The physical process
The physical process of miscarriage can vary. It often depends on the size of the pregnancy and on whether the loss happens naturally or as a result of medical or surgical management.
If you miscarry naturally, even in the early weeks of pregnancy, you are likely to have period-like cramps that can be extremely painful. This is because the uterus is tightly squeezing to push its contents out, like it does in labour – and some women do experience contractions not unlike labour. You are also likely to bleed heavily and to pass large clots. You may pass a recognisable baby or fetus, perhaps still in the pregnancy sac.
You may feel able to manage the pain and bleeding at home or you might feel that you need to go to hospital. If you’re not sure, contact your GP, out of hours service or 111 (England & Scotland) or 0845 46 47 (Wales).
If you miscarry naturally in the second trimester, you are likely to go through a recognisable process of labour and you will probably need hospital care. However, some women don’t have clear signs of labour and may deliver quickly at home. There is more information about late loss here.
Missed or incomplete miscarriage
If an ultrasound scan shows that your pregnancy has ended but the process of miscarriage hasn’t started or completed, you will usually offered a choice about how to manage the situation:
Natural management (also called expectant or conservative management): letting nature take its course
Medical management: using medication to begin or speed up the process of miscarriage
Surgical management (also called SMM): an operation to remove the pregnancy
If you choose to have medical or surgical management, 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.
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 research  comparing natural, medical and surgical management found that:
- the risks of infection or other harm are very small with all three methods
- your chances of having a healthy pregnancy next time are equally good whichever method you choose
- women cope better when given clear information, good support and a choice of management methods.
A more recent review  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.
We provide brief information below, but you can read more detail about all these types of management in this leaflet.
Some women prefer to wait and let the miscarriage happen naturally – and hospitals may recommend this too, especially in the first three months of pregnancy.
It can be difficult to know what to expect and when (it may take days or weeks before the miscarriage begins) but most women will experience abdominal cramps, possibly quite severe, and pass blood clots as well as blood. Some women describe the process as similar to the contractions of labour and it can be a long and exhausting process. It can help to have pain-killers such as ibuprofen to hand, as well as a supply of extra-absorbent pads.
You can read more about natural management on pages 5-7 of this leaflet.
This means treatment with pills and/or vaginal tablets (pessaries) to start or speed up the process of a delayed or missed miscarriage. Some women experience severe abdominal cramps as well as heavy bleeding with this option, but they may prefer this to an operation. If your baby has died after about 14 or 15 weeks, you are most likely to be managed medically.
As with natural management, some women say that the process is similar to the contractions of labour and it can be a long and exhausting process. It can help to have pain-killers such as paracetemol or co-codamol to hand, as well as a supply of extra-absorbent pads.
Hospitals sometimes differ in the way they give the treatment – for example, whether treatment is carried out in hospital or at home. In all cases, though, they should give you clear information about what to expect.
You can read more about medical management on pages 8-9 of this leaflet.
Surgical management of miscarriage (SMM)
This is an operation to remove the remains of your pregnancy. It is usually done under general anaesthetic but in some hospitals it can be done under local anaesthetic, when you stay awake. (See MVA below).
For many years, surgical management of miscarriage was called ERPC, an abbreviation for Evacuation of Retained Products of Conception, which means the removal of the remains of the pregnancy and surrounding tissue. Many people find this term upsetting, which is why it should not be used any more, but you might still hear it or see it written.
(Some people still call it a D & C, which is a slightly different procedure.)
Some hospitals offer surgical management with local rather than general anaesthetic. This is called MVA, which is an abbreviation for Manual Vacuum Aspiration. You may find it helpful to read Karen’s experience of MVA.
You can read more about surgical management on pages 10-13 of this leaflet.
In some cases …
You may opt for one method of management but find that things change. Laura has written about her missed miscarriage, which started naturally but required some hospital treatment too.
 The MIST (Miscarriage Treatment) Trial. J Trinder et al: Management of miscarriage: expectant, medical or surgical? Results of a randomised controlled trial (miscarriage treatment (MIST) trial). BMJ 2006;332:1235-1240 (27 May).
 ‘Management of first-trimester miscarriage: a systematic review and network meta-analysis’ is published in Human Reproduction Update, doi:10.1093/humupd/dmz002