Medical Management of Retained Pregnancy Tissue
Date issued: June 2024
For review: June 2026
Ref: B-477/KN/Early Pregnancy/Medical Management of Retained Pregnancy Tissue v3
PDF: Medical Management of Retained Pregnancy Tissue v3.pdf [pdf] 226KB
Introduction
Retained pregnancy tissue after a miscarriage or termination of pregnancy may need further treatment. Your ultrasound scan has identified some remaining pregnancy tissue within your uterus (womb) that has not come away. You have elected to try medical treatment to see if this will help the uterus expel the remaining pregnancy tissue.
What is Medical Management of Retained Pregnancy Tissue
Medical management is where your body will go through the process of trying to expel the retained pregnancy tissue brought on by taking some tablets, either orally 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 an operation under local or general anaesthetic.
- As no instruments are introduced into the womb, there is less risk of infection.
- You may feel more “in control” of the process because you are managing the procedure yourself.
Disadvantages of Medical Management
- There may be some side effects from the medication that may be used, especially when taken orally. These include nausea, diarrhoea, and very occasionally hot flushes. In order to avoid these, we do recommend that the tablets are given vaginally.
- You may experience pain, and almost certainly heavy bleeding. This is variable.
- In about 5 -10% of cases the pregnancy tissue does not come away. 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. This is not always necessary and your nurse or Doctor will decide this.
Treatment
You will be given 2 boxes of Misoprostol tablets to take home.
The first tablets (x4) should be inserted vaginally at your convenience. The second box of tablets administered buccally (x2 tablets between the gum and the cheek) 4 hours following this. The Misoprostol causes the cervix (neck of the womb) to soften and uterus to contract. The cervix will then open, and this causes the 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 bleeding and crampy pains to start at any time.
Most women will pass the retained pregnancy tissue within 48 hours of undergoing the treatment; however, it is important to understand that not everyone does. It can take up to a week or two to occur.
Bleeding
Be prepared for when the bleeding starts or becomes heavier. It is difficult to predict just how heavy the bleeding will be, but it may be heavier than a normal period. Some ladies do have heavy bleeding, with clots and bad cramps during a period.
You may pass blood clots in varying sizes, tissue that looks different to a period which may be alarming. Any tissue that is passed may be disposed of as you would dispose of sanitary pads during a period. Please contact us if you have any concerns over any tissue that passes.
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.
Pregnancy Advisory Service
- 01752 431129
Early Pregnancy Unit
- 8am to 5:30pm, Monday to Friday
- 01752 430887 or 01752 245212
Ocean Suite (all other times)
- 01752 430026
Once you have passed the retained tissue (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- 14 days after the process, but this bleeding should be noticeably lighter, more period like.
Discomfort /Pain
Having uterine cramping caused by the Misoprostol tablets can be quite painful, with cramping type pains and lower back ache occurring at any time, but especially when the tissue is about to pass.
The pains are because the uterus has to contract to open your cervix in order to pass blood and tissue.
It is advisable to be prepared with a suitable type of pain relief which you are able to tolerate.
The following pain relief are all very useful:
- Paracetamol
- Ibuprofen
- 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.
Sometimes using hot water bottles (not too hot) and warm baths or showers can help.
If the types of pain relief are insufficient, then contact the numbers at the back of this leaflet.
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 short 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, Pregnancy Advisory Service, 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, and this can be a very distressing event in a woman’s life. You may decide that you need to take some time off whilst the process 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?
Please do a pregnancy test after two weeks to ensure negative to confirm the process has been successful. If after two weeks you are certain that you have passed the pregnancy tissue 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 Pregnancy Advisory Service, Emergency Gynaecology Unit or the Early Pregnancy Unit and we will make arrangements to rescan you.
If the retained pregnancy tissue has not been expelled, then you have the options of
- Repeating the Medical Management.
- Expectant Management: waiting for the pregnancy tissue to be expelled spontaneously.
- Surgical Management under local or general anaesthetic.
If after the second treatment of Medical Management, you still do not pass the retained tissue the staff will ask you to come back to the Early Pregnancy Unit/ Emergency Gynaecology 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.
Please ring the EPU/EGU department to discuss your options at any time.
When can I expect a period?
Every woman is different regarding how soon they will have their next period. This can range from 3 to 6 weeks. Remember that this can vary as this event is 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 negative test, it may be advisable to contact your GP.
Do I need to inform anyone about my procedure?
No, we will have sent out information to your GP and if appropriate community midwife and ultrasound department so you will not need to worry about doing this. Please let us know if you do not want any of this information sent out.
The future
If you are planning a pregnancy in the future, we would recommend that you take daily folic acid which you can obtain from your GP (for 3 months before a pregnancy). Once you have had a period then we know that your hormones are back to normal, and you are healthy for the next pregnancy.
If you are not planning a future pregnancy at this time please start your contraception straight away as advised.
Please remember that nothing is too trivial to talk about.
If you are worried, we’d like to know.
Contact numbers
Pregnancy Advisory Service
- 01752 431129
Early Pregnancy Unit/ Emergency Gynaecology Unit
- 8am to 5:30pm, Monday to Friday
- 01752 430887 or 01752 245212
All other times:
- Ocean Suite (Gynae ward) 01752 430026
