If the fetus has stopped developing or has genetic defects that may lead to serious developmental problems, your doctor may offer these options for miscarriage management. The loss can be difficult both physically and emotionally. In this article, we’ll cover the different options and what to expect to help you navigate the situations.

When the pregnancy is nonviable, it is medically necessary to remove conceptus material to prevent further complications. If the conceptus material is not completely removed, it can lead to complications including:

• infections, sepsis, and shock
• bleeding
• disseminated intravascular coagulation or dangerous blood clots during pregnancy¹

Unless there is an emergency due to one of these complications, you have an option to wait for the pregnancy to resolve naturally. However, it is often safer and less painful to terminate in a controlled condition to prevent more severe bleeding or cramps in a natural miscarriage.

Safe miscarriage treatment options include medication induction and surgical procedures, such as vacuum aspiration, D&C, and D&E ²³. 

For more information on deciding between a natural versus a surgical miscarriage, read this article on 10 questions we asked before making the decision.

Expectant Management or Waiting for a Natural Miscarriage

Many women prefer to wait for the miscarriage to happen naturally without any medical intervention or just the use of painkillers.

However, this approach can be agonizing because it can take days or weeks for the bleeding to stop. The miscarriage can happen immediately or take up to 3 – 4 weeks to begin and a few weeks to completely resolve.

Depending on the stage of pregnancy, your experience with this approach may be very different. If the loss is very early, it may be more like a painful menstrual period. However, if the pregnancy is further along, you may experience labor-like contractions, which some may find traumatic if they are not prepared.

In some cases, you may start with this method but decide to fall back on the medical options. For example, if any conceptus materials remain, your doctor may recommend a surgical procedure to fully remove the remaining materials and prevent further complications.

Pros of natural miscarriage

1. There is no cost of surgery and medications, although you may need pain management and to take time off work.
2. No risk or side effects from medications or surgery.
3. You may feel less rushed by allowing the process to occur naturally.

Cons of natural miscarriage

1. Does not give you control of the miscarriage timeline.
2. May prolong the pain and suffering, both for miscarriage and pregnancy symptoms.
3. May need to fall back on surgical options to completely remove the conceptus materials.
4. You may experience the labor and see the miscarriage materials.
5. There is a risk of excessive bleeding.
6. If you are going through the process at home, natural miscarriage may be less conducive to self-collect high-quality samples for a pathologic examination and genetic analysis. If you choose these options and wish to have these tests done, speak to your doctor about how to collect your samples at home. In most cases, they will give you a sterile container for the sample and ask you to refrigerate (not freeze) it until you can drop it off at the lab or clinic within a specified time frame.

Medication-based miscarriage management (mifepristone and misoprostol)

Medication-based pregnancy termination is only indicated for pregnancies that are up to 10 weeks⁴.

First, you will take a drug called mifepristone. Usually, after 1 or 2 days, you will take a second medication called misoprostol orally or vaginally⁵. Both medications are necessary for the miscarriage to resolve.

Some centers prefer to give misoprostol vaginally because it is more effective that way, while others prefer the oral approach as it is more comfortable. Oral misoprostol may be taken buccally (between your teeth and cheek), or sublingually (under your tongue) as it is somewhat more comfortable ⁶⁷.

The product of conception typically passes in 4 – 6 hours after taking misoprostol. The material may appear like blood clots and you may experience some cramps during this process.

You will need to avoid heavy physical activity that day and be prepared with multiple female pads to absorb the bleeding. After completion, you should avoid vaginal intercourse and tampon use for the next two weeks⁸. 

If you are rhesus (Rh)-negative, you should receive an Rh immune globulin (RHOGAM) shot on the day of mifepristone administration⁹. 

Medication-based miscarriage management doesn’t require anesthesia, unlike surgical options, and it may be done at home. However, it might take more doses of misoprostol for the termination to occur. In some cases, if the product of conception does not completely pass, you may still need a D&C or D&E.

Side effects of these medications you might experience include nausea, vomiting, fever, chills, diarrhea, and headache¹⁰. 

Other contraindications (situations in which you cannot be offered this treatment) for medication-induced termination include¹¹:

• allergy to mifepristone, misoprostol, or other prostaglandins
• hemorrhagic (bleeding) disorder and anticoagulant therapy
• inherited porphyrias
• chronic adrenal failure
• long-term systemic corticosteroid use
• molar pregnancy

After a medication-induced pregnancy termination, you should schedule a follow-up visit with your OB/GYN. They will confirm that you are no longer pregnant and make sure you’re healing properly with a gynecological and an ultrasound exam¹². 

Conventional wisdom suggests waiting for 3 cycles before trying to conceive again. However, studies have shown that the wait time does not increase the odds of a successful pregnancy. In fact, less wait time is associated with better pregnancy outcomes¹³¹⁴. Remember to consult your doctor as the optimal wait time may vary from case to case.

Pros of medication-based miscarriage

1. May be empowering by giving you a level of control
2. May allow you to return to trying again sooner
3. Shortens the pain and physical suffering, including both pregnancy and miscarriage symptoms
4. Costs less than a D&C

Cons of medication-based miscarriage

1. May not fully expel the conception materials, and thus may require a D&C or D&E anyway.
2. Still requires going through cramps and bleeding
3. If you are going through the process at home, it may be less conducive to self-collect high-quality samples for a pathologic examination and genetic analysis. If you choose these options and wish to have these tests done, speak to your doctor about how to collect your samples at home. In most cases, they will give you a sterile container for the sample and ask you to refrigerate (not freeze) it until you can drop it off at the lab or clinic within a specified time frame.

Surgical miscarriage management options 

Surgical pregnancy termination includes vacuum aspiration, dilation and curettage (D&C), and dilation & evacuation (D&E), which are all done under general anesthesia. 

Dilatation and Curettage (D&C) is performed before 13 weeks of pregnancy. It is a short surgical procedure to open the cervix and use a curette to scrape or suction the conception materials from the uterine cavity. It takes 15-30 minutes.

Vacuum aspiration can be used up to 14 gestational weeks. The doctor will insert a tube into the uterus through the vagina, and use it to clean out the pregnancy material¹⁵. 

This procedure takes about 5 to 10 minutes and most women can go home a few hours later.

Dilation and Evacuation (D&E) are during the second trimestfer of pregnancy. Because there is typically more tissue to remove, the procedure may take longer. Your doctor may also use more instruments, such as forceps, to remove the pregnancy material than they would with a D&C ¹⁶. This procedure usually takes about 30 minutes and you can go home the same day.

Before these surgical procedures, you will take medications to dilate the cervix. Usually, these are the same medications as the ones used for medical miscarriage and are given a few hours or 1 to 2 days before the operation¹⁷¹⁸. 

In most cases, these procedures require general anesthesia, which carries some risks such as nausea, vomiting, after procedure pain, throat soreness, respiratory failure, cardiac failure, allergic reaction, and death (rarely). You should always tell your doctor if you have diabetes or are on blood thinners such as aspirin, heparin, lovenox, or warfarin¹⁹. 

Pros of surgical options

Compared to the natural and medication-based options, pros of surgical options include:

1. Makes it possible to collect samples for pathology examination and genetic analysis in a controlled clinical setting
2. Ensure that all conceptus materials are completely removed
3. Shortens pain and physical suffering from the miscarriage process

Cons of surgical options

1. If you are in the US, cost and insurance reimbursement may be a factor. Surgical miscarriage management typically costs more than medication and natural options. In addition, some insurers may not cover D&C or D&E.
2. There is a risk of developing Asherman’s syndrome or scar tissue on the uterine wall, which may lead to future miscarriage.
3. It is an invasive procedure with a risk of perforation to the uterus and damage to the cervix.
4. Any surgery that involves general anesthesia carries some risks (as discussed above).

How long to rest after a D&C, D&E, or vacuum aspiration

You should take a day off to rest and refrain from heavy physical activities. If the pregnancy was further along (>10 weeks), you may need 2 – 3 days to rest and recover from the surgery. However, listen to your body and take more time to rest if you still feel pain and discomfort more than a few days after.

Conventional wisdom suggests waiting for at least 3 months to try to conceive again. Generally, studies have not shown that waiting to conceive after surgical miscarriage management is beneficial ²⁰²¹. However, one study that analyzed endometrial thickness in women who miscarried after fertility treatments suggested that the endometrium may need up to 6 months after a D&C to fully recover²². You should consult your doctor as the best wait time may differ from case to case.

When to contact your healthcare professional after a surgical pregnancy termination?

• If you have pain or heavy bleeding – soaking two or more pads within an hour
• Have a fever, flu-like symptoms, or unusual vaginal discharge²³. 

Regardless of miscarriage treatment methods, you’ll likely have stomach cramps (pain) and vaginal bleeding that usually lasts a week or two. Sometimes light vaginal bleeding after a medication-based miscarriage treatment can last up to a month.

You may experience a range of emotions after these procedures, including relief, grief, and emotional instability. This is normal, and if it becomes difficult to cope with, consult your doctor, therapist, or midwife²⁴.