Miscarriage & Loss
(including complete, incomplete, or missed miscarriage)
What is early pregnancy loss (EPL)?
Early pregnancy loss (EPL), also referred to as a miscarriage, is the loss of pregnancy during the first 13 weeks of pregnancy
1 in 5 pregnancies end in loss; most often in the first trimester.
If you are facing an early pregnancy loss, we want you to know first and foremost, you did nothing to cause the loss. It is not your fault. Even though early pregnancy loss is a common experience, this does not make it any less difficult or painful. Your mental health is important, so ask for support if you need it. Everyone’s physical and psychological experience of loss is different. The wide range of emotions people feel when experiencing a pregnancy loss can be normal, and know what resources are available to you to support you through a loss.
After leaving an Emergency Department, you may also have uncertainty about what to expect and what may take place over the next few days to several weeks.
Depending on the stage you are in your loss, will determine what your physical experience of loss will be over the next few days to weeks.
The three types of early pregnancy loss include:
Click on the type of early pregnancy loss above to learn more about each.
What are the signs and symptoms of possible pregnancy complications/loss?Bleeding: Usually the first sign of early pregnancy loss is bleeding from the vagina. Vaginal bleeding may be light or heavy, constant or on and off. Pain/cramping: Usually in the lower belly or lower back. Passing tissue: In early pregnancy loss, dark red blood clots or thick stringy material may pass from the vagina. However, not all pain or bleeding ends with a pregnancy loss. Conversely, some people don’t have any symptoms at all when they experience a loss.
Tell me about pregnancy loss.Early pregnancy loss—a miscarriage in the first 13 weeks—happens in about one in five pregnancies. If it happens, it is most likely to occur within the first trimester of pregnancy. The most common sign of a miscarriage is bleeding. But not all pain or bleeding ends with a miscarriage. In fact, roughly half of all pregnancies will have spotting at some point in the pregnancy.
How do I know what’s normal or not? When should I seek medical attention?There are many causes of vaginal bleeding during early pregnancy (first trimester). Roughly 50% of all pregnancies will have some amount of bleeding during this time. Sometimes bleeding is a sign of a miscarriage but often it is not. Bleeding should not be ignored and should always be reported and investigated with your health care providers. If you are experiencing vaginal bleeding or pain, you should seek medical attention. If the bleeding is mild, it may be appropriate to follow-up with your family physician, midwife, or obstetrician, on an urgent basis, at your provider's discretion. If none of these options are available to you in the next one to three days, you may need to go to your local emergency department. Common causes of bleeding in the first trimester can include: i. Implantation bleeding: this is usually light bleeding or spotting that can happen when the fertilized egg implants in the uterus. ii. Subchorionic hemorrhage (or hematoma): this occurs when blood collects under one of the membranes (chorion) surrounding the embryo in the uterus. This is generally not dangerous to your pregnancy and usually resolves on its own. iii. Cervical bleeding: The cervix may bleed more during pregnancy as blood vessels are developing in this area. It is possible to have cervical bleeding after sex, a pap test, or a pelvic exam. iiii. Cervical polyp: This is a usually benign growth on the cervix that can bleed. v. Infection: such as urinary tract infection (UTI), sexually transmitted infections (STIs), or yeast infections. vi. Ectopic pregnancy: An ectopic pregnancy happens when the embryo implants outside of the uterus. The most common location is inside one of the fallopian tubes. If it grows in the fallopian tube, it can cause the tube to burst (rupture). An embryo cannot grow normally outside of the uterus and so these pregnancies will not be successful. vii. Early pregnancy loss: also referred to as a miscarriage, is the loss of pregnancy during the first 13 weeks of pregnancy (first trimester).
Should I go to the emergency department?Go to the nearest emergency department if you: Suddenly have severe pain in your abdomen that is not going away or helped with acetaminophen (Tylenol) Suddenly feel faint or like you are passing out Have very heavy bleeding (soaking more than three pads in three hours) Have chills or a fever higher than 38°C (100.4°F) These are what health care providers call ‘red flags’. These could be an indication that the pregnant person is in danger and should seek care in their nearest emergency department immediately.
I’m experiencing bleeding/pain during pregnancy, how do I find out if I am experiencing pregnancy loss?The two tests that are most helpful in determining if a pregnancy is not developing as expected or if it has ended are: 1) an ultrasound (a medical scan); and 2) a blood test (B-hCG) The blood test for human chorionic gonadotropin (hCG) is a hormone made by the developing placenta. A low or decreasing level of hCG can mean loss of the pregnancy.
What should I plan to bring if I’m going to the emergency department?It is unpredictable how long the wait time may be in the emergency department. In general, prepare for a lengthy visit. This may mean you may need to make necessary arrangements for work, child care, and/or transportation. Click here to read more about what to expect in the emergency department. Be sure to bring: Health card Relevant prior test results (bloodwork or ultrasound records if you have them) Water bottle Snack Phone and phone charger Reading materials
Types of Early Pregnancy Loss
A Complete Miscarriage occurs when all the pregnancy-related tissue has passed out of the uterus.
If you are diagnosed with a Complete Miscarriage at the Emergency Department or subsequent visits, you may continue bleeding for up to several weeks following the miscarriage. The bleeding can, at times, be heavy, including having to change thick maxi-pads every several hours or experiencing severe (but intermittent and resolving) pain and cramps. The bleeding, when heavy, can also have blood clots, which look like dark jelly. The bleeding, when heavy, can also have blood clots, which look like dark jelly. While this appearance can be scary, it is often normal.
If you are experiencing very heavy bleeding (soaking more than three pads in three hours), have severe pain that is not going away with Tylenol or suddenly feel faint or feel like passing out, go to the nearest Emergency Department.
You should have follow-up with your Family Doctor, and obstetrical care provider, or an early pregnancy clinic within one to two weeks following a Complete Miscarriage. At this follow-up appointment, the doctor will tell you if any additional blood work or ultrasounds are needed.
An Incomplete Miscarriage is one in which only some of the pregnancy-related tissue has left the body and some pregnancy tissue remains in the uterus. In this situation, vaginal bleeding and cramping may have already occurred.
If you are diagnosed with an Incomplete Miscarriage at the Emergency Department or subsequent visits, the doctor may have suggest different management options going forward.
Click links above to learn more about the management options for pregnancy loss.
A Missed Miscarriage is a pregnancy that stopped developing and there were not any symptoms such as vaginal bleeding to signal the pregnancy was ending in loss.
While the terminology ‘Missed’ can be confusing and difficult to hear, please know that you did not do anything wrong and that you did not ‘miss’ anything.
If you are diagnosed with an Missed Miscarriage at the Emergency Department or subsequent visits, the doctor may have suggest different management options going forward.
There are three management options for people with Missed Miscarriage: expectant, medical, and surgical management.
Click links above to learn more about the management options for pregnancy loss.
Management Options for Pregnancy Loss
A “watchful waiting” management approach is one in which the early pregnancy loss is not actively treated. The goal in expectant management is for the pregnancy to expel from the uterus without intervention (i.e. without medications or surgery).
For some individuals, they may choose to this option if bleeding has already started. Others may choose this option if there was early pregnancy loss confirmed, but have not started bleeding, and would prefer the process to naturally occur. This process may take days or weeks to complete, sometimes even two weeks or longer.
Sometimes expectant management will not be successful, and medication or surgery will be necessary.
Another option is to use medications to help the miscarriage progress faster. Some may prefer this in order to have greater control and predictability over the process.
Two medications that can be used are: 1) misoprostol alone, or 2) mifepristone and misoprostol combined (brand name Mifegymiso). Depending on how the medications are prescribed, they may be taken orally or inserted vaginally.
Misoprostol is used to dilate the cervix and assist with expulsion of the products of conception from the uterus. For those who have had miscarriages where bleeding has not already commenced, recent evidence supports pre-treatment with a medication called mifepristone, versus misoprostol alone, as it may increase the likelihood of completely expelling the gestational sac and avoiding surgical management. If you are prescribed mifepristone and misoprostol combined (brand name Mifegymiso), mifepristone 200 mg is given first and taken orally, followed by misoprostol 24 hours later. Currently, mifepristone in addition to misoprostol is not available at all pharmacies or hospitals in Ontario.
The use of these medications will cause increased cramping and bleeding over the following several hours in attempt to help pass the pregnancy tissue. For some, they may find it occurs quickly within the next 2 - 4 hours, for others, it may take 24 - 48 hours. The bleeding may be similar to a menstrual period or heavier. Some may continue to experience bleeding and cramping for up to 2 weeks, even after the passage of tissue. Additional side effects may include diarrhea, nausea, chills or severe cramping. Pain from the cramping may be reduced with use of acetaminophen/Tylenol (up to 2 extra strength, every 6 hours), and can be taken in addition to a non-steroidal anti-inflammatory such Advil (up to 2 extra strength, every 8 hours) or naproxen/Aleeve. Sometimes a narcotic may also be prescribed.
If you opt for medical management, you should also receive information from your prescriber on expected changes in bleeding, how to manage pain and nausea, and who to contact if bleeding does not start within 24 hours.
Unfortunately in some cases, medical management may not be successful and may require further assessment and/or additional medications or surgical management.
This approach involves vacuum uterine aspiration or dilatation and curettage (D&C) to surgically remove the pregnancy from the uterus.
After any of these options, you may continue bleeding for up to several weeks following the miscarriage. The bleeding can, at times, be heavy, including having to change thick maxi-pads every several hours or experiencing severe (but intermittent and resolving) pain and cramps. The bleeding, when heavy, can also have blood clots, which look like dark jelly. While this appearance can be scary, the amount of bleeding is concerning if you experience Red Flags (see below). If these Red Flags occur, you should return to the Emergency Department.
You should have follow-up with your Family Doctor, and obstetrical care provider, or an early pregnancy clinic within one to two weeks following a Missed Miscarriage. At this follow-up appointment, the doctor will tell you if any additional blood work or ultrasounds are needed.
Go to the nearest emergency department if you:
Suddenly have severe pain in your abdomen that is not going away or helped with acetaminophen (Tylenol)
Suddenly feel faint or like you are passing out
Have very heavy bleeding (soaking more than three pads in three hours)
Have chills or a fever higher than 38°C (100.4°F)