Management of miscarriage your options

Miscarriage terminology

Missed miscarriage

This is when the pregnancy has died or failed but remains within the womb. The scan may show a baby or fetus without a heartbeat or may show a pregnancy sac with nothing inside. This is usually because the fertilised egg hasn’t developed normally, so the pregnancy sac grows but the baby doesn’t.

There may be no signs that the pregnancy has ended, and it is only noticed in a scan. In other cases, there may be subtle changes or signs that something is not right. Some women describe not feeling pregnant anymore, a reduction in breast tenderness or fullness, no longer feeling sick, or having some light vaginal bleeding.

Incomplete miscarriage

This is when the miscarriage process has started but has not yet finished and there are still some remains of the pregnancy within the womb.

Management options

In both situations above, a full miscarriage can happen naturally. This is often called ‘expectant management’. However, the process can be speeded up, or ‘managed’ medically with drugs (medical management) or a small surgical operation (surgical management).

Ideally, women should be able to choose which treatment to have. However, in some cases your nurse or doctor may recommend one treatment over another.

It may help you to know that the chance of having a healthy pregnancy next time is equally good whichever method you choose.

Expectant management

Many women prefer to wait and let a miscarriage happen naturally. National guidance reports that expectant management should be the first method to consider.

What happens?

This can vary a lot depending on how pregnant you are and the scan findings. It can take anything from days to weeks for the miscarriage to begin. Once it does, you are likely to have strong period-like pains and bleeding. The bleeding may continue for a few weeks. It can however be difficult to predict what will happen and when.

We advise you to:

• Take painkillers if you need them such as paracetamol and ibuprofen.
• Use sanitary towels rather than tampons.
• Avoid sexual intercourse.
• Drink plenty of fluids.
• Try to rest at home.
• Preferably have someone with you.

We will contact you by telephone three weeks later to check that you have stopped bleeding and that your pregnancy test is now negative. If you are still bleeding, have a positive pregnancy test or have any other problems we will ask you to come back to the unit for review. Of course, if you prefer, we can arrange a follow-up appointment when we initially see you.

If you miscarry at home or somewhere outside of the hospital, you are most likely to pass the remains of the pregnancy when using the toilet. You may see a pregnancy sac and/or fetus.

You may want to simply flush the toilet, which many people do automatically, or you may want to remove the tissue for a closer look. You may decide to bury the remains yourself or you can bring them into our unit for us to look at and take care of. You can ask us more about this.

What are the risks?

Infection

This affects about 1 woman in every 100. Signs include a raised temperature, flu-like symptoms, vaginal discharge that looks or smells bad, abdominal pain that gets worse and heavier bleeding.

Haemorrhage (heavy bleeding)

Sometimes an emergency operation (surgical management of miscarriage) is needed to stop the bleeding and around 2 in 100 women will need a blood transfusion. We advise you to contact us or attend your local emergency department if you have heavy bleeding. We normally say ‘heavy bleeding’ is bleeding which soaks through a sanitary towel every hour and lasts more than three hours. However, we would also ask you to contact us if you are feeling unwell or unable to cope.

Retained tissue

Sometimes the pregnancy remains do not pass naturally and stay in the womb. We then offer either medical or surgical management to complete the miscarriage. 

In some cases, the pregnancy remains get stuck in the cervix, which can be painful and distressing. We then perform a vaginal examination, like having a cervical smear test and remove it.

What if I change my mind?

You can phone and speak to one of our specialist nurses at any point – our contact numbers are included at the end of this leaflet. You will have the option to request medical or surgical management.

What are the advantages and disadvantages of expectant management?

The main advantage of expectant management is that it avoids the need for hospital treatment and any surgical procedure. Many women also want their miscarriage to be as natural as possible and to be fully aware of what is happening. You may also find it easier to say goodbye to the pregnancy if you see the remains as it passes.

The main disadvantage is the need to wait for the miscarriage to happen and not knowing when it will happen. The process can also be painful and frightening. You may also bleed for a few weeks and need follow-up scans to check progress. Some women may still also end up needing medical or surgical management.

Medical management

This type of management involves taking one or two types or medication, to start cramps and bleeding to empty the womb. Your medical team will let you know exactly what medication you need.  The initial medication is usually a tablet (mifepristone) taken orally in the clinic. 

The second medication is usually given vaginally at home 48 hours later. They are easy to insert but if you feel uncomfortable doing it yourself, we can arrange for one of the nurses to do it for you. In some cases, you may be able to take the second medication orally if you prefer.

Most women can be treated as an out-patient and take the medicine at home. However, in some cases we will advise you to undergo treatment while admitted in the hospital.

What happens?

If you decide on medical management, we will usually have to take some blood tests from you, and you will be seen by a doctor who will take your written consent or permission for the treatment. They will explain the risks and benefits of the treatment.

You will be given tablets and some pain killers to take. If you are going home, one of our nurses will call you 48 hours after taking the misoprostol to see if you have started miscarrying. Some women may however start miscarrying after taking the initial medication.

If nothing has happened, we will give you the option to come back for a further dose of tablets or to book you in for surgical management. If you have started bleeding, we will offer you a follow-up telephone appointment in three weeks.

With medical management, most women will have period-like cramps that can be extremely painful. You are also likely to bleed heavily and pass some clots. Depending on how far along the pregnancy was when it stopped growing, you may also see a sac coming out and a fetus, which looks like a tiny baby. Many women find the process frightening and feel anxious about it. However, knowing what you might expect and having someone to call if you need to ask anything may help to reduce fear and anxiety.

What are the risks?

Haemorrhage (heavy bleeding)

This affects about 2 in 100 women, which is the same as women who undergo expectant management.

Infection

This affects 1 to 4 women in 100.

Failure

Medical management is effective in 80 to 90% of cases. If it fails or you develop an infection, you will be advised to have surgical management.

What are the advantages and disadvantages?

The main benefit is avoiding an operation. Some women see medical management as a more natural option compared to surgical management. It is more controllable than expectant management and the process tends to be completed more quickly.

The main disadvantages are that the process can be painful and frightening. You may also bleed for a few weeks and need follow-up scans to check progress. Some women may still also end up needing surgical management.

Surgical management (SMM)

This type of management involves an operation to remove the pregnancy tissue from the womb. It can be done under general anaesthetic or can be done when you are awake under local anaesthetic.

SMM under general anaesthetic

If you decide on this option, we will need to take some blood tests from you and a doctor will need to assess you and take your written consent for the procedure. We will also ask you to complete some forms about what you want done with the pregnancy remains that are being removed.

We appreciate that asking you to do this can be upsetting, but it is important. Most people opt for the remains to be tested and taken care of by the hospital, which we do in a sensitive manner. You can ask us more questions about this. However, some people will choose to make their own arrangements and we can help you to do this.

In most cases, we will give you a date for the procedure within a few days of being diagnosed with your miscarriage. You will be given advice on when to stop eating and drinking before the procedure (usually around six hours beforehand) and where and when to come. Please remove all jewellery, make-up, and nail varnish at home before coming to the hospital.

If your procedure is being carried out at the Royal Free Hospital you will usually be asked to attend the early pregnancy and acute gynaecology unit (EPAGU) at 7.30am. If your procedure is being carried out at Barnet Hospital you will usually be asked to attend the day surgery unit at 7.30am.

What happens?

When you come in, a nurse will prepare you for theatre. The anaesthetist and doctor performing the operation will usually visit you before you are taken to the operating theatre. In most cases you will be given tablets (of a drug known as misoprostol) prior to the procedure.

This is the same drug used in medical management of miscarriage. It is used to soften the neck of the womb to make the operation a bit easier. Unfortunately, sometimes the operation may be delayed and if you have already received the misoprostol, you might start having some cramps and vaginal bleeding.

When you go to theatre, a nurse will accompany you as far as the anaesthetic room. The anaesthetist will put a small needle into a vein on the back of your hand through which the anaesthetic is given. Most people feel groggy when they wake up after the anaesthetic, and some feel sick or emotional. These reactions are quite normal.

The operation itself takes about 15 minutes. The neck of the womb (cervix) is gradually opened and then a suction tube is inserted into the womb to remove the pregnancy tissue. A sample of the pregnancy remains is usually sent to the pathology department to check that it is normal pregnancy tissue. It is not usually tested again unless you are having further investigations because of previous miscarriages.

You will wake up from the operation in the recovery room and will stay there for about 30 minutes before being transferred back to the EPAGU or day surgery unit. You will be able to start eating and drinking gradually when you feel well enough.

Depending on your blood group, we may need to give you an additional injection of something called ‘anti-D’ after the procedure. Your nurse or doctor will discuss this with you if needed. If all is well and you have passed urine, you will be able to go home. You will need someone to collect you and you will not be able to drive or operate any heavy machinery for at least 24 hours after a general anaesthetic.

It is quite normal to have some abdominal cramps (like strong period pains) when you wake up. You may also bleed for two to three weeks after the operation. The bleeding may stop and start but should gradually tail off. If it stays heavy or gets heavier, please call us for advice.

What are the risks?

Haemorrhage (heavy bleeding)

This affects about 1 in 100 women.

Infection

This affects about 2 to 3 women in 100. We usually give you a single dose of antibiotics after the procedure.

Uterine perforation (tear in the womb)

In less than 1 in 200 women, the operation can cause a small tear in the womb. It is rarer still to get any other damage.

Scarring

Around 1 in 5 women may get some scarring (adhesions) in the lining of the womb after the procedure.

Retained tissue

Occasionally some pregnancy tissue remains in the womb and a second operation is needed to remove it.

Serious risks

This is rare (fewer than 1 in 30,000 cases) the procedure can result in hysterectomy (removal of the womb). This would only be if there is uncontrollable bleeding or severe damage to the uterus. About 1 in 10,000 women may have a severe reaction to the general anaesthetic.

What are the advantages and disadvantages?

The main benefit of surgical management is that you know when the miscarriage will happen, and you will not be aware of what is going on as you will have had a general anaesthetic. However, it does involve a need to come into hospital, having a general anaesthetic and a small operation, which some women find frightening.

A disadvantage is that we may not be able to offer you a slot for the procedure immediately. While we aim to offer women an appointment within 48 hours for the procedure, this is not always possible. There is therefore a chance that some women who choose this treatment will have a natural miscarriage before the date of their procedure. We therefore ask you to contact us if you have any heavy bleeding prior to your procedure.

SMM under local anaesthetic

This is also called manual vacuum aspiration or MVA. 

What happens?

The procedure is much the same as SMM, although you can eat and drink normally before the procedure and you will not have a general anaesthetic. The procedure is performed by our doctors in the early pregnancy unit.

You will be given tablets (misoprostol) to soften the neck of the womb which you may administer at home prior to coming into the hospital or take whilst here. When you come in we will ask you to change into a gown before entering our treatment room. We may then repeat a scan just to check what needs to be removed.

A speculum will be inserted into your vagina, like the one used for a smear test, and a local anaesthetic is then injected into the cervix. The neck of the womb is then slowly dilated (stretched open) and a narrow suction tube inserted into the womb. A handheld suction device will then gently empty your womb. This may cause some cramps like period pains.

At the same time, we may put an ultrasound probe on your tummy just to check the womb is empty or perform a transvaginal (internal) scan after the procedure.

The whole procedure will take 10-20 minutes and you will usually be able to go home 30-45 minutes after the procedure. Post-procedure cramps and bleeding will be like those you would experience after SMM under a general anaesthetic.

What are the risks?

The risks are mostly the same as SMM under general anaesthetic. There is a small risk of having a reaction to the local anaesthetic.

What are the advantages and disadvantages?

The advantages and disadvantages for this type of management are like that of SMM under a general anaesthetic. The main advantage of having the procedure under local anaesthetic is that there is no need to fast beforehand and you will not feel groggy like some women do after a general anaesthetic.

After a miscarriage

Your nurse or doctor will let you know if we need to follow you up after your miscarriage, but for many women no further appointments are needed. We would just recommend that you have an early scan in any further pregnancy for your own reassurance.

Often women ask when they will have their next period and when they can try to conceive again. It usually takes four to six weeks for your periods to return after a miscarriage, although it can take longer to settle into a regular cycle.

Some women will also find that their next period after a miscarriage is slightly heavier, which is completely normal. There are no firm guidelines about when you can try to get pregnant again, although it's often recommended that you wait until you have had at least one regular period. It is also important to be sure you are emotionally ready to try for another pregnancy after a miscarriage.

If we have sent any pregnancy remains to the laboratory to be tested, it will be a few weeks before any results are available. In many cases, we will only contact you if we have an abnormal result. We will advise you if we need to see you for any other follow-up.

If unfortunately, you have had previous miscarriages, you may qualify for referral to a recurrent miscarriage clinic. We will advise you about this process.

Some women need to take some time off after a miscarriage; others feel they want to get back to normal as soon as possible. If you need a sick certificate for work, we can provide this if indicated. We also have access to a women’s health counsellor who can provide extra support if needed.

If you have any other questions, please do not hesitate to ask a member of staff, or contact us by telephone.

Acknowledgement

This leaflet was written in conjunction with the Miscarriage Association.