What Are My Treatment Options After Miscarriage?

If you go to your first appointment and the ultrasound shows signs of a pregnancy loss, your doctor may order tests such as a hormone blood test or a pelvic ultrasound. Waiting for these results can leave you in an emotional limbo, sometimes for weeks, not knowing if you are still pregnant. During this period, you may have a hard time balancing hope with anxiety and logic with uncertainty.

There may also be a waiting period between knowing you’ve miscarried and the actual passage of the uterine contents. That means you may spend a week or more knowing that you no longer have a viable pregnancy. Your body may still look and even feel pregnant while you wait to get treatment. These “waiting periods'' aren't talked about very often, but they can be an intensely emotional time.

Expectant management means waiting for the pregnancy loss to happen by itself naturally, without medical treatment, or a visit to the hospital. You can expect bleeding that is heavier than a normal period, and you will pass what appear to be large clots mixed with white and tan pieces of tissue and sometimes clear sac-like areas. Expectant management is typically limited to those who lose their pregnancy in the first trimester. After 12 weeks, the uterine contents that need to pass are larger, and the placental tissue will have formed meaning that the cervix has to dilate more to allow them to exit. This can mean more pain and discomfort and potentially more bleeding that shouldn’t be managed at home.

Approximately 80% of people achieve complete passage of intrauterine contents within eight weeks. If expulsion doesn't happen on its own, medical or surgical treatment will be needed.

Even if the pregnancy is no longer viable, oftentimes you will not pass the uterine contents until 12 weeks. At this point, the placenta is supposed to take over hormone production from the ovaries, so when your body registers that the placenta is not producing pregnancy hormones, it registers the pregnancy loss, which leads to the actual passage of the pregnancy.

Expectant management is generally non-medicated, with the exception of over-the-counter medicines for mild to moderate symptoms like cramping. It’s possible you may initially proceed with expectant management, but only part of the uterine contents pass on their own. In this circumstance, your doctor may consider medical management (see below) or a surgical procedure called a D&C (see below), or they may use a small straw like device called a “pipelle” to remove the remaining tissue in the doctor’s office.

Expectant management happens at home. You may want a friend, partner, or family member to be there for emotional support, but it’s not necessary to have someone there to look after you from a medical perspective.

Some doctors will want you to follow up with a pelvic ultrasound to ensure the uterine lining looks empty as well as an HCG test to see a negative pregnancy test a few weeks after you’ve passed all of the tissue. As previously mentioned, it’s important to be prepared for the fact that passes will look like large clots mixed with white and tan pieces of tissue and sometimes clear sac-like areas. Your provider may ask you what types of tissues have passed, so it’s a good idea to keep track of what has passed or have your partner look at it if it’s upsetting to you.

After a pregnancy loss has been confirmed, you may prefer to speed up the process by taking a medication called misoprostol that can help your body to expel the pregnancy. This approach gives you more control over the timing of the tissue passage and is very effective in helping you avoid a surgical intervention. Similar to expectant management, medical management is typically limited to those who lose their pregnancy in the first trimester.

For about 70% of people, this treatment works within 24 hours. Pregnancy loss-related vaginal bleeding and cramps typically start within one to four hours of taking misoprostol, and you may have cramps for three to five hours. For some, the cramping is intense and swift, with a significant amount of tissue leaving the uterus all at once. For others, it can be less intense but take longer. Misoprostol does not lead to the full passage of the uterine contents for every person; in this case, your doctor may recommend a D&C.

The most common medication used in the medical management of miscarriage is misoprostol, which can be taken my mouth or inserted directly into the vagina, causing uterine contractions, dilating the cervix, and prompting the shedding of the uterine lining. Recent evidence from a June 2018 study suggests this medicine is more effective when combined with a second drug, called mifepristone, which works by blocking the hormone progesterone. With the two drugs in combination, about 83% of pregnancy losses were completed without surgical intervention compared to 67% with misoprostol alone. Depending on your local regulations, your doctor may or may not be able to administer mifepristone.

You may experience symptoms like cramping and pain, diarrhea, nausea, and vomiting, so you may want a support person looking after you. The experience can be an emotional one, as the body undergoes a lot of change very quickly. It’s important to be prepared for the fact that passes will look like large clots mixed with white and tan pieces of tissue and sometimes clear sac-like areas. Your provider may ask you what types of tissues have passed, so it’s a good idea to keep track of what has passed or have your partner look at it if it’s upsetting to you.

D&C procedures offer the quickest resolution of a pregnancy loss. Your healthcare provider will dilate your cervix and remove the uterine contents by either scraping the uterine wall with a small instrument called a curette or using a suction device. You can typically choose to be awake or not and have the option of general anesthesia (where you are asleep) or regional or local anesthesia (where you are awake and numbed to varying degrees). You can elect to have this procedure right away, or it may be recommended if expectant and medical management don’t lead to the full passage of the uterine contents. A D&C is also recommended if you experience pregnancy loss after the first trimester (about 10 to 12 weeks) when the pregnancy tissue is too big to pass easily on its own or with medications.

A D&C is done at your doctor’s office, an outpatient clinic, or at the hospital. The procedure itself only takes 10 to 15 minutes, but you may be asked to stay longer for observation.

Expect that you’ll feel tired and groggy the day of the procedure, especially if you’ve had general anesthesia. You’ll likely need someone to accompany you for the procedure and take you home, but it’s a good idea to verify this with your medical provider. You may be able to return to work and resume regular activity as soon as the following day. If you feel you need more time, many people opt to take a day or two of downtime. Your provider will likely tell you to refrain from exercise, sexual activity, tampons, and bathtubs or swimming for up to one to two weeks after the procedure to prevent infection.

A high temperature—especially when accompanied by additional symptoms such as a foul-smelling vaginal discharge, chills, or abdominal pain—may indicate a bacterial infection. An infection can result when you have a miscarriage, but your body does not fully expelling all uterine contents. It’s important to contact your doctor promptly if you have a fever, as bacterial infections can lead to serious complications.

While bleeding is absolutely normal, severe or abnormal bleeding is not and could be an indication of postpartum hemorrhage, a rare but potentially life-threatening condition where there’s excessive bleeding. Signs of postpartum hemorrhage include bleeding through one to two maxi pads per hour, pale skin, shakiness, and chills. If you or your partner notices these symptoms, you should seek medical attention immediately.

Passing one to two small clots around 2 cm in diameter is not unusual, but recurrent passage of large clots of blood should be discussed with your doctor.

Pain that doesn't resolve with 600 to 800 mg of ibuprofen or 500 to 1000 mg of acetaminophen.

Contact your doctor if you experience symptoms of a UTI such as an intense urge to urinate, a burning sensation when urinating, passing small amounts of urine frequently, pelvic pain, or blood in the urine. You may be at increased risk for a UTI after a D&C because a urinary catheter is used during the procedure.

If your blood type is A-, B-, O- or AB-, then you will likely need a shot of Rh immunoglobulin, which may have been discussed in initial conversations with your doctor when you became pregnant. This shot will neutralize any antibodies that may form if the fetal blood type was A+, B+, O+ or AB+ to prevent complications in future pregnancies. If there is clear documentation that the second parent also has a negative blood type, then your doctor may feel comfortable forgoing this shot.

If you have a D&C, or if you pass the uterine contents in one piece and are able to preserve them in a container, your doctor may be able to send it off for chromosome analysis, which can confirm the reason for the pregnancy loss. There are pros and cons to this. It may provide emotional comfort to know that the reason was a chromosomal abnormality, but it may also cause unnecessary worry if the results come back normal. This is not typically encouraged for those who have experienced only one to two pregnancy losses, and insurance often does not cover the cost, which can be as high as $500 to $1,500 dollars.