Missed or incomplete miscarriage – information for you

On this page we have collected the information you may need about missed or incomplete miscarriage or a blighted ovum (anembryonic pregnancy) during the Coronavirus pandemic.  Much of what you’ll find here is not specific to the virus, but hopefully this page will make it easier for you to find everything all in one place.

You will find information on ectopic pregnancy and coronavirus here.

You will find information on molar pregnancy and coronavirus here.

In some miscarriages the uterus (womb) empties itself completely.  But in others an ultrasound scan shows that the baby has died or not developed but has not been miscarried and you may be faced with making difficult decisions.  We hope the information here will help.

You’ll find here:

We also have a more general page on missed miscarriage, though most of the content is included below.

Some medical terms

Doctors have different ways of describing miscarriages where the uterus does not empty itself completely. The main terms used are:

Missed miscarriage (also called ‘delayed’ or ‘silent’ miscarriage)

This is where the baby has died or failed to develop but is still in your uterus. You might have had no idea that anything was wrong until you had an ultrasound  scan. You may still feel pregnant and have a positive pregnancy test.

Blighted ovum (also called ‘early embryo loss’ or ‘missed’ or ‘delayed’ miscarriage)

This is where an ultrasound scan shows a pregnancy sac with nothing inside. This is usually because the fertilised egg hasn’t developed normally so the pregnancy sac grows but the baby doesn’t. Sometimes the baby stops developing at such an early stage that it is absorbed back into the surrounding tissue. As with a missed miscarriage, you may still feel pregnant.

Incomplete miscarriage

This is where some but not all of the pregnancy tissue is miscarried. You may still have pain and heavy bleeding.

 

What happens next

In all the situations described above, a full miscarriage will happen naturally in time and some women choose this option. But the process can be speeded up, or ‘managed’ by medical treatment (drugs) or surgery (an operation).  If you choose to have one of these treatments, you may be asked to wait for a week or more for a second scan to make sure the pregnancy has ended before treatment begins.

Unless you need emergency treatment, you should usually be able to choose what treatment to have and be given information to help you decide between them.  However, your medical history may make some options unsuitable or your hospital may not offer all options.

During the Coronavirus (COVID-19) pandemic in particular, you are much less likely to be offered surgery, so you will most likely have to decide between natural (expectant) or medical management of miscarriage at home rather than being treated in hospital.

Having to choose between these methods can be difficult and distressing, but we hope that the information we have here will help you to understand the different options better, make it easier to decide and to prepare for and cope with the process.

It may help to know that research1comparing natural, medical and surgical management found that:

A more recent review [2] of 46 studies of miscarriage management concluded that all methods are equally effective in completing the process of miscarriage and recommended that women should be able to choose the method they feel best able to cope with.

Natural management of miscarriage (also called ‘expectant’ or ‘conservative’ management): letting nature take its course

Some women prefer to wait and let the miscarriage happen naturally. Doctors often recommend this, especially in the first eight or nine weeks of pregnancy. National (NICE) guidance also states that natural management should be the first method to consider. However, your choice will be important in deciding the best and safest option for you.

What happens?

This can vary a lot depending on the size of the pregnancy and the findings of the ultrasound scan. It can take anything from days to weeks before the miscarriage begins. Once it does, you are likely to have strong, possibly extremely painful cramps and bleeding. Some women describe the pain as like contractions in labour. The bleeding may go on for 2-3 weeks; or the small pregnancy sac in the womb may be reabsorbed without much bleeding at all. It can be very difficult to predict exactly what will happen and when.

You may be asked to contact or visit the hospital over the next few weeks. In some cases you may be offered a scan to check whether the uterus has emptied, but it is more likely that you will be asked to do a pregnancy test at home and to contact them again only if it is still positive after 2-3 weeks.  At this point you may be offered medical or surgical management.

Does it hurt?

Most women have period-like cramps that can be extremely painful, especially when the pregnancy tissue is being pushed out. This is because the uterus is tightly squeezing to push its contents out, much like it does in labour.  Paracetamol might help or you may find you need to use strong painkillers, such as co-codamol or similar, which combine paracetamol and codeine.

You are also likely to bleed very heavily and pass clots. These can be as big as the palm of your hand.  It might be wise to buy extra-absorbent pads – and certainly not to use tampons.

You may see the pregnancy sac, which might look different from what you expected. You may – especially after 10 weeks – see an intact fetus that looks like or is clearly a tiny baby.

Pavla describes her experience of natural management here.

What are the risks?

Infection

This affects about 1 woman in every 100, so some hospitals give antibiotics routinely to prevent it. Signs include:

Treatment is with antibiotics. You may need an operation to remove any remaining pregnancy tissue.  You will probably be advised to use pads rather than tampons for the bleeding and not to have sex until it has stopped.

Haemorrhage (extremely heavy bleeding)

About 2 in 100 women have bleeding bad enough to need a blood transfusion. Some of them need emergency surgery to stop the bleeding. If you are bleeding very heavily – or feel otherwise unwell or unable to cope – it may be best to contact the hospital where you were treated or your nearest Accident & Emergency Department.

Retained tissue

Sometimes a natural miscarriage doesn’t complete itself properly – even after a few weeks – and some pregnancy tissue remains in the uterus. You may need an operation to remove it.  In rare cases, pregnancy tissue gets stuck in the cervix (neck of the uterus1) and needs to be removed during a vaginal examination. This can be very painful and distressing.

What are the benefits?

The main benefit is avoiding hospital treatment. You may want your miscarriage to be as natural as possible and to be fully aware of what is happening. You may also find it easier to say goodbye to the pregnancy if you see the tissue and maybe the fetus or baby as it passes. You may still want advice, though, on what to do with the remains of your baby (see After the miscarriage below).

And the disadvantages?

Be prepared

If you decide to manage the miscarriage naturally, being prepared with sanitary pads, pain-killers and emergency contact numbers can help you cope with what happens. You may want to make sure you have people on hand or at the end of a phone to support you. 

After my second missed miscarriage I opted to let nature take its course.  It took two weeks until I had a miscarriage and although those weeks were very difficult, I found that I managed to accept the situation much quicker than previously. I also found my body got back to normal in a much shorter period of time.

Medical management of miscarriage

This means treatment with pills and/or vaginal tablets (pessaries) to start or speed up the process of a missed or incomplete miscarriage. Not all hospitals offer this option and it isn’t suitable for women with some health problems, including severe asthma or anaemia.

What happens?

The exact form of treatment your hospital offers will vary according to local practice and your type of miscarriage. And you may be treated as an in-patient or out-patient – again, this differs from hospital to hospital.

You may start with tablets to help break down the lining of the uterus, then be asked to come back two days later for the next stage of treatment or be given the second medication to use at home.  A small number of women miscarry after the first stage.

NICE guidance recommends that the first stage tablets may not be necessary, so you may go straight on to the second stage: tablets or pessaries to make your uterus contract and push out the pregnancy tissue. These are usually inserted into the vagina. You may have this treatment in hospital or be given the medication to use at home.

The medication may make you feel sick and can cause diarrhoea and flu-like symptoms. You may need more than one dose of this medication before the miscarriage happens. If you are taking it at home you should also be given pain relief, along with emergency contact numbers to use in case of problems. Your first period after the miscarriage may be heavier than usual.

Does it hurt?

Most women have period-like cramps that can be extremely painful, especially when the pregnancy tissue is being pushed out. This is because the uterus is tightly squeezing to push its contents out, much like it does in labour. You are also likely to bleed very heavily – much more than with a normal period – and pass clots. These can be as big as the palm of your hand. You may need to use extra-absorbent pads, possibly even more than one.

You may see the pregnancy sac, which might look different from what you expected. You may – especially after 10 weeks – see an intact fetus that looks like, or is clearly a tiny baby.

The hospital team should prepare you for what to expect. They should make sure you have strong pain relief. They may offer anti-sickness medication too.

Amy describes her experience of medical management here. And another Amy shares her story of medical management during the coronavirus lockdown here.

What are the risks?

Infection affects about 1-4 women in every 100. Haemorrhage affects about 2 in 100 – the same as for natural miscarriage (see ‘natural management’ above).

Medical management is effective in 80-90 per cent of cases. If it is not, or if you have an infection, you may be advised to have surgical management to complete the miscarriage.

What are the benefits?

The main benefit is avoiding an operation and the anaesthetic (general or local) that goes with it.  Some women see medical management as more natural than having an operation, but more controllable than waiting for nature to take its course.

As with natural management, you may prefer to be fully aware of what is happening.  You may find it easier to say goodbye to the pregnancy if you see the tissue and maybe the fetus or baby as it passes. You may still want advice, though, on what to do with the remains of your baby (see After the miscarriage on page 14).

And the disadvantages?

I was told it would be like a heavy period with cramps and may go on longer than usual. Because I had never had a miscarriage before, I did not know what to expect. I was unable to cope with the pain and needed strong pain-killers.

Surgical management of miscarriage: SMM

This is an operation to remove the pregnancy tissue. It is usually done under general anaesthetic which puts  you to sleep. But in some hospitals it can also be done under local anaesthetic, when you stay awake.

SMM under general anaesthetic

Surgical management is much less likely to be offered during the Coronavirus pandemic.

This used to be called called ERPC or ERPoC, which stands for Evacuation of Retained Products of Conception. You might hear it called it a D & C, which means dilatation and curettage but that is a slightly different procedure, usually carried out for women with period problems. Both of these terms are sometimes still used .

What happens?

The cervix (neck of the uterus) is dilated (stretched) gradually. This is usually done under anaesthetic but you might be given pills or vaginal pessaries before the operation to soften the cervix .A narrow suction tube is then inserted into the uterus to remove the remaining pregnancy tissue. This takes about 5-10 minutes.

A sample of the tissue removed is usually sent to the pathology department to check that it is normal pregnancy tissue. It is not usually tested further unless you are having investigations after recurrentmiscarriage.

Does it hurt?

If you are given tablets or vaginal pessaries before the operation, you may have cramping pain and perhaps some bleeding as the cervix opens. Having a general anaesthetic means you will not feel anything during the operation itself; and there are no cuts or stitches.

You may have some abdominal cramps (like strong period pain) when you wake up and for a few days afterwards. You may bleed for up to 2-3 weeks after the operation. Bleeding may stop and start but should gradually tail off. If it stays heavy, gets heavier than a period or makes you worried, it is best to contact your GP or the hospital.

I only bled for a short time after the operation (about 4-5 days like a period).  I only had mild aching and soreness the next morning.

 What are the risks?

What are the benefits?

With surgical management you know when the miscarriage will happen and can plan around that. With a  general anaesthetic you won’t be aware of what’s going on.  It may be a relief when the miscarriage is ‘over and done with’ and you can move on.

And the disadvantages?

Some women are frightened of anaesthetics, surgery and staying in hospital. Some prefer to let nature take its course and to remain aware of the miscarriage process.  The anaesthetic might make you feel groggy or unwell for a few days.

Some women refuse surgery because they worry that the diagnosis might be wrong and their baby is still alive. If this is your concern, don’t be afraid to ask for another scan just to be sure.

When I was told I had lost the baby I just wanted it to be all over as soon as possible. I was booked in immediately and had the op the following day. I was treated with great kindness and informed all the way along of what would be happening. I recovered physically within a couple of weeks.

 

SMM under local anaesthetic

Surgical management is much less likely to be offered during the Coronavirus pandemic.

This is also sometimes called MVA, which stands for Manual Vacuum Aspiration. It may be carried out in a hospital ward, a day surgery unit or an out-patient clinic.

What happens?

You may be given tablets or vaginal pessaries before the operation to soften the cervix, along with pain relief.  A local anaesthetic is injected into your cervix, or the cervix may be numbed with a gel and the cervix is then dilated (stretched) gradually.  A narrow suction tube is then inserted into the uterus to remove the remaining pregnancy tissue.  You will be offered further pain relief during the procedure and may have a scan afterwards.

This all takes about 10 minutes. Afterwards you will probably be advised to wait for an hour or two to make sure you are well enough to go home.

As with SMM under general anaesthetic, a sample of the tissue removed may be tested afterwards to check that it is normal pregnancy tissue.

Does it hurt?

If you are given tablets or vaginal pessaries before the operation, you might feel pain as the cervix opens.  Most women have cramps (like strong period pains) as the pregnancy remains are removed. But you will be given painkillers and/or nitrous oxide (‘gas and air’) if necessary and the pain probably won’t last long.

You may have some light vaginal bleeding afterwards. If it becomes heavy, it is best to contact the team that treated you.

Karen describes her experience of MVA here.

Are there any risks?

These are mostly the same as for SMM under general anaesthetic. There is a very small risk of having a reaction to the local anaesthetic.

I had the surgery done under local anaesthetic (just with gas and air). It was painful, but very quick. The actual removal took less than 5 minutes and just happened on the ward. Within an hour I walked home with my husband (though I am sure they expect you to be driven home), bleeding only a little bit and in no pain (just feeling empty).

What are the benefits?

As with SMM with general anaesthetic, you will know when the miscarriage will happen and may then feel you can move on. The procedure is quick and you will recover more quickly than from a general anaesthetic.  You may actually prefer to be awake and aware of what is happening.

And the disadvantages?

Some women prefer not to be aware of the process of miscarrying.  And you may worry about coping with pain or anxiety.

 

After the miscarriage: what happens to your baby

 In hospital

When a baby dies before 24 weeks of pregnancy, there is no legal requirement to have a burial or cremation.  Even so, most hospitals have sensitive disposal policies and your baby may be cremated or buried, perhaps along with the remains of other miscarried babies. It is possible that the Coronavirus pandemic may limit or delay these options.

The Royal College of Nursing advises that hospitals should offer parents the option of arranging individual or shared cremation or burial of pregnancy remains, usually paid for by the Trust; or, if parents prefer, the option of taking the baby’s remains home and making private arrangements.  You should be given time to decide – as well as the option not to make a decision at all.

However, actual practice varies a great deal and sadly, some hospitals in England and Wales may still treat the remains of an early loss as clinical waste unless you request otherwise.  (This is not illegal in England and Wales, but Scottish government guidance is different and all pregnancy remains are cremated or buried.)

If you want to find out about the arrangements at your hospital, ask a nurse or midwife on the ward or unit where you were cared for, the hospital chaplain, the PALS (Patient Advice and Liaison) officer, or the hospital bereavement service.

You may want to make your own arrangements for burying or cremating the remains of your baby, whether you use a funeral director or a specialist cremation service (depending on what they are able to offer at this time) or choose to bury the remains at home or somewhere else. You can read more about this on page 14 of this leaflet  and below. There are some things to think about and you may want to contact us for further information.

At home

If you miscarry at home or somewhere else outside a hospital, you are most likely to pass the remains of the pregnancy into the toilet. (That can happen in hospital too.)  You may look at what has come away and see a pregnancy sac and/or the fetus or baby – or something you think might be the fetus or baby.

You may want to simply flush the toilet – many people do that automatically – or you may prefer to remove the remains for a closer look. That’s natural too.

It wasn’t what I’d intended, but a friend said ‘Just think about your baby being swept through the system and then floating out to sea, bobbing about under the stars.’ I found that really comforting.

You may decide to bury the remains at home, in the garden or in a planter with flowers or a shrub. Or you may prefer to arrange burial in a local cemetery if that is possible at this time, or somewhere else that feels right.

Erin describes here how she and her partner created a special place in their garden for their miscarried baby.  And Jenny describes a woodland burial here.

You might want your GP or hospital to look at the remains. Be aware, though, that while they may be able to confirm you have passed pregnancy tissue, they probably won’t be able to carry out any tests on it.

If you have any questions about what to do or would just like to talk it through, you are welcome to contact us at the Miscarriage Association.  We know how difficult it can be to talk about these things but we’re here to listen and support.