We are so sorry that you have been diagnosed with an impending miscarriage.  We know that your visit today was met with unrealized expectations.  We also know that an overwhelming amount of information was discussed, and so we wanted to provide you with this webpage so you and your family can digest this news in your own timing.

Miscarriage is a common event that rarely can be prevented.  It is often the body’s way of addressing a pregnancy that was not normal.  Women commonly try to recall their specific activities around the time of the loss.  But please know that this is not your fault and you did not cause the miscarriage.  It wasn’t because you exercised.  It wasn’t because you got stressed.  It wasn’t because you had sex.  It wasn’t because you were in a smoked filled restaurant, painted a room, fell down, or had a glass of wine.

Even though you may have been very early with your loss, please know that the grief is very real for both parents.  It takes time to work through this grief, and it will last longer than any physical pain.  Grief can be empowering, but guilt is not.  If you are struggling emotionally and would like some help, please contact a provider in our office.

Medical Terminology

You may hear different medical terms referring to early pregnancy bleeding an loss, and may even hear the word ‘abortion’ substituted for ‘miscarriage’ in some medical documents.

• Threatened Miscarriage: A pregnancy in the first trimester with unexpected bleeding.  Bleeding is common, but still always of concern.  Women with bleeding are more likely to miscarry.  See the First Trimester Bleeding & Cramping information on the Obstetrics webpage.
• Missed Miscarriage:  A pregnancy that is determined to be non-viable, but before the maternal symptoms of bleeding and cramping have started.  Typically, this is a tragically unanticipated event where no heartbeat is seen on ultrasound at a routine medical visit.  This is often the first prenatal visit, anticipated with excitement and sharing – and then the terrible news delivered to you.
• Spontaneous (complete) Miscarriage: A pregnancy loss that had completely been expelled from the uterus.
• Incomplete Miscarriage: A pregnancy loss that has only partially been expelled from the uterus.  Typically, some of the pregnancy support tissue remains and contributes to ongoing cramping and bleeding.

What to do now?

Once you have been diagnosed with a pregnancy loss, there are three options for clinical management: Expectant, Surgical, and Medical.  The best option will depend on how far along the pregnancy was, the symptoms you are currently experiencing, and your personal preference.  In addition to ultrasounds, you may also require additional blood testing to assist in your management. Consider the benefits and risks of each treatment option carefully, and ask follow-up questions with your doctor at Arbor ObGyn.

Expectant Management

This is an approach where we wait for your body to react to the unsuccessful pregnancy, and the least involved management option.  You will go through the miscarriage process on your own at home.  You will most likely experience bleeding and cramping much like a heavy menstrual cycle.  You will also pass blood clots and tissue.  It tends to culminate after a few hours of intense cramping.  You will finally experience physical relief with expulsion of the pregnancy tissue.  An 8 week pregnancy is about ¾ inch in size, and the total encasing support tissue is grey/purple/red egg-sized.  We recommend using over-the-counter ibuprofen (four tablets of the 200mg every 8 hours) and acetaminophen (Tylenol) for the pain.   You can also use a heating pad, warm bath or shower.   The simple observation approach works best for women who are sonographically 6 weeks or less, but is also a reasonable choice through 8 weeks.  Most women will complete the miscarriage within two weeks of when the clinical diagnosis of impending miscarriage is made.

The advantages of the Expectant approach are that you can be in the comfort of your own home, and that you avoid the risks of a surgical procedure.  The disadvantage is that you do not have control over the timing for the physical miscarriage event, and that it may come at an inopportune moment such as at work or while traveling.  Another concern can be that the miscarriage event is unrelenting and your bleeding continues heavy enough that you need to go to the Emergency Room.  If you are soaking two pads per hour for two hours in a row, please contact the doctor or go to the Emergency Room.  You may still require a surgery if this happens.

We prefer to see you back in the office every two weeks until it is resolved.  We will do additional ultrasounds to either update you on the progression, or confirm the completeness of the miscarriage. If your miscarriage is not complete, we will review and offer you similar management options.  At your follow-up office we will also take time to review preparations for future pregnancies.

Surgical Management – D&C

Dilation & Curettage (D&C) is the surgical procedure to remove the pregnancy contents of the uterus.  The cervix is dilated about one centimeter with a series of graduated wands to allow other medical instruments to dislodge (curettage) the inside of the uterus.  Specially designed vacuum-assisting instruments are also used.

D&C can be done for anyone who requests it, but we tend to favor it for women of 8 weeks gestation and beyond due to the increased pain and increased risk of an incomplete miscarriage with the Expectant approach.  Another advantage of D&C is that you have more control over the timing of the miscarriage.  Some women would like to move forward rather quickly, as opposed to waiting a few weeks for a more natural outcome.

Complications of a D&C are rare but include infection, excessive bleeding, or perforation of the uterine wall.  Problems related to the anesthesia used also can occur.  In extremely rare cases scar tissue and adhesions may develop inside the uterus and cause challenges for menstrual cycles and future pregnancy attempts.

D&C can be done in our Arbor ObGyn office procedure suite or at the Rex Hospital operating room.  Our preference is to complete the procedure in our office, as it is usually a more comfortable setting for you and more efficient for scheduling.  For pregnancies that very far along, it may be preferred by your doctor to have the D&C at the hospital.  Intravenous sedation anesthesia is used at Rex Hospital, and on occasion with an anesthesiologist at Arbor ObGyn.  If your pregnancy loss is relatively early, then you may not need sedation and can be comfortable with oral narcotics and injectable anesthetics.  Your doctor can help you choose the best location and anesthetic plan for your surgery.

We try very hard to accommodate your schedule and personal needs when arranging a D&C.  In addition to arranging a date and time for surgery, our administrative staff with attempt to verify your insurance benefits.  Insurance coverage may be different if the D&C is in the office versus the hospital (typically more expensive).  If at the hospital, you will get individual bills from Arbor, Rex, Anesthesiology, and the Lab.  If having surgery at Rex Hospital, in order to accommodate you best we may ask the Arbor on-call doctor to perform your D&C surgery.  Your regular or diagnosing doctor may not be able to leave the office that day to perform your D&C.  The Arbor on-call doctor will certainly come see you in the hospital to review everything prior to surgery.

The D&C procedure itself only takes about twenty minutes.  You can expect to be in the Arbor office for 90 minute, or at Rex Hospital for four hours.  If your D&C is with sedation it is very important that you do not eat or drink anything for eight hours prior to the surgery.  You will need a driver to take you home after the procedure.  After a D&C you can expect to be tired for 24 hours, and have light cramping and bleeding.  Most women can resume work and life’s activities in 48 hours.  We ask you to refrain from tampon use or sexual intercourse until your follow-up appointment two weeks later.

Medication Management

The medication Misoprostol (Cytotec) can aid the initiation of a miscarriage event.  The medicine was originally a treatment for stomach ulcers, but it was realized that pregnant women taking Misoprostol would cramp and miscarry.  Nowadays it is a regular choice to aid a miscarriage.

Misoprostol is acceptable to use for pregnancies estimated to be 56 days (8 weeks) or less.  Successful miscarriage completion is typically seen in 80% – 90% of patients.  The advantage of Medication management is that you take some control over the timing of the miscarriage event itself.  The Misoprostol is administered by you at home.  Once initiated, the remainder of the miscarriage experience is similar to that describe above for women with Expectant management.   Side effects of treatment uncommonly include nausea, vomiting, diarrhea, fever, and chills.

Misoprostol is a prescription medication, and very inexpensive.  Your doctor will send two ‘doses’ of the prescription electronically to your pharmacy.  A standard dose is four 200 mcg tablets, totaling 800 micrograms.  To use the medication, lightly moisten each of the four tablets and insert vaginally – similar to the placement of a tampon.  Place as far inside the vagina as possible.  A drop of water on each tablet is all that is usually needed to moisten and activate them.

You should expect significant bleeding and cramping.  This may start as soon as 30 minutes after administration of the Misoprostol, and typically is within a few of hours.  Bleeding may be much heavier than a menstrual cycle, potentially with severe cramping.  If you are soaking two pads per hour for two hours in a row, please contact the doctor or go to the Emergency Room.  We recommend using over-the-counter ibuprofen (four tablets of the 200mg every 8 hours) and acetaminophen (Tylenol) for the pain.   You can also use a heating pad, warm bath or shower.

If you do not have significant bleeding, cramping and tissue passage, then re-administer the Misoprostol 24-hours after the first dose.  Again, gently moisten each of the 4 tablets and insert vaginally.  Call Arbor ObGyn if you still do not have a significant medication effect by the next day.

We plan to see you back in the office in two weeks.  We will do additional ultrasounds to either update you on the progression, or confirm the completeness of the miscarriage. If your miscarriage is not complete, we will review and offer you similar management options.  At your follow-up office we will also take time to review preparations for future pregnancies.

How to Plan for the Future

After you have completed the miscarriage, your cycle will typically return in 4-6 weeks.  This first cycle may be heavy with cramping.  At that time your fertility should return to where it was before the miscarriage. You can start trying again if you are ready, unless you have been advised otherwise by your provider.  There is no medical or fertility benefit to waiting longer.  Of course, deciding if and when to pursue pregnancy is a very personal choice.

Although it is a common fear, having a miscarriage does not mean you cannot have children.  Less than 5% of women will experience two consecutive miscarriages, and only 1% experience three or more.  Having a miscarriage does not always mean something is wrong with your health.  If you have two or three in a row though, your doctor may suggest tests to look for a cause.  Even with testing, most women never discover the reason for a miscarriage.

There are no medically proven treatments that can reduce miscarriage recurrence for otherwise healthy women.  When you are pregnant again, please call the office to schedule your first appointment.  If you would find it reassuring, we will be glad to see you at about 7 weeks, instead of 8-9 weeks along.  Please mention this to our receptionist.

Again, we are truly sorry that you have gone through this miscarriage.  Please know that your Arbor ObGyn providers and staff care about you, and desire to address all your questions and concerns.  Please do not hesitate to contact us.