The WHO and NIH define miscarriage as pregnancy loss before the first 20 weeks of gestation. Some other agencies and organizations define miscarriage as a loss of pregnancy occurring before 24 weeks of gestation. For informational purposes regarding treatment options, this website will use these three categories to define pregnancy loss:
Early miscarriage: Loss in the first trimester (within the first 13 weeks of gestation). It is also commonly referred to as Early Pregnancy Loss (EPL) and first-trimester loss.
Late miscarriage: Loss between 14 and 20 weeks of gestation.
Stillbirth: Loss after 20 weeks of gestation
Early miscarriage is more common and generally less risky than pregnancy loss occurring in the second and third trimesters. While this page predominantly focuses on Early Miscarriage treatment options, some resources providing information on treatment options for later pregnancy loss are available under "Second and third trimester loss."
While some early miscarriages can happen quickly and result in the complete passage of all pregnancy tissue within a few days to a few hours, other miscarriages can take longer. In cases where miscarriage is incomplete or missed, there are three main management options to consider: natural/expectant management, medical management, and surgical management.
"Natural" or "Expectant" management involves waiting for the miscarriage to happen on its own without medicine or a procedure. According to the American College of Obstetricians and Gynecologists (ACOG), with expectant management, approximately 80% of women and birthing people experience a complete miscarriage within 8 weeks.
Many choose expectant management because it is the least invasive of the three options. Additionally, many may feel a sense of agency or closure in allowing their body to pass the pregnancy naturally.
Medication is taken to induce the passage of the pregnancy. Those who choose medical management are generally given mifepristone at the clinic and a follow-up of misoprostol to take at home. The complete passage of pregnancy tissue generally takes up to 3 days. If, after 7 days, a complete miscarriage has still not occurred, a second round is usually given. The American College of Obstetricians and Gynecologists also reports that around 84% of medically managed miscarriages allow for the complete passage of all pregnancy tissue and remains.
Medical management can allow for more control over the time and place that a miscarriage occurs, since it generally occurs quite soon after taking the medication. For some, this is preferable to the long and unpredictable nature of expectant management, while still feeling less invasive than surgical management.
For Early miscarriage, the standard procedure is suction curettage, during which a gentle suction device is inserted through the cervix to remove the remains of your baby and pregnancy tissue. The operation can be performed in an office setting under local anesthesia or in a hospital setting under local or general anesthesia. According to the American College of Obstetricians and Gynecologists, it has an overall success rate of 99%.
While it is the most invasive of the three options, many also feel that it is the least emotionally taxing. Some of the reasons for this are listed below.
Many experiencing miscarriage wish for it to be over as quickly as possible. While Medical and Expectant management can take days or weeks, the surgical management generally takes 10-15 minutes. Also, because it happens in one sitting, there is no uncertainty as to when it will happen or when it will be over, and fewer follow-up appointments are needed.
Not having to see your baby's remains. Whether or not you want to see the remains of your baby after a miscarriage is a deeply personal and emotional decision for many. With the other two forms of management, the fact that you are passing your baby yourself means that you might see your baby's remains. While seeing the remains might give some people closure, for others, it can be highly distressing.
The option of being awake or unconscious during the procedure. For many, being awake gives more closure and makes them feel more in control of what is happening. Others find it less painful, emotionally and physically, to be unconscious during the procedure.
The medication and anesthetics given during the procedure might make it a less uncomfortable/painful process than medical or expectant management. While you may experience mild to moderate cramping after the procedure as well, it is generally considered less painful than what you might experience during medical or expectant management, and should last less long.
Some other factors that may determine how you treat your miscarriage include safety and accessibility.
The American College of Obstetricians and Gynecologists finds that all three treatment types have a low risk of complications.
However, some conditions and miscarriage complications can make surgical management the only option. The ACOG states that surgical management is necessary and urgent for those who present with hemorrhage, hemodynamic instability (shock), or signs of infection. According to the University of Iowa Healthcare, some signs of hemorrhage and shock include soaking 1 maxi pad in 1 hour for 2 to 3 hours and feeling lightheaded or dizzy. If you are exhibiting these symptoms, go to the ER. Some signs of infection include a temperature above 100.4 °Fahrenheit, and having bad-smelling vaginal blood or discharge.
Surgical management may also be necessary if both natural and medical management have failed, or if natural and medical management would be risky because you have an increased risk of hemorrhage or are especially vulnerable to the effects of a hemorrhage. Some factors that might increase the likelihood and danger of a hemorrhage during miscarriage include:
bleeding disorders
anemia
taking blood-thinning medication
being unable to receive a blood transfusion
Financial Accessibility
While cost should be the last thing anyone has to think about when going through pregnancy loss, the reality is that for many, miscarriage treatment can be a significant financial burden. Which option is most affordable depends on a variety of factors, including the state you live in, your financial status, your employer, insurance type, and the kind of healthcare facility you are treated at.
In general, expectant management is the least expensive (since you are not paying for medicine or a procedure), and surgical management under general anesthesia is the most expensive. However, surgical management under local anesthesia can be less expensive than medical management in some cases. In situations where surgical management and medical management cost a similar amount for the first round of treatment, surgical management may be more affordable. This is because surgical management is more likely to succeed on the first round of treatment than medical management, and because fewer follow-ups are required.
While you do not have to pay for natural management, for some, it could be a bigger financial burden in the long run. It can take time for a miscarriage to happen naturally. During this time, many experience contraction-like cramps, bleeding, and uncertainty as to when they might pass their baby and pregnancy tissue. This can make it very difficult, or even impossible, to work. While nobody should have to worry about going to work while experiencing a miscarriage, the unfortunate truth is that missing a couple of days of pay is not feasible for many Americans. In California, most employees are guaranteed a minimum of five days' leave for miscarriage under the Fair Employment and Housing Act. However, whether leave is paid or not depends on the employer's policy. Furthermore, many states do not require employers to give any time off for miscarriage.
Location
Many are limited by the availability of certain treatments at their local healthcare facilities. In the United States, people living in states with anti-abortion policies often struggle to get access to medical or surgical management. For example, state-level restrictions on the drug mifepristone, which is used in both abortion and miscarriage treatment, are making medical management less effective and accessible.
For help summarizing your options and making a decision, the charity Tommy's has a Management of Missed Miscarriage leaflet, which is available in English, Polish, Urdu, Romanian, Punjabi, Ukrainian, and Portuguese. Also included on the leaflet are the phone number and email for their free service that lets you speak to a midwife. Tommy's is a UK-based organization and may not be able to provide answers specific to the American healthcare system (or any other country's healthcare system) and state laws.
For more information, you can also read the leaflet Management of Miscarriage: Your Options, which goes more in-depth on the benefits and risks of each treatment type. This leaflet is from the Miscarriage Association, and like Tommy's, it is also a UK-based organization.
Pregnancy loss in the second and third trimesters is much rarer and can be incredibly shocking. Although treatment within the first few weeks of the second trimester can look a lot like Early Pregnancy loss treatment, treating pregnancy loss in later stages of gestation usually requires a D&C (a different type of surgical management) or delivery of the baby in a hospital setting. Loss in the second and third trimester can be more risky and complicated, so your course of action will most likely be informed by your doctor.
Tommy's has a page on their website that walks you through what might happen during a late miscarriage and another page for what might happen during a stillbirth. It is important to note that while in the US pregnancy loss is considered a stillbirth after the 20th week, in the UK (where Tommy's is based) pregnancy loss is only legally considered a stillbirth after the 24th week.
UC Davis Health also has a page that gives information about the treatment of a second-trimester loss. Readers should know that this site focuses more on the technical/medical side of treatment, so the language used is different from that on Tommy's website and this website. While some might prefer this over the language used on Tommy's, others might find it distressing.