Miscarriage: signs, diagnosis and what happens next

How common early losses are and why they happen

Early losses are common, although some remain unrecognised. The 2024 Australasian guideline estimates around 12 to 15 per cent of clinically recognised pregnancies; losses before this confirmation occur in addition. The figure therefore depends on when and how pregnancies are identified and is not a prediction of your individual risk. ACCEPT guideline 2024

Chance chromosomal changes in the pregnancy tissue are often involved. A study of 2,928 available tissue samples found chromosomal abnormalities in 60.4 per cent of the 2,107 first-trimester losses. This describes the group studied, not the cause of every individual loss. Often the cause in a particular case remains unclear. Shi et al., 2025

A loss does not show that you have done something wrong. Ordinary exercise, sex or a stressful day are not considered typical causes of early miscarriage. One loss does not establish permanent infertility either. When losses recur, doctors look more closely for factors that might be treatable. RCOG: causes and common concerns

Bleeding, fading symptoms or no signs at all

Bleeding, lower abdominal discomfort and cramps can occur with miscarriage, but can also have other causes, such as bleeding from the cervix. Even clots or something that looks like tissue cannot reliably establish a diagnosis at home. Without a previously confirmed pregnancy, a heavier or late period often cannot be reliably distinguished from a very early loss afterwards. The article on bleeding during pregnancy explains other possible causes.

Conversely, a missed miscarriage may initially cause no pain or bleeding. Nausea or breast tenderness can continue because hormone levels do not fall immediately. These symptoms can also lessen during a normally developing pregnancy. Their presence or absence cannot, on its own, tell you whether a pregnancy is viable. NHS: miscarriage

A positive home test followed by a negative one can fit with a very early loss. Different test sensitivities, diluted urine and reading errors also influence results. The strength of a test line is not a reliable way to monitor a pregnancy. If you have symptoms or unclear results, properly timed medical checks are more helpful than repeatedly comparing home tests.

When to get medical help promptly

Have bleeding or new pain assessed promptly if you are pregnant or might be pregnant. If your condition clearly worsens, do not wait for a planned appointment. Seek immediate help through an emergency department or your local emergency number if you have:

• very heavy bleeding, for example a pad becoming soaked soon after you change it, particularly with weakness;
• severe, persistent or one-sided lower abdominal pain;
• dizziness, fainting, collapse or severe problems with your circulation;
• pain at the tip of the shoulder together with abdominal pain, bleeding or dizziness.

Fever, chills or unpleasant-smelling discharge also need prompt medical assessment; get help immediately if you feel very unwell. An ectopic pregnancy or infection may cause similar symptoms. A small amount of visible bleeding does not rule out dangerous internal bleeding. RCOG: bleeding and pain in early pregnancy

In Germany, call 112 for an ambulance in a life-threatening emergency. For urgent problems outside normal surgery hours that are not life-threatening, 116117 can help. If you have the severe warning signs above, contacting an out-of-hours service must not delay emergency treatment. 116117: out-of-hours service or emergency call?

How the diagnosis is confirmed

The assessment brings together your symptoms, your medical history and usually a transvaginal ultrasound scan. It helps establish where the pregnancy is located and how it is developing. A transvaginal scan does not increase the risk of miscarriage. RCOG: investigations for suspected miscarriage

Very early on, one scan may not give a clear answer. Ovulating later can explain why less is visible than expected from the date of your last period. The diagnosis must therefore not depend solely on a calculated pregnancy week. Depending on the findings, the scan is repeated after a sufficient interval, often at least seven days and sometimes longer. This waiting period helps prevent a viable pregnancy being mistakenly diagnosed as a loss. NICE NG126: diagnosis

A positive test without a pregnancy being reliably identified inside or outside the womb is called a pregnancy of unknown location. Possible explanations include a very early pregnancy in the womb, a loss or an ectopic pregnancy. Blood hCG measurements around 48 hours apart are often considered alongside further scan findings. One hCG result cannot reliably establish the location or viability of a pregnancy; falling hCG also does not replace the agreed follow-up.

Living with an uncertain result

Waiting can be particularly difficult when your feelings move between hope and fear. A specific plan can make the uncertainty more manageable, even if it cannot remove it immediately. Ask what is already clear and what the next appointment is intended to establish. If you feel stable and have no warning signs, planned checks are an active part of your care.

• What did the scan show, and which diagnoses are still possible?
• When will I have the next scan or blood test?
• Which symptoms mean I should return sooner, and whom can I contact outside surgery hours?
• Can I bring someone with me and have the findings in writing?

Treatment: waiting, medicines or a procedure

Once the loss has been reliably confirmed, the next steps depend on bleeding, signs of infection, the scan findings and your wishes. If the womb is already empty and recovery is uncomplicated, further treatment may not be needed. Otherwise, there are often three possible approaches.

Waiting with medical support

The body may pass the tissue naturally. This can take days to weeks and is less predictable. Discuss pain relief, how to reach help and the next check-up. If the tissue does not begin to pass, symptoms persist or your preferences change, you can discuss the approach again.

Treatment with medicines

Medicines help the tissue pass. For a missed miscarriage, mifepristone followed by misoprostol is often more effective than misoprostol alone; this is not a general rule for every type of miscarriage. Your care team will discuss the treatment plan and available medicines with you. Discuss bleeding, pain, possible side effects and aftercare beforehand.

Surgical treatment

The tissue is usually removed by suction, also called suction curettage. This offers more predictability and may be needed for heavy bleeding, infection or when another treatment has not worked. Your distress and preferences matter too. Discuss the anaesthetic, benefits and risks, including bleeding, infection and, rarely, injury to the womb.

If it is medically safe, you can take time to decide and change your mind later. No option is a measure of how you are coping with the loss. The relative effectiveness of the medicines has been studied in a randomised trial, among other research. Schreiber et al., 2018; current recommendations: NICE NG126: management.

Follow-up and pregnancy tests that remain positive

Agree how it will be confirmed that the miscarriage is complete. Depending on treatment, symptoms, ultrasound and sometimes hCG are relevant. The German-language guideline recommends an ultrasound seven to 14 days after medical management. Other care pathways use a urine test after about three weeks. These are agreed follow-up plans, not a period during which you are expected to tolerate symptoms. DGGG, OEGGG and SGGG: guideline on early pregnancy loss

hCG may remain detectable for a while after a loss. How quickly a test becomes negative depends partly on the starting level and what has happened. A positive test at the agreed follow-up point, continued or increasing bleeding, pain or fever needs further assessment. Warning signs require assessment even with a negative test.

If you are RhD-negative, ask about anti-D prophylaxis early. This aims to prevent antibodies forming that could affect later pregnancies. The German-language guideline considers the pregnancy week and the type of treatment; advice after surgery differs from that for a very early spontaneous loss. Your clinic should therefore clarify whether and when you need the injection. Recommendations vary internationally. AWMF: early pregnancy loss, anti-D prophylaxis section

The days ahead: recovery, sex and your cycle

Bleeding, cramps and tiredness can be considerable even after an early loss. Once the tissue has passed, bleeding may continue for around one to two weeks, but should generally ease. With expectant management, it may take longer for the process to start. Worsening symptoms need another assessment. RCOG: the course of recovery

Ease everyday demands if you can and arrange support, particularly if you are alone. You can return to gentle activity as you feel able. If you have pain or your bleeding increases, take a break and seek advice if needed.

The German-language guideline finds no evidence to support a blanket ban on tampons, menstrual cups, sex or physical activity after an uncomplicated early loss. Pads can help you judge how much you are bleeding. How you feel and specific advice for injuries, infection or a complicated recovery are what matter. You do not have to resume anything simply because it is medically possible. DGGG, OEGGG and SGGG: activity after early loss

Your next period often arrives after around four to eight weeks, though your cycle may take longer to settle. Ovulation can happen earlier, so a new pregnancy is possible before the first period. If you do not want to become pregnant yet, discuss contraception. Arrange a check if your period does not return or tests remain unclear. NHS: recovering from miscarriage

Support at home, at work and in saying goodbye

The next few days can be easier if someone you trust is available, comes to appointments or helps with shopping and childcare. You can choose whom to tell about the loss and how much to explain. A midwife, pregnancy counselling service or bereavement group may also offer support.

If you cannot work because of how you feel physically or emotionally, discuss medical certification for sick leave. Since June 2025, Germany has also had maternity protection periods after miscarriage from the 13th week of pregnancy. Eligibility and the length of protection depend partly on the pregnancy week and employment circumstances. German Federal Family Portal: rules following miscarriage

You may wish to keep a scan picture, write a letter or arrange a small farewell ritual. Something else may help you, or none of these may feel right. If you have questions about pregnancy tissue or a possible burial, the hospital can explain local arrangements. There is no obligation to grieve in a particular way. BIÖG: grief after miscarriage or stillbirth

A further pregnancy and repeated losses

After a single early miscarriage, a later pregnancy often has a successful outcome. There is no guarantee, but one event does not justify assuming a permanently poor outlook either. Once the loss is medically complete and you feel physically and emotionally ready, an uncomplicated loss often does not require a fixed wait of several months. Particular findings or treatments may mean a different interval is needed.

A follow-up discussion can help: when should you contact the clinic after a new positive test, when is a scan useful, and what happens if bleeding returns?

Before trying again, discuss your medicines and folic acid needs with your clinician. After a loss during IVF treatment, agree the timing of the next embryo transfer with your treatment team. Advice after a spontaneous pregnancy cannot simply be applied to IVF. NHS · PubMed

Repeated losses are a reason for a structured consultation. Some guidelines begin assessment after two losses; others define recurrent miscarriage as three or more. Your history, age and the type of losses influence when investigation is useful. This may include the shape of the womb, the thyroid, certain clotting or autoimmune factors, and genetic questions where the history makes them relevant. Not every specialist test improves treatment. RCOG: recurrent miscarriage

There is no fixed timetable for grief

An early loss, or one only discovered later, can have a deep emotional impact. Some people initially feel numb; others feel sad, angry or relieved to finally understand what has happened. Grief can grow stronger later, when appointments and physical symptoms are over. The stage of pregnancy does not determine how you are allowed to feel.

Partners may grieve too and respond differently. That does not automatically mean they care less. Counselling may help if you find it hard to talk things through together. Seek professional support if sleep, eating or everyday life remain very difficult, or if panic, distressing memories and avoidance seriously restrict you. You can seek help at any time, without waiting for a set number of days or weeks.

Myths and facts about miscarriage

There cannot be a miscarriage without bleeding.

A missed miscarriage may initially cause no noticeable symptoms. A confirmed finding matters, not the absence of a warning signal.

Less nausea means the pregnancy has ended.

Pregnancy symptoms fluctuate. Individual symptoms can neither confirm nor exclude a loss.

I caused the loss through stress or exercise.

Ordinary daily demands are not a typical explanation. Many early losses involve developmental processes outside your control.

I will not be able to have a child after a miscarriage.

One loss does not establish infertility. After repeated losses, targeted investigations may help, but they cannot predict the outcome with certainty.

Conclusion

A miscarriage may be clearly noticeable or go unnoticed at first. Careful diagnosis, clear follow-up arrangements and care suited to the findings and your needs provide safety. You do not have to interpret individual symptoms yourself or manage the loss alone.