Miscarriage medical management

Information for women under 13 weeks of pregnancy

We are very sorry that you or someone close to you has had a miscarriage and this leaflet is to help you choose what treatment to have.

This leaflet is to help explain what is going to happen next and how the miscarriage can be ‘managed’ by medical treatment. This information is to guide you so you can make an informed decision.

It might help you to know that research comparing medical management of miscarriage using medication with surgical intervention or natural miscarriage found that:

the risks of infection or other harm are very small with all three methods
your chances of having a healthy pregnancy next time are equally good whichever method you choose
women cope better when given clear information, good support and a choice of management methods.

What is medical management of miscarriage?

Vaginal tablets (pessaries) called Misoprostol help start or speed up the process of a miscarriage. This treatment is unsuitable for women with some health problems, including severe asthma or anaemia.

What happens?

Misoprostol softens the neck of the womb (cervix) and causes the muscles of the womb (uterus) to contract. Misoprostol does not have a UK licence for use in pregnancy but is a recognised and approved drug of choice, very commonly used to help with the management of miscarriage.

You will have a blood test and be asked to sign a consent form. You will then be given an appointment to come for your treatment.

At this appointment, the Misoprostol will be given to you to insert in the vagina – this can be done by yourself or by the Nurse. The Misoprostol makes your uterus contract to push out the pregnancy. If you do not want to insert the pessaries into the vagina, you can put the tablets under your tongue. You can go home15-30 minutes after the pessaries/ tablets have been inserted/taken. The miscarriage will take place at home. We will organise a call with you in the following few days and if the miscarriage has not started within a week, you may need to return for a second dose.

What are the side-effects of the medication?

The medication may make you feel sick and can cause diarrhoea and flu-like symptoms, which may be worse if you have taken oral tablets.

What should you expect?

You can lead life as ‘normal’, but we recommend that you are prepared for the miscarriage process.

Most women will miscarry within 48 hours of having the Misoprostol; however, it is important to understand that it could take up to a week to happen.

Pain and bleeding

Most women have period-like cramps that can be very painful, especially when the pregnancy tissue is being pushed out. This is because the uterus is tightly squeezing to push its contents out, much like it does in labour. You will need pain relief such as paracetamol and ibuprofen and we can also provide you with codeine-based pain relief and anti-sickness medication. Sometimes using hot water bottles (not too hot) on the tummy can help ease the pain. If you are still having pain, please contact us (contact numbers on page 4).

The amount of bleeding can vary. It might be more than with a normal period and you may pass clots. These can be as big as the palm of your hand. You may see the pregnancy sac, which might look different from what you expected. You may, especially after 10 weeks, also see a tiny baby (fetus).

Generally, if you are soaking more than 2 sanitary towels per hour for more than 4 hours, you are losing too much blood. Although this depends on how you are feeling as well.

We understand that bleeding at home can be very frightening. Please call us for advice:

Call the early Pregnancy Unit 01296 316469 8am-1pm, Monday-Friday.
At all other times please call ward 15 on: 01296 316500 or 01296 316365

Once you have miscarried (passed blood clots) the bleeding should ease and become lighter. Although you may see some further clots, the bleeding should become lighter and the cramping should ease.

You may bleed for 10-14 days after the miscarriage, this should become lighter over time and will become dark red or brown (but it should be lighter, more like a period).

What are the risks?

The main risks are infection (about 1-4 women in every 100) or haemorrhage (heavy blood loss) (about 2 in 100) – the same as for natural miscarriage.

Signs that you may have an infection include fever or shivering, vaginal discharge that smells foul or looks infected, tummy pain or tenderness that continues after you have taken pain relief.

Medical management is effective in 80% (8 out of 10) of cases. If it is not, or if you have an infection, you may be advised to have surgical management to complete the miscarriage.

What are the benefits of medical management of miscarriage?

The main benefit is avoiding an operation and anaesthetic. Some women see medical management as more natural than having an operation, but more controllable than waiting for nature to take its course.

As with natural management, you may prefer to be fully aware of what is happening, to see the pregnancy tissue and maybe the baby.

How you may feel

You may find the process painful and frightening, although good information about what to expect can help.
You may be anxious about how you will cope with pain and bleeding, especially if you are not in hospital at the time.
You may be frightened about seeing the remains of the pregnancy.
Bleeding can continue for up to three weeks after the treatment and you may need follow-up scans to check on progress.
Some women may ultimately require surgical treatment.

Hygiene

Your cervix is opened slightly to allow blood to drain and we want to reduce the risk of infection getting in.

Therefore, we advise NOT to wear tampons or to have sexual intercourse whilst you are bleeding. It is also advisable NOT to go swimming or to take long soaks in the bath as these may increase the risk of infection. It is safe for you to take showers and short baths in warm but not very hot water. Once you have stopped bleeding you can continue as normal.

Getting back to normal

Going back to work is an individual decision. It depends on how heavy your bleeding is, and how you feel generally – the loss of a pregnancy can be a very distressing event in a woman’s life. You may decide that you need to take some time off or take things easy whilst the actual miscarriage is happening. Some women need more time off than others. Many women feel that at least a few days off work may be necessary. You can self-certificate for the first week off work, and after that you will need to see your GP for a fitness for work certificate. You can resume exercise and sexual intercourse whenever you feel ready.

After the miscarriage

In hospital

In our hospital, when a baby dies, in accordance with the Human Tissue Act, the gestation sac/ fetal remains are sensitively buried, along with remains of other miscarried babies. This burial service is attended by the Hospital’s Chaplain at a service held once a month.

Even if you miscarry in hospital you may want to make your own arrangements for burying or cremating the remains of your baby. You can do this through a Funeral Director or carry out your own burial at home. Please note: if you are in a rental property, you should not bury the remains in the garden. See further information below.

At home

If you miscarry at home or elsewhere outside a hospital, you are most likely to pass the remains of the pregnancy into the toilet. This can happen in hospital too. You may look at what has come away and see a pregnancy sac and/or the baby – or something you think might be the baby. You may want to simply flush the toilet – many people do that automatically – or you may want to take a closer look. That is natural too.

You may want to bring the remains to us, and we can look at them for you. If you want us to, we can send the remains to the laboratory to confirm this was pregnancy tissue, and we can also sensitively bury this for you according to the hospital’s policy.

What happens afterwards?

The Early Pregnancy staff will organise a telephone appointment with you in the following week to see how things have progressed. If you are certain that you have miscarried, then we do not need to see you again. We recommend you do a urine pregnancy test 3 weeks after the miscarriage and contact us if it is still positive. If you are in any doubt, or have little or no vaginal loss, then we will make arrangements to see you for a urine pregnancy test and possibly arrange another scan.

If the miscarriage is not complete, then you have the following options:

Repeating the Misoprostol
Waiting for the miscarriage to occur spontaneously
Surgical management to remove the pregnancy

Can you change your mind?

Yes, you can change your mind about having medical management. The other options are:

Surgical management – removal of the pregnancy under a general anaesthetic
Expectant management – waiting for the onset of miscarriage to occur naturally.

Please ring the Early Pregnancy Unit to talk about your options at any time.

When can you expect a period?

Every woman is different in terms of how soon after they miscarry that they have their next period. This can range from 3 to 6 weeks. Remember that this can vary as you are experiencing the loss of a pregnancy, and the body and your hormones can take time to return to normal. Often the next period can be different to those you normally have (heavier or lighter), but this is nothing to be concerned about, unless the bleeding is very heavy and prolonged, when you should contact your GP.

If you do not have a period within 6 weeks of your miscarriage, you are advised to contact your GP.

Do you need to tell anyone about your miscarriage?

No, the Early Pregnancy Unit will have sent information to your GP and Community Midwife. Any ultrasound scan or hospital appointments will be cancelled, so you will not need to worry about doing this. Unfortunately, we will not be able to stop the appointment letters that have already been sent out.

The future

We recommend you take daily folic acid (preferably for 3 months before a pregnancy) and wait for at least one period before you try again. Once you have a period then we know that your hormones are back to normal.

We hope that this information helps you to make informed decisions at what may be a difficult and distressing time.

Please remember that nothing is too trivial to talk about. If you are worried, we would like to help.

Contact numbers

Early Pregnancy Unit: 01296 316469
You can call this number 8am-1pm, Monday–Friday.

At all other times please call:
Ward 15 01296 316500 or 01296 316365

Further information and support

Miscarriage association: www.miscarriageassociation.org.uk

Bears charity: www.achingarms.co.uk

Information about burying your baby at home

If you want to bury your baby at home, please remember:

You may not always live at that address
The baby should not be buried near a water supply
The baby must be buried at least 90cm deep
If you do not own the land, permission must be sought from the landowner
Others using the land should be informed of the burial
Keep a note of the exact place of burial with the deeds in case you want to take your baby with you if you move
You may prefer to bury your baby in a simple casket or box, in case you do want to move, or you can bury the baby in a planter, which can be moved easily.
If you bury your baby in a designated place, eg the Aylesbury Cemetery or Snowdrop Garden, High Wycombe, you will always be able to visit.
You can obtain further information from The Institute of Cemetery & Crematorium Manager (Inc.), phone 0208 9894661