Second trimester miscarriage

The purpose of this leaflet is to provide the patient with information on the nature, causes, risk factors and symptoms of miscarriage.

Miscarriage is defined as the loss of an intrauterine pregnancy before the 22nd week of pregnancy. Early miscarriages are very common. Around 8-20% of miscarriages occur before the 20th week of pregnancy; 80% of them occur within the first 12 weeks.

Causes of miscarriage

• The yolk sac begins to form, but the embryo fails to develop.
• The embryo dies.
• The embryo has a random genetic abnormality.
• The pregnant woman suffers from a chronic condition.
• The pregnant woman has uterine fibroids.
• The pregnant woman has an abnormal uterus.

Since there are many reasons why a miscarriage may occur, it is very difficult to determine a specific cause in a particular case.

Risk factors for miscarriage

• Previous miscarriages
• Age (>40 years)
• Smoking
• Alcohol use
• High fever
• Procedures during pregnancy (amniocentesis, chorionic villus sampling)
• Other (exposure to chemicals, infections, radiation, medications, and stress)

Symptoms of miscarriage

• Vaginal bleeding
• Pain in the lower abdomen
• Depletion of the common early signs of pregnancy (nausea, vomiting, breast tenderness)
• In a missed miscarriage, the foetal cardiac activity and development has stopped. There may be no abdominal pain or vaginal bleeding. An ultrasound examination is performed to determine whether the foetus is alive and located in the uterus.

In an incomplete miscarriage, the yolk sac has begun to detach from the uterus and the women experiences lower abdominal pain and spotting or bleeding from the genital tract. A miscarriage may also be accompanied by an infection in the uterus, characterised by fever, chills, flu-like symptoms and foul-smelling vaginal discharge.

Management of miscarriage

Medications that induce uterine contractions are administered or surgical evacuation of the uterus is performed to encourage the emptying of the uterine cavity and stop bleeding. Sometimes no intervention is needed.

Medical management involves taking a medication called misoprostol. Misoprostol is well tolerated by most patients, causing only temporary side effects such as nausea, abdominal pain, fever and chills. Following the administration of medication, the uterus may empty within a day, but it may take longer and it may be necessary to use different combinations of medications.

In a late miscarriage, the pain experienced during the process of passing the pregnancy tissue can be similar to labour pains. You can take painkillers to ease the pain. If the pain is unbearable, be sure to inform the nurse on duty so that they can administer the painkillers on time. You will be provided with a nurse call button. After you start experiencing contractions, you should keep the nurse on duty updated of any changes in your condition and let them know

immediately if you need to go to the toilet. The foetus is passed through the vagina. Complete emptying of the uterus may take time.

Sometimes surgical management is required. The need for surgical evacuation of the uterus is more likely in late miscarriages. Vaginal bleeding during a miscarriage is heavier than a typical menstrual period. Over the next few days, the bleeding gets lighter. Blood transfusions are rarely required.

Following late miscarriage your breasts may produce milk. This is manifested as fullness and tenderness of the breasts. To relieve pain, take painkillers and apply cold compresses to your breasts. A supportive bra is recommended. A little milk can be expressed from a very full and tender breast, but try not to empty the breast. If necessary, you will be given a single dose of cabergoline to suppress milk production. The situation will resolve on its own within about a week. If the tenderness of the breasts does not go away or a painful lump appears in the breast, accompanied by fever, a gynaecologist should be consulted.

Things to keep in mind

• Vaginal bleeding can last up to 5 weeks (i.e. until the next menstruation).
• A gynaecological examination should be performed within two to four weeks.
• Having sexual intercourse without a condom, using tampons, swimming and bathing are not allowed for 3 weeks after a miscarriage.
• If desired, an effective method of contraception can be started right away. Additional information about this will be provided by your gynaecologist.
• If you experience fever (over 38 °C), severe abdominal pain or bleeding following a miscarriage, seek emergency medical care at the Women’s Clinic of East Tallinn Central Hospital at Ravi 18, Tallinn. In case of complications, antibiotics or medications that control bleeding are administered if necessary, surgical evacuation of the uterus may be performed, and hospitalisation may be required.
• Having a miscarriage can be a tragic experience for any woman. Therefore, pregnancy crisis counselling is available to you while in the hospital.
• If you are rhesus negative, you will be given a medication called Rhesonativ after a miscarriage to prevent Rh incompatibility in subsequent pregnancies.
• Experiencing a single miscarriage without complications does not affect the outcome of future pregnancies.

ITK1117

Approved by the decision of the Care Quality Commission of East Tallinn Central Hospital on 30.11.2022 (protocol no. 18-22)