Miscarriage Guide

‍Know Your Rights:

Miscarriage is defined as the loss of a pregnancy before 22 weeks gestation, and is common among women in their reproductive years. Studies show that 1 in 4 known pregnancies end in miscarriage. The statistic of miscarriage is likely higher, as many very early miscarriages often manifest themselves as a period, leading some women to be unaware of the pregnancy in the first place. 

This guide will provide clear information about identifying a miscarriage, the rights available for women experiencing a miscarriage, and how to navigate the situation through the Israeli healthcare system. 

We hope this guide can ease the burden of this difficult situation, by empowering you with the knowledge to ask the right questions, advocate for yourself, and manage the situation. Although very technical, we come to you with this guide with the utmost sensitivity and understanding for the challenges and sadness that are a deep part of pregnancy loss at any stage.

Recognizing a Miscarriage:

An early/first trimester miscarriage is considered a loss of pregnancy in the first 12 weeks of pregnancy, whereas a late/second trimester miscarriage occurs up to about 20 weeks. After 22 weeks, the loss of pregnancy is generally considered a stillbirth. Regarding the birth and rights, the process for stillbirth would be similar to a live birth.

Understanding Types of Miscarriages:

1. Threatened miscarriage (הפלה מאיימת): An imminent danger to the fetus that may result in a possible miscarriage. This can appear as vaginal bleeding usually in the first trimester. 
2. Complete miscarriage (הפלה שלמה): A cessation of the pregnancy followed by the pregnancy sac exiting the body completely. 
3. Partial miscarriage (הפלה חלקית): A cessation of the pregnancy, but the content of the pregnancy does not entirely exit the body. 
4. Missed miscarriage (הפלה נדחית): The woman has no symptoms of miscarriage. The miscarriage is only discovered during an ultrasound when no heartbeat is detected.
5. Ectopic Pregnancy (הריון חוץ-רחמי): The fetus grows outside of the woman’s fetus, usually implanting into the fallopian tube. The pregnancy must be terminated and is considered a medical emergency requiring intervention immediately to protect the mother.
6. Chemical pregnancy (הריון כימי): Very early pregnancy loss (weeks 4-5) when an embryo is fertilized but does not fully implant into the uterine wall. Pregnancy tests may continue to be positive, but the pregnancy is not viable.
7. Molar pregnancy (הריון מולה): A rare complication when abnormal cells develop in place of the placenta. This condition requires immediate medical intervention.

Signs of Miscarriage:

• Severe cramping 
• Pain on one side of lower abdomen/pelvis (possible ectopic pregnancy)
• Spotting, bleeding, blood clots
• Feeling unwell, such as experiencing flu-like symptoms 
• Extremely high or low HCG (human chorionic gonadotropin) levels, or an abnormal increase in HCG levels. 

⇒ Tip: Miscarriage can happen suddenly when a woman experiences heavy bleeding, but will often occur gradually with spotting and light pain that slowly increases. Light spotting in early pregnancy is common and can be normal, but any spotting in pregnancy should be discussed with your OBGYN.

Seeking Medical Attention for a Miscarriage:

Bleeding during pregnancy is taken very seriously. It is important to speak to a professional for guidance as to what to do next.

1. Call your OBGYN: If they are available, explain your symptoms and they will tell you what to do. To reach an OBGYN in the kupah, you will generally need to call the branch secretary and request the doctor call you back. Explain your concern and the urgency of the situation.
2. A family doctor, your moked (hotline), or nurse: Often, your regular OBGYN will not be available when symptoms begin. In this case, especially if you are concerned about an emergency, contact these resources for a referral to a women’s health clinic  or other emergency services.
3. Women’s Health Clinic: Depending on the time of day, the situation, etc, you may be able to receive assistance from a women’s health clinic (מרכז בריאות האישה). Many kupot have these clinics in major cities which allow for walk-ins, and you can be assessed by a nurse, an ultrasound technician, and/or doctor.
4. Emergency Room: Depending on the time of day or severity of the situation, you may need to go to the emergency room. You may be sent by your doctor, or call the moked on the way for a referral. If you are concerned about an acute emergency, do not hesitate to go straight to the ER.

Getting an Ultrasound:

• Requesting a Hafnaya: Although not always required, it is generally recommended to ask that a hafanaya be sent to the ER/Urgent Care to avoid disputes over payment after treatment. Any follow up ultrasound through your kupah will require a hafnaya and an appointment.
• During the Ultrasound: The technician will check for a fetal heartbeat, the gestational age of the fetus, the location of the sac, amount of amniotic fluid, and the size of the uterus. You will then be referred to a doctor. In the ER a doctor may be the one performing the ultrasound.
• Please note: If the pregnancy is earlier than 10 weeks gestation, or it is hard for the technician to see, you will likely need a transvaginal ultrasound. Many women are unaware of this method of ultrasound until they require one, and while not painful, the experience may be uncomfortable for some women.

No Heartbeat Detected:

• If gestational age is less than 6 or 7 weeks, you will likely be sent for a blood test to determine your hCG levels, and asked to come for a follow up ultrasound in 1 or 2 weeks to determine the status or development of the pregnancy. 
• If the gestational age is 7 weeks or later, and there is no heartbeat, the doctor will almost certainly determine a miscarriage. 
• The pregnancy loss must be confirmed by both a gynecologist and ultrasound technician.
• The woman must have someone with her when she is informed about the pregnancy loss. If she doesn't have someone with her then a hospital psychologist or social worker must be present.

Heartbeat Detected:

• If a normal heartbeat is detected and all other findings are normal and appropriate for the gestational age, you’ll be referred back to your doctor for a follow up. In most of these cases, this is an indication that the pregnancy is developing as normal. Assuming symptoms don’t change/worsen, many women are observed as they would be in a normal pregnancy.
• If a heartbeat is detected, but there are additional signs that the pregnancy is not developing properly (abnormal heart rate, small for gestational age, abnormal sac size, etc), you will be referred to your doctor, and he/she will often request close observation. This will include follow up ultrasound to determine fetal growth, observe any other abnormalities, and determine if a high risk OBGYN is necessary for the remainder of the pregnancy.

⇒ Tip: For general concerns, your local women’s clinic is usually a good place to start. Your regular kupah gynecologist is generally not able to answer your questions immediately, and an ultrasound at the women’s clinic will often be the right solution. Although the initial US and nurse’s visit is quick, be prepared to wait up to an hour to see a doctor. 

Treatment Options:

If a miscarriage is determined there are several methods of treatment. There is no one preferred method, it should be a joint decision between you and your doctor.  This chart summarizes your options after a miscarriage is diagnosed, and what is required to receive each one. 

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Removing the Fetus:

Hospitals are obligated to remove the fetus from a woman as quickly as possible; at most within 3 days from when the loss was discovered.

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Additional Information:

• Regardless of which route is taken, a follow up ultrasound will be needed to determine whether the miscarriage was complete, that there is no remaining tissue, and that the uterus has gone back to its regular size. That can generally be done in the kupah, and a hafnaya and appointment are required.
• Repeated miscarriages (3 or more):

• If a woman has 3 or more consecutive miscarriages, your doctor will generally suggest further investigation to see if there is an underlying medical reason for the repeat miscarriages. (Some tests may require a hitchayvut in addition to a hafnaya, see our Infertility Guide).
• If you have multiple miscarriages with live births in between it is not considered repeat miscarriages, and further investigation may not be necessary. However, the woman and her doctor can discuss if it may be worth some testing to investigate the cause of the frequent pregnancy loss.

⇒ Tip: We encourage you to advocate for yourself, and reach out to any relevant contacts (protexia) you have when dealing with miscarriage treatment. This often helps expedite the process of receiving an appointment, especially when it comes to scheduling a D&C. Although the law indicates that the fetus must be removed within 72 hours, in practice it takes some pushing to ensure this happens.

Benefits and Rights After a Miscarriage:

Employment Rights:

      If miscarriage occurred before 22 weeks of pregnancy:

• Working adults are entitled to 7 sicks days based on their accrued sick days to recover from miscarriage. These absences are calculated like other health related absences. Have your family doctor write you a sick note. Your doctor does not need to disclose the reason for the sick days. 
• The employer is forbidden from changing the terms of your job or firing the employee while she absent is because of a miscarriage.
• For more information on employment rights and sick leave, see our portal on Kol Zchut.

   If miscarriage occurred after 22 weeks of pregnancy:

• The accepted interpretation is that women who have a miscarriage or termination of pregnancy after 22 weeks are considered to have given birth, and are entitled to the same legal rights and protections that women who have give birth to a live baby are entitled to, with the exception of rights that are related to caring for the child. 
• For additional information on maternity leave and pregnancy rights, see our Kol Zchut Maternity Leave Portal and our Pregnancy Guide.

⇒ Tip: Once you’ve used your entitled miscarriage sick days, you are no longer protected from being fired through the pregnancy or miscarriage employment laws. We encourage you to use your discretion when choosing whether or not to inform your employer about your miscarriage. By law, your doctor does not need to disclose the specific reason for the use of the sick days.

Support:

• Yad L’Olim
• Merkaz Panim
• PUAH : Fertility. Medicine. Halacha.
• Bishvilech Center 
• Women and Their Bodies – WTB 
• Facebook Group- Pregnancy and Infant Loss Support in Israel (Private Group)

⇒ Tip: Find support: Dealing with pregnancy loss at any stage can often lead to anxiety and depression, as well as a general sense of isolation. We recommend finding a family member or friend to support you (in addition to your partner, who is also dealing with his/her own challenging experience). You may also want to seek professional help, and see a therapist through your kupah or privately.

Sources:

• הפלה טבעית: כל מה שחשוב לדעת 
• הפלה טבעית | שיבא - הריון ולידה 
• Removal of a Fetus from the Womb within 3 Days of Discovery of the Loss 
• ריקון הרחם לאחר הפסקת הריון טבעית - מידע רפואי - תאור ההליך 
• טיפול תרופתי או גרידה לריקון הרחם במקרים של הפלה טבעית?, ספריית מאמרים
• Employment Rights for Women after a Miscarriage (Right) - All Rights (Kol-Zchut) 

‍Please note: 

All resources linked to www.yadlolim.org/healthcare are the original work of the Yad L’Olim Healthcare Division in memory of Shira Pransky z”l. 

All resources linked to www.kolzchut.org.il/en are the exclusive translations of the Yad L’Olim Healthcare Division in memory of Shira Pransky z”l. 

External links to outside resources are reputable sources, however we are not responsible for the content or any changes made.

For further information and personal assistance, please contact Yad L’Olim’s Healthcare Division at healthcare@yadlolim.org