Surviving a miscarriage

PHOTO: Getty Images

Many people are surprised to learn that one in every four to five pregnancies may result in miscarriage. Additionally, approximately 15 percent of women have more than one miscarriage. If you or a loved one are grieving from a recent miscarriage, it is important to know you are not alone and, more than anything, know it is not your fault.

Below are the answers to some of the most frequent questions we receive from women who have experienced a miscarriage loss.

Does one miscarriage mean I’m more likely to have another?

Not necessarily; after one miscarriage your risk of a future miscarriage is about 20 percent. However, after two consecutive miscarriages, the risk goes up to 30 percent and is as high as 40 percent after three consecutive losses. That being said, to have consecutive losses is less common. Only 2 percent of pregnant women will have two consecutive losses and less than 1 percent will have three consecutive losses.

What are the most common causes of miscarriage?

Most of the time the cause is unknown. The majority of the time (some experts say 50-60 percent of losses) are a result of a chromosome problem in the embryo.

What are some common miscarriage risk factors? 

• Advanced maternal age (particularly age 40+)
• Heavy smoking
• Alcohol or drug use during the first trimester
• Extremes of weight

What are the most common symptoms of miscarriage?  

Women most commonly present with vaginal bleeding or pelvic pain.  

Does my health and/or lifestyle impact the likelihood of miscarriage?

Women are encouraged to live a healthy lifestyle prior to pursuing pregnancy. Some things are beyond her control, like her age, but others like tobacco or alcohol use should be avoided. A healthy weight prior to pregnancy also helps decreases risks for complications during the pregnancy.

Certain infections, including listeria, parvovirus B19, and herpes simplex, among others, may increase the risk of miscarriage due to infection of the pregnancy.

Endocrine conditions, including thyroid dysfunction and diabetes, can increase the risk of miscarriage if not well managed.

Some women may have variations in their uterus increasing their risk of a miscarriage including a uterine septum, fibroids or scar tissue in the uterine cavity. 

Do fertility treatments play into this at all? Are women who undergo IVF/IUI more or less likely to miscarry? 

Women who require fertility treatments have a similar rate of miscarriage as women who conceive spontaneously. As in the general population, the age of the egg provider affects the risk of miscarriage.

Are there steps I can take to prevent miscarriages?

While miscarriage cannot be prevented, the best chance for a successful pregnancy is when it is planned and you’re in good health. It is always a good idea to schedule an appointment with your doctor to discuss preconception planning. A prenatal vitamin with at least 400 mcg of folic acid started before getting pregnant can be very important in early development of the embryo. 

At what stage of pregnancy do miscarriages normally occur?

Approximately 80 percent of miscarriages occur in the first trimester, or first 13 weeks of pregnancy. They become less common the further along the pregnancy. Miscarriages are significantly less common after 12 weeks. The incidence of miscarriage decreases to 1 or 2 percent after the first trimester and decreases with increasing gestational age. 

What about after 20 weeks?

After 20 weeks, the risk of pregnancy loss is less than 0.5 percent. While chromosomal abnormalities are the most common cause of first trimester loss, second trimester losses tend to result from fetal abnormalities, prior surgery on the cervix, uterine abnormalities (fibroids, abnormal uterine shapes – i.e. bicornuate uterus), poorly controlled maternal health conditions, some autoimmune diseases, thrombophilias (disorders associated with abnormal formation of blood clots), or trauma.

After a miscarriage, what medical steps do I need to take?

There are three options for any patient who miscarries: expectant management, medical management or surgical management. The decision as to which option is best should be based on physician recommendation, in addition to your preference. 

• Expectant management, or watchful waiting, is allowing time to see if the body passes the pregnancy on its own. The majority of cases are expelled within the first two weeks after diagnosis of an abnormal pregnancy. Some patients and physicians may prefer to wait until closer to four to six weeks to see if this happens on its own. While this may be the most “natural” process, it comes with the uncertainty of when and if the pregnancy will expel on its own. 

• Medical management includes using a medication like misoprostol or Cytotec, which is a prostaglandin analog that is commonly used to evacuate uterine contents after a miscarriage. This medication is highly effective, low cost and has few side effects. Additional benefits to medical management include avoiding surgery, allowing the patient to be at home for the process and control over the timing. You will need to be followed by your physician to ensure the process is complete.

• Surgical management or dilation and curettage, more commonly known as D&C, is the fastest and most effective way to treat a miscarriage. While it does carry some minor risks associated with surgery and anesthesia, it has the added benefits of allowing the patient to not feel or remember the process. Some facilities, including the Pavilion for Women, also may be able to offer genetic testing of the fetal tissue which may confirm a chromosomal cause for the miscarriage.

How long do I need to physically recover from a miscarriage?

An uncomplicated D&C is an outpatient procedure. You will typically go home after a couple hours of observation. Most of the time, patients are feeling relatively normal after the first 24 hours. I typically recommend allowing at least one day of recovery after the procedure for physical and emotional healing. Patients may gradually increase their physical activity as tolerated. Spotting can be expected for the first one to two weeks. You will have to avoid intercourse for two weeks after surgery. 

How long do I have to wait before trying again?

The recommendations vary. The World Health Organization calls for waiting six months, but there is newer evidence that an otherwise healthy woman does not have to wait beyond the completion of the miscarriage before trying again. Some advocate for waiting until one normal menstrual cycle after miscarriage in order to allow accurate pregnancy dating. Recent studies also showed improved pregnancy outcomes when pregnancy occurred within the first three to six months after pregnancy loss.

All of this should be discussed directly with your physician. 

What are the biggest miscarriage myths out there? 

• Miscarriage is rare: As discussed before, up to 25 percent of recognized pregnancies may end in miscarriage

• It’s the woman’s fault she miscarried: Chromosomal abnormalities are the most common cause of miscarriage

• Stress causes miscarriage

• Coffee causes miscarriage: Excessive caffeine intake (10 cups a day) may increase your risk, but the studies are not definitive

• Bleeding in the first trimester always means miscarriage: Up to 40 percent of patients have bleeding in the first trimester

• Exercise, work, or lifting can cause miscarriage: There are actually very few restrictions during pregnancy for most patients. Exercise is encouraged for physical and mental well-being during pregnancy and very few patients need to avoid it.

• Having one miscarriage means there is no chance of having a successful pregnancy

What advice do you have for women grieving a miscarriage?   

For women grieving, it is important to know you are not alone. Many people feel uncomfortable discussing miscarriage, but it is very common. More than anything, know that the miscarriage was not your fault.