Is severe cramping normal after miscarriage?

Dear Doctor,

My sister suffered a miscarriage and has been in and out of pain ever since. There are painkillers she was given after she was discharged, and advised to go on bed rest, but it is now almost two weeks and the pain still keeps her up at night sometimes. Is this expected?

Stella

Dear Stella,

Miscarriage involves evacuation of the premature foetus or products of pregnancy from the uterus.

It is a painful procedure and emotionally traumatic experience, and there are multiple causes for pain, after the miscarriage as well.

Pain immediately after and even up to one to two weeks of miscarriage can be due to trauma to the uterine muscle or cervix (lower part of uterus) or to the pelvic floor. Pain is mostly in form of cramps and usually occurs over the lower abdomen and back. It lasts till there is complete healing of soft tissues of the uterus or pelvic floor. Involvement of the nerves of the uterus or pelvis can also cause backache or cramp-like pain in the legs. This pain can be avoided by avoiding lifting heavy weights, for few days, or doing hectic physical work or having sex, after a miscarriage, that is, activities which stress muscles of lower abdomen or pelvis.

Another most common cause for persistent pain after a miscarriage is infection. Infectious germs can enter either through the vagina or through contaminated tools or hands. Risk is higher with unskilled persons, outside a proper health care setting. Having sex, soon after miscarriage, use of vaginal tampons, urinary tract infections, intra uterine device (IUD), are other sources of infection. To prevent this, one should avoid sex for at least two weeks after the miscarriage.

Septic shock after a miscarriage can cause severe abdominal pain, with high fever and shock. This is a medical emergency and needs urgent attention.

Perforation of the uterus is also a potentially fatal complication of miscarriage, which is manifested by severe abdominal pain, fever and shock. It also needs urgent medical intervention.

Drinking plenty of water, after a miscarriage, keeps the person well hydrated and prevents urinary tract infection, from where microbes can go to the anatomically close uterus. One should also take a high fibre, low fat, diet in form of small frequent meals, post miscarriage. This prevents dyspepsia and constipation, two factors which can contribute to the abdominal pain, after the ordeal.

Pain killers which reduce inflammation as well, like non-steroidal anti-inflammatory drugs (NSAIDS), are important in pain management following a miscarriage. In severe pain, it can be in form of injections, whereas tablets or ointments for local application are good enough for mild to moderate, tolerable pain. Hot compresses or hot pads are also useful in pain relief.

Apart from pain relief, due attention should be given to identify any underlying treatable cause for pain. For example, in case of infection, antibiotics would be necessary, to clear the infection. Suspected septic shock or perforation of the uterus, are indications for urgent hospitalisation for necessary intervention. 

Dr. Rachna   Pande is a specialist in internal medicine. 

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