IN AN EMERGENCY

 

DIAL 111

When and where to seek medical advice

WHEN TO SEEK ADVICE

If you have any concerns  or questions please seek medical advice. The information on this page should not replace professional medical advice.

Seek medical advice if:

  • you are pregnant and you have any pain or bleeding

  • you do not get your period within 6-8 weeks after experiencing a miscarriage.

 

Seek immediate medical attention (dial 111 or get a ride to hospital) if:

  • you are bleeding heavily enough to soak more than one sanitary pad per hour, for two hours

    • This is a hard one to judge because heavy bleeding can be a natural part of a miscarriage but it can also be a sign that you require immediate medical attention. 

  • you feel light headed or faint

  • you are feeling sick or vomiting

  • you experience fever and chills

  • you experience pain that is not manageable

  • or if there is an odour to any discharge.

(1) (2)

WHERE TO SEEK ADVICE

Healthline

Healthline is open 24 hours a day, 7 days a week.

If you have any concerns at all, at any time, please don't hesitate to call them on 0800 611 116. 

Primary Health Organisation (PHO)

Your PHO is the medical centre that you are signed up with (your local GP). You are covered for free maternity services up until two weeks after a miscarriage occurring, after two weeks you will have to pay for the appointment (3). When you are booking an appointment it may be beneficial to ask for a GP who specialises in Obstetrics and Gynaecology. You may also want to write down any questions that you have before you go in.

Midwife (LMC)

If you have registered with a midwife you can call or text them for advice and any necessary referrals. Miscarriage is a secondary care issue (not treated by midwives) so it may be that you only talk to your midwife over the phone to describe symptoms (assessment), and to decide on your next step (referral). See our what to expect from your midwife flowchart for more info. 

Specialist

If this is your third consecutive miscarriage your LMC or PHO can refer you to a specialist. You can also contact a fertility specialist or gyneacologist without a referral. 

 

Symptoms of miscarriage

- if you are pregnant and experience any of these symptoms please seek professional advice

The presence of these symptoms may or may not mean that you are having a miscarriage as less than 50% of threatened miscarriages proceed to an actual miscarriage (4). Miscarriage can also occur with no noticeable symptoms and may only be discovered at an ultrasound scan (see Missed Miscarriage) You should speak to your doctor, midwife, or specialist, if you have any bleeding from your vagina, or if you think you may be having – or have had – a miscarriage. All bleeding during pregnancy should be checked.

SYMPTOMS: (4)

  • Vaginal Bleeding - could be light spotting or heavy bleeding

  • Fluid, blood clots or tissue passing from the vagina

  • Abdominal pain or cramping

    • the cramping could be more like labour contractions, depending on your gestation and whether or not this is your first pregnancy

  • Lower back pain

  • Pregnancy-related symptoms cease e.g. morning sickness goes away

  • Fever or chills

  • Weight loss (5)

See our physiology of miscarriage section for an understanding of what is happening in your body and where these symptoms are coming from. 

Types of miscarriage

- medical professionals may diagnose your miscarriage as one of these types

 Missed miscarriage:  

A missed miscarriage gets its name because this type of miscarriage has already taken place before anyone realises. Missed miscarriages are often revealed at an ultrasound scan, where the scan shows that the pregnancy tissue remains in the womb, but that the pregnancy will not progress beyond this point. If there is a possibility that the gestation of the embryo is too early for a heartbeat HCG blood tests or a follow up scan may be needed to confirm whether or not it is a miscarriage. 

Symptoms: There may be no symptoms. The mother may notice that early pregnancy symptoms, such as nausea and breast soreness, have lessened or disappeared. Sometimes there may be a brownish discharge or a little bleeding. 

 

Threatened miscarriage: 

Is when some symptoms of a miscarriage are present but a miscarriage has not yet occurred (and may not).

Symptoms: Any vaginal bleeding during early pregnancy is an indication that a miscarriage could occur. There may also be mild abdominal cramps or lower back pain. Please note that, although vaginal bleeding can be a precursor to miscarriage, 50% of women who experience it will go on to carry their babies to full term. 

  • If you experience any vaginal bleeding during pregnancy always contact your health professional.

Inevitable miscarriage:

Is the presence of miscarriage symptoms which  indicate that a miscarriage will undoubtably occur. 

Symptoms: The presence of bleeding, cramping, and cervical dilation (opening) indicates that a miscarriage is inevitable. Women often experience either dull or sharp pain in the abdomen and lower back. They may also pass tissue with clot-like material from the vagina.

Incomplete miscarriage:

Is when a miscarriage has partially occurred but some tissue still remains in the womb. 

Symptoms: Pregnancy tissue remaining in womb, heavy vaginal bleeding, dilation of the cervix and severe cramping.  

 

Complete miscarriage:

Is when no pregnancy tissue remains and the pregnancy has ended. 

Symptoms: Vaginal bleeding may continue for a while, similar to a period. The cervix is closed and the womb is empty.

 

Septic miscarriage: 

A septic miscarriage involves an infection within the womb.

Symptoms: fever or chills may indicate a septic miscarriage. 

(2) (4) (6) (7)

Please note: this video (8) includes medical descriptions of miscarriage, including use of the term ‘products of conception’ to describe the tissues of the placenta, baby and amniotic sac.

 
 

What is happening in your body during a miscarriage

When a miscarriage occurs there are some things that your body is doing to let go of the pregnancy. As with any birth, every miscarriage is unique so please take these descriptions as a general guide only for what a complete miscarriage with no complications may be like. 

 

If you have opted for expectant management of your miscarriage or if you are naturally experiencing a miscarriage, the pregnancy hormones in your body will be naturally decreasing over time. With this decrease in hormones, the early placenta tissue and lining of the womb are no longer supported to continue to grow and begin to come away. This is a similar process to a period (when the normal menstrual cycle hormones - oestrogen and progesterone - decrease), however, because the lining of the womb has become thickened to support the pregnancy, the bleeding is generally more, and the pain is more severe. When the pregnancy tissue exits the uterus canal (os) the pain and bleeding is generally at its worst and settles soon afterwards (this is when your cervix is dilating). 

 

If you have opted for medical management of your miscarriage the medication will soften your cervix and will stimulate your womb to contract and empty itself. Sometimes bleeding may start straight away, but there may be a delay of 2 or 3 days, or even longer. Most women start to bleed within the first 24 hours. Bleeding and pain may last for up to 1-2 days before the miscarriage is completed. You may then experience period-like bleeding for the next two weeks.

 

Bleeding:

Please seek professional advice if you are concerned about the amount of blood you are losing, if you become faint or lightheaded, if you are feeling sick or vomiting, or if there is an unpleasant smell. Health professionals may want to know how much you are bleeding so it can be a good idea to keep track of how often you need to change sanitary pads. If you are bleeding heavily enough to soak through more than one sanitary pad an hour, for two hours this could be an indication that you may need medical attention. 

 

Once the miscarriage starts you can expect some bleeding, and for a short time (up to four hours) it may be quite heavy with some tissue and clots passed. The bleeding will settle to ‘period-like’ bleeding within a few hours of passing the baby and pregnancy tissue. After that the bleeding will decrease to light bleeding which should settle down over about two weeks. This bleeding is the result of the opening in the lining of your womb left by the detachment of the placenta. The size of this opening and the time that it takes to stop bleeding depends on your gestation and the size of your placenta. For miscarriage, bleeding could take up to two weeks while, as a comparison, for a full term birth it could take up to six weeks. Your next period may be a little heavier than normal. Please see your GP if you do not get your period within the next 6-8 weeks. 

 

Lower Abdominal Pain

The level of physical discomfort you feel will depend on the gestation of your pregnancy and whether you have given birth before. If you experience a miscarriage with your first pregnancy you may experience more intense labour-like symptoms as your cervix thins and dilates for the first time ever. Your womb will contract and your cervix will open (dilate) enough to let the baby and all the other pregnancy tissues out. Take pain relief as recommended (if you have been to see a doctor they may have prescribed you some stronger medication e.g. codeine phosphate). A hot water bottle or heated wheat bag may help. Strong pain should only last for a few hours. Please seek help if the pain is not manageable. You may have some period-like cramps for 2-3 days after the miscarriage as your womb goes back to its pre-pregnant size. 

 

What will you see? 

What you see when you miscarry depends on how far your pregnancy has progressed. A woman having a miscarriage at 6 weeks gestation will pass a very small embryo of approximately 1.2 cm in length compared to a 12 week gestation fetus that is 9 cm in length. The pregnancy may be passed in the sac, or the sac could have burst and you may pass a long stringy piece of tissue. If the pregnancy is more advanced and the sac ruptures you may experience a gush of fluid from your vagina (your waters breaking). You may be able to identify the embryo/fetus as it passes or it may pass in a blood clot and you might not see anything. If the pregnancy ceased some weeks before the miscarriage there may be no recognisable embryo or fetus. You can let this pregnancy pass into the toilet or you can collect it and bury it. No testing will be carried out on the pregnancy tissue unless you have been informed otherwise. 

 

Milk Production/Lactation 

Some women produce milk following a miscarriage. It may help to wear a firm fitting bra and to avoid touching your breasts during this time. You can take Paracetamol if you have any breast tenderness or discomfort. This discomfort usually disappears within 24 to 48 hours.

Management options

The management options available to you will depend on your medical history, the gestation of your pregnancy, and the type of miscarriage you are experiencing. Whichever management option you choose there will be a 1 in 20 risk of infection. Remember, you are in control, this is your choice and it is ok to change your mind at any time. Your lead maternity carer (LMC) will discuss your options with you. If you have not registered your pregnancy with an LMC get in touch with a doctor at your local medical centre. You will be covered under free maternity healthcare up until two weeks after a miscarriage. 

Options:

  • Expectant management is where you wait for the baby and any remaining pregnancy tissue to pass naturally from your body.

  • Medical management involves taking medications to help you pass the baby and other pregnancy tissue from your body.

  • Surgical management involves having the baby and/or any remaining pregnancy tissue surgically removed from your body.

If there is no baby or pregnancy tissue left in your body (a complete miscarriage) no medical treatment will be required. As miscarriage is a natural occurrence there is no medical concern unless you have experienced three miscarriages in a row or are showing signs that you need medical advice (see here). You may still want to book in to see your local doctor for your own peace of mind. If you do go to see your GP, you may want to write down any questions that you have before you go in as sometimes doctors can wonder why you are there if there is no sign of infection and you have no questions ready. Question ideas: How do I know that all of the pregnancy tissue is gone? Are there any local support groups that you can put me in touch with? Are there any counselling services available for me?

Expectant Management - Also known as ‘conservative management’ or ‘waiting and seeing’.

Expectant management is waiting for nature to take its course. Up to two-thirds of women will have a complete miscarriage by the end of four weeks of expectant management. 80% of women who have an incomplete miscarriage will naturally complete the miscarriage with no need for medical assistance. Occasionally, there can be an increased chance of infection with a delay between the pregnancy becoming unviable and a complete miscarriage occurring. For what to expect during expectant miscarriage please see our ‘physiology of miscarriage’ section. You may also want to check out our list of ‘things to help you through a miscarriage at home’.  

 

Advantages:

  • Natural.

  • You can be in the privacy or your own home.

  • No anaesthesia involved.

  • No hospital visits or operations required.

  • You are in control of what you do with the baby/tissue that comes out.

  • You can go through the physical process which may help with your emotional process.

 

Disadvantages:

  • Unpredictable - it is not possible to predict when it will happen and how long it will take. 

  • There is a small chance that some tissue will remain in the womb and you may need to have medical or surgical management. 

  • You may find it difficult knowing the fate of your pregnancy and still having the baby inside you.

  • You may just want to be pregnant again without any delay.

 

There are some situations when it is not advisable to use expectant management:

  • Very heavy bleeding with low blood pressure or low blood count

  • Signs of infection.

  • Molar Pregnancy

  • If you have an IUD inserted

  • Recurrent miscarriages

  • History of severe illness

  • Pregnancy greater than 12 weeks

Medical Management - This is the use of medication in the form of pills or pessaries (vaginal tablets) to speed up and complete the natural process of miscarriage. The medication will most likely be misoprostol. Misoprostol has been proven to be an effective treatment for 80 - 85% of women who are under 13 weeks gestation. Misoprostol is widely used and demonstrates advantages over available alternatives, however, you may be required to sign a waiver for the use of misoprostol as it is not registered by its manufacturer for use in pregnancy. If you would like to know more about the use of misoprostol check out this article from American Family Physician.

 

What to expect:

The actual procedure may differ between hospitals. Misoprostol can be administered either under the tongue or via the vagina. You may have to wait 30 minutes before going home to ensure you don’t have an allergic reaction to the medication. You will then go home and complete the miscarriage there. You may be given another dose of misoprostol to have the next day. Check out our checklist of things to help you through a miscarriage at home and our physiology of miscarriage section for more information about what may be happening in your body.

 

Advantages:

  • No surgery or anesthetic 

  • No need to stay in hospital

  • Can be started on same day as you go in for a hospital appointment

  • It speeds up the natural process

  • You are in control of what you do with the baby/tissue that comes out 

  • You can go through the physical process which may help with your emotional process.

 

Disadvantages:

  • Need to go to hospital for an appointment

  • For some women bleeding may not occur within 24 hours

  • A small number of women may still need surgical management

  • A small number of women may experience mild side effects

  • The medication may not be suitable for all women. 

Surgical Management - This option is a minor surgical procedure that involves using a small instrument to open your cervix and to remove the baby and any remaining pregnancy tissue. This may be performed under a general anaesthetic but for most women it can be carried out under a local anaesthetic (you will be awake and will have medications to make you comfortable). Your health professional will talk to you about which anaesthetic option is best for you and your gestation. This procedure may be called MVAC (Manual Vacuum Aspiration Curettage), EVAC (Evacuation of the Uterus), or D&C (Dilation and Curettage), depending on the instruments used and the regional DHB that you are in. The procedure usually takes between 10 and 20 minutes to perform. You may want to check out our what to expect with surgical management section. 

 

Advantages:

  • The miscarriage will be completed on the day of the surgery

  • Less bleeding

 

Disadvantages:

  • This will require two visits to a clinic, an initial visit and then an appointment for the surgical procedure.

  • Surgical management of miscarriage is a relatively safe procedure but there is still a small risk of complications such as anaesthetic-related problems, infection, or damage to the cervix, womb or other internal organs. Occasionally a small amount of pregnancy tissue can remain and a second procedure could be required. 

  • There may be no identifiable pregnancy tissue for you to take home.

(2) (9) (10)

 
 
 
 

What is happening in your body during a miscarriage

- the physiology of miscarriage

When a miscarriage occurs there are some things that your body is doing to let go of the pregnancy. As with any birth, every miscarriage is unique so please take these descriptions as a general guide only. 

 

If you have opted for expectant management of your miscarriage or if you are naturally experiencing a miscarriage, the pregnancy hormones in your body will be naturally decreasing over time. With this decrease in hormones, the early placenta tissue and lining of the womb are no longer supported to continue to grow and begin to come away. This is a similar process to a period (when the normal menstrual cycle hormones - oestrogen and progesterone - decrease), however, because the lining of the womb has become thickened to support the pregnancy, the bleeding is generally more, and the pain is more severe. When the pregnancy tissue exits the uterus canal (os) the pain and bleeding is generally at its worst and settles soon afterwards (this is when your cervix is dilating). (11)

 

If you have opted for medical management of your miscarriage the medication will soften your cervix and will stimulate your womb to contract and empty itself. Sometimes pain and bleeding may start straight away, but there may be a delay of 2 or 3 days, or even longer. Most women start to bleed within the first 24 hours. Bleeding and pain may last for up to 1-2 days before the miscarriage is completed. You may then experience period-like bleeding for the next two weeks.

 

Bleeding

Please seek professional advice if you are concerned about the amount of blood you are losing, if you become faint or lightheaded, if you are feeling sick or vomiting, or if there is an unpleasant smell. Health professionals may want to know how much you are bleeding so it can be a good idea to keep track of how often you need to change sanitary pads. If you are bleeding heavily enough to soak through more than one maternity or heavy-flow sanitary pad per hour, for two hours, this is an indication that you may need medical attention. 

 

Once the miscarriage starts you can expect some bleeding, and for a short time (up to four hours) it may be quite heavy with some tissue and clots passed. The bleeding will settle to ‘period-like’ bleeding within a few hours of passing the baby and pregnancy tissue. After that the bleeding will decrease to light bleeding which should settle down over about two weeks. This bleeding is the result of the opening in the lining of your womb left by the detachment of the placenta. The size of this opening and the time that it takes to stop bleeding depends on your gestation and the size of your placenta. For miscarriage, bleeding could take up to two weeks while, as a comparison, for a full term birth it could take up to six weeks. Your next period may be a little heavier than normal. Please see your GP if you do not get your period within the next 6-8 weeks. 

 

Lower Abdominal Pain

The level of physical discomfort you feel will depend on the gestation of your pregnancy and whether you have given birth before. If you experience a miscarriage with your first pregnancy you may experience more intense labour-like symptoms as your cervix thins and dilates for the first time ever. Your womb will contract and your cervix will open (dilate) enough to let the baby and all the other pregnancy tissues out. Take pain relief as recommended (if you have been to see a doctor they may have prescribed you some stronger medication you can also check out our checklist for some other pain relief options). A hot water bottle or heated wheat bag may help. Strong pain should only last for a few hours. Please seek help if the pain is not manageable. You may have some period-like cramps for 2-3 days after the miscarriage as your womb goes back to its pre-pregnant size. 

 

What will you see? 

What you see when you miscarry depends on how far your pregnancy has progressed. A woman having a miscarriage at six weeks gestation may pass a very small baby of approximately 1.2 cm in length compared to a baby of 12 weeks gestation that may be 9 cm in length. The baby and other tissues may be passed in the sac, or the sac could have burst and you may pass a long stringy piece of tissue. If the pregnancy is more advanced and the sac ruptures you may experience a gush of fluid from your vagina (your waters breaking). You may be able to identify the baby as it passes or it may pass in a blood clot and you might not see anything. If the pregnancy ceased some weeks before the miscarriage occurs, there may be no recognisable baby. You can let all of this pregnancy tissue pass into the toilet or you can collect it and bury it. No testing will be carried out on the pregnancy tissue unless you have been informed otherwise. 

 

Milk Production/Lactation 

Some women produce milk following a miscarriage. It may help to wear a firm fitting bra and to avoid touching your breasts during this time. You can take Paracetamol if you have any breast tenderness or discomfort. This discomfort usually disappears within 24 to 48 hours.

Recovery

To allow your cervix and womb time to heal, avoid hot pools, sex, and tampons (or any other vaginal penetration) for two weeks or until bleeding has stopped.

 (9) (10) (12) (13)

 

What happens during surgical management of a miscarriage

The procedures used in surgical miscarriage management will vary depending on many factors including; your medical history, the gestation of your pregnancy, and the DHB in which you receive surgery. Please take the following descriptions as a general guide only. Much of the information below is graphic in detail so please take care if you choose to read on. 

 

Pre-operative preparation of the cervix (cervical priming)

Before your surgery you will be given medication to soften your cervix and help it to be dilated. This is because the surgery will be conducted via your cervix.  It is most likely that this medication will be misoprostol (as used for medical management). You may experience some cramping or bleeding. 

Pain Relief

The procedure can be performed under a general anaesthetic or using local anaesthetic with sedation. If you are having local anaesthetic, you may be given pre-operative pain relief and drugs for ‘conscious sedation’ that make you feel relaxed and minimise your pain. These may be in the form of tablets or intravenous drugs. 

 

The Procedure (MVAC, EVAC, D&C or Suction Curettage)

A small device (a speculum) will be inserted to open your vagina. Your cervix will be numbed with a local anaesthetic and then gently dilated (stretched). 

 

Vacuum aspiration is a common surgical management of miscarriage in New Zealand. With vacuum aspiration a small tube (a cannula) will be inserted through your dilated cervix into your womb. The tube is attached to a mild suction pump or syringe (a manual vacuum aspirator or MVAC), and is used to carefully remove the contents of your womb.

 

Dilation and curettage (D&C) is another common surgical management of miscarriage in New Zealand. A thin scoop-like surgical instrument (a curette) is inserted through your dilated cervix into your womb. The curette is used to scrape tissue from the wall of your womb (curettage). Sometimes vacuum aspiration and low-pressure suction may be used as well. 

 

For later pregnancies, tissue forceps may also be used. 

 

Baby’s Remains

Prior to the surgical procedure you can ask to keep the baby and pregnancy tissue (this may be referred to as the ‘products of conception’). Be aware that where vacuum aspiration or a curette has been performed the baby is unlikely to be recognisable. Hospital staff may want to send the tissue away to confirm that it is pregnancy tissue. 

 

Afterwards

Please follow the advice of medical professionals over and above the advice listed here. And please seek medical advice if you have any concerns.​

  • Immediately after the procedure you will rest in the recovery room until it is safe for you to go home. 

  • It is a good idea to relax for the rest of the day and to take it easy for a day or two. You will usually be able to resume your normal activities within a couple days (recovery for later gestation pregnancies may take longer).

  • It is common to experience some minimal cramping and period-like pain after the procedure. Pain relief medication such as paracetamol (Pamol) or ibuprofen (Nurofen) should help to ease discomfort. If this pain relief is not sufficient, please seek medical advice.  

  • The amount of bleeding and its duration after the procedure is different for each woman. However, many women describe having some bleeding for a day or two, then stopping for a day or two, then having some light bleeding over the next few days. There are some women who experience no bleeding at all. If you develop heavy bleeding (soaking a pad every 30-60 minutes) you need to get to your nearest emergency department. 

  • To allow your cervix and womb time to heal, avoid hot pools, sex and tampons (or any other vaginal penetration) for two weeks or until bleeding has stopped. 

(1) (2) (10) (14) (15)

 
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