Miscarriage

Overview

A miscarriage is the loss of a pregnancy. Vaginal bleeding is the main sign, ranging from light spotting to heavy bleeding, and lower tummy cramping and pain are also typical. Some people have no symptoms and learn of the loss at a scan, which is called a missed miscarriage. The NHS says the cause is often not identified, and that it may take some time to recover physically and emotionally. Tommy's says miscarriages are very rarely caused by something the person did or did not do.

Symptoms

What a clinician may find

• Vaginal bleeding, from light spotting to heavy bleeding.
• Lower tummy cramping and pain.
• Heavy bleeding with clots.
• No symptoms at all in a missed miscarriage, found at a scan.

Complications

• Heavy bleeding that soaks a pad, which the NHS lists as a reason to call 999.
• A high temperature (fever), which NHS inform Scotland lists as a reason to seek medical advice immediately.
• Emotional effects, with the NHS noting that recovery can take some time physically and emotionally.

Diagnosis

NICE says people referred with suspected miscarriage are offered an ultrasound scan to identify where the pregnancy is and whether it is viable. Where the scan and the date of the last period disagree, NICE says the scan findings guide management. Some people have no symptoms and learn of a missed miscarriage at a scan.

Treatment

NHS inform Scotland describes three ways to manage a miscarriage: waiting for it to finish on its own, tablets (medical management), or an operation to remove the pregnancy from the womb. NICE says clinicians should discuss all the options so that the person can make an informed choice.

Prevention

The NHS says an increased risk of miscarriage is not linked to emotional stress, shock, exercise, lifting, working, sex, air travel or spicy food. Tommy's has a page on reducing the risk of miscarriage and lists body mass index outside a healthy range, heavy drinking, air pollution and poorly managed diabetes as possible contributors.

Key facts

What are the signs of a miscarriage?

Vaginal bleeding is the main sign of a miscarriage. The NHS describes it as ranging from light spotting or brownish discharge to heavy bleeding with bright red blood or clots. Lower tummy cramping and pain are also typical.

Some people have no symptoms at all and only learn of the loss at a scan, which is called a missed miscarriage. NHS inform Scotland says light bleeding or spotting before 12 weeks of pregnancy is common and is often not a sign of miscarriage, but that bleeding at any point in pregnancy is a reason to seek help.

The NHS says to call 999 or go to A&E for heavy red bleeding that soaks a pad, severe tummy pain, shoulder pain, or feeling faint or losing consciousness. For lighter bleeding or milder tummy pain, the NHS says to contact the maternity unit or, if there is not one, a GP or NHS 111. NHS inform Scotland also advises seeking medical advice straight away for a high temperature or for pain that pain relief does not control.

What causes a miscarriage?

The NHS says there are many reasons why a miscarriage may happen, and that the cause of some miscarriages is often not identified. Miscarriages in the first trimester are usually linked to problems with the baby. Tommy's says the most common cause of early miscarriage is a problem with the baby's chromosomes, and that these problems happen by chance.

For later miscarriages, the NHS lists long-term conditions such as poorly controlled diabetes, severe high blood pressure, lupus, kidney disease and thyroid disorders, as well as infections and a weakened cervix. NHS inform Scotland lists age, blood clotting problems, smoking and heavy caffeine or alcohol use as things that raise the risk without directly causing a miscarriage. Tommy's says the risk increases as the biological parents get older.

Tommy's says miscarriages very rarely happen because of something the person did or did not do. The NHS says an increased risk of miscarriage is not linked to emotional stress, shock, exercise, lifting, working, sex, air travel or spicy food. NHS inform Scotland says it is unlikely that anything the person did or did not do caused the miscarriage.

How is a miscarriage diagnosed and where is care given?

NICE guideline NG126, Ectopic pregnancy and miscarriage: diagnosis and initial management, says that people referred with suspected miscarriage are offered an ultrasound scan to identify where the pregnancy is and whether it is viable. NICE says ultrasound features alone are not reliable enough, so the scan is considered together with the clinical picture and blood hCG levels. Where the scan and the date of the last period disagree, NICE says to use the scan findings to guide management.

NICE says early pregnancy assessment services should offer ultrasound and hCG measurement, with staff trained in sensitive communication. It also says that when a scan shows a complete miscarriage but no earlier scan confirmed a pregnancy in the womb, the possibility of a pregnancy of unknown location should be kept in mind, with follow-up until a definite diagnosis is reached.

The NHS describes an ectopic pregnancy as a fertilised egg implanting outside the womb, usually in one of the fallopian tubes. NHS inform Scotland describes recurrent miscarriage as generally meaning three or more early losses, and says further tests may be used to look for an underlying cause.

What are the treatment options?

NHS inform Scotland describes three ways to manage a miscarriage. Expectant management means waiting for the miscarriage to finish on its own, and the person does not need to stay in hospital for it. Medical management uses tablets. Surgical management means an operation to remove the pregnancy from the womb. NICE says clinicians should discuss all the treatment options so that the person can make an informed choice.

NICE says expectant management is the first-line approach for a confirmed miscarriage. NICE's updated guideline recommends mifepristone in combination with misoprostol for the medical management of missed miscarriage. NICE also says that when a miscarriage is threatened and a heartbeat has been confirmed, the person should return for further assessment if the bleeding gets worse or carries on.

NHS inform Scotland says people are offered prescription painkillers or given advice on over-the-counter ones. The NHS describes pain relief as commonly advised, and NHS inform Scotland names a high temperature, or pain that cannot be managed with pain relief, as reasons to seek medical advice straight away.

Emotional recovery and support after a miscarriage

The NHS says that it may take some time to recover from a miscarriage, physically and emotionally, and that anyone struggling to cope can talk to a GP. It says a GP can point to support services, and that counselling and charities such as Miscarriage UK and Tommy's are available.

The Miscarriage Association, which now presents itself as Miscarriage UK, offers a helpline, live chat, email support and support groups led by trained volunteers. The groups are open to anyone affected by pregnancy loss, including partners, family members and loved ones. The charity does not provide counselling itself, but its website has a page on counselling after a miscarriage and a counsellors directory. It says it cannot give medical advice and points people with health concerns to a GP or NHS 111. For phone support outside its opening hours it points to Samaritans on 116 123, which is free and open 24 hours.

Tommy's runs a free midwives' helpline covering any type of pregnancy loss, staffed by midwives trained in bereavement support. Tommy's says the line is non-urgent, and for urgent concerns it advises contacting a GP or NHS 111, or 999 in an emergency. Cruse Bereavement Support runs a free helpline for anyone who is grieving.

Frequently asked questions