You have been diagnosed with a miscarriage. In case of a miscarriage, the amniotic sac does not contain fruit or there is no heartbeat to be seen. This loss can bring a lot of grief. It is important to think about this. At the same time, you need to make a choice about how to handle the situation. We understand that there is a lot coming at you. That is why in this leaflet we discuss what a miscarriage is and what treatment options there are. This leaflet is an addition to the conversation that your treating midwife or doctor has had with you.
What is a miscarriage?
A miscarriage is the loss of an early pregnancy. A miscarriage can occur in the first 16 weeks of pregnancy. It is known that about 15% of pregnancies in the first 10 weeks lead to miscarriage. A miscarriage can have several causes. Usually there is an abnormality in the chromosomes during the construction of the fruit. Often there is no clear reason for this. This chromosome aberration is rarely
hereditary. Usually there are no consequences for a subsequent pregnancy. A miscarriage is not caused by physical exertion. For example, activities such as making love, falling, cycling, sports or motorcycling cannot cause miscarriage.
How do we investigate a miscarriage?
When we expect you to have or have had a miscarriage, the obstetrician or gynecologist first makes an internal ultrasound. With a vaginal ultrasound, we insert a thin device into the vagina. Around the device is a condom. Sometimes we use lubricant to make it easier to insert. This ultrasound gives a sharp picture of the uterus and ovaries. Through a vaginal ultrasound we can see a pregnancy from four weeks of pregnancy. With a healthy pregnancy, we can see the heart beating from about six weeks. With the help of this ultrasound, we can see if you have a miscarriage.
How does a spontaneous miscarriage happen?
In the beginning you have little blood loss. This blood loss can last for several days. If the miscarriage continues, you will usually lose a lot of bright red blood. You can also lose clots. Clots are bright red lumps of blood that can be the size of a fist.
If the miscarriage continues, you will get abdominal pain. The abdominal pain resembles severe menstrual pain. The pain comes in waves: it lasts for a few minutes and then goes away again. Usually the pain subsides when blood has come out of the uterus again. It may be that you have abdominal pain for a few minutes to hours, that it goes away again and comes back later. The abdominal pain ensures that everything that is in the uterus is brought out by means of squeezing movements. In this way, your body cleans the uterus. If the uterus is empty, the blood loss becomes less and the abdominal pain turns into a nagging pain. The day after the miscarriage you lose as much blood as during menstruation. The abdominal pain is as good as over. You will continue to lose blood for another 5 to 10 days. Just like with a menstruation, it slowly becomes less and darker in color.
Advice in case of miscarriage
- You cannot prevent or stop a miscarriage. This can also not be done by taking bed rest or medication.
- If the blood loss increases or you get menstrual-like pain, make sure there is someone around you who you feel safe with. If the blood loss or cramps are (temporarily) severe, support from a trusted person is important.
- For menstrual-like pain, you can use paracetamol or painkillers such as Naproxen, Aleve, Diclofenac.
- You do not have to store the rejected tissue.
- Do not use tampons. The uterus must be able to remove the rejected fruit.
Examination after spontaneous miscarriage
If the fruit has been expelled, we can use a vaginal ultrasound to see if the miscarriage was complete. We look at whether the uterine cavity is empty. The internal ultrasound does not have to take place immediately after the miscarriage. This can also be done a few days later. With a normal course of a miscarriage, an ultrasound is not required as standard. When the uterine cavity is empty, you no longer need additional treatment.
No spontaneous miscarriage yet
The gynecologist discusses the various possibilities to initiate the miscarriage. Below we list all the different options again, so that you can think about your choice quietly.
What are the possibilities?
Option 1: wait for spontaneous progress
One of the possibilities is to wait a little longer for the spontaneous course of the miscarriage. We advise this especially when there are signs of an incipient miscarriage (abdominal pain or blood loss). If we have determined that you have had a miscarriage, we recommend waiting one to two weeks. Often a spontaneous miscarriage starts. About 50% of women go through a spontaneous miscarriage in two weeks. If you choose to wait, it is wise to think about how long you want to wait. It is also important to discuss this with the midwife or doctor. Waiting can’t hurt medically. It also has no consequences for a new pregnancy and the chance of complications is small. It can only be a strange/awkward idea. If you later decide to want an operation, you can still opt for it. In case of a lot of or persistent blood loss or pain, an intervention may still be necessary. If waiting is justified and your preference is, the doctor or midwife will agree with you that you will return for a check-up after one week. The doctor or midwife then discusses how we proceed.
Option 2: Treatment with medications
You can also opt for treatment with medications. These drugs are called mifepristone and misoprostol. Mifepristone and misoprostol have a high success rate of complete miscarriage (80%).
What side effects are there?
Possible side effects of mifepristone are: headache, nausea, vomiting, stomach pain, abdominal pain, diarrhea, fatigue, chills or fever, dizziness. Possible side effects of misoprostol may include nausea, vomiting, diarrhea and fever.
When should you not use misoprostol?
- you are allergic to misoprostol;
- your kidneys are continuously not working properly (chronic renal insufficiency);
- you always use corticosteroid;
- you have severe asthma;
- you have a heart defect;
- you have diabetes, which is not well controlled.
When should you not use mifepristone?
If you have asthma, you should be careful when using This medicine. Your doctor will decide with you whether you are going to use This medicine.
How to use mifepristone and misoprostol
You can use mifepristone and misoprostol at home. You must first take 200 milligrams of mifepristone and 36 hours later insert 4 tablets of misoprostol at once (800 μg) as high as possible vaginally. You can choose whether you do this in the morning or rather in the evening. After a few hours you can already get abdominal cramps. The miscarriage is expected to occur within 24 hours. If this is not the case, we can give you 4 tablets a second time. At the outpatient clinic you will receive a total of 8 tablets. It may be that the tablets come out. This is not a bad thing. The active substance is then already absorbed by the body. When using mifepristone you pay a deductible of € 40 at the pharmacy,-.
What are the risks?
Mifepriston is effective and safe. Misoprostol is effective and safe, but is not yet registered for the treatment of miscarriage. It is registered as a stomach protector. The drug is widely used worldwide, has been extensively researched and proven safe for inducing miscarriage.
When do you get a check-up?
About a week after insertion of the misoprostol, you will return to the outpatient clinic for a check-up. If you have previously experienced the miscarriage, please contact the outpatient clinic. With the ultrasound, the gynecologist checks whether the miscarriage is complete and the uterine cavity is empty. You may not have had a spontaneous miscarriage. Then we can still schedule a curettage for you.
Option 3: Suction curettage
Some women find it difficult to wait until the miscarriage starts on its own and the bleeding stops again. It can be emotionally and practically annoying to wait for a spontaneous miscarriage. Physically it can be difficult if the blood loss lasts for a long time. For some women, these are reasons to intervene earlier. This can be done by having a curettage carried out. With this surgical procedure, the miscarriage is completely removed in 95% of women.
How does a curettage work?
With a curettage we suck the uterus through the vagina with a thin tube empty. The bleeding stops when we have removed all tissue residues. This happens within a few days.
How long does a curettage take?
A curettage takes 5 to 10 minutes. You will receive a short general anaesthetic and will not notice any of this procedure. You will be admitted to the Day Treatment department for this. Please note that you do not plan anything else that day. You can usually go home the same day.
How is the recovery going?
The recovery after a curettage varies per person. It varies from a few days to 2 – 3 weeks. This has to do with the anesthesia, the desulphurization and the amount of blood loss that you have had during the miscarriage.
What complications are there?
With a curettage there is a small chance of a complication that requires further treatment. The risks are the anesthesia itself and any chance of infection, bleeding or damage to the uterus.
When do you return for a check-up?
You do not necessarily need a checkup. If you do want an appointment, you can call the gynaecology outpatient clinic to make an appointment 6 weeks after the curretage. Of course, you can always call if you have any questions, or if there are any problems. For example, in case of persistent blood loss or when you do not get your period.
What happens if the miscarriage is not complete?
It may be that there has been a miscarriage, but that there is still a small remnant left behind. You can wait and see if you can have a curettage carried out.
When should you contact us after a miscarriage on curettage?
It is wise to warn the doctor or midwife in the following situations:
- With heavy blood loss (prolonged and more than a normal menstruation). Especially with complaints of seeing asterisks or fainting.
- In case of persistent complaints. If you continue to have cramping pain and/or heavy blood loss, this may indicate an incomplete miscarriage. A (new) curettage may then be necessary.
- In case of fever. A temperature of (>38 °C) or higher 24 hours after administration of misoprostol.
- In case of anxiety.
Emotional recovery A miscarriage is often very drastic.
The miscarriage suddenly brings an end to the plans and fantasies about the expected child. Many women initially react rather shocked. The sadness can be very intense, especially in the first few weeks. In addition to sadness, there may be other feelings such as guilt, shame, disbelief, anger, a feeling of emptiness, failure of one’s own body or jealousy towards other pregnant women. These feelings are very understandable. Take the time to process these feelings and try to talk about them with someone you trust. To the outside world, the loss is usually invisible. This makes it harder to share your feelings with others. Everyone processes a miscarriage in his or her own way.
When can you get pregnant again?
Over time, there is often a desire for a next pregnancy. We recommend that you wait with a next pregnancy until you have had your period again. You can expect the next period about four to six weeks after the miscarriage, although it can also be a little earlier or later. If the period does not occur, contact your doctor or midwife. Be alert, prior to the first period you are often already fertile. In addition, it is of course important that you are both emotionally ready again. In most cases, a subsequent pregnancy proceeds without problems. The first three months of pregnancy are of course exciting, would it go well this time? If you have the need, you can contact your midwife or the hospital early in the pregnancy. This way we can help you to get through the first exciting period. If this is necessary for you, we can make an ultrasound around seven weeks of pregnancy.
Do you have any questions?
If you have any questions after reading this leaflet or if you are worried, please contact your obstetrician or gynecologist.