Inevitable miscarriage is one of the unfortunate ways women can unintentionally lose a pregnancy. An inevitable miscarriage causes vaginal bleeding and cramping. During examination, a gynecologist will be able to see that woman's cervix is dilated and the uterus contains evidence of the miscarriage. Ultrasound and fetal heart rate testing will also show that the pregnancy has ended. While the body will usually pass this tissue through the cervix and vagina, this process can be painful and emotionally troubling. In some cases, the products of conception may not pass on their own, which may cause severe bleeding and/or infection, which can be fatal if left untreated. Fortunately, women have several options to remove the tissue of the ended pregnancy, which we will discuss.
The subject of miscarriage includes several confusing and even controversial terms. This, in itself, can add to difficultly of this troubling time. Therefore, we describe the key terms of miscarriage.
The term abortion is an emotionally and politically charged word. However, abortion is also a medical term that refers to a pregnancy that is expelled from the uterus prior to 20 weeks of gestation. In other words, any time a fetus leaves the womb within the first 20 weeks of pregnancy is called an abortion.
The medical term for miscarriage is “spontaneous abortion,” which means the pregnancy ended early due to natural causes or trauma, not a medical procedure. Due to weight associated with the term, we will use the term miscarriage instead of abortion for the remainder of this article.
Types of Miscarriage
There are five main types of miscarriage. In a threatened miscarriage, the pregnancy may continue successfully or it may progress to a lost pregnancy. The other four forms of miscarriage, list below, indicate that the pregnancy has ended.
- Inevitable miscarriage – Vaginal bleeding, cramping, dilated cervix, tissue in the uterus
- Incomplete miscarriage – Vaginal bleeding, cramping, dilated cervix, tissue in the uterus
- Missed miscarriage – Usually no symptoms, cervix is not dilated
- Complete miscarriage – The fetus and placenta are fully expelled from the body
Your gynecologist will be able to run additional tests to determine if a miscarriage has occurred and what type it is. This testing will include a pelvic examination, and may include heart rate measurements and ultrasound testing. If the pregnancy has ended, your gynecologist will discuss treatment options.
What to do When a Pregnancy has Ended
In an inevitable, incomplete, or missed miscarriage, the remaining tissue (fetus, placenta, and amniotic sac) must leave the body. The first decision a woman must make is whether to let this process happen on its own or to undergo treatment to facilitate the process.
The body should eventually eject the remaining tissue from the body without the need for a medical treatment or surgical procedure. Allowing the body to expel the tissue this way is called expectant management. The main advantage to expectant management is the woman avoids a medication or surgical procedure. Unfortunately, the timing of process is unpredictable, and it causes pain and bleeding. Women will not know when the process will occur or exactly how long it will take. It usually starts with spotting or light bleeding, less than a typical period. Heavier bleeding and cramping increase over two to four hours followed by intense cramping and pain as the tissue is expelled through the cervix, exiting through the vagina. There may be crampy pain for up to two weeks after the tissue has been expelled.
Expectant management is usually only appropriate for pregnancies up to 14 weeks gestation. Women should also be in good health and have no signs of infection. It may take two weeks for the body to expel the tissue after an incomplete miscarriage, and it usually takes three to four weeks in a missed miscarriage. If the process does not happen within four weeks, surgical evacuation is recommended.
Evacuation Using Medication
Certain drugs can speed up the rate that the body expels the tissue. When a drug is given for this purpose, it is called medication evacuation. Unless there is a strong reason not to use it, misoprostol is the drug of choice for medication evacuation. It is the drug of choice because it is relatively inexpensive and safe. It may be given orally, under the tongue, or placed in the vagina, depending on the type of miscarriage. Other drugs used for medication evacuation include methotrexate, or tamoxifen, but they do not appear to be any better than misoprostol.
It is important to note that medication evacuation does not necessarily mean the tissue will be expelled immediately. In one study of women who used misoprostol for medication evacuation, 71% had fully expelled the tissue within 3 days and 84% by 8 days. For the remaining 16% of women, the misoprostol did not expel the tissue within four weeks of taking the drug.
The most definitive way to remove remaining tissue after an inevitable, incomplete, or missed miscarriage is through surgical evacuation. As the name suggests, a surgical evacuation is a surgical procedure to remove the remaining tissue from the uterus. The surgical procedure has many names—dilation and curettage, dilation and evacuation, and evacuation and curettage—but the process is the same. The cervix is dilated and tissue is removed with vacuum or surgical instruments. The procedure is performed under anesthesia, either general anesthesia (the woman is unconscious) or, more commonly, with conscious sedation and a nerve block to deaden the pain. Most surgical evacuations are performed in an operating room, but some doctors may perform the procedure in the clinic. In either case, the procedure is same day surgery; no hospitalization is required.
Surgical evacuation is reasonably safe and highly effective. Only 3% of women undergoing the surgical evacuation still had remnants of tissue after the procedure. The vacuum procedure is generally safer than the one that uses cutting instruments; the procedure is faster, and there is less blood loss and pain with vacuum. Severe complications are rare, but damage to the uterus may interfere with the woman’s ability to become pregnant in the future.
A miscarriage is an emotionally difficult experience, especially when the end of the pregnancy is not the end of the process. Women may choose to allow the process to proceed on its own or choose a medication or surgical evacuation. Women who wish to avoid the pain and bleeding of expectant management or medication evacuation may consider surgical evacuation performed by an experience medical provider.