Miscarriage

You have just been informed that your pregnancy will not have a favourable outcome. Although we have already discussed miscarriage with you, this brochure will provide you with more detailed information which you can read at home at your own convenience.

What is a miscarriage?
The first months of pregnancy, particularly the first 12 weeks, form a vulnerable period. The embryo starts to develop and implants in the wall of the uterus. Unfortunately things don’t always go right during this early stage, and if that’s the case, the pregnancy will end in a miscarriage. A miscarriage is then the loss of a non-viable embryo in the beginning of the pregnancy. There are different reasons for why an embryo dies and this is actually quite common, with one in ten women experiencing a miscarriage.

Symptoms
The first thing you will notice is that the usual symptoms of pregnancy – breast tenderness, morning sickness and nausea – will stop unexpectedly. You may get the feeling that something is wrong, although this can happen in a normal pregnancy too. The first clear sign of a miscarriage is vaginal bleeding, although bleeding doesn’t always have to mean that the pregnancy will end in a miscarriage. An ultrasound scan can be performed to determine whether the pregnancy is viable. If not, you will usually develop abdominal pain and cramping. The amount of pain depends on how far along in the pregnancy you are at the time of the miscarriage. On the other hand, some women have no usual signs or symptoms of miscarriage, or only light spotting, brown discharge and mild cramping.

Causes
In 95% of cases the miscarriage is a result of a problem that occurred when the genetic material from the egg and sperm combined during fertilisation. Nature’s way of solving this ‘problem’ is to end the pregnancy. This is most often due to random chance and not to inherited chromosomal abnormalities, so there is no increased risk for a subsequent pregnancy. In the remaining 5% of cases, the miscarriage could be due to implantation problems, infection, uterine malformations, fibroids or an unknown cause.

Nothing you do can cause a miscarriage. So activities like engaging in physical exercise, having sex, falling, biking, riding a horse or motorcycle – none of these can be blamed for a miscarriage. Such activities could however precede the physical symptoms of miscarriage in a pregnancy that had already stopped growing.

What happens during a miscarriage?
How a miscarriage takes place varies greatly from one woman to the next but the following is generally true: It may start with a few days of light spotting, followed by heavier bleeding of bright red blood. (Be sure to take the necessary precautions to protect your clothing and bedding). The amount of bleeding can be heavier than a normal period, sometimes with blood clots which can be quite large. If you are start passing a lot of blood clots, be sure to call your midwife or the midwifery department at Bronovo Hospital on 070 – 312 41 41.

As the miscarriage continues, you will get more pain and cramping similar to bad period cramps. The pain comes in waves, lasting a few minutes and then subsiding, and is associated with the amount of vaginal bleeding. The pain could go away after only minutes or hours and then come back later.  The pain is caused by the uterus contracting to expel the contents. Once the womb is completely empty, meaning that all the pregnancy tissue has been removed, the pain and bleeding will stop and the cervix will close.

Bleeding usually continues for 5 to 10 days, tailing off at the end of this time and becoming darker in colour as in a normal period.

What happens after a miscarriage has been confirmed?
Passive approach: waiting for nature to take its course. Generally nature will take its course and the miscarriage will proceed without need for medicine or surgical intervention. In 50% of cases, all the pregnancy tissue will be expelled within two weeks of when the bleeding started, sometimes longer. Women who don’t require any treatment usually cope better with the emotional aspects of miscarriage.

If you choose to let nature take its course, it’s important to consider in advance how long you wish to wait and discuss this with your midwife or gynaecologist. From a medical point of view, waiting is not harmful and carries no risks for a new pregnancy, but the option of having a D&C (dilatation and curettage) always remains available.

D&C
Some women find it hard to sit back and wait for the baby to miscarry and for the bleeding to stop. This can be difficult - emotionally, physically (especially if there is prolonged bleeding) and from a practical perspective – and explains why some women choose to have a D&C. This is a surgical procedure in which a soft plastic tube is passed through the cervix into the uterus and the pregnancy material is removed by suction or by means of a small instrument called a curette. Once all the tissue has been removed, the bleeding stops within days. The operation is done under general anaesthesia and takes only 5 to 10 minutes. You can usually go home the same day.

What you can do
There is nothing you can do to prevent a miscarriage and no amount of bed rest or medicine can save the pregnancy once a miscarriage is imminent. During and after the miscarriage you will feel tired and empty. It’s very important to take a lot of rest – for both your physical and emotional well-being.

If you are having pain, you may use a painkiller such as paracetamol. You may take two 500mg tablets at a time, up to four times a day. Do not use aspirin, as it also acts as a blood thinner. Using a hot water bottle or taking a hot shower can also help relieve the pain. While you are miscarrying the mouth of the uterus is partially open; to reduce the risk of infection, do not use tampons during this time.

What we can do for you
For women who miscarry at home, not knowing for sure whether the expelled material is actually pregnancy tissue can be disturbing. If you wish, you can collect the expelled material and bring it to the hospital so we can check the nature of the contents, and if you wish, have it tested in the lab.

If you are having any physical complaints, please do not hesitate to call us at any time of day or night. We are also available to answer any questions you may have and will do what we can to support you emotionally during this difficult time.

Anti-D immunoglobulin
Many midwives and doctors advise giving women with a rhesus-negative blood group an injection of anti-D immunoglobulin (also referred to as anti-D) after a miscarriage. This prevents the formation of rhesus-antibodies, which could create problems in a subsequent pregnancy. Anti-D is not required, however, if ultrasound shows that the baby died at a very early stage or in cases of blighted ovum where no embryo ever developed, as there is no risk of antibodies forming. In general, anti-D is administered if the miscarriage occurred after the tenth week of pregnancy.

When should you seek medical care?

• If you are having heavy vaginal bleeding for an extended period of time (more than during a normal menstruation). Brief heavy bleeding can occur, especially when you pass the pregnancy material. If in one hour you need two pads to soak the blood, be sure to call us.
•  If you are dizzy, feel faint, or pass out, call us immediately.
• If you develop a fever while you are still miscarrying or after having had a D&C. A fever of 38˚C or greater could be a sign of infection.
• If heavy vaginal bleeding and abdominal pain persist after a miscarriage or D&C, the miscarriage may be incomplete, meaning that the womb is not yet empty. A curettage may be indicated.
• If you have questions or just need to talk, please do not hesitate to call us.

Physical recovery
It takes a few weeks to a month or more to recover physically from a miscarriage or D&C. Vaginal bleeding can continue for one or two weeks, being bright red initially and later turning brownish. During this time, it is better to abstain from having sexual relations, using tampons, taking baths and going swimming. Normal periods should resume in 4 to 6 weeks. Having had a miscarriage does not make it harder to get pregnant again.

Emotional recovery
Some women have more trouble coping with a miscarriage than others. Every woman reacts in her own way and this often depends on various factors, such as if she already has other children, if she had trouble getting pregnant and how the actual miscarriage proceeded. For many women, a miscarriage is an extremely traumatic experience that is followed by a grieving process. A miscarriage not only marks the end of the pregnancy, it also shatters future expectations and plans. Women experience sorrow, disappointment, guilt, anger, emptiness and disbelief. Everyone processes these emotions in their own way and at their own speed. It is always important to talk about these feelings and to give yourself whatever time you need to deal with them. Sharing your emotions with other women who have had a miscarriage can also be very helpful. So don’t be ashamed to express your grief and sense of loss and seek the support you need.

Getting pregnant again
After a period of time, different for everyone, women often start longing for a new pregnancy. It is advisable to wait until you have had at least one normal menstruation and that you and your partner are emotionally ready for a new pregnancy.

A subsequent pregnancy usually develops normally. However, you will probably be especially nervous during the first three months, fearing that things will go wrong again. If you need support, be sure to contact us early in the pregnancy. We could also arrange for you to have an ultrasound when you are at least 8 weeks pregnant.

Support organisations
In the Netherlands there is no national support group specifically for women who have had a miscarriage. There are, however, some local organisations that can answer your questions and refer you for help in the area where you live.

FIOM, Stichting Ambulante FIOM, see www.fiom.nl.
The FIOM organises meetings for women who have gone through a miscarriage. It has nine regional offices; addresses can be found on the website (only Dutch text available). You can call to find out if a meeting will be planned in your area.

Stichting Contactpunt voor miskramen, see www.miskramen.nl.
This website (only Dutch text available) is a meeting place for women who have had a miscarriage. It was started by two women who wanted to help provide much-needed emotional support to other women after a miscarriage. They do this by arranging meetings where women can share experiences and via a telephone helpline.

Useful websites
Both websites below provide helpful information:
www.womens-health.co.uk/miscarr.asp. This site strives to improve the availability of accurate health information for women. Focusing on reproductive issues, visitors to this site will find articles on pregnancy, infertility, miscarriage, PCOS, endometriosis, pregnancy complications and other issues important to a woman's well-being. Women’s Health was originally created by Dr. Danny Tucker in 1997. Dr. Tucker is a consultant Obstetrician & Gynaecologist in Taranaki, New Zealand.

www.nvog.nl. This is the website of the Dutch Society of Obstetrics and Gynaecologists (Nederlandse Vereniging voor Obstetrie en Gynaecologie), the professional society for obstetricians and gynaecologists.

We hope this brochure has helped answer some of your questions. If you require additional emotional support, please do not hesitate to contact us.

Edition: April 2009/96