What is a miscarriage?
Miscarriage is the loss of a pregnancy in the first 20 weeks. (In medical articles, you may see the term “spontaneous abortion” used in place of miscarriage.) About 10 to 20 percent of known pregnancies end in miscarriage, and more than 80 percent of these losses happen before 12 weeks.
This doesn’t include situations in which you lose a fertilized egg before a pregnancy becomes established. Studies have found that 30 to 50 percent of fertilized eggs are lost before or during the process of implantation – often so early that a woman goes on to get her period at about the expected time.
Spotting the signs of a miscarriage
If you have these signs of miscarriage, call your doctor or midwife right away so she can determine whether you have a problem that needs to be dealt with immediately:
- Bleeding or spotting. Vaginal spotting or bleeding is usually the first sign of miscarriage. Keep in mind, though, that up to 1 in 4 pregnant women have some bleeding or spotting (finding spots of blood on your underpants or toilet tissue) in early pregnancy, and most of these pregnancies don’t end in miscarriage.
- Abdominal pain. Abdominal pain usually begins after you first have some bleeding. It may feel crampy or persistent, mild or sharp, or may feel more like low back pain or pelvic pressure.
If you have both bleeding and pain, the chances of your pregnancy continuing are much lower. It’s very important to be aware that vaginal bleeding, spotting, or pain in early pregnancy can also signal an ectopic or a molar pregnancy.
Also, if your blood is Rh-negative, you may need a shot of Rh immune globulin within two or three days after you first notice bleeding, unless the baby’s father is Rh-negative as well.
Some miscarriages are first suspected during a routine prenatal visit, when the doctor or midwife can’t hear the baby’s heartbeat or notices that your uterus isn’t growing as it should be. (Often the embryo or fetus stops developing a few weeks before you have symptoms like bleeding or cramping.)
If your practitioner suspects that you’ve had a miscarriage, she’ll order an ultrasound to see what’s going on in your uterus. She may also do a blood test.
What causes a miscarriage
Between 50 and 70 percent of first-trimester miscarriages are thought to be random events caused by chromosomal abnormalities in the fertilized egg. Most often, this means that the egg or sperm had the wrong number of chromosomes, and as a result, the fertilized egg can’t develop normally.
Sometimes a miscarriage is caused by problems that occur during the delicate process of early development. This would include an egg that doesn’t implant properly in the uterus or an embryo with structural defects that prevent it from developing.
Since most healthcare practitioners won’t do a full-scale workup of a healthy woman after a single miscarriage, it’s usually impossible to tell why the pregnancy was lost. And even when a detailed evaluation is performed – after you’ve had two or three consecutive miscarriages, for instance – the cause still remains unknown half the time.
When the fertilized egg has chromosomal problems, you may end up with what’s sometimes called a blighted ovum (now usually referred to in medical circles as an early pregnancy failure). In this case, the fertilized egg implants in the uterus and the placenta and gestational sac begin to develop, but the resulting embryo either stops developing very early or doesn’t form at all.
Because the placenta begins to secrete hormones, you’ll get a positive pregnancy test and may have early pregnancy symptoms, but an ultrasound will show an empty gestational sac. In other cases, the embryo does develop for a little while but has abnormalities that make survival impossible, and development stops before the heart starts beating.
If your baby has a normal heartbeat – usually first visible on ultrasound at around 6 weeks – and you have no symptoms like bleeding or cramping, your odds of having a miscarriage drop significantly and continue to decrease with each passing week.
What puts you at a higher risk for miscarriage
Though any woman can miscarry, some are more likely to miscarry than others. Here are some risk factors:
- Age: Older women are more likely to conceive a baby with a chromosomal abnormality and to miscarry as a result. In fact, 40-year-olds are about twice as likely to miscarry as 20-year-olds. Your risk of miscarriage also rises with each child you bear.
- A history of miscarriages: Women who have had two or more miscarriages in a row are more likely than other women to miscarry again.
- Chronic diseases or disorders: Poorly controlled diabetes and certain inherited blood clotting disorders, autoimmune disorders (such as antiphospholipid syndrome or lupus), and hormonal disorders (such as polycystic ovary syndrome) are some of the conditions that could increase the risk of miscarriage.
- Uterine or cervical problems: Having certain congenital uterine abnormalities, severe uterine adhesions (bands of scar tissue), or a weak or abnormally short cervix (known as cervical insufficiency) up the odds for a miscarriage. The link between uterine fibroids (a common, benign growth) and miscarriage is controversial, but most fibroids don’t cause problems.
- A history of birth defects or genetic problems: If you, your partner, or family members have a genetic abnormality, have had one identified in a previous pregnancy, or have given birth to a child with a birth defect, you’re at higher risk for miscarriage.
- Infections: Research has shown a somewhat higher risk for miscarriage if you have listeria, mumps, rubella, measles, cytomegalovirus, parvovirus, gonorrhea, HIV, and certain other infections.
- Smoking, drinking, and using drugs: Smoking, drinking alcohol, and using drugs like cocaine and MDMA (ecstasy) during pregnancy can all increase your risk for miscarriage. Some studies show an association between high levels of caffeine consumption and an increased risk of miscarriage.
- Medications: Some medications have been linked to increased risk of miscarriage, so it’s important to ask your caregiver about the safety of any medications you’re taking, even while you’re trying to conceive. This goes for prescription and over-the-counter drugs, including nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and aspirin.
- Environmental toxins: Environmental factors that might increase your risk include lead; arsenic; some chemicals, like formaldehyde, benzene, and ethylene oxide; and large doses of radiation or anesthetic gases.
- Paternal factors: Little is known about how the father’s condition contributes to a couple’s risk for miscarriage, though the risk does rise with the father’s age. Researchers are studying the extent to which sperm could be damaged by environmental toxins but still manage to fertilize an egg. Some studies have found a greater risk of miscarriage when the father has been exposed to mercury, lead, and some industrial chemicals and pesticides.
- Obesity: Some studies show a link between obesity and miscarriage.
- Diagnostic procedures: There’s a small increased risk of miscarriage after chorionic villus sampling and amniocentesis, which may be performed for diagnostic genetic testing.
Your risk of miscarriage is also higher if you get pregnant within three months after giving birth.
What to do if you think you might be having a miscarriage
Call your doctor or midwife immediately if you ever notice unusual symptoms such as bleeding or cramping during pregnancy. Your practitioner will examine you to see if the bleeding is coming from your cervix and check your uterus. She may also do a blood test to check for the pregnancy hormone hCG and repeat it in two to three days to see if your levels are rising as they should be.
If you’re having bleeding or cramping and your practitioner has even the slightest suspicion that you have an ectopic pregnancy, you’ll have an ultrasound right away. If there’s no sign of a problem but you continue to spot, you’ll have another ultrasound at about 7 weeks.
At this point, if the sonographer sees an embryo with a normal heartbeat, you have a viable pregnancy and your risk of miscarrying is now much lower, but you’ll need to have another ultrasound later if you continue to bleed. If the sonographer determines that the embryo is the appropriate size but there’s no heartbeat, it means the embryo didn’t survive.
If the sac or the embryo is smaller than expected, the absence of a heartbeat might just mean that your dates are off and you’re not as far along as you thought. Depending on the circumstances, you may need a repeat ultrasound within one to two weeks and some blood tests before your caregiver can make a final diagnosis.
If you’re in your second trimester and an ultrasound shows your cervix is shortening or opening, your doctor may decide to perform a procedure called cerclage, in which she stitches your cervix closed in an attempt to prevent miscarriage or premature delivery. (This is assuming your baby appears normal on the ultrasound and you have no signs of an intrauterine infection.) Cerclage isn’t without risk, and not everyone agrees on what makes you a good candidate for it.
If you’re showing signs of a possible miscarriage, your doctor or midwife may prescribe bedrest in hopes of reducing your chances of miscarrying – but there’s no evidence that bedrest will help. She may also suggest that you not have sex while you’re having bleeding or cramping. Sex doesn’t cause miscarriage, but it’s a good idea to abstain if you’re having these symptoms.
You may have light bleeding and cramping for a few weeks. You can wear sanitary pads but no tampons during this time and take acetaminophen for the pain. If you are miscarrying, the bleeding and cramping will likely get worse shortly before you pass the “products of conception” – that is, the placenta and the embryonic or fetal tissue, which will look grayish and may include blood clots.
If you can, save this tissue in a clean container. Your caregiver may want to examine it or send it to a lab for testing to try to find out why you miscarried. In any case, she’ll want to see you again at this point, so call her to let her know what’s happened.
What happens if you don’t pass the tissue
There are different ways of handling this, and it’s a good idea to discuss the pros and cons of each with your caregiver. If there’s no threat to your health, you may choose to wait and let the tissue pass on its own. (More than half of women spontaneously miscarry within a week of finding out that the pregnancy is no longer viable.) Or you may decide to wait a certain amount of time to see what happens before having a procedure to remove the tissue.
In some cases, you can use medication to speed up the process, although there may be side effects such as nausea, vomiting, and diarrhea. If you choose to wait or take medication to try to speed it up, there’s a chance you’ll end up needing to have the tissue surgically removed anyway.
On the other hand, if you find that it’s too emotionally trying or physically painful to wait for the tissue to pass, you may decide to just have it removed. This is done by suction curettage or dilation and curettage (D&C).
You’ll definitely need to have the tissue removed right away if you have any problems that make it unsafe to wait, such as significant bleeding or signs of infection. And your practitioner may recommend the procedure if this is your second or third miscarriage in a row, so the tissue can be tested for a genetic cause.
Suction curettage and traditional D&C
The procedure doesn’t usually require an overnight stay unless you have complications. As with any surgery, you’ll need to arrive with an empty stomach – no food or drink since the night before.
Most obstetricians prefer to use suction curettage (or vacuum aspiration) because it’s thought to be slightly quicker and safer than a traditional D&C, though some will use a combination of the two. For either procedure, the doctor will insert a speculum into your vagina, clean your cervix and vagina with an antiseptic solution, and dilate your cervix with narrow metal rods (unless your cervix is already dilated from having passed some tissue). In most cases, you’ll be given sedation through an IV and a local anesthetic to numb your cervix.
For suction curettage, the doctor will pass a hollow plastic tube through your cervix and suction out the tissue from your uterus. For a traditional D&C, she’ll use a spoon-shaped instrument called a curette to gently scrape the tissue from the walls of your uterus. The whole thing may take about 15 to 20 minutes, though the tissue removal itself takes less than ten minutes.
Finally, if your blood is Rh-negative, you’ll receive a shot of Rh immune globulin unless the baby’s father is Rh-negative, too.
What happens after a miscarriage
Whether you pass the tissue on your own or have it removed, you’ll have mild menstrual-like cramps afterward for up to a day or so and light bleeding for a week or two. Use pads instead of tampons and take ibuprofen or acetaminophen for the cramps. Avoid sex, swimming, douching, and using vaginal medications for at least a couple of weeks and until your bleeding has stopped.
If you begin to bleed heavily (soaking a sanitary pad in an hour), have any signs of infection (such as fever, achiness, or foul-smelling vaginal discharge), or feel excessive pain, call your practitioner immediately or go to the emergency room. If your bleeding is heavy and you begin to feel weak, dizzy, or lightheaded, you may be going into shock. In this case, call 911 right away – don’t wait to hear from your caregiver, and don’t drive yourself to the ER.
The chance of having another miscarriage
It’s understandable to be worried about the possibility of another miscarriage, but fertility experts don’t consider a single early pregnancy loss to be a sign that there’s anything wrong with you or your partner.
Some practitioners will order special blood and genetic tests to try to find out what’s going on after two miscarriages in a row, particularly if you’re 35 or older or you have certain medical conditions. Others will wait until you’ve had three consecutive losses. In certain situations, such as if you had a second-trimester miscarriage or an early-third-trimester premature birth from a weakened cervix, you might be referred to a high-risk specialist after a single loss so your pregnancy can be carefully managed.
Conceiving again after a miscarriage
You may have to wait a bit. Whether you miscarry spontaneously, with the help of medication, or have the tissue removed, you’ll generally get your period again in four to six weeks.
Some practitioners say you can start trying to conceive again after this period, but others recommend that you wait until you’ve been through another menstrual cycle so that you have more time to recover physically and emotionally. (You’ll need to use birth control to prevent conception during this time, because you may ovulate as early as two weeks after you miscarry.)
How to cope after a miscarriage
Though you may be physically ready to get pregnant again, you may not feel ready emotionally. Some women cope best by turning their attention toward trying for a new pregnancy as soon as possible. Others find that months or more go by before they’re ready to try to conceive again. Take the time to examine your feelings, and do what feels right for you and your partner. For more information see our article on coping with pregnancy loss.
You may find help in a support group (your caregiver can refer you to one) or in our Community’s miscarriage support discussions.
If you’re feeling overwhelmed by your sadness, call your caregiver. She can put you in touch with a therapist who can help.
What is stillbirth?
When a baby dies in utero at 20 weeks of pregnancy or later, it’s called a stillbirth. (When a pregnancy is lost before 20 weeks, it’s called a miscarriage.) About 1 in 160 pregnancies ends in stillbirth in the United States. Most stillbirths happen before labor begins, but a small number occur during labor and delivery.
If you’ve recently received the heartbreaking news that your baby has died in the womb, your grief may be overwhelming. To find support, see the last section of this article or see our articles on coping with pregnancy loss and honoring a baby who dies in pregnancy.
How is stillbirth diagnosed?
A pregnant woman may notice that her baby is no longer moving and visit her healthcare provider, or she may find out at a regular prenatal visit. The provider listens for the baby’s heartbeat using a handheld ultrasound device called a Doppler. If there’s no heartbeat, an ultrasound is done to confirm that the heart has stopped beating and the baby has died.
Sometimes the ultrasound provides information that helps explain why the baby died. The practitioner also does blood tests to help determine – or rule out – potential causes. In addition, you may opt to have an amniocentesis to check for chromosomal problems that might have caused or contributed to the stillbirth. (You’re likely to get more complete information about your baby’s chromosomes from an amnio than from tissue samples after delivery.)
How is a stillborn child delivered?
Some women need to deliver without delay for medical reasons, but others may be allowed to wait a while, to prepare for delivery or give labor a chance to begin on its own. During this time, their provider follows them closely to make sure they’re not developing an infection or blood clotting problems.
Most women, though, choose to have labor induced soon after they learn of their baby’s death, either through labor and delivery or through a procedure performed under local or general anesthesia.
Labor and delivery
If a woman’s cervix has not begun to dilate in preparation for labor, her caregiver may insert medicine into her vagina to start that process. Then she gets an IV infusion of the hormone oxytocin (Pitocin) to stimulate uterine contractions. The vast majority of women are able to deliver vaginally.
Dilation and evacuation (D&E)
If a woman is still in her second trimester and she has access to an experienced practitioner, she may be able to have the baby’s body removed in a procedure known as dilation and evacuation (D&E). During the D&E, she’s put under general anesthesia or given IV sedation and local anesthesia while the doctor dilates her cervix and removes her baby.
For women who have a choice between these two delivery options, here are a few factors to consider:
The D&E may be a better choice for women who prefer a rapid, more detached procedure. And in experienced hands, women are less likely to have complications from a D&E than from an induction, though the risk of complications is low for both procedures.
Induction may be a better choice for women who want to experience birth as part of their grieving process and who want the option of seeing and holding their child. In addition, an autopsy of the baby after an induction may provide more clues about the cause of the stillbirth than one done after a D&E.
What happens after the baby is delivered?
Patients and their healthcare providers should discuss beforehand what will happen. Patients can let their provider know if they want to hold their baby or perform cultural or religious rituals soon after birth.
The medical team can do tests to try to determine the cause of the stillbirth. First they examine the placenta, membranes, and umbilical cord right after delivery. Then they ask permission to have these tissues thoroughly analyzed in the lab and to do genetic testing and an autopsy on the baby.
This may be difficult for parents who are grieving for their child. And even a thorough evaluation may not answer the question of why the baby died.
On the other hand, parents may learn valuable information. For example, if the stillbirth was the result of a genetic problem, the mother can be on the lookout for it in her next pregnancy. Or she may find out that the cause is something that’s unlikely to recur, such as an infection or a random birth defect, which may be reassuring if she wants to become pregnant again.
Providers can explain to parents what might be learned from an autopsy, how it’s done, and what it would cost. (Autopsies aren’t always covered by insurance and can cost up to $1,500.) For parents who decide not to have a complete autopsy done, there are less invasive tests that may provide some useful information. These include X-rays, MRI, ultrasound, and tissue sampling.
Tests are also done on the mother, along with a thorough evaluation of her medical, obstetric, and family history for clues to the cause of the stillbirth.
What are the causes of stillbirth?
In many cases, the cause of death is never discovered, even after a thorough investigation. And sometimes more than one cause contributes to a baby’s death.
Common causes include:
- Poor fetal growth. Babies who are growing too slowly have a significantly increased risk of stillbirth, especially those whose growth is severely affected.
- Placental abruption. Placental abruption, when the placenta starts to separate from the uterus before a baby is delivered, is another common cause of stillbirth.
- Birth defects. Chromosomal and genetic abnormalities, as well as structural defects, may result in stillbirth. Some stillborn babies have multiple birth defects.
- Infections. Infections involving the mother, baby, or placenta are another significant cause of stillbirth, particularly when they occur before 28 weeks of pregnancy. Infections known to contribute to stillbirth include fifth disease, cytomegalovirus, listeriosis, and syphilis.
- Umbilical cord accidents. Accidents involving the umbilical cord may contribute to a small number of stillbirths. When there’s a knot in the cord or when the cord is not attached to the placenta properly, the baby may be deprived of oxygen. Cord abnormalities are common among healthy babies, however, and are rarely the primary cause of stillbirth.
- Other events, such as lack of oxygen during a difficult delivery or trauma (from a car accident, for instance), can also cause stillbirth.
What puts some women at higher risk for stillbirth?
Anyone can have a stillbirth, but some women are more at risk than others. The odds of having a stillborn baby are higher if the mother:
- Had a previous stillbirth or intrauterine growth restriction in a previous pregnancy. A history of preterm birth, pregnancy-induced hypertension, or preeclampsia increases the risk, too.
- Has a chronic medical condition such as lupus, hypertension, diabetes, kidney disease, thrombophilia (a blood clotting disorder), or thyroid disease.
- Develops complications in this pregnancy, such as intrauterine growth restriction, pregnancy-induced hypertension, preeclampsia, or cholestasis of pregnancy.
- Smokes, drinks, or uses certain street drugs during pregnancy.
- Is carrying twins or more.
- Is obese.
Other factors come into play, too. African American women are about twice as likely as other American women to have a stillborn baby. Women who haven’t had a baby are also at higher risk.
There’s some evidence suggesting that women who become pregnant as a result of in vitro fertilization (IVF) or a procedure called intracytoplasmic sperm injection (ICSI) have a higher risk of stillbirth, even if they aren’t carrying multiples.
Age – at either end of the spectrum – affects risk as well. Both teens and older pregnant women are more likely to have a stillbirth than women in their 20s and early 30s. The increase in risk is most marked in teens under 15 years old and women age 40 and older.
For teens, experts suspect both physical immaturity and lifestyle choices may contribute to the higher risk. Older women are more likely to conceive a baby with lethal chromosomal or congenital abnormalities, to have chronic conditions like diabetes and high blood pressure, and to be carrying twins, all of which are risk factors for stillbirth.
How can I reduce my risk of stillbirth?
Before you get pregnant
If you’re not yet pregnant, schedule a preconception visit with your healthcare provider. This will give you a chance to identify and treat any problems that have come up since you were last seen. And if you have a chronic medical condition, such as diabetes or high blood pressure, you can work with your provider to make sure it’s under control before you try to conceive.
Let your provider know about any prescription medication you’re taking, so adjustments can be made if necessary. And check with your provider before taking over-the-counter and herbal medications to find out if they’re safe (and in what amount) during pregnancy.
Take 400 micrograms of folic acid a day (alone or in a multivitamin), beginning at least a month before you start trying to get pregnant. Doing so can significantly reduce your baby’s risk of neural tube birth defects, such as spina bifida.
If you’re obese, consider losing weight before you attempt to conceive. (Never try to lose weight during pregnancy, though.) Your caregiver can help you figure out how to get down to a healthy weight. Guidelines from the Institute of Medicine recommend that obese pregnant women limit their weight gain to between 11 and 20 pounds.
While you’re pregnant
Don’t smoke, drink alcohol, or use street drugs during pregnancy. If you’re having trouble giving up cigarettes, alcohol, or drugs, ask your provider for a referral to a program that can help you quit. Research has shown that women who quit smoking after their first pregnancy reduce their risk of stillbirth in the next pregnancy to the same level as nonsmokers.
Call your provider right away if you have any vaginal bleeding in the second or third trimester. This can be a sign of placental abruption. Other signs to report to your provider immediately include uterine tenderness, back pain, frequent contractions or a contraction that stays hard (like a cramp that doesn’t go away), and a reduction in your baby’s activity.
Your practitioner may recommend that you do a daily kick count starting around 28 weeks of pregnancy. One approach is to record how long it takes the baby to make ten distinct movements. If you count fewer than ten kicks in two hours, or if you feel that your baby is moving less than usual, contact your healthcare provider immediately so you can be evaluated and monitored, as necessary.
Be aware of other symptoms that could signal a problem during pregnancy and call your caregiver without delay if you suspect something’s wrong.
If you’ve previously had a stillbirth (or have a high-risk pregnancy for other reasons), you’ll be carefully monitored throughout pregnancy and begin fetal testing during the third trimester, usually starting at 32 weeks. You’ll have tests to monitor your baby’s heart rate, including nontress tests and biophysical profiles. If the results indicate that your baby would be better off delivered than remaining in utero, you’ll be induced or have a c-section.
I’ve had a stillbirth. What’s the risk of it happening again?
If your medical team wasable to determine what caused your stillbirth, they may be able to provide some information about your chances of suffering another loss.
The chances are greater, for instance, if you have a medical condition that’s still present, such as lupus, chronic hypertension, or diabetes, or if you had a pregnancy complication that makes another stillbirth more likely, such as a placental abruption.
But even if the cause of your stillbirth isn’t likely to recur, you may be very anxious in future pregnancies. It’s hard not to worry that it will happen again.
Review your situation with your provider before trying to get pregnant again. (If you’re seeing a different healthcare provider, make sure the new provider has access to your complete record, including lab results.)
You may also want to consult with a perinatologist (a high-risk specialist), if one’s available in your community, and other specialists, as needed. For example, if your baby suffered from a genetic disorder, a genetic counselorcan help you understand your risk of stillbirth or other complications in another pregnancy.
Where can I get more information or support?
- The National Institute of Child Health and Human Development has established the Stillbirth Collaborative Research Network to research the causes of stillbirth and provide support for families experiencing this loss.
- The International Stillbirth Alliance is a coalition of organizations dedicated to understanding and preventing stillbirth and caring for bereaved families.
- The Maternal and Child Health Library at Georgetown University provides information on infant death and pregnancy loss.
- First Candle (formerly the SIDS Alliance) provides information and supports research aimed at preventing SIDS and stillbirth. It also offers grief support to those affected by the death of a baby.
What is early pregnancy failure?
Early pregnancy failure (also known as blighted ovum or anembryonic gestation) is a common cause of miscarriage. It happens when a fertilized egg implants in the uterus but never develops into an embryo. If you have an early pregnancy failure, you may not find out about it until the end of your first trimester.
What will happen if I have an early pregnancy failure?
With an early pregnancy failure, you’ll still get a positive result on a pregnancy test, because the placenta begins to develop and starts to secrete human chorionic gonadotropin (hCG), the hormone that these tests look for. Early on, you may also have some common pregnancy symptoms , such as fatigue, nausea, and sore breasts. Later, when the hormone levels begin to go down, these symptoms will subside and you’re likely to have spotting or bleeding.
At first you might notice some reddish-brown staining. Later you might have cramps or bleeding as your hormone levels recede. If you’re having cramps or bleeding, or your uterus isn’t growing as it should, or if your healthcare practitioner can’t hear the baby’s heartbeat with a Doppler by 12 weeks or so, you’ll have an ultrasound to check on your baby. If it’s a case of early pregnancy failure, the ultrasound will show an empty gestational sac.
You’re likely to miscarry – that is, to expel the gestational sac and accumulated tissue – by the end of your first trimester, though it may happen earlier than that. The miscarriage process can take weeks, though, and once you find out you aren’t carrying a baby, you may find it’s too emotionally wrenching or physically uncomfortable (if you’re cramping a lot) to wait for a spontaneous miscarriage.
In that case, you may be able to use medication to speed up the miscarriage process. Or you may decide to have a procedure – a suction curettage or a dilation and curettage (D&C) to remove the tissue. You’ll need to have the tissue removed if you have any problems that make it unsafe to wait for a miscarriage, such as significant bleeding or signs of infection.
When can I try to conceive again?
Some practitioners recommend waiting to conceive until you’ve had a period, which is likely to happen four to six weeks after you miscarry or have the tissue removed. (You’ll need to use birth control while you wait, since you may ovulate as early as two weeks after you miscarry.)
After that, you’re in the clear. And one Scottish study of over 30,000 women concluded that women who get pregnant within six months of having a miscarriage actually have the best odds of having a healthy pregnancy. Those women had fewer miscarriages or ectopic pregnancies than women who got pregnant six to 12 months after their miscarriage.
However, while you may be physically ready to get pregnant again, you might not feel ready emotionally. Every woman copes with the grief of early pregnancy loss in her own way, and some women find it takes months until they’re interested in trying to conceive again.
Does having an early pregnancy failure once mean I’m likely to miscarry again?
No. Although you’re likely to be worried about the possibility of another miscarriage, fertility experts don’t consider a single early pregnancy loss to be a sign that there’s anything wrong with you or your partner. Most practitioners will wait until a woman has had two or three consecutive miscarriages to order special blood and genetic tests to try to find out what’s going wrong.
What is a molar pregnancy?
A molar pregnancy happens when a fertilized egg develops into a growth called a mole instead of into a normal embryo. You may still have typical pregnancy symptoms in the beginning. But eventually you’ll have bleeding and other symptoms that indicate something is wrong.
It can be scary and sad to lose a pregnancy this way. But as long as you get proper treatment, you’re unlikely to have any long-term physical consequences.
How common are molar pregnancies?
About 1 in 1,500 pregnancies in the United States is a molar pregnancy. If you’re under age 20 or over age 35, or if you’ve had a previous molar pregnancy, or two or more miscarriages, your chances of having a molar pregnancy are higher. Women of Southeast Asian descent also seem to have a higher risk of molar pregnancy.
What causes a molar pregnancy?
A molar pregnancy happens when there are certain problems with the genetic information (the chromosomes) in the fertilized egg at conception. The result is that the egg may develop into a growth with no embryo (this is called a complete mole) or an abnormal embryo (a partial mole).
In normal pregnancies, the fertilized egg contains 23 chromosomes from the father and 23 from the mother. This isn’t the case with a molar pregnancy.
In most complete molar pregnancies, the fertilized egg contains two copies of the chromosomes from the father and none from the mother. In this case, there’s no embryo, amniotic sac, or any normal placental tissue. Instead, the placenta forms a mass of cysts that looks like a cluster of grapes.
In most partial molar pregnancies, the fertilized egg has the normal set of chromosomes from the mother and two sets from the father, so there are 69 chromosomes instead of the normal 46. (This can happen when chromosomes from the sperm are duplicated or when two sperm fertilize the same egg.)
In a partial molar pregnancy, there’s some normal placental tissue among the cluster of abnormal tissue. The embryo does begin to develop, so there may be a fetus or just some fetal tissue or an amniotic sac. But even if a fetus is present, in most cases it’s so abnormal that it can’t survive.
How would I know if I had a molar pregnancy?
Early on, you might have typical pregnancy symptoms, but at some point you’ll begin to have some spotting or heavier bleeding. It might be bright red or a brownish discharge, continuous or intermittent, light or heavy. This bleeding could start as early as six weeks into your pregnancy or as late as 12 weeks.
You might also have severe nausea and vomiting, abdominal cramping, and abdominal swelling (because your uterus may grow more rapidly than usual).
Some women develop preeclampsia before midpregnancy if they have an undiagnosed molar pregnancy. However, because ultrasound helps practitioners diagnose molar pregnancies earlier these days, it’s rare to carry one long enough for this condition to develop.
Call your doctor or midwife right away if you have any spotting or bleedingduring your pregnancy. These symptoms don’t necessarily signal a molar pregnancy, but your practitioner will probably order an ultrasound to find out what’s causing them and may do a blood test to measure your levels of the hormone hCG. If you do have a molar pregnancy, the ultrasound will show cysts that look like a cluster of grapes in your uterus, and your levels of hCG will be higher than normal.
What’s the treatment for a molar pregnancy?
If you’re diagnosed with a molar pregnancy, you’ll need a D&C (dilation and curettage) or suction curettage to remove the abnormal tissue. This procedure can be done under general or regional anesthesia, or you can be sedated intravenously.
To perform a D&C, the doctor inserts a speculum into the vagina, cleans the cervix and vagina with an antiseptic solution, and dilates the cervix with narrow metal rods. She then passes a hollow plastic tube through the cervix and suctions out the tissue from the uterus. Finally, she uses a spoon-shaped instrument called a curette to gently scrape the rest of the tissue from the walls of the uterus.
You’ll most likely also have a chest X-ray afterward to see whether abnormal cells from the molar pregnancy have spread to your lungs. It’s rare for these cells to spread to other parts of the body, but if they do, the lungs are the most common site.
Your practitioner will then want to monitor your levels of hCG once a week to make sure they’re declining – an indication that no molar tissue remains. Once the levels go down to zero for a few weeks in a row, you’ll still have to have them checked every month or two for the next year.
Occasionally, abnormal cells remain after the tissue is removed. This happens in up to 11 percent of women with partial moles and 18 to 29 percent of women with complete moles and it’s called persistent gestational trophoblastic neoplasia.
In most cases, the persistent moles can be treated with chemotherapy. But a very small number of them (1 in 20,000 to 40,000) will advance to a form of malignant cancer called gestational choriocarcinoma.
With prompt and appropriate treatment, nearly 100 percent of cases of gestational choriocarcinoma are curable when it hasn’t spread beyond the uterus. Even in rare cases in which the abnormal cells have spread to other organs, 80 to 90 percent of cases can be cured. After you’re in complete remission, you’ll need to have your hCG levels monitored for a year, and possibly other regular testing.
(One thing to note: If you decide you don’t want another pregnancy, you might opt for a hysterectomy instead of a D&C, because it lowers your risk that the abnormal cells will return. Women over 40 who have complete moles are often offered this option because they’re at particular risk.)
When can I try to get pregnant again?
No matter what kind of treatment you’ve received, you’ll need to wait a year after your hCG levels go back down to zero before trying to get pregnant again. If you got pregnant before then, your hCG levels would rise and it would be impossible for your practitioner to tell whether abnormal tissue was growing back.
The good news is that having a molar pregnancy doesn’t affect your fertility or ability to have a normal pregnancy, even if you’ve had chemotherapy. You’re not at any increased risk for stillbirth, birth defects, preterm delivery, or other complications. And your odds of having another molar pregnancy are only 1 to 2 percent. You’ll have a first-trimester ultrasound in any subsequent pregnancies to make sure all is well.
How can I cope with my sense of fear and loss?
Having a molar pregnancy can be frightening. Like any woman who has miscarried, you’re dealing with the loss of your pregnancy, but in this case, you’ve had an unusual condition that most people have never heard of and you’re concerned for your own health as well.
You’ll have to go in for at least a year of weekly or monthly follow-up visits before you can try to conceive again, and you may be very anxious about the possibility of having persistent abnormal cells. If you do have persistent disease, treatment with chemotherapy can be very draining and can delay your next pregnancy even longer.
You may feel devastated by your experience. Your partner may also be feeling sad or helpless and may have trouble figuring out how to express those feelings or how to be supportive. It’s perfectly okay to seek counseling if you think it will help you or your partner. Ask your caregiver where to get counseling or find support groups.