Medical Management of Miscarriage Up to 10-week size gestation
Date issued: October 2023
Review date: October 2025
Ref: B-198/MAT/KN/Med Man Miscarriage v8
PDF: Medical Management of Miscarriage Up to 10-week size gestation 2023 v8.pdf[pdf] 162KB
Introduction
Miscarriage of pregnancy is very common with as many as one in four to five confirmed pregnancies ending this way. Most happen in the first 12 weeks of pregnancy. This leaflet is designed to guide you through the process.
Types of miscarriage
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Inevitable miscarriage. This is when you have bleeding early in your pregnancy and your cervix is open, which means your pregnancy will be lost.
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Incomplete miscarriage. This is when a miscarriage has started but there is still some tissue left in your womb. Your cervix is usually open.
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Complete miscarriage. This means that your pregnancy has been lost. Your womb is empty, and your cervix has closed.
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Delayed or missed miscarriage. This means that although your developing baby has died, you have not had much or any bleeding. It is not unusual to have much in the way of pain or bleeding when this type of miscarriage occurs
The pregnancy may have stopped growing several weeks prior to the diagnosis.
What is Medical Management of Miscarriage?
Medical management of miscarriage is where your body goes through the process of miscarrying the pregnancy like a natural miscarriage. This process is brought on by taking some tablets, orally and/or vaginally. This almost certainly means experiencing some heavy vaginal bleeding and cramping pains.
Advantages of Medical management
In more than 90% of cases there is no need for any further procedures e.g., an operation under local or general anaesthetic.
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As no instruments are introduced into the womb, there is less risk of infection
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You may feel more “in control” of the process because it is more like a natural miscarriage, rather than undergoing minor surgery.
Disadvantages of Medical management
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There may be some side effects from the medication. These include nausea, diarrhoea, and very occasionally hot flushes.
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You may experience pain, and almost certainly heavy bleeding. This is variable.
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In about 5 -10% of cases the miscarriage is incomplete. After discussion with the medical team, it may be decided to complete the process by repeating the medical management or by an operation under a general or local anaesthetic.
What will happen?
Blood Tests
Before you start your treatment, we may need to take a blood test to check your blood count to make sure you are not anaemic.
Treatment
You will be given a tablet called Mifepristone to take orally. It works by stopping the supply of hormones that maintain the interior of the uterus. You will then be able to go home.
The nurse will give you 2 boxes of tablets containing Misoprostol to self-administer. The first tablets (x 4) should be administered vaginally after 48 hours. The second box of tablets administered buccally (x 2 between gum and cheek) 4 hours following this. The nurse will instruct you how to do this.
The Misoprostol causes the cervix (neck of the womb) to soften and uterus to contract. The cervix will then open and there will be increased bleeding and period type pain which varies in severity.
What to Expect
You can lead life as “normal” and be out and about but we would recommend that you be prepared for the miscarriage process.
Most women will miscarry within 48 hours of undergoing the treatment with Misoprostol; however, it is important to understand that not everyone does. It can take up to a week or two to occur.
Bleeding and Pain
Be prepared for when the bleeding starts or becomes heavier. It is difficult to predict just how heavy the bleeding will be, but it will certainly be heavier than a normal period. You may pass blood clots in varying sizes, tissue and even a recognizable sac with, or without, an embryo or baby, which may be alarming.
Pain varies from mild to quite severe abdominal cramps. The pains are because the uterus has to contract to open your cervix in order to pass the pregnancy, blood and tissue.
Please ensure you have adequate pain relief available which you are able to tolerate. It is also advisable to have someone with you who can support you through this process.
The following pain relief are all very useful:
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Paracetamol
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Ibuprofen
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Codeine based painkillers
Most of these can be brought over the counter although your GP or the hospital may prescribe you codeine-based pain relief if necessary.
If the types of pain relief are insufficient, then contact your GP or the numbers at the back of this leaflet.
Sometimes using hot water bottles (not too hot) and warm baths or showers can help.
We understand that bleeding at home can be very frightening and please do ring for advice if you are unsure of what to do. If you are bleeding heavily, using more than two pads an hour for two hours or feeling dizzy and/or unwell please seek medical attention.
A question that is often asked is ‘what will happen to my baby?’
Most women who choose this type of management make their own arrangements. If this is not what you want, then please ask for information about the choices available.
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Early Pregnancy Unit, 8am to 5.30pm, Monday to Friday, 01752 430887 or 01752 245212
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Ocean Suite (all other times), 01752 430026
Once you have actually miscarried (passed clots of blood or tissue) then the bleeding should ease and become lighter. Sometimes not all will be passed, and some further clots and bleeding may occur on and off over the next couple of weeks. Then the bleeding should become lighter, and the cramping should ease.
It is not unusual to bleed for 10 to 14 days after the miscarriage, but this bleeding should be noticeably lighter, more period like.
Hygiene
You are advised NOT to wear tampons or to have sexual intercourse whilst you are bleeding at all. It is also advisable NOT to go swimming or to take long soaks in the bath as these may increase the chance of infection. Your cervix is opened slightly to allow blood to drain, and we want to reduce the chances of infection getting in.
Avoid hot baths whilst you are bleeding heavily, as you may feel faint. However, it is safe for you to shower or have a warm bath.
Once you have stopped bleeding then you can continue as normal.
Signs of Infection
If you start to feel unwell, develop an unpleasant smelling discharge, a high temperature, experience “tummy” pain that is not helped by pain relief, or the bleeding increases then this may be a sign of infection and you need to contact your doctor or the staff on the Early Pregnancy Unit or Ocean Suite as soon as possible.
Work
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 whilst the actual miscarriage is happening. Some ladies 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 thereafter you will need to see your GP to be provided with a sick certificate. Women who work in the home also need support from partners, family or friends at this difficult time.
What Happens after 2 weeks?
If after two weeks, you are certain that you have miscarried then we do not need to see you again. If you are in any doubt, or have little or no vaginal loss, then you need to contact the Early Pregnancy Unit and we will make arrangements to rescan you.
If the miscarriage is not complete, then you have the options of:
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Repeating the Medical management.
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Expectant management: waiting for it to occur spontaneously.
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Surgical management under local or general anaesthetic.
If after the second treatment of medical management, you still do not miscarry the staff will ask you to come back to the Early Pregnancy Unit for further assessment.
This may be a urine pregnancy test and/or an ultrasound scan.
Can I change my mind?
Yes, you can change your mind about having medical management and choose one of the other options which are expectant or surgical management.
Please ring the EPU department to discuss your options at any time.
When can I expect a period?
Every woman is different regarding how soon, after they miscarry, they will have their next period. This can range from 3 to 6 weeks. Remember that this can vary as you are experiencing a loss of a pregnancy, not a period, and the body and your hormones can take time to return to normal. Often the next period can be different than that which you normally experience (heavier or lighter, again this is nothing to be concerned about, unless the bleeding is very heavy and prolonged – in which case consult with your GP)
If you do not have a period, within 6 weeks of your miscarriage, it may be advisable to contact your GP.
Do I need to inform anyone about my miscarriage?
No, The Early Pregnancy Unit will have sent out information to your GP, community midwife and ultrasound scan department and hospital appointments, so you will not need to worry about doing this.
The future
Whether you decide that you wish to try for another baby is an extremely personal decision that only you and your partner can decide.
Should you feel that at some time you may be ready to try again it is recommend that you take daily folic acid (preferably for 3 months before a pregnancy) and wait for at least one period following a miscarriage before trying for another baby. Once you have had a period then we know that your hormones are back to normal, and you are fit and healthy for the next pregnancy.
For emotional or psychological support:
Kirsty Willis (Bereavement midwife) 01752 433148 or kirstie.willis@nhs.net
www.miscarriageassociation.org.uk
www.nhs.uk/conditions/miscarriage
www.pregnancycrisiscare.org.uk
Please remember that nothing is too trivial to talk about.
If you are worried, we would like to know.
Contact numbers
Early Pregnancy Unit
8am to 5.30pm, Monday to Friday, 01752 430887 or 01752 245212.
Ocean Suite (Gynae ward)
All other times, 01752 430026
