It is a simple fact that some pregnancies end in miscarriage. If we consider all pregnancies, including very early ones, the rate of pregnancy loss is at least 25%, possibly even higher. Miscarriage risk declines through the first trimester of pregnancy. For pregnancies observed at week 6, 17% end in miscarriage; for those developing normally at week 10, this is only 7%.
These are numbers for a single pregnancy. When you consider that many women have multiple pregnancies and multiple children, the risk of ever having a miscarriage is much higher than 25%.
Despite this reality, miscarriage is still discussed less frequently than it might be. Before I had children, I recall learning that a close friend had experienced a miscarriage in the past and thinking, “Wow, I can’t believe I know someone who has miscarried.” But as more and more of my friends began getting pregnant, I realized it wasn’t unusual at all.
There are various reasons it can seem hidden. One reason is that because the risk of pregnancy loss is high, many people do not share the news of pregnancy until around 12 or 13 weeks. This is completely understandable from the standpoint of an individual, but it contributes to an air of secrecy. This can leave women feeling alone, isolated, and unsupported during what is already a traumatic time.
It also leaves us with many unanswered questions, and here I will cover a few of the core ones:
- How do you know if you had a miscarriage?
- What causes miscarriage?
- What to do after a miscarriage?
Before we begin, I want to note that the term “miscarriage” refers to both the loss of a pregnancy and the physical passing or removal of tissue.
What does a miscarriage look like?
Early pregnancy loss (including a chemical pregnancy) is typically discovered in one of two ways. Some women will have symptoms, like bleeding and cramping, that suggest a possible loss. Perhaps as many as 80% of miscarriages start this way, but it should be said that a very large share of women have some bleeding and cramping in early pregnancy that is not associated with miscarriage. (If you are experiencing bleeding or cramping in the first trimester of pregnancy, you should call your doctor.)
In the remaining cases, a pregnancy loss is detected during a routine ultrasound. This is sometimes referred to as a “missed miscarriage.”
In either case, an ultrasound (usually performed transvaginally, meaning the probe is in the vagina) is necessary to be sure about a miscarriage. And even with an ultrasound, it is not always completely clear whether a miscarriage has occurred. There are some ultrasound findings that are considered “diagnostic,” meaning they definitively indicate that a miscarriage has happened. These include the absence of a heartbeat earlier in gestation or a loss of a heartbeat later in gestation, if one was detected earlier.
There are other findings that can appear on an ultrasound that could indicate miscarriage, like lack of a heartbeat in a smaller fetus, a very slow heartbeat, or no evidence of an embryo despite seeing a yolk sac. But these findings may also mean that the pregnancy is less far along than originally thought. In these cases, the standard procedure — although it can feel like torture — is to wait a week and then repeat the ultrasound. Sometimes blood work is done as well (for the hormone hCG, with or without progesterone level). At this point, miscarriage is often confirmed, although in some cases the news is happier.
Miscarriage detection is most difficult and most uncertain very early in pregnancy. By eight or nine weeks of pregnancy, a normally developing fetus has a strong heartbeat and recognizable development. As a result, it is easier to see if the pregnancy is not progressing normally. Early on in pregnancy — at six weeks or even early into the seventh — it can be harder to tell how a fetus is developing because physicians may be a day or two off in dating the pregnancy.
Miscarriage after the first trimester is much less common, but bleeding or cramping would be signs of it as well, and detection through an ultrasound is similar.
What causes miscarriage?
In the first trimester, a very large share of miscarriages (perhaps as high as 90%) are a result of a chromosomal abnormality. This could be an extra chromosome or a missing chromosome, or a deletion within a chromosome that is crucial for development. Usually you will not know the specific cause.
The most significant risk for miscarriage is older maternal age. As women age, and their eggs age, chromosomal problems become more likely. It’s a little complicated to use the language that age “causes” miscarriage, but it is a very important risk factor.
Does stress cause miscarriage?
Extreme forms of physical stress may play a role in miscarriage. In historical contexts, pregnancy loss seems more common during periods of famine. There is also more recent evidence that significant stressful life events correlate with miscarriage risk. This latter evidence is difficult to interpret, since these stressful life events tend to cluster with other characteristics that may, in fact, be the drivers of pregnancy loss.
These studies tend to focus on very stressful life events, such as the loss of a partner. More typical life stresses are unlikely to play a role in miscarriage.
Does sex cause miscarriage?
No, sex and orgasm do not cause miscarriage. There is no evidence to suggest they would and no mechanical reason why this would play a role.
What causes multiple miscarriages?
Most miscarriages happen at random, and having had one miscarriage only slightly elevates the risk of having a second.
However, after multiple losses, doctors are more likely to consider whether there is something else going on. In most cases, we do not understand the reason for even multiple miscarriages. It may be age or simply random chance. There are a couple of known causes of recurrent miscarriage, including issues with uterine shape, an autoimmune disorder called antiphospholipid syndrome, and a genetic issue called balanced translocation. These are all things a doctor might screen for if you have had more than one, and especially more than two, first-trimester losses.
What are the treatment options?
In many cases, a miscarriage completes on its own, without a need for medical intervention. However, in cases where the pregnancy loss is detected by ultrasound, there are effectively three options for what to do next. You can wait to miscarry on your own (sometimes called “expectant management”), you can have a medical miscarriage (using medications to induce a miscarriage), or you can have a dilation and curettage (commonly called a D&C), where the tissue is surgically removed.
The good news is that all three of these options are safe and carry a low risk of further complications, which are similar for all of them. In the end, the choice comes down to preference. A central tradeoff is that while both the expectant management option and the medical miscarriage option may be more private, they are less certain to work than the surgical option. This means that in some cases a D&C may still be necessary.
If you choose to wait and let a miscarriage occur on its own, this will happen within two weeks in about 80% of cases. A complete miscarriage is more likely (about 90%) if bleeding has already started. Miscarriage in this case will be accompanied by bleeding and cramping; the bleeding is usually heavier than a normal period, although women are typically warned to watch for very severe bleeding. The typical guideline is if you use two super-maxi pads per hour for two or more hours, call your doctor. The severity of cramping can also vary across women — for some, it is more like a heavy period, but for many others it can be extremely intense, close to labor contractions.
A medical miscarriage is done using a medication called misoprostol, which is administered vaginally (as a suppository) or orally. Evidence suggests this is much more likely to lead to a complete miscarriage if it is combined with a second drug, mifepristone, which is taken orally before the misoprostol. With the two medications in combination, about 83% of miscarriages were completed; with the misoprostol alone, that same study found that 67% were completed.
As with a non-medically-induced miscarriage, this will be accompanied by bleeding and cramping. In either case, if your doctor determines that the miscarriage is not completed, it will be necessary to either try an additional misoprostol dose or perform a surgical D&C to complete the procedure.
The third option is to have a D&C immediately, which can sometimes be done in a doctor’s office and otherwise will occur in a hospital or ambulatory surgical center. The procedure is performed with pain relief, most commonly a form of sedation or general anesthesia for which you would be asleep. The use of pain relief means it may be uncomfortable but should not be painful. The procedure involves dilating the cervix and either suctioning or removing tissue. The D&C doesn’t take long — usually only 10 to 15 minutes for the procedure — and it’s typically done as an outpatient procedure, meaning you do not have to stay overnight in the hospital.
After a D&C, some bleeding and cramping is common, although typically neither will be as severe as with the other two miscarriage options.
Which of these methods is the right choice is a deeply personal decision. For some women, the option to wait may feel more natural. Other women may not want to wait but also do not want to have even minor surgery. In those cases, the medical option may be best. This option is also less expensive, if insurance coverage is a concern. Some women may decide they want the certainty that things are over, so they can start to recover. There is no correct decision here, but making the right one depends on having all the information.
What happens after a miscarriage?
Recovery for everyone looks a little different, and there is no right time when you will feel “back to normal” again. Be gentle with yourself during the recovery period and beyond.
Bleeding
After a pregnancy loss, it is very common to experience bleeding and some cramping. Depending on the timing of the loss, this may be like a period or a bit heavier. If you pass larger clots or are worried about the amount of bleeding, you should call a doctor. Bleeding should subside in one to two weeks.
Breastfeeding
If you are breastfeeding a child, it is completely fine to continue to do so after a miscarriage.
Trying again
After a miscarriage, many women and their partners wonder when it is safe to try to get pregnant again. There is virtually no evidence-based guidance on this. For a week or two after a miscarriage, there is a “common sense” recommendation to abstain from sex to avoid infection, but there isn’t any hard evidence on that either. Generally, when you feel ready to try again, there is no reason not to do so.
If you are undergoing fertility treatments, you will work with your doctor to decide when the right time is to resume those.
Closing thoughts
Miscarriage can be lonely, it can be devastating, and it can be confusing. Reassuringly, most women who miscarry go on to have healthy pregnancies. This can be hard to see when miscarriage is kept so secret, but if it happens to you, you are not alone. Not at all.
The bottom line
- A miscarriage is typically discovered in one of two ways: recognizing symptoms like bleeding and cramping that suggest a possible loss, or what is sometimes referred to as a “missed miscarriage” when it is detected during a routine ultrasound.
- In the first trimester, a very large share of miscarriages are a result of a chromosomal abnormality. The most significant risk for miscarriage is older maternal age. As women age, and their eggs age, chromosomal problems become more likely.
- If a miscarriage does occur, there are effectively three options: wait to miscarry on your own, use medications to induce a miscarriage, or have a D&C. Which of these methods is the right choice is a deeply personal decision.
- There is no evidence-based guidance on when the right time to try to get pregnant again is. Generally, when you feel ready, there is no reason not to do so. If you are undergoing fertility treatments, you will work with your doctor to decide when the right time is to resume those.
We recognize that readers of ParentData identify in different ways — read more about our approach to gender-inclusive language here.
About our sponsor
Ro is a healthcare platform that’s helped millions access tools to achieve their health goals in fertility, weight loss, sexual health, and more. Data-driven and clinically-backed, Ro offers telehealth, labs, and pharmacy services to enable seamless, convenient care.
Log in