Miscarriage: What happens, bleeding and duration

A miscarriage looks different for every woman: it often starts with spotting and cramps, and sometimes there are no signs at all. When the tissue passes, the bleeding is usually heavier than a period and can last up to about three weeks afterward. If you wait it out, passing the tissue takes a few days to several weeks. If a pad is soaked soon after you put it on or you feel dizzy, call 911 (or your local emergency number) right away (US information). You don’t have to read everything at night: the first steps are under “At home: What helps now”, and all warning signs are in the box at the end.

It often begins with spotting and cramping pain that feels like a period. Bleeding and pain then often become much stronger than usual, sometimes with nausea or diarrhea. The strongest pain usually comes shortly before the tissue passes and eases quickly afterward.

There is also the other way: no bleeding, no pain. Only at the ultrasound does it show that the pregnancy has stopped developing. This is called a missed miscarriage. Not feeling anything beforehand doesn’t mean you missed something. The examination includes the ultrasound and sometimes a blood test, because the hormone hCG doesn’t rise as usual when a pregnancy isn’t developing.

Bleeding in early pregnancy doesn’t automatically mean a miscarriage. Whether there is one is determined by your doctor with an ultrasound and a conversation. If the finding isn’t clear yet, for example because it is very early, the ultrasound is often repeated after one to two weeks. If you are bleeding and are or could be pregnant, call your ob-gyn’s office the same day; after hours, call the same number, as there’s usually someone on call.

On the cause: in the first weeks it is often random changes in the embryo’s genetic material that nobody caused. The vast majority of losses are due to factors you can’t influence. Blame has nothing to do with it. There is no evidence that everyday stress or normal physical activity is a cause.

How long a miscarriage takes depends on the path you choose with your doctor. If you wait it out, it can take from a few days to several weeks for the tissue to pass, and the timing can’t be planned. If you take pills, contractions and bleeding usually start within 48 hours, and passing the tissue can stretch over several days. A D&C is a short procedure with a scheduled appointment.

The pain, cramping or contraction-like, is usually strongest shortly before the tissue passes and then gets weaker. Pain relievers can help. Ask your provider’s office which one suits you or, at night, call the same number and reach the on-call provider. Tell them what you’ve already taken.

Every miscarriage is different. What friends or forums report is not a norm. The warning signs and the follow-up ultrasound are what you can hold on to.

How heavy the bleeding is in a miscarriage shows mostly when the tissue passes: it is usually much heavier than in a period.

The next paragraph describes what you may see. Skip it if you don’t want to read that right now.

The blood can look bright red, dark red or brownish. Clots can pass, as well as lining tissue and sometimes the gestational sac. The tissue can be gray, pink or whitish and look stringy. Depending on the week, the embryo or fetus itself may be visible, very small. Seeing that can affect you deeply, physically and emotionally. You decide whether you look.

There is no fixed number at which bleeding is “too heavy”. As a guide: if a pad is soaked soon after you put it on or you feel dizzy doing so, call 911 (or your local emergency number). If the bleeding is heavier than a period but without these signs, call today and say that you are pregnant. Pads show you the amount best and are the simplest choice in the first days; whether tampons or a menstrual cup suit you is something to clarify with your provider’s office.

If you would like to collect the tissue, a strainer in the toilet helps. If you want, it can be examined: keep it in a tightly closing container in the refrigerator until you hand it to your provider’s office. Ask your provider’s office beforehand whether your health plan covers the testing.

After the tissue passes, bleeding can last up to about three weeks, in some cases longer. It usually gets lighter over time. After a D&C you can usually expect only light bleeding and little pain.

If the bleeding gets lighter after a few days, that is the usual course; the follow-up is still part of it. If it stops very suddenly, the follow-up also makes sense, because the ultrasound shows whether everything has passed. If it gets noticeably heavier again after a few days, call the same day. If a fever over 100.4 °F (38 °C) or increasing pain comes along, go to the ER right away, even days after the tissue passed or after the procedure.

You’re allowed to ask for help.

• Call your ob-gyn’s office: After hours, call the same number, as there’s usually someone on call. Say that you are pregnant and bleeding. Someone there will tell you whether to come in.
• Bring someone along: If you can, get someone to be with you. That feels good and helps if you need help. If you are alone, say so on the phone. If the bleeding is heavy, don’t drive yourself.
• Note what is happening: Write down when it started, how heavy the bleeding is (how many pads), pain and fever, ideally with the time. Keywords are enough, or ask someone to do it for you.
• Listen to yourself: Go by how you feel. If you get dizzy or feel close to fainting, lie down and call 911 (or your local emergency number) right away.

Once it is clear that the pregnancy isn’t continuing, there are usually three paths. You decide together with your ob-gyn and can still change the approach later. A confirmed miscarriage without warning signs is usually not an emergency, and you don’t have to decide right away. Still, contact your provider’s office soon.

• Waiting: The body passes the tissue by itself. For most women it passes completely this way; if not everything passes, pills or a procedure follow. Your uterus isn’t operated on, but the timing can’t be planned.
• Pills: Your provider prescribes a medicine with the active ingredient misoprostol, which prompts the uterus to contract. It is given on an outpatient basis, so you don’t stay in the hospital; ask whether you take it at the office or at home. You then usually go through the contractions and bleeding at home. If not everything has passed, a second dose may follow. The pills are often used off-label; the cost is low, but coverage depends on your plan, so ask your provider’s office beforehand. Nausea, abdominal pain, diarrhea or fever are more common, usually only briefly. If a fever lasts longer than 24 hours or comes on later, go to the ER right away or call your ob-gyn’s office right away. Talk beforehand about which pain reliever you can take, and don’t stay alone.
• D&C or aspiration: A short procedure, usually as an outpatient and under anesthesia. It can be scheduled. As with any procedure there are rare risks, which your doctor discusses beforehand. In rare cases it is the only way, for example with very heavy bleeding or if tissue remains.

If everything is moving fast, you’re allowed to bring someone along and ask for time to think, as long as there are no warning signs. Also ask at the office how long it can take, when the follow-up is and whether you can get a note for work.

After a natural or medicated miscarriage, an ultrasound appointment is part of the care, usually after 7 to 14 days. It shows whether everything has passed. If tissue remains, it can pass with your next period, or your provider’s office discusses pills or a procedure.

Ask about your blood type at your first contact; if you have prenatal records, it is listed there, and your provider’s office can give you a copy. If it is Rh-negative, your provider’s office will clarify whether you need an Rh immune globulin shot (also called anti-D).

A pregnancy test can stay positive for a few more weeks, because the hormone falls only slowly. Whether everything has passed is clarified by the follow-up at the office. If the test line gets fainter, that is the expected course; if the test turns positive again after a negative result, call soon. If the test is still positive after about three weeks, talk to your provider’s office. Pregnancy symptoms fade only slowly, and mood swings are possible.

The first period after a miscarriage often comes after about five to six weeks, sometimes later. In individual cases ovulation can happen as early as 8 to 10 days afterward, so even before the first period. If you keep a cycle calendar, don’t log the bleeding as a period but as a note, otherwise it shifts the predictions.

Calculation and observing your cycle are not suitable for contraception, even in the weeks after a loss. If you don’t want to become pregnant right now, talk to your provider’s office about birth control.

Whether and when you want to try again is not a purely medical question. After a natural miscarriage you don’t need to wait a cycle; after a D&C it can make sense to wait for a period. There are different recommendations on sex: some advise waiting until symptoms have eased, because of the risk of infection. Ask your provider’s office what applies to you.

If it is already your second miscarriage or you are worried, ask your provider’s office about an evaluation; you can do that earlier. In the US, an evaluation is usually offered after two miscarriages, and genetic testing of the tissue can already make sense after two. That is not a reproach to you.

If you can’t work, ask your provider for a note for work, even if you are physically fit again but not emotionally ready. What your employer needs to see, and what you have to share, depends on your employer and your state; HR can tell you.

In the US, there’s no national maternity protection law. What you’re entitled to depends on your employer, how long you’ve worked there and your state. Ask HR about FMLA, paid leave and pregnancy accommodations. Many employers must make reasonable adjustments for pregnancy-related needs, including after a miscarriage.

Miscarriage is fairly common, even if it feels as if you were the only one. That doesn’t make the loss smaller. For many it is a child they have lost, even in an early week.

Grief runs very differently. Anger, emptiness, envy of pregnant women and feelings of guilt occur, as do relief or feeling nothing at all. Some are exhausted right away, others only weeks later. If low mood, anxiety or sleeplessness don’t ease, look for support from your primary care provider, your ob-gyn or a counselor. If you no longer want to live, call or text 988, free and available 24/7.

Partners and those around you often react clumsily. You can say what helps you: listening, taking over calls and appointments, not asking over and over. If you’re lost for words, you can show them this section.

Rules on burial or cremation after a miscarriage and on how hospitals handle the tissue differ by state and by hospital. If you would like to arrange one, a funeral home or your care team can tell you what is possible where you live. Whether a certificate is possible also depends on your state; ask your care team.

Ask your ob-gyn’s office or your health plan what follow-up care and support are available around a pregnancy loss. Further places to turn to in the US are Share Pregnancy & Infant Loss Support, the National Maternal Mental Health Hotline (1-833-852-6262, free, 24/7) and your care team, who can tell you about local support groups.