Everyday we see patients who are going through a miscarriage. It is defined as a loss of pregnancy before 20 weeks. We believe it is important for you to understand the entire process.
In an OB/GYN clinic we help women go through miscarriages everyday. In fact, 15-30% of all pregnancies end in miscarriage. Think about it — out of 100 pregnancies, about 15-30 of them end in miscarriage. As healthcare providers, we want to offer emotional support, guide you through the medical decision making process, but moreover, educate you regarding the process of pregnancy and what happens during a miscarriage. Even though we can’t say it (because it gets too personal), chances are that we too have been through this and can truly say “I know how you feel”.
Having a miscarriage can be very difficult. Sometimes, the emotional impact can take longer to heal than the physical impact. Allowing yourself to grieve can help you accept the loss over time. Most miscarriages occur within the first few weeks of pregnancy. Miscarriage after 12 weeks is rare and affects only 1-2 % of pregnancies. The process of fertilization and maintaining a pregnancy is quite complicated and whenever anything goes wrong in that cycle, it can lead to a miscarriage.
This can happen at many stages of pregnancy. Some happen before a fetus forms and others happen after the fetus develops a heartbeat. On ultrasound, we can see the normal progression of pregnancy. Once the pregnancy sticks to the lining, a gestational sac forms. The gestational sac looks like a balloon with water. This will eventually become the amniotic fluid. After this stage, a yolk sac forms, then finally from that the fetus/baby will develop. A heartbeat should be seen at about 6 weeks of pregnancy, or 2 weeks after conception.
Many times we cannot explain why a miscarriage happens. The most common cause is a genetic abnormality in the fetus. Most of the time, these abnormalities are not inherited, but happen because of chance. Other reasons for miscarriage include hormonal imbalances, placental problems, infections, alcohol and drug use, high blood pressure, and diabetes.
Please remember that you did not cause the miscarriage. Many women suffer internally trying to figure out if they did something wrong. Did I workout to hard? Maybe I drank to much coffee? Was it something I did? The answer is “No”. Plain and simple. You cannot cause a miscarriage. Something was wrong with the pregnancy to begin with. Your body (or mother nature) naturally knew something was wrong and because of this, it intervened.
Diagnosing a miscarriage
It is very important to get an accurate diagnosis when a miscarriage happens. We use your history, do an exam, use the HCG blood test, and sometimes do an ultrasound. HCG (human chorionic gonadotropin) is a hormone produced by the placenta, which can be found in the blood or urine. When you do a pregnancy test at home, it is measuring the HCG levels. It can be detected in the blood at about day 8-11 after conception and in the urine 12 days after conception. The HCG cannot tell you how far along you are, because the actual number varies greatly. But we do know that the HCG will approximately double every 48-72 hours in a normal pregnancy. This test can also can help us determine if the pregnancy is abnormal. But please keep in mind that this is just a guideline. The HCG has a wide range of normal.
We also use ultrasound to visualize the pregnancy, inside the uterine lining or elsewhere. There are times that no pregnancy is seen because it is too early. On the ultrasound we are looking for a gestational sac, then a yolk sac, then a fetus. Once a fetus is seen with a heartbeat, the chances of a miscarriage drop down to < 5%.
What happens during a miscarriage?
Miscarriage is not an event. It is a process. Some women come in bleeding while others come in for a routine exam to find out that the fetus is not viable. Because of this, there are many definitions we use for the stages of a miscarriage. These are important as it helps guide how to manage a woman’s specific situation.
- A missed miscarriage refers to a pregnancy that is inside the uterus, but stops developing. The woman does not have any bleeding or outward signs of a miscarriage. The only way to identify this is by an ultrasound, and sometimes bloodwork (HCG).
- An incomplete miscarriage refers to a woman who is bleeding and currently passing blood or tissue, but the miscarriage is still in progress. We can usually identify this by a woman’s description, an exam, and possibly an ultrasound.
- A threatened miscarriage refers to a woman who is having bleeding, but there is no problem noted on the ultrasound. The bleeding may stop, or may get worse. Only time will tell if things will be normal.
- A completed miscarriage is when the miscarriage is all done, and there is no more tissue in the uterus.
During a pregnancy loss, the body expels the tissue inside the uterus. Bleeding is the most common sign of a miscarriage. Cramping can also occur. If this all happens naturally, heavy bleeding and cramping can occur for a few hours. This usually tapers off into a heavy period. The farther along you are in pregnancy, the more bleeding you will experience. During the process, most people do not see a baby or fetal tissue. Rather, it is mostly blood, clot, and placental tissue.
What are the treatment options?
Once a miscarriage is identified, you will have three main options.
Waiting and watching is called expectant management. The body is amazing and it knows what to do. Because of this, most women pass the pregnancy tissue without any interventions. It can take up to 4-6 weeks after the pregnancy loss for the body to pass all of the tissue and bring the hormones down to non-pregnant levels.
Inducing a delivery by medication is called medical management. We have a tablet that can be taken by mouth or placed into the vagina. It works by making the uterus contract and expel the tissue and blood. It mimics the natural process of miscarriage. Misoprostol is a medication that can be used for this process. It is an alternative to surgery. The pills are very small and can be swallowed or placed in the vagina. Misoprostol works by softening the cervix and by causing uterine contractions. This expels the contents of the uterine cavity. It usually works within 12-24 hours after taking the pills. The miscarriage will occur at home. Success (expelling all of the pregnancy tissue and placenta) rates are 70-90%. If you do not miscarry, you may need another dose. Side effects can include nausea, vomiting, abdominal pain, or diarrhea. You cannot take misoprostol if you are allergic to medications like Ibuprofen or aspirin.
- After taking misoprostol, you will experience uterine contractions, cramping and bleeding. You will have heavy bleeding for a few hours and then it should taper off. The bleeding is usually heavier than a normal period. Depending on how far along you are, you may also see tissue and blood clots.
- Call your doctor if the bleeding is heavy and does not stop after a few hours, or if you feel dizzy or lightheaded. Bleeding heavily for a long period of time during a miscarriage can be a very serious problem.
Surgery management can also be done. This is called a suction D&C. The “D” stands for dilating the cervix and the “C” Stands for curettage or cleaning out of the uterine cavity. Using this method, we can remove all of the contents of the uterus. A D&C is done in a surgery center or an office setting. A small amount of anesthesia is used; you are awake for this procedure and breathing on your own, but very drowsy and not aware of what is happening. The procedure takes only a few minutes. During the D&C, your legs are in stirrups and a speculum is used. The cervix is dilated and a suction device is used to remove everything in the lining. The risks include bleeding, infection, or rarely, poking a hole through the back of the uterus called a uterine perforation. These complications are very rare and the procedure is actually very simple. After a D&C, you are sent home within a couple of hours. A small amount of bleeding, pain, and cramping is common. You will recover within a couple of days.