Miscarriage — the loss of a pregnancy before 24 weeks — is far more common than most people realise. Around one in five recognised pregnancies ends in miscarriage, most of them in the first twelve weeks, and many more are lost before a period is even missed. Despite that, it remains surrounded by silence, guilt and misinformation. This article explains why it happens, how it is diagnosed and managed, and what the outlook is for the next pregnancy. If you are bleeding now, our article on bleeding in early pregnancy covers what to do today.

Why miscarriage happens

The great majority of early miscarriages — around two thirds — happen because the embryo has a chromosomal abnormality: an error that occurred by chance when the egg or sperm formed or at fertilisation, and that is incompatible with development. This is nature's quality control, not a fault in the mother's body. The risk rises with the woman's age because the proportion of eggs with such errors rises: roughly 10% at 25, 20% at 35, and over 50% after 42.

Less common contributors include uncontrolled diabetes or thyroid disease, womb abnormalities such as a septum or fibroids inside the cavity, antiphospholipid syndrome (an immune clotting disorder), some infections, heavy smoking and alcohol, and obesity. Later losses, after 12–14 weeks, have a different pattern of causes, including cervical weakness and infection.

What does not cause miscarriage deserves equal emphasis: ordinary work, exercise, lifting, sex, stress, a fright, travelling, or a food you ate. Women search for something they did wrong; almost always there is nothing.

How it is recognised

Bleeding and cramping are the usual symptoms, though some miscarriages are found only at a routine scan when the heartbeat has stopped — a "missed" or silent miscarriage. The diagnosis is made by transvaginal ultrasound, and it must be certain before anything is done. An embryo with a crown-rump length of 7 mm or more with no heartbeat, or a pregnancy sac of 25 mm or more with no embryo, confirms miscarriage; anything smaller or uncertain is rescanned after 7–14 days. That wait is hard, but it protects wanted pregnancies that are simply earlier than the dates suggest. A pregnancy that cannot be seen in the womb at all is treated as a possible ectopic pregnancy until proven otherwise.

The three ways a miscarriage can be managed

Once miscarriage is certain and you are clinically stable, there are three options. None is medically superior for every woman; the right choice depends on the scan findings, how much bleeding there is and your own preference.

  • Expectant (natural) management — waiting for the womb to empty itself, usually within one to two weeks. Suitable for most incomplete miscarriages; success is lower for a missed miscarriage with an intact sac. Expect bleeding heavier than a period with cramps, then settling; a repeat test or scan confirms completion.
  • Medical management — misoprostol tablets (sometimes after mifepristone) cause the womb to contract and expel the pregnancy, usually within 24–48 hours. It avoids an operation but involves heavier bleeding and pain at home, and about one in five women later needs a surgical procedure.
  • Surgical management — evacuation of retained products of conception (ERPC), a 10–15 minute procedure under short anaesthetic, or manual vacuum aspiration under local anaesthetic. It is quickest and most predictable, and is advised if bleeding is heavy, there are signs of infection, or the other methods have not worked.

Whichever route, anti-D is given to women with a rhesus-negative blood group if surgery is performed (and in some other circumstances), and a pregnancy test three weeks later should be negative. Bleeding that becomes very heavy — soaking a pad an hour — fever, foul discharge or feeling faint needs urgent assessment.

After the loss

Physically, bleeding settles within one to two weeks and the next period usually arrives in four to six. Emotionally there is no timetable. Grief after miscarriage is real grief, and it affects partners too; it is not "only" an early pregnancy. Say so to family who minimise it, and ask for support — including professional support — if you are struggling.

Recurrent miscarriage — when tests are needed

One miscarriage, or even two, does not call for investigation: the chance of the next pregnancy succeeding remains high, and tests almost always come back normal. After three consecutive losses — or earlier in some circumstances, such as a loss after 12 weeks or in older women — investigation is worthwhile. The standard tests are antiphospholipid antibodies, thyroid function, a check of the womb cavity by 3D scan or hysteroscopy, and, where available, chromosome testing of the pregnancy tissue; karyotyping of the parents is reserved for specific findings. Even after three losses, in about half of couples no cause is found — and the live birth rate in the next pregnancy is still around 60–70%, with supportive early-pregnancy care alone.

Where antiphospholipid syndrome is confirmed, low-dose aspirin and heparin improve the outcome. Where it is not, "blood thinners", steroids and immune treatments have not been shown to help and should not be given routinely. Vaginal progesterone has a modest benefit in one specific group — women who are bleeding in early pregnancy and have had previous miscarriages; see our article on progesterone in pregnancy (Sinhala).

Trying again

There is no medical reason to wait several months. Once bleeding has stopped and you feel ready, you may try in the next cycle; large studies show that conceiving within six months of a miscarriage is, if anything, associated with slightly better outcomes than waiting longer. Start folic acid (5 mg if you are diabetic, obese or have had a previous affected pregnancy; otherwise 400 micrograms), stop smoking, moderate alcohol, and get diabetes or thyroid disease under control first. Early review and a reassurance scan at 6–8 weeks in the next pregnancy are reasonable, particularly after more than one loss.

The bottom line

  • Miscarriage affects about one in five recognised pregnancies; most are due to chance chromosomal errors in the embryo.
  • Nothing you did — work, exercise, sex, stress, food — caused it.
  • Diagnosis must be certain on scan before any treatment; a repeat scan is often needed.
  • Natural, medical and surgical management are all acceptable; the choice is yours unless bleeding or infection decides it.
  • Tests are reserved for three consecutive losses; even then most couples go on to a successful pregnancy.
  • You can try again as soon as you feel ready.

If you have had a miscarriage and would like to talk through what happened and plan the next pregnancy, you can consult us at Sugabi Clinic Ragama or book a video consultation.

References

  1. National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management (NG126) [Internet]. London: NICE; 2019 [updated 2023 Aug 23; cited 2026 Oct 5]. Available from: nice.org.uk/guidance/ng126
  2. Royal College of Obstetricians and Gynaecologists. Recurrent miscarriage (Green-top Guideline No. 17) [Internet]. London: RCOG; 2023 [cited 2026 Oct 5]. Available from: rcog.org.uk
  3. NHS. Miscarriage [Internet]. London: NHS; [cited 2026 Oct 5]. Available from: nhs.uk
  4. Quenby S, Gallos ID, Dhillon-Smith RK, Podesek M, Stephenson MD, Fisher J, et al. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet. 2021;397(10285):1658–67. doi:10.1016/S0140-6736(21)00682-6
  5. Coomarasamy A, Dhillon-Smith RK, Papadopoulou A, Al-Memar M, Brewin J, Abrahams VM, et al. Recurrent miscarriage: evidence to accelerate action. Lancet. 2021;397(10285):1675–82. doi:10.1016/S0140-6736(21)00681-4
  6. Coomarasamy A, Devall AJ, Cheed V, Harb H, Middleton LJ, Gallos ID, et al. A randomized trial of progesterone in women with bleeding in early pregnancy. N Engl J Med. 2019;380(19):1815–24. doi:10.1056/NEJMoa1813730
  7. Chu JJ, Devall AJ, Beeson LE, Hardy P, Cheed V, Sun Y, et al. Mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomised, double-blind, placebo-controlled trial. Lancet. 2020;396(10253):770–8. doi:10.1016/S0140-6736(20)31788-8
  8. Kangatharan C, Labram S, Bhattacharya S. Interpregnancy interval following miscarriage and adverse pregnancy outcomes: systematic review and meta-analysis. Hum Reprod Update. 2017;23(2):221–31. doi:10.1093/humupd/dmw043