Editor’s note/trigger warning: The following is a candid discussion of what a miscarriage at various stages of gestation looks and feels like, as well as options for how pregnancy loss at various stages is managed. It may be difficult for anyone who is processing a miscarriage to read.
Natural Womanhood has previously addressed many aspects of miscarriage, from personal stories to help for emotional healing. We’ve also discussed the ways that fertility awareness and a restorative reproductive medicine (RRM) approach offer hope to women with hormonal imbalances seeking to avoid miscarriage, as well as women who have already suffered miscarriage(s) and are pregnant or looking to conceive again. Here, we’re adding to our miscarriage resources a very practical primer on your options for managing a pregnancy loss, organized by trimester. If you’re reading this because you or someone you know has lost a baby, from one mom of miscarriage to another, please know that you’re not alone.
While pregnancy loss at any time from conception to birth is a tragedy, the scope of this article is limited to losses before 20 weeks (after which a pregnancy loss is called a stillbirth, not a miscarriage, and which is managed somewhat differently than miscarriages). I interviewed a board-certified OB/GYN, Dr. Jennifer Dust, who has 15 years of experience caring for moms of miscarriage.
First trimester miscarriage
The vast majority of miscarriages occur during the first trimester, or the first 13 weeks of pregnancy. Dr. Dust says that recommendations for treatment options based on gestational age are calculated based on how much the baby has developed, or at what point the baby stopped growing (ex. 8 weeks gestation), not how far along the woman was when she realized or learned that something was wrong (e.g., Baby died at 10 weeks, but mom didn’t find out until her next appointment at 13 weeks–which is a phenomenon known as a missed miscarriage).
Expectant management
In an early, uncomplicated miscarriage, your body will likely deliver your baby much as it would an older baby, that is, via contracting of the uterus, (slight) dilation of the cervix, and passage through the vagina.
You may prefer to pass your baby’s remains in a familiar environment, surrounded by those you love and who love you. Expectant management means that you allow nature to take its course, and wait to go into labor on your own at home. Most healthcare providers are comfortable with expectant management so long as the baby was 13-14 weeks gestation or less at the time of loss. Depending on how far along the baby was at the time of loss, women may safely wait as long as 4-6 weeks after the miscarriage diagnosis to go into labor on their own, so long as they don’t develop a fever (which would indicate an infection, and could be serious). Expectant management in the first trimester is effective at delivering the baby completely 70-80% of the time, according to a 2002 study [here].
Pain (in the form of uterine cramping) and vaginal bleeding are the most significant challenges to consider as you decide whether to opt for expectant management vs medication management or surgical management. As Dr. Dust summed up expectant management at home for me, “The woman has to deliver at home, which can sometimes be very bloody and very painful.”
Dr. Dust added that after 8-9 weeks gestation, “There’s a lot more blood loss and a lot more pain.” She reports having “multiple conversations” with patients who are past 9 weeks gestation and want expectant management so that they know what concerning symptoms should trigger a trip to the ER. In general, if you soak a pad in an hour for two hours in a row, you should go to the ER.
When deciding how best to manage an early miscarriage, consider how far you live from a hospital. If you started bleeding profusely, how long would it take you to get there? Also consider who will handle childcare (if you have older children) and other tasks when you begin to bleed, cramp, and pass the fetal and pregnancy tissue; the further along you were at the time of loss, the more your body will feel the effects of what is essentially a form of labor.
In some cases, your body will pass some but not all of your baby’s remains and the pregnancy-related tissue. If this happens, you will likely hear your doctor, midwife, or other healthcare provider refer to it as “retained products of conception,” “incomplete passage of pregnancy tissue,” or “incomplete uterine emptying.” Incomplete passage is suspected in women who develop a fever (suggesting infection), or may be signaled by excessive bleeding. In those cases, your healthcare provider will discuss medication management or surgical management with you.
Medication management
Medication management of a miscarriage means that the woman is given medications at her doctor’s office, but then typically waits at home to pass the baby’s remains and pregnancy tissue. Medication management includes Mifepristone and Misoprostol (given 24 hours after Mifepristone, and may be given vaginally or by mouth).
These are the same two medications given for chemical abortions. We share this information not to scare you away from this option–which may be medically necessary, and which does not constitute an induced abortion in this case–but to make you aware so that you’re not confused or surprised if your provider suggests this course of action to you. Again, in the case of miscarriage, these medications can be used without moral qualms or fears of legal repercussions, because the baby has already passed away of natural causes.
Dr. Dust says that Mifepristone and Misoprostol will lead to “passage of the pregnancy about 90% of the time. If it doesn’t, the woman then has to come back and then be offered either an additional dose of Misoprostol, or surgical management.” She also noted “the additional dose of Misoprostol can automatically be offered for [losses after] 9 weeks because those are harder to pass.”
Dr. Dust observed that when women opt for medication management “after 9 weeks gestation, I’m not a huge fan of offering at-home management. I’ve just seen a lot of bleeding, a lot of pain, a lot of visits to the emergency room.”
While Mifepristone and Misoprostol is the recommended regimen for medication management, Dr. Dust shared, “many hospitals do not have Mifepristone available on the formulary.” In those cases, patients are given just the Misoprostol, and then another dose 24 hours later. Misoprostol alone is successful about 75% of the time [here][here][here].
As with expectant management, bleeding (requiring blood transfusion about 2% of the time) and pain and possible retained placenta or other fetal or pregnancy tissue and infection (occurring up to 2% of the time) are all possible [here]. Nausea, vomiting, diarrhea, and abdominal pain are common [here].
Surgical management
Surgical management refers to dilation & curettage (D&C), though a sharp “curette” or scraping tool is rarely used nowadays. Instead, physicians favor a suction cannula, which is less likely to perforate the uterus. A D&C may also be called uterine aspiration, and it takes place with IV pain medication or some level of anesthesia in an outpatient setting or a hospital for losses up to about 14 weeks gestation. Some women prefer a D&C because “it’s planned, it’s scheduled, they can prepare for it. They know that their time spent with their miscarriage is finite, it will be over after that [for most people],” says Dr. Dust.
Retained fetal tissue and/or placenta occurs up to 10% of the time with a D&C, a risk which decreases when the provider uses ultrasound guidance. However, Dr. Dust cautioned that most providers do not use ultrasound, and that whether they do or don’t is up to them and not up to the patient. Bleeding, infection, uterine perforation, and injury to the cervix (occurring up to 3.3% of the time) are all unlikely but possible complications of a D&C.
Depending on how far along you were at the time of your miscarriage, your baby may have developed to a point of having recognizable body parts. If that was the case and you have a D&C, please be aware that you will not have intact remains afterwards. Still, you can request your baby’s remains be returned to you after your surgery, and tips on making this request respectfully and firmly are here.
Second trimester miscarriage
Expectant management
Expectant management can be offered for 13+ weeks losses, but Dr. Dust noted it is not the recommended option, due to significantly increased (though still relatively rare) risk of severe or even life-threatening maternal infection or even an extremely rare but potentially fatal maternal complication called disseminated intravascular coagulopathy (DIC). Dr. Dust said she allows patients who have a second-trimester loss perhaps a few days of expectant management, but most often “if you diagnose it, it’s time to manage it.”
Medication management
Some moms prefer medication management (as opposed to the surgical option) because the baby is delivered intact, and the mom can see and spend time with her baby afterwards. Dr. Dust explained, “In the second trimester, we prefer medical management as an inpatient. It’s the same medication- Mifepristone followed by Misoprostol.” If Mifepristone is not available, multiple doses of Misoprostol are given as with first trimester medication management. IV pain medication and epidurals are all available to women medically managed in the hospital.
Dr. Dust continued, “The downside of medical management in the second trimester is that it can take some time. It may take 24 hours” before delivery.
While uterine rupture risk from medication management is just half of one percent (0.05%), it’s possible in women who have previously had 1 or more Cesarean sections. Retained placenta is “fairly common” and would require surgical management. Bleeding and hemorrhage are also possible, though unlikely. As a rule, the further along a woman is when she miscarries, the higher the risk of complications.
Surgical management
Surgical management offers women the ability to deliver quickly if there’s a medical reason such as heavy bleeding (hemorrhage) or signs of infection. “The further along in the pregnancy, the more dangerous a surgical procedure is. You have to dilate the cervix more, there’s more risk for retained products,” says Dr. Dust.
Beyond 14 weeks gestation, the surgical procedure is a dilation & evacuation (D&E). Some doctors, like Dr. Dust, are not trained to perform D&Es, and if surgical treatment is preferred by the woman or necessary due to failed medication management, then a referral to another hospital may be necessary. In those cases, the woman will be pre-treated with Misoprostol to ripen and help dilate her cervix. “Unfortunately,” Dr. Dust noted, “there will not be an intact baby. They do have to pull apart tissues using forceps.”
After surgery, the baby’s remains will be sent to pathology for examination, which may yield some explanation for why your baby died (for example, if there was a problem with the placenta). Then, your baby’s remains can be returned to you for private burial, or you may choose to have them buried with, for instance, other miscarried babies’ remains in a ceremony performed by the hospital. Check with your hospital about what they offer.
The likelihood of needing a repeat surgical procedure after a D&E is approximately 1 percent [here].** Hemorrhage occurs about 2.6% of the time [here]. As with first-trimester surgical management, cervical injury occurs about 3.3% of the time [here]. Uterine perforation occurs less than 1% of the time [here]. Infection can occur up to 4% of the time [here].
How can you know the miscarriage is complete?
No matter the stage at which you miscarry or whether you’ve opted for expectant management, medication management, or surgical management, an ultrasound can confirm that you’ve passed all the fetal and pregnancy tissue. Your doctor may also check human chorionic gonadotropin (hCG) levels via a blood draw or series of blood draws (to ensure that hCG levels trend down to zero). A physical examination may also be performed, to ensure that your cervix is no longer dilated.
If you’ve experienced a miscarriage, you have options
How far along you were in your pregnancy when your baby died will inform to some extent your options for management (yes, I know that “management” is such an inadequate term). Yes, there are pros and cons to each method, and you deserve to receive complete information for each option. You also deserve to be cared for by a compassionate provider who respects and facilitates the option you choose (so long as it doesn’t unnecessarily jeopardize your health). Be sure to bring a support person (spouse, friend, whoever) with you to any appointments (in-person or telehealth) so they can bring up any questions you meant to ask but forgot. And, barring a true medical emergency, take the time you need to slow down and process the information presented to you.
**Research into management of second-trimester miscarriages is scant, which is why the resources listed here are based primarily on second-trimester abortions. This is an unfortunate reality.
Additional Reading:
5 ways the medical community can support women who experience miscarriage
How to chart your cycle and figure out when you will ovulate after a miscarriage
Healing after the loneliness and heartbreak of a miscarriage
