Pearl obstetrics | gynaecology

Facts about early miscarriage

What is early miscarriage?

Early miscarriage is when a woman loses her pregnancy in the first three months. It may be accompanied by vaginal bleeding and pain.

Many early miscarriages occur before a woman has missed her first period or before her pregnancy has been confirmed. Once you have had a positive pregnancy test, there is around a one in five (20%) risk of having a miscarriage in the first three months. Most miscarriages occur as a ‘one-off’ event and there is a good chance of having a successful pregnancy in the future.

Why does early miscarriage occur?

Much is still unknown about why early miscarriages occur. The most common cause is chromosome problems. Chromosomes are tiny thread-like structures found in all the cells of the body. In order to develop normally a baby needs a precise number of chromosomes. If there are too few or too many chromosomes, the pregnancy may end in a miscarriage.

What is the risk of having a miscarriage?

The risk of miscarriage is increased by:
• A woman’s age – the risk of early miscarriage increases with age. At the age of 30, the risk of miscarriage is 1/5 (20%). At the age of 42, the risk of miscarriage is ½ (50%).
• Health problems – as an example, poorly controlled diabetes can increase the risk of an early miscarriage.
• Lifestyle factors – smoking and heavy drinking are linked with miscarriage. There is no scientific evidence to show that stress causes a miscarriage.

Sex during pregnancy is not harmful and is not associated with early miscarriage. There is no treatment to prevent a miscarriage.

What happens if it is a miscarriage?

If the miscarriage has completed, you will not need any further treatment. If the miscarriage has not completed, there are 2 options available. You may choose to have an operation, or you may prefer to let nature take its course.

Letting nature take its course (expectant management)

Expectant management is successful in 50 out of 100 women (50%). It can take time before bleeding starts and it is normal for the bleeding to continue for up to three weeks. Bleeding may be heavier than normal and you may experience cramping pain. In 1/20 cases, emergency admission for haemorrhage or severe pain is necessary. If bleeding does not start or the miscarriage has not completed, you will be offered the option of having an operation.

Having an operation (surgical treatment)

The operation is usually carried out under general anaesthetic. Surgery is usually arranged as a planned operation, usually within a few days. Surgical treatment is successful in 95 out of 100 women (95%).

You may be advised to have surgery immediately if:
• you are bleeding heavily and continuously
• the miscarriage is infected
• expectant management is unsuccessful.

The cervix is gently opened and the pregnancy tissue removed by use of a suction device. You may be given tablets to swallow or vaginal pessaries before the operation to soften the cervix and make the operation easier and safer. This operation is called an evacuation (emptying) of the womb (uterus). You may hear this described as ‘evacuation of retained products of conception’ (ERPC). This operation is similar to a D&C (dilatation and curettage).

The operation (evacuation) is safe, but there is a small risk of complications. These complications do not happen very often. They can include heavy bleeding (haemorrhage), infection, a repeat operation if not all the pregnancy tissue is removed and, less commonly, perforation (tear) of the womb that may need repair.

The risk of infection is the same if you choose expectant or surgical treatment.

When should I phone for help?

If you
• are worried about the amount of bleeding
• are worried about the amount of pain you are in and the pain-relieving drugs are not helping
• have a smelly vaginal discharge
• get shivers or flu-like symptoms
• are feeling faint
• have pain in your shoulders.

Phone our office on 9330 0893. Out of hours or if the answerphone service is on, phone Attadale hospital on 9330 2368 and they will advise.

Are there any tests?

It is normal for some tissue removed at the time of surgery to be sent for analysis in the laboratory. The results can confirm that the pregnancy was inside the womb and not an ectopic pregnancy (when the pregnancy is growing outside the womb). It also tests for any abnormal changes in the placenta (molar pregnancy).

Dr Sillender additionally recommends that the tissue is sent for genetic analysis. This is not routine in most services, but it often brings peace of mind if it is clear that there were chromosomal problems which meant that the baby would never have developed properly.

There are other tests which are usually used if you have three miscarriages in a row. However, Dr Sillender is happy to arrange these tests if you’ve had two miscarriages, as most women will want to know if there’s anything wrong by then.

What happens next?

To reduce the chance of infection, sanitary towels are advised rather than tampons until the bleeding has stopped. You may also be advised to wait until you have stopped bleeding before you have sex.

When you leave hospital, a letter (known as a discharge letter) with details of your treatment will be sent to your general practitioner.

Your next period will be in 4-6 weeks’ time. Ovulation occurs before this, so you are fertile in the first month after a miscarriage. If you do not want to become pregnant, you should use contraception. If you want to become pregnant start taking folate or a multivitamin containing folate.

Making sense of what has happened can take time. Losing a pregnancy is a deeply personal experience that affects everyone differently. It can affect the woman, her partner and others in the family. Many couples find talking helps. SANDS Australia is an organisation set up to provide support. Their phone number is 1300 0 sands (1300 072 637). It is normal to feel grief, anger, loss, emptiness, shock and sadness. Physical symptoms such as sleep problems, fatigue and loss of appetite are common. Some women feel relief if they didn’t want to be pregnant. These feelings and symptoms subside with time.

When can I return to work?

This will vary for each woman. You should be able to go back to work after a week or so. It can take longer than this to come to terms with your loss.

When can we try for another baby?

The best time to try again is when you and your partner feel physically and emotionally ready. It used to be thought that you should wait a few months before trying again, but we know now that doesn’t matter, and there are no problems if you get pregnant again straight away.

Is there anything else I should know?

If you are planning a pregnancy, you should have 400 micrograms daily of folic acid when you first start trying until 12 weeks of pregnancy. This reduces the risk of your baby being born with a neural tube defect (spina bifida).

For information and testing for recurrent miscarriage (which means two or three early pregnancy losses in a row) speak to Dr Sillender.

You should get as healthy as you can before as well as during your next pregnancy. You should eat a healthy balanced diet, and not smoke.

It is advisable to stay within the maximum recommended units of alcohol (and not drink at all when you confirm pregnancy) and take regular exercise.

Dr. Mark Sillender. Consultant obstetrician & gynaecologist