6 Week Miscarriage Clot

Overview

A miscarriage is a spontaneous pregnancy loss during the first 12 to 24 weeks of pregnancy.¹ A miscarriage can be 'early' or 'late', depending on how far into the pregnancy it occurs. An 'early' miscarriage occurs within the first trimester of pregnancy (the first 12 weeks). It is relatively common and affects 1 in 5 pregnancies² without people realising their pregnancy. A 'late' miscarriage occurs in the second trimester (between 12-24 weeks) and is not as common, affecting 1-2% of total pregnancies.² A loss of pregnancy beyond week 24 is a 'stillbirth'. In most cases, the leading indicators of a miscarriage include heavy vaginal bleeding, cramping, and pain in the lower abdomen. Many women miscarry early in their pregnancy without even realising it and often mistake it for a heavier menstrual cycle.

There are 6 different types of miscarriage varying in their cause and stage of pregnancy. Miscarriages can be classified as threatened, inevitable, complete, incomplete, missed, or recurrent based on the clinical history and findings of digital pelvic examination.³

• Threatened: When the body indicates the likeliness of a miscarriage, it is referred to as a 'threatened miscarriage'. In this case, abnormal vaginal bleeding and lower abdominal pain are accompanied by continued pregnancy. Although vaginal bleeding is common during early pregnancy, symptoms other than spotting in the first trimester can be considered a threatened miscarriage
• Inevitable: An inevitable miscarriage can follow a threatened miscarriage or happen without a warning. Vaginal bleeding and lower stomach cramps will be more severe compared to a threatened miscarriage. During this type of miscarriage, the developing foetus passes through the cervix within the blood
• Complete: Diagnosis of complete miscarriage starts with an ultrasound failing to identify any sign of pregnancy in the uterine tissue. Vaginal bleeding continues for several days and cramping is common, much like labour or intense period pain
• Incomplete: This type of miscarriage is defined by the presence of retained pregnancy tissue without a well-defined gestational sac. Vaginal bleeding and lower abdominal cramping continue as the uterus empties itself
• Missed: Also referred to as 'early fatal demise', ‘blighted ovum’, ‘delayed’, or ‘silent miscarriage’ is an early stage in a miscarriage with an intact gestational sac remaining in the uterus despite the death of the foetus. In the missed miscarriage, brown discharge is seen without any  unusual side effects. Often, the person does not realise that they've lost the foetus because of no noticeable signs or indicators
• Recurrent miscarriage is when 3 or more consecutive miscarriages happen, affecting 1% of those assigned female at birth (AFAB) during their reproductive age.⁴ Most miscarriages happen because of chromosomal abnormalities³ and people do not need to be routinely tested for less common causes of miscarriage unless they have persistent losses

Although a miscarriage cannot be prevented once begun, it can be managed in many ways.

• Surgical procedures: Surgical evacuation of the lost foetus is a common form of management for incomplete miscarriage, usually involving vacuum aspiration or sharp curettage.⁵ Surgical procedures may be the most effective in cases with heavy bleeding, pain or infection or if medical and natural management has failed
• Medical intervention: With this method, people may be given medication that allows the foetal tissue to be passed
• Natural management: Otherwise known as 'expectant management' or 'watch and wait', this method involves letting the lost pregnancy pass from the womb naturally which can happen within a few days to weeks

At 6 weeks, nothing recognisable can be seen in most cases of a miscarriage. If there is bleeding, however, some may notice clots containing fluid-filled sacs - the embryo and a placenta may be within these sacs.

Signs of miscarriage

The most common sign of a miscarriage is vaginal bleeding.⁶ A 2003 study found that in a sample of people who experienced a complete miscarriage, more than 50% had vaginal bleeding, with some undergoing surgical evacuation.⁶ Bleeding varies from light spotting or brown discharge to heavy bleeding or clots. Bleeding can fluctuate over the course of many days. It is important to note that vaginal bleeding is common during early pregnancy and does not always indicate a miscarriage. Other symptoms include:

• Cramping and pain in the lower abdomen and/or back
• Vaginal fluid discharge
• Release of foetal and placental tissue from the vagina  
• End of  pregnancy-related symptoms

When a pregnancy develops outside the womb, like an ectopic pregnancy, it is not possible to save the foetus. Medical intervention is vital to minimise the risk of internal bleeding. Symptoms of an ectopic pregnancy differ slightly from those of the usual miscarriage:

• Shoulder pain
• Diarrhoea and vomiting
• Persistent abdominal discomfort localised to one side of the abdomen
• Feeling nauseous, light-headed and fainting
• Vaginal bleeding or spotting after pain has startedWhat happens during a miscarriage?

When are miscarriages most likely to occur?

Most miscarriages happen in the first 12 weeks of pregnancy.⁷ Environmental risks, occupational risks and previous miscarriages, as well as endocrine, autoimmune and thrombotic abnormalities, are some factors that increase the likelihood of a miscarriage which are explained bellow.⁸

• Environmental risk: exposure to potentially teratogenic or mutagenic agents has been linked to adverse reproductive outcomes in many studies⁸
• Many drugs and environmental chemicals have been shown to cause chromosomal damage in animal studies,⁹ but there is lack of data from human srudies
• Recent studies have found that maternal exposure to organic solvents increases the risk of foetal abnormalities¹⁰
• Consuming more that four cups of coffee in a day during early pregnancy has been shown to be linked with miscarriage¹¹
• Smoking cigarettes in early pregnancy is associated with a severe increase in the risk of miscarriage, growth abnormalities and trophoblast infection¹²
• A recent prospective cohort study found that alcohol consumption in the first trimester of pregnancy is associated with an increased risk of miscarriage.¹³
• Occupational risks: people who are continually exposed to free radicals, pollutants and chemicals experience an increased risk of miscarriage and have higher rates of recurrent miscarriages⁸
• Previous miscarriage: recurrent miscarriages suggest recurring episodes of early pregnancy loss that usually has an underlying systemic cause. Previous miscarriages increase the risk of repeated loss¹⁴ The risk of miscarriage increases proportionately to the number of prior miscarriages or with characteristics of the index of pregnancy loss such as form, week of pregnancy or chromosomal sturucture and count. It can be assumed that repeated pregnancy losses are associated with prognosis for future pregnancy outcomes, which is different in those suffering sporadic miscarriages
• Endocrine disorders: several endocrinopathies, such as luteal phase defect, progesterone deficiency and polycystic ovaries, increase the likelihood of miscarriage
• Luteal phase defect: Noyes et al.¹⁵described that insufficient progesterone production and a defective corpus luteum are correlated with inadequate endometrial maturation, congenital disabilities, infertility and recurrent miscarriage
• Polycystic ovaries: studies have reported that patients experiencing classical endocrinopathies associated with PCOS are at increased risk of miscarriageafter spontaneous or assisted conception¹⁶
• Autoimmune disorders: in patients with diabetes, several studies have reported the direct correlation between control of blood sugar and the incidence of miscarriage which was measured by glycosylated haemoglobin levels (HbA 1c). One study found a significant and consistent correlation between adverse foetal outcomes (abortions, miscarriage and malformations) and HbA 1c in the first trimester of pregnancy in patients with type 1 diabetes.¹⁷ Thyroid dysfunction has also been shown to increase the chance of recurrent miscarriages¹⁸
• Thrombotic state: Thrombin-antithrombin complexes (TAT) are significantly elevated in those AFAB experiencing recurrent miscarriage, compared to age-matched fertile control groups without history of pregnancy loss¹⁹

What may you see during a miscarriage?

6 Weeks

At 6 weeks, the indication of a miscarriage is mostly vaginal bleeding and abdominal pain. Most people AFAB do not recognise they are having a miscarriage during this time. Bleeding often happens with clots and the loss of fluid-filled sacs.

8 Weeks

At 8 weeks, expelled tissue is no different to heavy menstrual bleeding - often dark red and shiny. Some have reported finding a fluid sac with an embryo inside, sometimes identifying physical attributes such as eyes, arms and legs.

10 Weeks

10 weeks into pregnancy, the developing foetus is usually fully formed but is small and difficult to identify. Blood clots resemble dark red, jelly-like masses directly released from the placenta. The sac containing the foetus is contained inside one of these clots.

Complications with miscarriage

A miscarriage can have profound emotional and physical impacts on the body.

• Many report psychological distress after pregnancy loss
• It has been reported that 20% of miscarriages accompany depression and/or anxiety, with symptoms persisting for 1-3 years in some cases²⁰
• Grief is a commonly reported complication following a pregnancy loss.²¹ The risk of more intense or longer-lasting grief is likely greater if a) the person strongly desires to become a parent, b) has waited considerable amounts of time to conceive, c) has experienced pregnancy loss in the past, or d) finds it difficult to cope with distressing situations
• Further miscarriage or pregnancy issues: having a miscarriage increases the likelihood of having another miscarriage,¹⁴ as well as several complications like pre-eclampsia and preterm delivery.²²
• Bacterial infection: surgical and medical interventions for miscarriage management increase the likelihood of sepsis and pathogenic infection.²³ A 2013 study from Albania found that those who had medically induced abortions and previous history of miscarriage, showed a higher prevalence of bacterial vaginosis compared to others²⁴
• Fever: the United States Centres for Disease Control and Prevention found that Q fever infection is associated with adverse pregnancy outcomes¹
• The American Pregnancy Association found that physical symptoms from emotional distress, namely drowsiness and fatigue, can occur following miscarriage
• Pelvic pain: a 2016 study found that pelvic pain and vaginal bleeding was present in all patients who suffered a miscarriage²⁵

Ectopic pregnancy

Ectopic pregnancy has been described as "the most common life-threatening emergency in early pregnancy".²⁶ An ectopic pregnancy is where the gestational sac forms outside the uterus, putting patients at risk of fallopian tube rupture and catastrophic haemorrhage.^{27, 28} In case of an ectopic pregnancy, spontaneous tubal abortion or regression and other medical interventions might be performed. Surgical management of ectopic pregnancy should be limited to those who refuse or have contraindications to medical treatment, those in whom medical therapy has failed and those who are haemodynamically unstable.²⁶

When to seek medical attention

If you experience vaginal bleeding, contact your general practitioner or midwife immediately. Suppose you are presenting the symptoms of a miscarriage. In this case, you'll likely be referred to a hospital for future testing, where ultrasounds can help determine whether or not you're having a miscarriage. 

If a miscarriage is confirmed, your doctor or midwife will discuss the options for itsmanagement. Medical or surgical intervention may be recommended if the pregnancy tissue isn't passed naturally within a couple of weeks. 

Does a miscarriage impact future chances of pregnancy?

A miscarriage can increase the chance of another in the future.¹⁴ Complications such as pre-eclampsia and preterm delivery may follow pregnancy loss.²²

Despite these complications, you can have a successful pregnancy immediately after a miscarriage. After a miscarry, the body restores its usual reproductive cycle. Although it is recommended to wait several months before getting pregnant again, there are studies on pregnancy within 1-3 months after a miscarriage .²⁹ A 2017 study found that pregnancy within 3 months of a miscarriage lowered the risk of a subsequent miscarriage compared to those who waited longer than 3 months (36).³⁰ However, your doctor may suggest a different approach for your health depending on your circumstances.

Summary

A miscarriage is a spontaneous loss within the first 24 weeks of pregnancy. Depending on the stage and cause of the miscarriage, medical intervention, surgical methods, or natural procedures may be used to manage the pregnancy loss. At 6 weeks, most patients don't see anything recognisable when they miscarry, although heavy bleeding and clotting are common. Several physiological and environmental risk factors can increase the likelihood of a miscarriage. The loss of a pregnancy is associated with profound emotional and physical consequences; it is fundamental to discuss further treatment options that are personalised to the individual to minimise such conditions.