Miscarriage

In one in five pregnancies (20%) vaginal bleeding occurs in the first trimester (up to 14 weeks). Many women find this disturbing, and the thought of a miscarriage is quickly raised. Yet in only half of these cases miscarriages occur.

INNOCENT BLEEDING

There are a number of innocent situations in which blood loss may occur. This is not a miscarriage. Some examples are:

  • Penetration bleeding: When the foetus nestles in the endometrium, bleeding can occur. This usually occurs between the fourth and sixth week.
  • Contact bleeding: As soon as you are pregnant, the cells on the outside of the cervix are extra sensitive. The cervix is located inside the vagina. Mechanical pressure can cause these cells to bleed rapidly. This can happen, for example, after intercourse (making love), pressing hard stools, physical exertion, or coughing a lot.
  • Other causes: If you have hemorrhoids, it is possible that the blood loss is caused by this. An unnoticed cut after shaving can also be the cause. Sometimes someone has bleeding without the pregnancy being at risk, but there is no obvious reason.

HOW DO I RECOGNIZE A MISCARRIAGE?

The course of a miscarriage is different for everyone. But it usually begins with vaginal bleeding that increases in volume. The bleeding may increase within hours to days and be heavy for a short period (6-12 hours). This may be accompanied by contractions-like pain, or severe menstrual pains. A person may also lose clots or pieces of tissue (endometrium).

The loss of the foetus is not always clearly visible. After the pregnancy tissue has been shed, the loss of blood and the abdominal pain will subside. Bleeding after a miscarriage may even last two to three weeks, but it usually stops within about ten days.

WHEN SHOULD I CALL THE MIDWIFE?

If you experience vaginal bleeding, check with yourself whether it is possibly due to one of the innocent causes (see above). If not, or if you are very concerned, contact your midwife. Be sure to call in case of:

  • Ample blood loss. That is, as in (more than) a normal menstruation.
  • Lots of abdominal pain/cramps.
  • Fever, more than 38 degrees Celsius.

If necessary, the midwife will make an appointment for you for an ultrasound.

Ultrasound

The ultrasound technician can determine whether the pregnancy is intact or whether there has been a miscarriage. Usually an internal (vaginal) ultrasound is done. These are the possible results:

  • The ultrasound is good: From about 6 weeks it is possible to see the heartbeat of the embryo. Determining the heart action greatly reduces the risk of miscarriage, so that is a good thing. But despite a good ultrasound, a miscarriage cannot be ruled out completely. This means that the pregnancy is intact at the time of the ultrasound, but that does not mean that it will stay that way. If necessary, the ultrasound scan be repeated a few weeks later.
  • The ultrasound is not good: If the gestational cavity is larger than 20 mm, and/or the embryo is longer than 5 mm, heart action will always be visible in an intact pregnancy. If the ultrasound technician must establish that this is not the case, then there is inevitably a miscarriage.
  • The ultrasound is unclear: If someone is still in the beginning stages of pregnancy (before the 6th / 7th week), it may be that the heart has yet to start beating. The ultrasound technician will then not see any heart action, but it cannot be determined whether there is a miscarriage. The ultrasound will then be repeated within a few weeks.

If the ultrasound technician is unable to determine a pregnancy that is implanted in the uterus, there is the possibility of an ectopic pregnancy, called EUG (Extra Uterine Gravidity). An EUG is very rare, and diagnosing it is difficult. If an EUG is suspected, you will be referred to an obstetrician for further testing.

GRIEF

How people cope with a miscarriage is different for each individual. A miscarriage is usually the loss of a desired pregnancy. Sometimes women do not have a good feeling about the pregnancy beforehand, especially if there was blood loss. The ultrasound then confirms the premonition. For others, the bad news is like a bolt from the blue. Whatever the case, take time to process it and give your grief some space. Talk about it with people around you. Ten percent of all pregnancies end in a miscarriage, so there are more "fellow sufferers" in your own community than you might think. Many women are comfortable taking time off work during their miscarriage period. When a miscarriage occurs, many women feel guilty and wonder if something in their actions may have caused the miscarriage. These feelings are usually unjustified. No, you don't get a miscarriage from a paracetamol, stress, sex, lifting a shopping crate or that one glass of wine. In the vast majority of cases the cause of a miscarriage is a (spontaneous, non-hereditary) defect in the chromosomes of the embryo. The embryo would then never be able to grow into a healthy baby.

WHAT TO DO IN CASE OF a MISCARRIAGE?

After being diagnosed with a miscarriage, there are a few options:

  • Wait for a spontaneous course of action.
  • Induce the miscarriage with medication.
  • Have a curettage.

Below, each option is explained. The advantages and disadvantages listed may be perceived differently by each person.

WAIT FOR A SPONTANEOUS occurrence

After the ultrasound technician has established that there is a miscarriage, you can wait until the miscarriage occurs by itself. Within two weeks after the ultrasound 60% of the women have lost blood. It is medically justifiable to wait at least two to three weeks. The advantage of this is that the miscarriage can be experienced in one's own surroundings, and the grief can be experienced at home. It is the most natural situation and avoids the complications of medical interventions. A disadvantage is the emotional burden and that your pregnancy symptoms (such as nausea) may remain. There is also the chance that you will still need a curettage when the miscarriage has not (completely) taken place or when there is excessive blood loss.

INDUCE THE MISCARRIAGE WITH MEDICATION

The drug Misoprostol causes uterine contractions, after which in 90% of cases the miscarriage will occur. This medicine was originally intended for stomach and intestinal problems. It has also proved to be very suitable for obstetric purposes but is nevertheless not registered for this. When inducing the miscarriage with Misoprostol tablets the risk of complications is just as low as when waiting for a spontaneous course. The advantage is that the miscarriage can be experienced in one's own surroundings, and the grief can be experienced at home. A disadvantage is the emotional burden and that your pregnancy symptoms (such as nausea) may remain. There is also the chance that you may still need a curettage when the miscarriage has not (completely) taken place or when there is excessive blood loss.

HAVE A CURETTAGE

A curettage is a medical procedure performed by a gynaecologist. The pregnancy tissue is surgically removed from the uterus using a suction curettage or a scraper. This procedure is carried out under general anaesthesia and through day hospitalisation. If you want a curettage, the midwife will refer you to a gynaecologist. An appointment is usually possible within two to five days. You will first have an informative preliminary discussion with a doctor and then with the anaesthetist. Then they will agree with you on when the operation will be performed. The entire process, from referral by your midwife to curettage, can easily take one to one and a half weeks. The advantage is that curettage is 99% effective, and the process is relatively controllable. The disadvantages are in the form of medical complications, such as infection, damage (perforation) to the uterus, incomplete curettage, the risk of narcosis and the chance of adhesions (which are detrimental to your fertility).

MAKe YOUR CHOICE

After the ultrasound technician has established the miscarriage, your midwife will contact you by telephone and help you to make your choice. If necessary, make a list of your questions before this telephone call so that she can answer them for you. Take your time to think about your choice, there is no rush. If you prefer, you can also make an appointment for an interview at the practice.

IMPORTANT TO KNOW

There are a number of things you should take into account when you have a miscarriage:

  • You may take paracetamol for the stomach pain. Always take two tablets at a time. You can take a maximum of 3000 to 4000gr per 24 hours. So that is 3 or 4 times two tablets of 500 mg. Preferably do not use Ibuprofen.
  • To prevent infection, you must not have intercourse as long as the loss of blood lasts. Bathing is also not recommended. Do not use tampons, just sanitary towels.
  • If you have any special questions, please contact the midwife on duty at the emergency number.
  • Always call in case:
    • Too much blood loss, more than three pads an hour.
    • Complaints such as dizziness, fainting, stargazing in combination with extensive blood loss.
    • Fever over 38 degrees Celsius.
    • Too much abdominal pain despite paracetamol.
    • If you know that your blood group is D-rhesus negative, tell your midwife. Sometimes it is necessary for you to receive an injection with rhesus antibodies.

AFTER THE MISCARRIAGE

The loss of blood after a miscarriage or curettage can last for 2 to 3 weeks. Usually, you will have your period again some four to six weeks later. You may then become pregnant again. If the bleeding after the miscarriage lasts longer than three weeks, or you have not had your period after 8 weeks (and you are not pregnant again), it is possible that some miscarriage tissue has remained in the uterus. This can be assessed by ultrasound. Assessing the lost tissue or foetus during the miscarriage is not useful and can say little about the completeness of the miscarriage.

MULTIPLE MISCARRIAGES

Some women have more than one miscarriage. In this case, it is possible to do further research into possible underlying causes. Someone who has had two miscarriages can have her and her partner's chromosomes tested. The test will determine whether one of the partners is a carrier of a translocation chromosome. For women who have had more than two miscarriages, the gynaecologist may conduct further blood tests or an ultrasound examination of the uterus and ovaries.

ANOTHER PREGNANCY

If you have experienced one miscarriage, the chances of recurrence in a subsequent pregnancy are not or barely increased: around 10%. Viewed positively that is a 90% chance of a good pregnancy! After a miscarriage your fertility is the same as before. There is nothing medically wrong with becoming pregnant again immediately after a miscarriage and/or curettage. However, many women prefer waiting for at least one period before trying again. It provides confirmation that the miscarriage was complete and that "everything is working again". Consider using folic acid in your next pregnancy as well. Are you a smoker? Then try to stop smoking, as smoking women experience miscarriages more often than women who do not smoke. The use of alcohol can also have a negative effect on getting pregnant. Are you overweight? If so, you may want to discuss your lifestyle with a nutritionist. Obesity increases the risk of miscarriage.

Early ultrasound Blood loss during pregnancy Prenancy complaints