I have a miscarriage, do I have to undergo surgery?
Not always. You will usually be given the option of either conservative management or a D&C (dilatation and curettage)/evacuation of retained products of conception (ERPC).
The decision will be reached after full discussion with you, depending on several clinical factors.
I had a D&C – will this cause any problems?
A D&C (dilatation and curettage) or evacuation of retained products of conception (ERPC) is carried out to reduce the chance of infection and ensure that you don’t continue bleeding over the following weeks.
Very rarely, it can cause infection of the womb lining with persistent loss or an offensive odour. If this happens it usually responds well to a short course of antibiotics.
The D&C doesn’t weaken your cervix or make you more likely to miscarry in subsequent pregnancies.
I opted to have conservative management – will this cause any problems?
You will be offered close monitoring including regular scans about every 2 weeks and advice about possible signs of infection to look out for, such as offensive vaginal discharge. However, infection risk is minimal.
You may experience pain and bleeding similar or slightly heavier than a menstrual period.
If the bleeding or the pain is severe you should present to hospital as an emergency and probably be offered surgery as above.
How long will this bleeding last and when will my periods return?
The loss will probably continue for about 7-10 days, tailing off toward the end of this time. It shouldn’t be heavier than a period, and shouldn’t have an offensive discharge.
If you’re worried, see your GP or practice nurse for some advice.
Normally your next period will come by 6 weeks or so. If they were irregular before, then it may be longer. Also, your fertility returns before your next period, so if you feel pregnant again a pregnancy test might be useful.
I am bleeding but my scan shows my pregnancy is continuing?
Provided the bleeding is not too heavy and the pain is controlled by simple painkillers, then you can go home.
As long as the bleeding continues, it is advisable to keep off work. Bed rest is not essential and does not seem to influence whether the bleeding will continue and result in a miscarriage or not.
If a pregnancy is destined to miscarry, there is, unfortunately, nothing effective that you or your doctor can do.
What if more than one miscarriage is experienced?
If a woman has two or three miscarriages in a row, this is known as a recurrent spontaneous miscarriage.
A referral to a gynaecologist for special investigation is recommended.
If all of our thorough investigations into your physiology, hormones and immune system are negative, then the chances of your next pregnancy being successful are 70%. If however, we diagnose a problem, then it is more than likely that your next pregnancy will miscarry unless you are treated.
When can I try for another baby?
There are no hard-and-fast rules. The right time to try for children again will vary from one couple to another. It is, of course, advisable to recover from the worst of the emotional upset before starting another pregnancy.
Some couples decide that they want to begin trying for a pregnancy right away, while others feel that this is too soon and need time to get over this loss. There is no ‘right’ thing to do, and you have to go with your feelings.
We normally recommend that you wait for your first period and begin trying from then. In any case there’s no reason you can’t make love as soon as you feel ready. If you don’t want to get pregnant, talk to your GP soon about contraception suitable for you.
Will my next pregnancy be successful?
Following one miscarriage, the risk of the next pregnancy being a miscarriage is not increased beyond the overall risk of one in five.
Remember to keep taking folic acid to reduce the risk of the baby being affected with spina bifida.
If you smoke, give up.
Often a woman gains considerable re-assurance by having an early scan. Ask your doctor or gynaecologist about this.
What can I do to improve my chances for next time?
You can prepare yourself for pregnancy by taking regular exercise, eating a healthy diet, reducing stress and getting your weight to within normal limits.
All these improvements can give you something to concentrate on, and improves chances for long-term fertility.
Certainly reducing your alcohol intake and stopping smoking will help, too.
Remember to start taking Folic acid to help normal development of the baby’s nervous system.
How will my family and I feel when I go home?
Reaction to a miscarriage is very variable and once again there’s no ‘right’ way to feel – a range of reactions are possible and normal. In addition to the grief you may feel, your body will be undergoing some profound hormonal adjustments, which may make you feel very emotionally volatile.
Grief is a very normal reaction to the loss you have experienced and it may be as intense as that after any other loss. Many women describe a feeling of numbness and emptiness following a miscarriage. Some may feel anger, guilt, failure, depression, sadness, lack or loss of interest in sex, tiredness, sleeping problems or jealousy at the sight of pregnant women and babies.
Some couples withdraw, feeling alone and isolated, others may wish to talk about their loss.
Men often feel they have to be strong for their partner and find their loss particularly difficult to talk about. Although it is difficult at first, it may help to try and tell family or close friends how you feel.
Children can be very perceptive and whenever possible need to be included as part of the family unit. You may need to explain to them if they are old enough to understand. They may also be sad, upset or feel guilty thinking that they did something wrong leading to the miscarriage.
Where can I get more information?
Bookshops stock books on pregnancy and many of these contain some information on miscarriage and optimising health for future pregnancies.
Your GP may be able to give some more specific advice. The practice nurse may run a well-woman or preconception clinic – phone the practice for more details.
If I have elevated NK cells or thrombophilia does that mean I will become ill with other diseases in the future?
If you have elevated NK cells that were done as part of the investigations for your miscarriages, they have no other effect on you, now or in future.
With regards to thrombophilias, it depends on the type of the problem. In general, you will be more prone to having blood clots with long-haul flights, major operations, being pregnant etc. The risks vary with different types of thrombophilias, as well as your personal and your family’s health history. I would recommend either seek advice from our clinic or ask your GP to refer to your local haematologist.
What is a miscarriage?
A miscarriage is the loss of a pregnancy before 24 weeks, with most miscarriages actually occurring during the first 12 weeks of pregnancy. Unfortunately, miscarriage is very common, affecting one in five pregnancies. There are different types of miscarriages:-
Silent (missed) miscarriage – Some women have no symptoms at all and the miscarriage is only diagnosed by the absence of the fetal heart when they are given an ultrasound scan.
Incomplete miscarriage – Some women will bleed and may have pain. An ultrasound will show remaining products still within the womb.
Complete miscarriage – Some women will bleed and may have pain, then it settles. An ultrasound will shows an empty womb cavity.
Blighted ovum – Some women have no symptoms at all and the miscarriage is only diagnosed by the presence of an empty sac within the womb when they are given an ultrasound scan.
What are main causes of miscarriage?
How can they be treated?
Do I need to have had 3 miscarriages to see you?
I’ve had tests done on the NHS. Can you use these results?
I’m having IVF with another clinic. Can I see you alongside them?
Mr Hassan Shehata MBBS FRCOG FRCPI is a UK based Consultant Obstetrician and Gynaecologist and a subspecialist in Maternal Medicine. He is the head of department for women’s health at Epsom and St. Helier University Hospitals NHS Trust.