Jennifer Stewart: To start, Dr. Lal, what is medically considered a miscarriage, and how common are miscarriages?

Dr. Lal: A miscarriage, medically, is the loss of a pregnancy within the uterus during the first 12 weeks of pregnancy. We think it affects about 15 to 20% of people who become pregnant, and the data suggests the number may actually be higher than that.

Sometimes people miscarry before they even realize they were pregnant. They may simply miss their first period, and then their next period comes a little later and may be heavier than expected. In those cases, the pregnancy may never have been diagnosed with a positive pregnancy test.

Catherine Clark: Can you talk to us about the most common causes of miscarriage? Obviously, there are different stages at which pregnancy loss can happen, but what are the most common causes early in pregnancy?

Dr. Lal: In the first 12 weeks of pregnancy, the most common cause is something called aneuploidy, which means the developing embryo has an abnormal number of chromosomes.

We all have 23 pairs, or 46 chromosomes, but a fetus with aneuploidy will have either fewer or more than that number in a way that is incompatible with life.

You can also have miscarriages later on, from 13 to 20 weeks, and those are more often associated with anatomical abnormalities of the uterus or cervix, infection, or maternal health conditions.

Pregnancy losses that happen after 20 weeks are often referred to as stillbirths. These are usually related to abnormalities involving the placenta or the fetus, or a significant maternal health condition that impacts the pregnancy. Thankfully, although these losses are often more devastating because they occur later in pregnancy, they account for less than 1% of all pregnancy losses.

Jennifer Stewart: I know pregnancy can be an anxiety-inducing time for many women who are trying to conceive or are newly pregnant. What are some of the real risk factors women should be aware of before or during pregnancy?

Dr. Lal: Sadly, the most common risk factor relates to the most common cause, which is aneuploidy, and that’s not something a woman can modify.

We do know that the risk of aneuploidy increases as maternal age increases, but many of us haven’t met the person we want to build a family with when our eggs are chromosomally at their most perfect.

There are also other risk factors, including maternal health conditions such as uncontrolled diabetes, inflammatory bowel disease, and other chronic illnesses that can affect the health of a pregnancy.

Some medications are not safe to take in early pregnancy. Lifestyle factors such as smoking, alcohol use, activity level, and maintaining a healthy weight can also impact a healthy pregnancy.

Catherine Clark: Are there particular symptoms that should never be ignored in early pregnancy? Are there red flags women should be watching for?

Dr. Lal: Yes, definitely.

The symptoms we encourage women to come to the hospital for are those that could suggest either an ectopic pregnancy – which is when the pregnancy implants somewhere other than inside the uterus – or that the amount of bleeding during a miscarriage is more than we would expect.

There are three main signs to watch for:

  • Heavy vaginal bleeding. A good rule of thumb is if you’re soaking a pad an hour for two consecutive hours, you should come to the emergency department.
  • Severe abdominal pain or shoulder-tip pain. Shoulder-tip pain seems like an unusual symptom, but if you have blood in your abdomen, it can irritate the underside of the diaphragm. The same nerves that supply the diaphragm also supply the skin over the shoulder tip, which is why that pain can occur.
  • Feeling lightheaded or experiencing a loss of consciousness, which can indicate you’ve lost more blood than you realize. Sometimes it’s difficult to accurately judge how much blood you’re losing.

Jennifer Stewart: Is shoulder-tip pain usually on one particular side, or can it happen on either side?

Dr. Lal: Either side.

Jennifer Stewart: That’s really interesting, and certainly a symptom many people wouldn’t be aware of. How is a miscarriage managed from a medical perspective?

Dr. Lal: There are really three approaches to caring for someone experiencing a miscarriage, and it’s a conversation between the patient and their healthcare provider. First and foremost, we take into account the patient’s wishes, along with any medical circumstances that might make one option safer than another.

The most common approach is what’s called expectant management, or “watch and wait.” A patient may come in with some bleeding, we can see the miscarriage is underway, her blood count is stable, she lives close to a hospital, and she has someone who can bring her back if the bleeding becomes heavier. In those cases, we allow nature to take its course.

If expectant management doesn’t work, or the patient wants a more active approach, we can prescribe medication that causes the uterus to contract and empty the pregnancy tissue. Depending on what we see on ultrasound, we may use one medication or two.

The third option is surgery. If medical management isn’t successful, or if waiting or medication isn’t considered safe—for example, if the patient’s blood count is very low, she lives far from a hospital, or her personal circumstances would make an emergency return difficult—we can surgically remove the pregnancy tissue under anesthesia.

Catherine Clark: You’ve outlined the different treatment options and explained that the decision is influenced by both medical factors and the woman’s own preferences. But miscarriage isn’t only a medical experience – it’s also an incredibly emotional one. How do you have those conversations with women who are going through this in the hospital?

Dr. Lal: Absolutely. I think the physical aspect of miscarriage has long been recognized, but it’s only more recently that we’ve really begun to appreciate the mental health impact of pregnancy loss.

The intensity of grief can be just as strong as losing someone you knew and loved. We know the risk of post-traumatic stress disorder after miscarriage can be as high as 20%, the risk of moderate to severe depression can be as high as 10%, and there’s also an increased risk of anxiety.

Those effects don’t simply disappear once the miscarriage is over from a medical perspective. They can linger and affect the patient, their partner, and even other children in the home as everyone comes to terms with the loss.

One of the most important things is reassuring patients that, in the vast majority of cases, there is nothing they could have done to prevent the miscarriage. It wasn’t because they went for a run, had sex, lifted a heavy box, or anything like that. As we discussed earlier, the most common cause is an abnormal number of chromosomes—something completely outside of their control.

It’s also important to recognize that many women go through this alone. Sadly, there’s still a social stigma around miscarriage, and many women are reluctant to tell the people who would normally be their support system.

I remind them that miscarriage happens to about one in five women. Chances are they already know someone who has experienced one. Sharing their story with someone they trust, in a safe space, can help them connect with people who understand and can support them.

It’s also important to recognize that the people around them often have good intentions but may say things like, “You’re young, you’ll have another,” or “It was early,” or “The baby wasn’t born yet.”

But for many people, once they see that positive pregnancy test, they’ve already imagined preschool, school, and an entire future for that child. They’re grieving that loss, and that’s completely valid.

It’s important to give yourself permission to feel that full range of emotions because that’s part of the healing process.

Ultimately, I think the key is to empower women to feel what they need to feel and to surround them with support. Sometimes the most meaningful thing someone can say is simply, “I’m very sorry this happened. How can I help you?” rather than trying to minimize the loss or reassure them that they’re fine. That kind of support—from physicians, partners, family, and friends—can make a tremendous difference.

Jennifer Stewart: This is a bit of a loaded question, but how do we shift the social stigma around miscarriage? There’s still this perception that if it happens early, it’s not that big of a deal—that women should take a day or two off, get back to work, and carry on. Given how immense the grief can be, how do we change that public narrative?

Dr. Lal: That’s an excellent question.

I think it’s really about improving awareness. If you look back to a time before we openly talked about mental health, for example, it simply wasn’t something families discussed. Now, through public education campaigns and greater awareness, we’re much more open about those conversations, and that’s made a tremendous difference.

The same is true for suicide prevention and many other issues that affect people’s well-being. I think miscarriage deserves a similar approach.

Part of that means making early pregnancy assessment clinics an integral part of care and talking about miscarriage more openly. In the United Kingdom, they’re ahead of us in this regard. They have more than 200 early pregnancy assessment clinics that provide supportive, multidisciplinary care, making miscarriage care a natural part of the healthcare system rather than having patients return to an emergency department for repeat blood work and ultrasounds.

Catherine Clark: A lot of women wonder this after a miscarriage. How long should someone wait before trying to conceive again?

Dr. Lal: That’s a very good question, and I think there are really two aspects to deciding when it’s the right time to try again.

The first is the physical aspect. After an uncomplicated miscarriage, once you’ve had your first menstrual period, you can physically try to conceive again.

But there’s also the very important mental and psychological aspect. It takes a lot of courage to try again because there’s always the possibility of experiencing another miscarriage. Ultimately, it’s a decision each person has to make when they feel, in their heart, that they’re ready.

I also like to say there’s a bit of a golden opportunity after a miscarriage, before planning another pregnancy, to pause and optimize your health.

It’s a chance to ask whether there are medications that could be adjusted to make them safer during pregnancy, or whether a chronic health condition could be better managed. We know pregnancies tend to be healthier when chronic conditions are well controlled.

It’s also an opportunity to receive vaccinations that can’t be given during pregnancy but are recommended beforehand, such as the measles, mumps, and rubella vaccine or the chickenpox vaccine.

If you’re overdue for a Pap test—which is recommended after age 25—that’s another good opportunity to have it done. It’s also the right time to start taking folic acid, ideally two to three months before conception, to help reduce the risk of neural tube defects.

Finally, it’s important to make sure your iron levels and blood count have recovered. Some people lose a significant amount of blood during a miscarriage, and restoring iron levels before conceiving again can contribute to a healthier pregnancy.

So, I think it’s a combination of allowing your body to recover, optimizing your overall health, and making sure you’re emotionally and psychologically ready before trying to conceive again.

Jennifer Stewart: My final question: What are some of the biggest myths or misconceptions about miscarriage that you wish more people understood?

Dr. Lal: I think the most important takeaway from our conversation today is that, in the vast majority of cases, miscarriage is not the patient’s fault.

There’s generally nothing you did—or didn’t do—that caused the miscarriage or that would have changed the outcome.

I also think it’s important to recognize that every emotional response is valid. Most people will feel sadness, but you may also feel anger. Some people even feel relief. Perhaps it was an unplanned pregnancy, and once they became pregnant, they realized it wasn’t what they had anticipated.

For some, a miscarriage can also become an opportunity to think about contraception and decide, “I don’t want to find myself in this situation again, and now I can make a different plan moving forward.”

Everyone heals on their own timeline. You have to wait until you feel, within yourself, that it’s the right time and the right moment to move forward.

Lastly, for people who do hope to conceive again, I would say not to lose hope. Even the darkest night is followed by a bright sunrise.

After 25 years of caring for patients, I’ve had the privilege of seeing that the vast majority of people who want to conceive again do go on to have healthy pregnancies. So if that’s your wish, don’t lose hope, because there’s often brightness around the corner.