As an obstetrician-gynecologist, Dr. Maria D’Iorio of Novant Health WomanCare - Winston-Salem helps women welcome their babies into the world.
She’s also there when a pregnancy ends early.
Up to 30% of pregnancies result in miscarriage, D’Iorio said, but many patients haven’t considered the possibility until it happens to them. Then “it’s so much information, all at once, and they have to make decisions,” D’Iorio said. “It would be really helpful if women had a little more exposure going in.”
To help demystify this common but often unspoken experience, we asked D’Iorio to walk us through what patients should know, from why miscarriages happen, to what to expect and how to navigate the decisions that follow.
Expert care for every stage of pregnancy.
What is a miscarriage?
A miscarriage is the unexpected loss of a pregnancy prior to 20 weeks.
Around 80% of miscarriages take place in the first trimester, sometimes before a woman even knows she is pregnant.
Why does miscarriage happen?
In short, because it’s really complicated to make a whole human.
The most common cause is that the unborn baby isn’t developing properly, usually due to a genetic mutation that occurred by chance as the pregnancy formed.
Your body doesn’t want to go through all that effort and energy if a pregnancy isn’t going to become a healthy baby. Miscarriage is the body’s natural process of dealing with it.
Some women are devastated. Others feel relieved. It’s normal to feel a range of emotions.
What puts someone at risk for a miscarriage?
A miscarriage can happen to anyone. Here are some things that put you at higher risk:
- Age: The risk of miscarriage gradually climbs starting at 35; that increase gets steeper starting at 40. By age 45, a woman has an 80% chance of miscarriage.
- Medical conditions: Certain infections can cause miscarriage, along with conditions like cervical insufficiency, a uterine abnormality, fibroids, polyps or scarring in your uterus. Some chronic medical conditions like autoimmune conditions, obesity and polycystic ovary syndrome (PCOS) can also increase the risk for miscarriage.
- A history of miscarriage.
- Binge drinking, smoking, substance use or exposure to harmful chemicals.
What happens during a miscarriage
What are the signs of a miscarriage?
Call your ob-gyn if you’re pregnant — or could be pregnant — and are having these symptoms:
- Spotting or bleeding
- Abdominal pain
- Cramping
- Passing fluid or tissue from the vagina
These could be signs of a miscarriage, so it’s important to check in with your ob-gyn.
However, not every woman has symptoms of their miscarriage; some women don’t, and they learn they’ve had a miscarriage during a routine ultrasound scan.
How is a miscarriage confirmed?
Often you’ll know within one visit if your pregnancy is still viable — but sometimes it takes up to two weeks to be sure.
- If you’re having miscarriage symptoms and haven’t had an ultrasound yet: Your ob-gyn will ensure you aren’t experiencing a dangerous condition called ectopic pregnancy. To do this, they’ll conduct a pelvic exam, order a transvaginal ultrasound, and repeat blood tests over a few days to monitor your pregnancy hormone levels.
- If you’re having symptoms and have had an ultrasound showing a pregnancy in your uterus: Your ob-gyn will order another ultrasound. If ultrasound shows that the unborn baby has stopped growing and developing, or no longer has a heartbeat, miscarriage is confirmed.
How is a miscarriage treated?
If there’s no pregnancy tissue left in the womb, you don’t need further treatment.
If the tissue’s still there, you have three choices.
- Medication
If you pick this route, your ob-gyn will give you an oral medication called mifepristone, which you’ll take in their office. Within 24 to 48 hours, you’ll take a second medication called misoprostol either orally or vaginally; your uterus will begin contracting and expelling tissue a few hours after you take the medicine. Most women experience bleeding and pain they describe as a very bad period; ibuprofen and a heating pad can help.
The combination of medications is typically about 95% effective in passing all the tissue. If tissue remains, a surgical procedure called a D&C is recommended.
- Dilation and curettage (commonly called a “D&C")
Patients who choose a D&C pick it because “they just want this over with,” D’Iorio said. “It’s over in 30 minutes, and you know it’s done.”
If you’ve had previous miscarriages and want to do genetic testing on the tissue, a D&C can offer a more direct route to testing.
- Expectant management
Once your body begins miscarrying, you can bleed and cramp for up to two weeks, putting you at risk for heavy bleeding and possible infection. This option is “good for patients who feel very comfortable with managing significant bleeding and cramping at home,” D’Iorio said. “But you have to check in regularly with your doctor.”
Within eight weeks, 80% of women have passed all the tissue; if tissue remains, a D&C is recommended.
How much time should I take off work after a miscarriage?
With expectant management, you can work until your body begins passing the tissue. Then, you likely won’t be able to work until the heavy bleeding has stopped.
With medication or a D&C, D’Iorio recommends a minimum of 48 to 72 hours after completing the process to allow for physical and emotional recovery. Women with physically demanding jobs may need additional time off.
Women are often worried about telling their employer. D’Iorio’s advice? “Your job doesn’t need to know why you can’t come in — this isn't their business,” D’Iorio said. “We’ll give you a note saying you have a medical condition that necessitates you being excused from work for this amount of time.” It’s up to you if you want to share more.
It’s not your fault — and other things worth knowing
Did I cause my miscarriage?
Even if you drank coffee, didn’t sleep well, had sex, lifted something heavy, exercised or drank a glass of wine before you knew you were pregnant — “there’s nothing you did or didn't do that caused this to happen,” D’Iorio said. “And there’s nothing you could have done differently that would have changed this.”
When you get a virus and spike a fever, “you don’t have the fever because you did something wrong,” D’Iorio said. “You have a fever because your body’s protecting you against a virus.”
Similarly, a miscarriage protects your body for the future: “This miscarriage is your body doing what it's supposed to do to maximize your chances of a future healthy pregnancy.”
How does miscarriage affect a couple?
Couples often feel guilty, even though it’s not their fault. Frustration is also common — “They wish they had more answers,” D’Iorio said. Couples may also disagree about whether, or how soon, they should try to get pregnant again.
It’s normal to grieve, even if the pregnancy was early. “Often, couples plan their pregnancies and have a lot of expectations,” D’Iorio said. “You might have told other people in your lives. There's a lot to grieve.”
And amid the grief, D’Iorio offers this: “You got pregnant — this means that you and your partner can get pregnant together.”
After a miscarriage
How soon will I be “back to normal” after a miscarriage?
- Physically: Your ob-gyn will see you one to two weeks after your D&C, medication or completed miscarriage. At this point, “most women are feeling pretty back to normal physically, and most will go back into normal menstrual cycle within one to two months,” D’Iorio said. The further along in pregnancy you were, the longer it can take to feel back to normal physically.
- Emotionally: Emotional healing is more individualized. “Some women are ready to try again right away, and some women are really devastated. It’s such a broad range,” D’Iorio said.
Although you may never feel like the exact same person after a loss, you deserve to feel your full range of emotions –including joy – in time. If you’re struggling, D’Iorio recommends working with a therapist who specializes in peripartum or postpartum mental health.
When can I try to get pregnant again after a miscarriage?
You may have heard that you need to wait at least one cycle before you try again. That’s not medically necessary, D’Iorio said, although it can help you more accurately date a future pregnancy.
D’Iorio’s advice? “Start trying again whenever you’re feeling emotionally ready.”
Am I likely to have another miscarriage?
“Most women who have a miscarriage will go on to have a healthy pregnancy,” D’Iorio said. At least 85% of women who have had one loss will go on to have a successful pregnancy the next time.
A small percentage of women may have an underlying condition that causes recurrent miscarriages. If you’ve had two or more miscarriages, your doctor may discuss genetic testing with you.
Women who have had repeated miscarriages sometimes take a supplemental hormone called progesterone in early pregnancy; your ob-gyn can provide individual guidance.
In summary
D’Iorio wants women to know that it's common to have a miscarriage, maybe even more than one, especially in the first trimester. “It doesn't mean that something is wrong with them, that they did something wrong or that they can’t have a healthy normal pregnancy in the future,” D’Iorio said.
“Most women that I have helped through a miscarriage come back with a healthy pregnancy, and I’m so happy to help them again.”
If you have questions or concerns about a current pregnancy, reach out to your ob-gyn — and know that they’re there for you, no matter what.
