New laws and lawsuits threaten safe and effective miscarriage care in the United States.
When you first learned the facts about pregnancy — from a relative, perhaps, or a friend — you probably didn’t learn that up to one in three people end in miscarriage. .
What causes a miscarriage? How is it treated? And why is proper miscarriage health care under scrutiny — and in some parts of the United States, becoming harder to find?
What is a miscarriage?
Many people who come to us for care are excited and hopeful about starting their families. It’s devastating when an expected pregnancy ends early.
Miscarriage is a catch-all term for pregnancy loss before 20 weeks, counting from the first day of the last menstrual period. Miscarriage occurs in one in three pregnancies, although the risk gradually decreases as the pregnancy progresses. At 20 weeks, it occurs in less than 1 in 100 pregnancies.
What causes a miscarriage?
Usually there is no obvious or single cause of miscarriage. Certain factors increase the risk, such as:
- Pregnancy at an advanced age. Chromosomal abnormalities are a common cause of pregnancy loss. As people age, this risk increases.
- Autoimmune disorders. While many pregnant women with autoimmune diseases like lupus or Sjogren’s syndrome have successful pregnancies, their risk of pregnancy loss is higher.
- Some diseases. Diabetes or thyroid disease, if poorly controlled, can increase the risk.
- Certain conditions in the womb. Uterine fibroids, polyps, or malformations can contribute to miscarriage.
- Previous miscarriages. A miscarriage slightly increases the risk of miscarriage in the next pregnancy. For example, if a pregnant woman’s risk of miscarriage is one in 10, it may increase to 1.5 in 10 after her first miscarriage and four in 10 after three miscarriages.
- Certain medications. A developing pregnancy can be affected by certain medications. It is safer to plan for pregnancy and receive pre-pregnancy counseling if you have a chronic illness or condition.
How is a miscarriage diagnosed?
Before ultrasounds in early pregnancy became widely available, many miscarriages were diagnosed based on symptoms such as bleeding and cramping. Now people can be diagnosed with miscarriage or early pregnancy loss during a routine ultrasound before they notice any symptoms.
How is a miscarriage treated?
Being able to choose the next step in treatment can help emotionally. When there are no complications and the miscarriage occurs in the first trimester (up to 13 weeks of pregnancy), the options are:
Do not act. Passing blood and pregnancy tissue often happens at home naturally, without the need for medication or a procedure. Within a week, 25% to 50% will pass pregnancy tissue; more than 80% will do so within two weeks.
What there is to know: This may be a safe option for some people, but not all. For example, heavy bleeding would not be safe for someone with anemia (lower than normal number of red blood cells).
Take medicine. The most effective option uses two drugs: mifepristone is taken first, followed by misoprostol. Using only misoprostol is a less effective option. The two-step combination is 90% successful in helping the body eliminate pregnancy tissue; taking misoprostol alone is 70% to 80% successful in doing so.
What there is to know: Bleeding and cramping usually start a few hours after taking misoprostol. If bleeding does not start, or if there is still pregnancy tissue in the uterus, surgery may be needed: this occurs in about 1 in 10 people using both medicines and 1 in 4 people who do not use than misoprostol.
Use a procedure. During dilation and curettage (D&C), the cervix is dilated (widened) so that instruments can be inserted into the uterus to remove pregnancy tissue. This procedure is nearly 99% successful.
What there is to know: If someone has life-threatening bleeding or shows signs of infection, this is the safest option. This procedure is usually performed in an operating room or surgery center. In some cases, it is offered in a doctor’s office.
If you miscarry in the second trimester of pregnancy (after 13 weeks), discuss the safest and best plan with your doctor. Typically, second trimester miscarriages require intervention and cannot be managed at home.
Red Flags: When to Seek Help During a Miscarriage
During the first 13 weeks of pregnancy: Contact your healthcare provider or go to the emergency room right away if you experience
- heavy bleeding combined with dizziness, lightheadedness, or feeling faint
- fever over 100.4°F
- severe abdominal pain not relieved by over-the-counter pain relievers, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). Note: Ibuprofen is not recommended during pregnancy, but can be taken safely if a miscarriage has been diagnosed.
After 13 weeks of pregnancy: Contact your healthcare provider or go to the emergency room right away if you experience
- all of the symptoms listed above
- fluid leak (your water may have broken)
- severe abdominal or back pain (similar to contractions).
How is the management of miscarriages evolving?
Unfortunately, political interference has had a significant impact on safe and effective miscarriage care:
- Some states have banned a procedure used to treat second-trimester miscarriages. Called dilation and evacuation (D&E), this procedure removes pregnancy tissue through the cervix without making any incisions. A D&E can be lifesaving in cases where heavy bleeding or infection complicates a miscarriage.
- Federal and state lawsuits, or laws banning or seeking to ban mifepristone for abortion care, directly limit access to a safe and effective medication approved for miscarriage care. This could affect miscarriage care nationwide.
- Many laws and lawsuits that interfere with miscarriage care provide a life-saving exception for a pregnant patient. However, complications from a miscarriage can develop unexpectedly and worsen quickly, making it difficult to ensure that people receive prompt care in life-threatening situations.
- States that ban or restrict abortion are less likely to have physicians trained to perform a full range of miscarriage care procedures. Additionally, clinicians-in-training, such as medical residents and medical students, may never learn to perform a potentially life-saving procedure.
Ultimately, legislation or court rulings that prohibit or restrict abortion care will reduce the ability of doctors and nurses to provide the highest quality miscarriage care. We can help by asking our legislators not to pass laws that prevent people from getting reproductive health care, such as restricting medications and procedures for abortion and miscarriage care.