High-risk pregnancy, miscarriage and loss in Spain

Key rules

• Emergency: For bleeding or other warning signs, go to hospital urgencias or call 112; no health card is needed.
• Referral: Your midwife or family doctor refers you to the hospital high-risk unit, where an obstetrician decides follow-up and delivery.
• Blood group: If you miscarry and are Rh-negative, you are given an anti-D injection.
• Regional differences: Referral criteria, miscarriage options and bereavement support vary by region and hospital.

When to go to emergency

Go to a hospital emergency department (urgencias), ideally its obstetric-gynaecological service, if you have any of these:

• vaginal bleeding
• fluid leaking
• severe or constant abdominal pain
• regular contractions before 37 weeks
• much less movement from the baby, or none
• severe headache or visual disturbances
• sudden swelling of the face or hands
• fever or vomiting that will not stop
• chest pain or breathlessness
• convulsions or fainting
• a painful, swollen leg

Call 112 if the bleeding is heavy, you feel faint, or you cannot get to the hospital safely. Emergency care is available at any hospital emergency department or by calling 112, with no health card needed.

How high-risk referral works

Your risk is assessed at your first prenatal visit, usually with a midwife (matrona) or your family doctor in primary care. They look at your history and test results.

Things that can raise your risk include:

• a chronic illness such as diabetes, high blood pressure, or heart, kidney or thyroid disease
• earlier pre-eclampsia, preterm birth or stillbirth
• a multiple pregnancy
• being under 16 or over 40
• a very low or very high body mass index
• findings during the pregnancy, such as poor growth of the baby, placenta praevia or gestational diabetes

If you are at higher risk, the midwife or doctor refers you to the hospital's high-risk obstetrics unit, the ARO. There an obstetrician decides your follow-up and your delivery plan.

The label is not fixed. Risk can be reassessed at any visit, and if the problem resolves you may go back to routine care. Exact criteria and referral forms differ by region and hospital, so ask your health centre how it works where you live.

If you have a miscarriage

At the hospital you will usually have an examination and a transvaginal ultrasound. Sometimes you will also have blood tests, including your blood group. If you are Rh-negative, you are given an anti-D injection.

You then choose a way to manage the miscarriage with the doctor, depending on the type of miscarriage, how much you are bleeding and what you prefer. The options are waiting, medication, or a minor procedure. The decision block below sets them side by side. Which options a hospital offers can vary.

Afterwards, follow-up is with the hospital gynaecology unit, your midwife or your family doctor.

Support after a loss

After a late miscarriage, stillbirth or the death of a newborn, many public hospitals follow a bereavement protocol. Depending on the hospital, this may include:

• a private room
• time with your baby
• keepsakes such as photos and footprints
• psychological support
• help with funeral arrangements and registration

You can also ask for a record or certificate of the loss. Spain's health ministry has published an official guide on perinatal bereavement care, and many hospitals base their protocols on it. Quality and psychology support differ between hospitals and regions, so ask the ward team what is available.

Outside the hospital, the associations Umamanita and El Parto es Nuestro run peer groups and training for families.

The checklist, warnings and questions below cover what to ask and what to watch for.

Choosing between options

How do you want a miscarriage to be managed?

• Wait and let it pass naturally: Fits when the doctor finds the miscarriage is progressing and the bleeding is manageable, and you prefer to avoid medication or a procedure.

• Take medication: Fits when you want to avoid a procedure but not wait. You take misoprostol, with or without mifepristone, to help the miscarriage along.

• Have a minor procedure: Fits when bleeding is heavy or the miscarriage is not completing, or when you prefer it done in one step. It is done by aspiration or curettage.

You choose together with the doctor, based on the type of miscarriage, how much you are bleeding and your own preference. If bleeding is heavy or you feel faint, call 112 instead of waiting.

Checklist

• Tell your midwife (matrona) or family doctor about any chronic illness, such as diabetes, high blood pressure, or heart, kidney or thyroid disease.

• Tell them about earlier pregnancy problems: pre-eclampsia, preterm birth or stillbirth.

• Ask whether you are being referred to the hospital high-risk obstetrics unit (ARO).

• Ask the obstetrician who will decide your follow-up and your delivery plan.

• Ask at each visit whether your risk has been reassessed.

• Go to the hospital emergency department, ideally its obstetric-gynaecological service, if you have bleeding or suspect a miscarriage.

• Ask for your blood group to be checked during the assessment.

• Agree with the doctor how the miscarriage will be managed.

What to watch out for

• A risk factor nobody knows about: Your risk is judged from your history and tests at the first prenatal visit. A condition or past complication you do not mention can be missed, and then you are not referred to the hospital high-risk unit. Tell your midwife or family doctor about chronic illness, earlier pre-eclampsia, preterm birth or stillbirth, and a multiple pregnancy.

• Assuming the rules are the same everywhere: The exact criteria and referral forms differ between regions and hospitals. A friend's experience in another area may not match yours. Ask your midwife which hospital unit you are referred to and what happens next.

• Treating the label as permanent: Risk can change at any visit. New findings such as growth restriction, placenta praevia or gestational diabetes can move you into high-risk care, and if a problem resolves you may return to routine care. Keep every follow-up appointment and ask each time whether your risk level has changed.

Frequently asked questions

Can I go back to routine care after being classed as high-risk?

Yes, you can go back to routine care if the problem that made your pregnancy high-risk resolves. Your midwife or doctor can reassess your risk at any visit, so ask at each appointment whether your follow-up still needs to stay with the hospital unit.

Will I get an injection if I miscarry and I am Rh-negative?

Yes, you are given an anti-D injection (immunoglobulin) if you are Rh-negative. The hospital checks your blood group with a blood test during the assessment. Tell the doctor your blood group if you already know it.

What can the hospital offer after a late miscarriage or stillbirth?

Many public hospitals offer a private room, time with your baby and keepsakes such as photos and footprints. They also offer psychological support and help with funeral arrangements and registration.

Is there support outside the hospital after losing a baby?

Yes, associations such as Umamanita and El Parto es Nuestro run peer groups for families after a loss. The Ministry of Health has also published an official guide on perinatal bereavement care. Ask your hospital whether it follows a loss protocol.