Miscarriage

A miscarriage is the loss of a foetus in the first trimester of pregnancy. Unfortunately, 1 out of 10 pregnancies will end in miscarriage.

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About miscarriages

A miscarriage is the loss of a foetus in the first trimester of pregnancy. Unfortunately, 1 out of 10 pregnancies will end in miscarriage.

Here you can find our information in Dutch about miscarriage (miskraam).

What is a miscarriage?

The foetus develops in the first months of pregnancy. It settles in the uterine wall. Unfortunately, this does not always go to plan. When a foetus is not viable, it will not settle properly. We call this a miscarriage or a spontaneous abortion. There are several reasons why a foetus may die and detach from the uterine wall.

Cause

In 95 out of 100 cases, miscarriages are caused by problems with the foetus's chromosomes. This means that the foetus is not viable. When this happens, nature has a solution, which is to reject the foetus. In many such cases, the foetus will suffer from chromosomal abnormalities. Generally, such disorders are not hereditary, meaning there is no additional risk of a subsequent pregnancy ending in miscarriage.

In the other 5 out of 100 cases, the miscarriage will be caused by the following:

  • an unsuccessful uterine implantation;
  • an infection;
  • an abnormally shaped womb;
  • a fibroid;
  • an unknown cause.

You cannot cause a miscarriage yourself. Miscarriages are never caused by a fall or physical exertion. For example, having sex, riding a bicycle, riding a horse or riding a motorcycle in themselves do not cause miscarriages. However, a fall or physical exertion may induce a miscarriage that would have happened, anyway.

Symptoms

The following symptoms are indicative of a miscarriage:

  • Your symptoms of pregnancy disappear.
    Your breasts stop hurting. You stop suffering from morning sickness. You may also have the feeling that something is wrong, but this feeling is shared by many pregnant women who do not end up miscarrying.
  • You suffer vaginal bleeding.
    However, in itself, bleeding does not necessarily mean that your pregnancy will end in a miscarriage. If you experience bleeding, we will perform an ultrasound to see if you are still pregnant. The amount of blood you lose can vary greatly.
  • You suffer abdominal pain.
    If you are actually having a miscarriage, you will generally experience abdominal pain. Typically, the longer the gestation period, the worse the pain will be. The severity of the abdominal pain can vary greatly from person to person.

Sometimes, a pregnancy will end without you noticing. In such cases, the ultrasound will tell us that the heart is no longer beating.

Course of the miscarriage

The course of a miscarriage can vary greatly from person to person. Broadly speaking, this is what happens when you are having a miscarriage:

  • In the beginning, you will experience some slight vaginal bleeding. This may go on for several days.
  • If the miscarriage continues, you will generally lose a lot of bright red blood. The amount of blood you will lose can range from a regular period to a particularly severe period. Make sure you protect your clothes and bedding from becoming blood-stained.
  • You may lose blood clots. These are bright red clots of blood that can be the size of a fist. If you have lost more than one blood clot, please contact our staff at the birthing rooms or HMC's Obstetrics ward.
  • If the miscarriage continues, you will experience abdominal pain. This abdominal pain will be like severe menstrual cramps. For some women, the pain will feel like contractions. The pain will come in waves, lasting for a few minutes each time before receding again. Some women will suffer abdominal pain for a few minutes or a few hours, which will then stop but come back later. This abdominal pain is caused by the squeezing motions produced by the uterus. This is the body's way of expelling what is inside the womb. Once the womb is completely empty, the pain will disappear.
  • Once your uterus is empty, you will once again suffer regular bleeding, as when you are having your period. The cervix will then close again. The bleeding will stop completely within two weeks.

What can you do?

Your options are as follows:

  • wait and see
  • take some medication
  • undergo curettage

Watch the videos on degynaecoloog.nl about the options open to you in the event of a miscarriage (videos are in Dutch).

Wait and see

In general, you can wait out the end of a miscarriage. In half of all miscarriages, the uterus will expel the foetus in its entirety. This is done within two weeks of the onset of bleeding. With this option, the miscarriage takes a natural course. Women who choose this option are sometimes better able to process the emotions inherent in a miscarriage.

If you wish to wait until your uterus has expelled the foetus of its own accord, think about when you would like to discuss this with the midwife or doctor. Waiting is not bad from a medical point of view and will not affect a future pregnancy. You can still opt for curettage (see below) later if necessary.

Take some medication

In consultation with your doctor, you may decide to take some medication – a combination of Mifegyne and misoprostol (Cytotec). These tablets will induce a natural miscarriage. You can undergo this treatment at home. We would advise you not to be home alone during the treatment. Make sure there is someone around to support you and take you to the hospital if necessary.

How does it work?

Mifegyne is a medication that allows misoprostol to be effective. It causes the cervix to soften somewhat and open up a little. Generally, you will take this medicine at the hospital. In some cases, you can take it at home.

Misoprostol is a medication that causes uterine cramps, which then expel the pregnancy tissue from the uterus. This is effective for 8 to 9 out of 10 women. It will take several hours to several days for the miscarriage to start. In 1 to 2 out of 10 women, the miscarriage will not start, or some of the pregnancy tissue will remain inside the uterus.

If the uterus is not completely empty, the bleeding will not stop within two weeks after the miscarriage. In such cases, to empty the uterus, you can opt for curettage (see below) or hysteroscopy. During hysteroscopy, the doctor will look inside your uterus with a camera and remove all the tissue that still is left inside the uterus.

How to take the medication

The doctor in the outpatient clinic will first give you a 200-milligram tablet of Mifegyne. You should swallow this with a glass of water. This medicine will soften the cervix and allow the misoprostol to be more effective. You will be given eight tablets of misoprostol to take home with you.

After 24 to 48 hours have passed since you took the tablet of Mifegyne, you will administer four 200-milligram tablets of misoprostol to yourself at home. You should insert these tablets as deeply as possible into your vagina, preferably in the morning. After insertion, lie down for 15 minutes. Generally, the miscarriage will start within a day.

If you do not suffer any bleeding or cramps after 48 hours, that means the first tablets are not working. If this is the case, you can insert the next four misoprostol tablets.

Side effects

In the Netherlands, misoprostol is only registered as a medicine to treat stomach ulcers. Uterine cramps are one of the side effects of misoprostol, which we can use to our advantage. Other side effects of misoprostol include:

  • diarrhoea;
  • abdominal cramps;
  • nausea;
  • dizziness;
  • headache;
  • chills;
  • a slight increase in body temperature;
  • fever (sometimes).

Pain relief

You can take NSAIDs to relieve the pain associated with the cramps. These are painkillers that are more effective at pain relief than paracetamol. NSAIDs include naproxen, ibuprofen and diclofenac. The package insert will tell you how many tablets you can take per day. Your pain will be relieved most effectively if you take naproxen and paracetamol at the same time, as soon as the cramps begin.

After the treatment

If the pills cause the onset of a miscarriage, you may experience various degrees of vaginal bleeding for up to three weeks. If you are still bleeding after three weeks, contact the Gynaecology outpatient clinic.

You will have your period as usual after four to six weeks, sometimes a little later. If you wish to get pregnant again, you do not necessarily have to wait. However, in many cases, we will recommend waiting for one menstrual cycle, to make sure your cycle has resumed.

Risk of infection

After the treatment, the cervix will still be open, which means you will be at a slight risk of infection. For this reason, you must refrain from the following while you are experiencing vaginal bleeding:

  • using tampons;
  • having sex;
  • swimming;
  • taking a bath.

You can take a shower, though.
If you have a fever of more than 38.5 °C within two weeks of undergoing the treatment, please contact the Gynaecology outpatient clinic.

Check-up

Two weeks after treatment, you will have a check-up at the outpatient clinic to see if the miscarriage is complete. In approximately 1 to 2 out of 10 women, the amniotic sac or part thereof will still be present. If this is the case for you, you can opt for curettage, after all. If any products of conception remain in the uterus, you can opt for hysteroscopy.

Curettage

Some women find it difficult to wait for the miscarriage to start of its own accord and for the bleeding to stop. This can be both emotionally draining and impractical. Waiting can be physically demanding if the bleeding is prolonged. Some women therefore choose to undergo curettage. During curettage, the gynaecologist will empty the uterus by sucking out residual tissue by means of a thin tube inserted into the vagina or by scraping the uterine wall with a curette.

The gynaecologist will perform this procedure either in an outpatient operating theatre or in an 'ordinary' operating theatre. The difference between the different types of operating theatres is that no anaesthetist needs to be present in the outpatient operating room.

Outpatient operating theatre

In the outpatient operating theatre, the gynaecologist will numb the cervix with a few small injections. You will be conscious as usual during the procedure. Sometimes, no anaesthesia will be necessary, in cases where the cervix is already slightly dilated. You can go home immediately after the procedure.

Ordinary operating theatre

In the ordinary operating theatres, you will undergo short-acting general anaesthesia. As a result, you will not notice the procedure. The curettage procedure will take 5 to 10 minutes. Once the gynaecologist has removed all the residual tissue, the bleeding will stop of its own accord, within a few days to two weeks. After the procedure, you will go to the recovery room. Generally speaking, you will be allowed to go home the same day.

Complications

A complication is an additional medical problem that may occur. All medical procedures come with a risk of complications, and this procedure is no exception. Fortunately, complications are unlikely to occur during curettage. Please find a list of potential complications below:

  • severe bleeding (26 out of 10,000 women);
  • accidental perforation of the uterine wall (2 out of 1,000 women);
  • incomplete curettage (very rare);
  • growth of adhesions in the uterine cavity – Asherman's syndrome (very rare).

Anti-D immunoglobulin

If you have rhesus negative blood type, you will be given anti-D immunoglobulin (anti-D) after experiencing a miscarriage. This medicine will prevent the development of rhesus antibodies, which may cause problems in a future pregnancy. In the event of a spontaneous miscarriage after 10 or more weeks' gestation, the gynaecologist will give you anti-D. You will also receive anti-D after curettage, regardless of the foetus's gestation period.

Recommendations

  • You cannot prevent or stop a miscarriage from happening, not even by keeping to your bed ('bed rest') or taking medication.

  • During and after a miscarriage, you may feel very tired and empty. Therefore, it is vital that you rest a lot during this period. Rest is important for your mind and body.

  • If you experience any pain, feel free to take some paracetamol, in combination with an NSAID. When you do, take two 500-milligram tablets of paracetamol together, up to four times a day. Use the NSAID as directed in the package insert.

  • You may find that warmth will make you feel better. For example, fill a hot-water bottle with hot water or take a hot shower.
    • Do not use tampons during and shortly after a miscarriage. They may increase your risk of infection, because your cervix may still be slightly dilated.

Recovery

Physiological recovery

Most women have a smooth physiological recovery after a miscarriage or curettage. Once the uterus is empty, your bleeding will gradually subside. The abdominal pain will morph into a nagging discomfort. On the day after the miscarriage, you will lose as much blood as during your period. The abdominal pain will be almost gone by then. You will continue to bleed for 5 to 10 days. As with your period, the bleeding will gradually become less heavy. In the beginning, the blood will sometimes be bright red, but it will usually turn slightly brownish later on. As long as you continue to bleed, we would advise the following:

  • Do not use tampons.
  • Do not have sex.
  • Do not swim.
  • Do not take any baths.

You will have your next period after four to six weeks, although this may be a little sooner or later. You will not have more difficulty conceiving after having a miscarriage.

Emotional recovery

Some women are able to get over a miscarriage fairly quickly, while others need a little more time to do so. It depends on things such as whether someone already has children, how hard it was to fall pregnant and how the pregnancy was progressing. All women deal with miscarriages in their own way. It is hard to say how long it will take you to get over the miscarriage, as this is different for everyone.

It is important that you acknowledge your grief and talk about it with others. Take your time, and do not feel guilty about needing a lot of time. For some women, miscarriages are a dramatic event that will cause them to go through a period of grief. A miscarriage not only puts a stop to your pregnancy, but also to your vision of the near future. As a result, a miscarriage may cause you to experience a great deal of grief, disappointment, feelings of guilt, anger, emptiness and disbelief. Because the loss is generally invisible to those around you, you may find it helpful to talk to people who have gone through the same thing. Do not hesitate to share your grief with others. There is always someone out there who can support you.

Getting pregnant

In most cases, couples will want to try to conceive again after some time has passed. Some will want to get pregnant again sooner than others do. In some cases, they may never have stopped wanting to fall pregnant in the first place. If you want to conceive again, you do not necessarily have to wait before you try again. We do generally recommend not trying for one menstrual cycle afterwards, just to make sure your cycle has resumed. In addition, it is obviously important that you and your partner are both emotionally ready.

In most cases, a subsequent pregnancy will go off without a hitch. However, you may feel nervous in your first trimester and wonder if things will go well this time around. Feel free to contact us early on in your pregnancy. That way, we can help you get through this nerve-racking first trimester. If necessary, we will perform an early ultrasound. This can be done after seven weeks' gestation.

In what cases should you contact HMC at once?

Contact HMC immediately by calling 088 979 21 04:

  • if you experience prolonged vaginal bleeding and bleed more heavily than during a period. It is OK if your bleeding is heavier for a short time, particularly at the moment your uterus is expelling the foetus;
  • if you need two large sanitary pads within one hour to absorb all the blood
  • if you experience dizziness or fainting, or if you are seeing stars;
  • if you develop a fever during a spontaneous miscarriage or after undergoing curettage. A body temperature of 38 ˚C or higher may indicate an infection;
  • if, after a spontaneous miscarriage or curettage, you experience heavy and prolonged bleeding and suffer prolonged severe abdominal pain. This may indicate an incomplete miscarriage, in which case you may need to undergo curettage or hysteroscopy.

Do you have any questions?

If you experience any physical symptoms or problems, or if you have any questions or doubts, you can call us, day and night. You can also contact us at any time with questions about the course of your miscarriage or for emotional support. You may find it helpful to talk to an expert about all the things you are experiencing and feeling.
If you still have any questions after reading this leaflet, please discuss these with your physician. Please contact HMC's Gynaecology/Midwifery outpatient clinic during office hours by calling 088 979 2422.

More information and support

Books (in Dutch)

  • 'Met lege handen' [Empty-handed]. M. Cuisinier and H. Janssen. H. Van Holkema en Warendorf, third edition, 2000, ISBN 9026966997.
  • 'Als je zwangerschap misloopt' [When your pregnancy goes wrong]. M. van Buren, W. Braam. De Kern, Baarn, sixth edition, 1999. ISBN 9032506749.
  • 'Tussen iets en niets: omgaan met het verlies van een prille zwangerschap' [Between something and nothing: Dealing with miscarriage]. Spitz, M. Keirse and A. Vandermeulen. Lannoo Tielt, 1998, ISBN 9020934449.

Websites

  • www.degynaecoloog.nl
    Website of the Dutch Society for Obstetrics and Gynaecology (NVOG, in Dutch).
  • www.knov.nl
    Website of the Royal Dutch Organisation of Midwives (KNOV, Information in English available).

 

Miscarriage

Why HMC?

  • personal attention, both for yourself and for your partner;
  • excellent collaboration with midwives based in The Hague.