• About 60% of the miscarriages occurring during the first thirteen weeks of pregnancy are caused by problems in the chromosomes of the embryo. This is nature's way of eliminating embroyos with genetic problems. Often the miscarriage occurs before the woman is aware she is pregnant. Most chromosomal problems happen by chance and are not likely to happen again.

• Sometimes, though, the chromosomal problem is inherited from the parents. This is more likely with repeated miscarriages or in families where there is a history of birth defects. Genetic testing can be ordered on the fetal tissue from the miscarriage, or on blood from the parents.

• Congenital uterine abnormalities have been associated most often with second-trimester pregnancy loss. However, 10-15% of women with recurrent early pregnancy loss have congenital uterine abnormalities.
• Sometimes the cervix is incapable of holding a pregnancy (incompetent cervix). This might be due to previous cervical surgery or injury.
• There are maternal diseases that may lead to a higher incidence of miscarriage, including: poorly controlled diabetes, systemic lupus erythematosis (SLE or lupus), high blood pressure. Sometimes a hormonal imbalance can cause an early miscarriage.
• Some people have a genetic condition which makes them more likely to form blood clots which may increase the risk of miscarriage. Most commonly this involves second and third trimester fetal loss.
• Some women form antibodies that might make them more likely to miscarriage.
• Infection with some viruses (eg, rubella, herpes simplex, and measles viruses; cytomegalovirus; and coxsackieviruses), bacteria (Listeria) or parasites (Toxoplasmosis) can cause a miscarriage.

• Although a common concern of patients, environmental factors rarely have been linked to sporadic pregnancy loss.
• Study results are conflicting on the association of smoking, use of alcohol, and use of caffeine with sporadic pregnancy loss. They may act in a dose-dependent fashion or synergistically to increase the rate of sporadic pregnancy loss. However, none of these habits has been associated with recurrent pregnancy loss.
• Exercise does not appear to increase the rate of sporadic pregnancy loss, particularly in women in good physical condition, and there are no studies of exercise effects in women with recurrent pregnancy loss.
• Ideally all women should take folic acid for one to three months before conception. Deficiencies in folic acid have been associated with neural tube defects.

• The most common symptoms of impending miscarriage are vaginal bleeding and cramping. Not all pregnancies with bleeding end in miscarriage, though. About 30% of pregnancies with early vaginal bleeding go on to term and end with a healthy baby. Because the threat of miscarriage exists with bleeding, your doctor will want to watch you more carefully over the next few days. You may be followed with ultrasounds or blood tests.
• Sometimes an ultrasound will show that the fetus is no longer alive, or didn't develop even though the pregnancy has not yet miscarried.

• 1. To allow the pregnancy to pass on its own
• 2. Take a medication to induce passage of the pregnancy
• 3. A surgical procedure called a Dilation and Currettage (D&C) can remove the pregnancy.

See below for more information on each option:

• It is difficult to determine when a miscarriage will occur. Sometimes this can occur within a day or two of the diagnosis of a failed pregnancy, but other times it can take a few weeks to occur.
• Bleeding at the beginning of a miscarriage may be light, continuing over several days. Mild lower abdominal or lower back aches may accompany the bleeding. As the miscarriage progresses, the bleeding will get heavier and the cramping may get more painful. As the cervix dilates (opens), tissue may be passed. If you think you have passed fetal tissue, put it in a clean container and bring it with you to your doctor. Rarely, you may notice a gush of clear fluid from the vagina, without pain or bleeding. You may take tylenol, motrin or tylenol with codeine for the cramps.
• Remember to call your doctor if you have any of the following symptoms:

• It is important to be certain all the tissue relating to the pregnancy is removed. If the cervix is open and tissue has been passed, we will probably follow the progression with blood tests. Sometimes the body does not completely expel all the products of conception. A D&C might need to be performed to finish the process. Sometimes the bleeding from a miscarriage is so heavy a D&C might be needed to prevent further blood loss.
• The advantage of expectant management is that you may avoid surgery and the side effects of some medications. Disadvantages are that the uncertainty of the waiting period can be difficult, especially since miscarriage is already an emotionally trying time.

• If the pregnancy has ended early and you meet certain criteria, you may be elligible to take a medication to induce your body to pass the miscarriage.
• The medication is called Misoprostol and works about 80-90% of the time. Most people have some heavy bleeding and cramping a few hours after taking this medication and will pass the pregnancy in 12-24 hours. A small percentage of women may take up to a week to pass the pregnancy.
• You can expect bleeding for 7-10 days after passing the pregnancy with spotting for a few days after that.
• Advantages of medical induction of miscarriage are that you may avoid a surgical procedure and you may miscarry in the privacy of your own home with support from your partner, family, or friend. Disadvantages are that it can be painful and that a small percent will not completely miscarry on their own or may have heavy bleeding and may require a D&C to remove the remaining products of conception.
• Side effects from Misoprostol include uterine cramping, nausea, vomiting, and diarrhea.

• If your pregnancy has miscarried but you have not passed it your doctor may offer you a D&C (Dilation and Currettage). This is a surgical procedure in which the cervix or the opening to the uterus is gently widened (dilated) and the pregnancy is removed (currettage).
• This is highly effective and a very safe procedure. This can usually be scheduled within a few days to a week.
• Benefits of a D&C are that a light intravenous sedative or anesthetic can be used so that any discomfort involved can be minimized. There are some rare risks to the procedure including bleeding, infection, scarring, retained products and perforation of the uterus or the surrounding organs, potentially requiring additional surgery, including another D&C.

• You may notice some spotting or bleeding and discomfort for a few days up to two weeks. Taking it easy for a few days will keep the bleeding to a minimum. Please call your doctor if you notice any of the following:

  Heavy bleeding (saturating a pad an hour for more than 2 hours)
  Fever or chills
  Severe pain

• We recommend that you refrain from using tampons or intercourse for two weeks.

• Because miscarriage is unfortunately so common, we do not generally do any tests after the first miscarriage. Most women (60-70%) will go on to have a healthy pregnancy the next time.

• If you have had a second miscarriage we will do some tests to investigate some of the causes of recurrent miscarriage.

• However in 50% or more of couples with recurrent pregnancy loss, an evaluation, including genetic testing and evaluation of the reproductive organs will be inconclusive. Therefore, a majority (approximately 50-75%) of couples with recurrent pregnancy loss will have no certain diagnosis.
• Some tests are:

  .	A karyotype might be done on you and your partner to identify a possible parental chromosome abnormality, which occurs in approximately in 2-3% of couples who have recurrent miscarriages
  	A hysterosalpingogram to determine if there is a structural abnormality of the uterus
  	A karyotype on the products of conception.
  	Hormonal studies of thryroid and prolactin
  	Anticardiolipin and antiphopholipid antibodies.

• Some experts believe that tender loving care by your health care provider and family and stress/anxiety reduction may play an important role.

• A miscarriage, no matter how early, can leave parents with a sense of loss. Although there may not be physical changes others could see, bonding has taken place between the mother and fetus. Many women go through a period of sadness, guilt and anger about the miscarriage.
• You need to be aware that most of the time there was nothing you could have done to prevent the loss. Most women go on to have a normal pregnancy in the future.
• If you need help or support in recovering from the loss of a pregnancy, talk to your physician. There are resources and support groups available.

• Whenever a pregnancy ends too early, the emotional healing can take longer than the physical healing. Both parents need time to grieve the lost pregnancy before moving on. Only you can decide how long you will take to be emotionally ready.
• Physically, it may take four to six weeks for your body to return to normal. We generally recommend that you wait until you have had one normal period before you try to conceive again.
• You should continue to take your prenatal vitamins.