What happens after you have been informed that you have had a miscarriage?
Information about Early Pregnancy Loss or Miscarriage
A miscarriage is the unplanned ending of a pregnancy before the 20th week of gestation. If you have just been informed that you have had a miscarriage, you may find the information contained here to be helpful in answering many questions. About 20 per cent of pregnancies end in miscarriage and most miscarriages occur before the 12th week of pregnancy. The main cause of pregnancy loss is chromosome abnormalities. Other conditions such as infection, developmental abnormalities, and hormonal disruptions could also be responsible. There are several terms you may hear used to describe miscarriage and below is a list of these terms and what they mean.
Complete Miscarriage, also known as a Complete Abortion
This is diagnosed when the fetus and all placental tissue have been expelled from the uterus following a history of bleeding and possibly cramping. This can be confirmed when an ultrasound scan shows that your uterus is empty. Usually no further medical or surgical treatment is required.
Incomplete Miscarriage, also known as an Incomplete Abortion
This is the diagnosis when an ultrasound scan shows that there is still tissue remaining in the uterus, even after a history of bleeding and when some tissue has already been passed. Sometimes this will require medical or surgical intervention
Delayed or Missed Miscarriage, also known as a Missed Abortion
This is diagnosed when the fetus has died before 20 weeks of pregnancy but has not been expelled. Sometimes this is only found when you have a routine ultrasound scan for dating or genetic screening, or if you had spotting, bleeding or cramping and your doctor has sent you for an ultrasound.
Anembryonic Pregnancy, also known as a Blighted Ovum
This is what happens when the pregnancy begins and the amniotic sac develops, but the fetus does not develop. The sac can grow fairly large. If greater than 20 mm with no developing fetus present, it is known as an anembryonic pregnancy. In most cases you have signs and symptoms of a normal pregnancy until diagnosed by an ultrasound scan.
An ectopic pregnancy is a pregnancy that begins to grow somewhere outside of the uterus. The most common place this happens is in the fallopian tube (98%). This is often referred to as a “tubal pregnancy”. Sometimes this can also happen in the ovary, cervix or abdominal cavity. Diagnosing this can be difficult sometimes. Once a diagnosis is made however, prompt treatment is required by either surgery, or medication.
What happens after you have been diagnosed with a missed or incomplete miscarriage?
If you have been diagnosed with an incomplete or missed miscarriage, or blighted ovum, the doctor will discuss with you the three options available to you.
Some people prefer to wait and let the pregnancy and tissue (products of conception) pass on its own. If you choose to wait, you can expect bleeding and cramps similar to what is experienced during a heavy menstrual period. There may be clots or pale coloured tissue passed. As for the pain from cramping, you may use acetaminophen (Tylenol) or ibuprofen (Advil, Motrin). Occasionally, if the bleeding becomes too heavy or the cramping becomes too painful, you may need to seek care at the nearest Emergency Department. If all tissue is not passed, further treatment may be required. The bleeding and cramping could begin at any time, but it can take several weeks for your body to recognize that the pregnancy is not progressing normally. There usually isn’t any physical harm to you by waiting, but emotionally some people want a quicker resolution to the pregnancy loss.
The benefits of expectant management are that it is a natural process. The chance of infection or other complications are low. However, you may change your mind about choosing a different management option at any time. You will need a follow-up appointment at the clinic to confirm that all of the tissue has passed.
Another option for treatment is to use medication to help expel the tissue. The type of medication needed depends on the type of miscarriage you have had.
Those experiencing an incomplete miscarriage or incomplete abortion will be offered a medication called Misoprostol. Misoprostol is a drug that is used for the treatment of gastric ulcers and to manage obstetrical and gynecological problems. It is an effective medical option for early pregnancy loss.
Individuals who have been diagnosed with a i) delayed miscarriage (missed miscarriage or missed abortion), or ii) anembryonic pregnancy or blighted ovum, will be offered a two-step medication treatment that includes Mifepristone and Misoprostol. This combination of medications is taken over a 48 hour period and involves a two-step process:
- Step One: Take one tablet (200 mg) of Mifepristone by mouth; wait 24 hours.
- Step Two: 24 hours after taking the Mifepristone, insert four tablets (800 mcg) of the Misoprostol tablets into the vagina, one at a time. Wait 24 hours. Insert a second dose of four tablets (800 mcg) of Misoprostol into your vagina 24 hours after taking the first dose of Misoprostol. You will be provided with complete instructions on how and when to use each medication if you choose this option.
Some people who choose medical management may experience excessive bleeding or pain. If you experience excessive bleeding or pain, you will need to return to the Emergency Department. In this case, a surgical treatment Dilation and Curettage (D&C) could still be required, if not all the tissue is passed. The benefits of using medication as a treatment is that it can be done at home where the control of when to use the medication is up to you, as its the comfort and privacy of your own home. If effective, you will avoid having surgery and any risks associated with it.
A surgical procedure called a D&C is also available to you. This will be booked through Day Surgery at the hospital. The procedure is usually done under general anesthetic. The surgeon gently dilates the cervix and suction is used to clear the tissue from the uterus. A curette (a small blunt spoon-shaped instrument) may be used to ensure that all tissue has been removed. The tissue is sent to the laboratory for examination. The procedure usually takes about 5 to 10 minutes. The physician will explain the risks and complications to you in further detail. Very rarely or in urgent cases you may be booked for the D&C for the same day if the operating room can accommodate you. The clinic will book this for you. You will be directed to Day Surgery area to wait for the procedure. You may have to wait for several hours before your procedure is done if they are very busy in the operating rooms. After the procedure, you will go the Recovery Room for a short period of time, and then return to Day Surgery. You will be discharged from there when you feel well enough to go home. Please be sure that you have made arrangements for someone to take you home. The benefit of choosing a D&C is that in most cases, the miscarriage will be complete after the procedure and no further treatment is required. Usually, you are directed to make a follow up appointment with your own family physician.
Choosing an Option
When you first hear the diagnosis of a “missed miscarriage”, or “blighted ovum” you could experience many emotions. You may experience anxiety, shock, grief, guilt and sometimes relief. You may find after hearing this news that you do not remember everything the physician explained to you, and therefore you may have difficulty deciding how to proceed. You do not have to make any immediate decisions. You may want to go home to think about your options and discuss it with your family, partner or support persons. You will be scheduled for a follow-up appointment with the clinic to choose an option at a later date. We encourage you to make decisions based on your values, family, previous experiences andtime commitment from work. Be sure to write down any questions you may have for the physician. Even if you think you heard everything said to you, there is a possibility that you will have missed some information so don’t worry if you ask the same questions again. You may change your mind at any time about the option you have chosen. You can call the clinic for an appointment if you just want to come in and discuss another option or if you have any concerns
SUPPORT AFTER MISCARRIAGE
Individuals and families experience and respond to the experience of miscarriage in a variety of ways. The Pregnancy and Infant Loss (PAIL) Network is an organization dedicated to supporting families who are/have experienced a pregnancy loss. They offer free group and individual peer support services. The PAIL Network also acknowledges that there is no time limit on grief. For this reason, families can access their services at any time for as long as they need. If you would like to access these resources please go to https://pailnetwork.sunnybrook.ca/ or call 888-303-7245.
IT IS IMPORTANT TO REMEMBER If you experience excessive bleeding (more than two to three thick pads per hour for more than two hours), or if you are experiencing severe pain or cramping that is not relieved with pain medication, you need to go to the nearest emergency department.