Management | Cork Miscarriage

Management of Miscarriage

Once a miscarriage has been diagnosed and the type of miscarriage identified, there is a choice of management options available.

You should be provided with verbal and written information regarding treatment options and advised of the risks and benefits associated with each approach.

You will be offered conservative, medical or surgical management based on a combination of your symptoms, how far along you are in the pregnancy, if you have recurrent miscarriage, ultrasound scan findings, and other factors such as your medical history, where you live, and supports available to you.

It is advised that you take your time when making your decision. It is important to remember that it is your decision, and the doctors and midwives are there to offer you support and information.

The flow chart below is intended to be a useful summary of the care pathways available for the different types of miscarriage, from complete miscarriage to missed/incomplete miscarriage.

Conservative management

Conservative management involves holding back from medical or surgical intervention and waiting for the miscarriage to happen by itself. During this time, you may experience some bleeding and discomfort.

What happens during conservative management?

Conservative management is an appropriate method for you if you:

have no sign of infection
do not have excessive bleeding
do not have a high temperature
have no or mild abdominal pain
are at an early gestation
do not live too far from CUMH
have sufficient supports regarding childcare/transport.

After the ultrasound scan confirms a miscarriage, you will return home to allow the natural process of miscarriage to occur. You will be offered an ultrasound in around two weeks, if you have no bleeding within that time, to see if you want to continue with conservative management, or if you want to change to medical or surgical management.

You are likely to experience vaginal bleeding and abdominal pain over the next few days. It may not occur immediately and may take up to three weeks to start, especially if it is a missed miscarriage. There will be heavy bleeding for a few hours as the pregnancy passes, then lighter bleeding (somewhat like a normal period) for up to two weeks after this.

During the early stages of pregnancy, it can be challenging to differentiate between pregnancy tissue and large blood clots. That is why it is important to stick to the hospital’s recommended follow-up plan to make sure all the pregnancy tissue has passed, and to rule out the possibility of a molar pregnancy.

After the bleeding ceases, you will need to take a home pregnancy test three weeks later and contact the EPU if the test result is positive. You may be asked to come back to the EPU for a blood test or an ultrasound scan to ensure that the miscarriage process is complete.

For information about identifying pregnancy tissue, please see here.

Are there any risks with conservative management?

All treatments of miscarriages are associated with some risks. The risks associated with conservative management of miscarriage are low, but they can occur. They include:

Feeling faint: 1-2 in 100 women
Heavy bleeding: 1 in 100 women
Heavy bleeding requiring a blood transfusion: 1 in 1000 women
Incomplete emptying of the womb / retained pregnancy tissue which requires further treatment: 3-10 in 100 women (this is an estimate, depends on the type of miscarriage)
Infection: 1-3 in 100 women.

More women are now opting for conservative management, which has been proven to be a safe option. Importantly, there is no conclusive evidence to suggest that choosing conservative management increases the risk of infection. The risk of infection remains relatively consistent whether one chooses conservative, medical, or surgical management.

When should I attend the hospital?

You may feel large clots passing. If you have any concerns contact your GP or the CUMH Emergency Room.

If the bleeding is very heavy, i.e. you need to change a sanitary towel (pad), with blood clots, every 15 minutes for more than an hour, you need to attend the Emergency Room at CUMH.

You should also attend the hospital if you:

develop severe abdominal pain which is not relieved by painkillers
have a high temperature
feel very unwell.

In these situations, there is a small possibility that you may require treatment with antibiotics or an emergency operation if the pain and bleeding do not settle after you attend CUMH.

After the bleeding ceases, you will need to take a home pregnancy test three weeks later and contact the EPU if the test result is positive. You may be asked to come back to the EPU for a blood test or ultrasound scan to ensure that the miscarriage process is complete).

You should contact the EPU if bleeding persists longer than two weeks or, if after two weeks you have no bleeding, for re-assessment.

Sometimes taking time off work or normal activities to recover physically and mentally is beneficial. If you need a certificate for work, the EPU staff will be able to provide you with one.

You can find more information in the CUMH Leaflet ‘Conservative Management of Miscarriage’.

Medical management

Medical management for miscarriage involves taking medication to speed up the process of passing the pregnancy tissue . 80 – 90% of women will have a complete miscarriage with the use of these medications.

The most common approach for inducing miscarriage is medical management.

What happens during medical management?

FMedical miscarriage involves the use of two medications - mifepristone and misoprostol. Mifepristone is the first medication and must be taken in the presence of a doctor. These tablets are taken by mouth. The most common side effect is nausea. You can have anti-sickness medicine before taking the mifepristone if you feel nauseated. If you vomit within one hour of taking mifepristone you may need to contact the EPU for a repeat dose.

After 24 hours, and before 48 hours (ideally 36 hours), you will be asked to take misoprostol. It is rare that miscarriage starts after mifepristone alone. It is important to still take the misoprostol too to ensure that the miscarriage process is completed.

Misoprostol tablets generally work better if taken by buccal administration, which means that the tablets are placed in the mouth between the gums and the inner lining of the cheek. They are left for 30 minutes to dissolve – without eating, drinking, smoking or chewing gum during this time. You then rinse your mouth and swallow. They can also be taken vaginally.

Misoprostol tablets work by softening the neck of the womb. You will have the option to choose whether a doctor administers the tablets for you, or, more commonly, you can self-administer them at home. If no bleeding occurs 24 hours after taking the misoprostol tablets, contact the EPU to discuss options such as repeat medical treatment.

Depending on the size of the pregnancy sac and how close you are to CUMH, your healthcare provider may suggest staying in the hospital until the miscarriage happens. For pain relief, taking a non-steroidal anti-inflammatory drug one hour before taking the misoprostol tablets is recommended.

For information about identifying pregnancy tissue, please see here.

Are there any risks with medical management?

Using medication to treat early pregnancy miscarriage is a safe and effective option. Many studies report that this treatment is successful in completing miscarriage in about 80% - 90% of cases.

Risks of medical management of miscarriage include:

Feeling faint: 1-2 in 100 women
Heavy bleeding: 1 in 100 women
Heavy bleeding requiring a blood transfusion: 1 in 1000 women
Incomplete emptying of the womb/retained pregnancy tissue which requires further treatment: 1-10 in 100 women (this is an estimate, depends on the type of miscarriage)
Infection: 1-3 in 100 women.

Are there any side effects of the medication?

Side effects of the medication can include nausea, vomiting, cramping, diarrhoea, or hot flushes.

After taking the medication you may experience lower abdominal pain and vaginal bleeding. The bleeding is heavier than a period and can last up to 7 to 10 days. You may feel large clots passing.

It is advisable to use sanitary towels (pads) rather than tampons to reduce the likelihood of infection. The abdominal pain is typically worse than period pain, and regular pain relief should be taken.

About 80 - 90% of women will experience a complete miscarriage within a week of using misoprostol tablets.

Are there any alternatives to having medical management at home?

You can discuss inpatient management with your medical team, who may advise you to remain in CUMH throughout the duration of the medical management process when:

the pregnancy is advanced (over 10 weeks)
you live far away from the hospital
you have another medical condition
you have limited support at home
you express a definite preference for in-patient medical management.

When should I attend the hospital?

You may feel large clots passing. If you have any concerns, contact your GP or the Emergency Room or EPU. If the bleeding is very heavy, i.e. you need to change a sanitary towel (pad) with blood clots every 15 minutes for more than an hour, you need to attend the Emergency Room.

You should also attend the hospital if you:

develop severe abdominal pain which is not relieved by painkillers
have a high temperature
feel very unwell.

You will be given the choice of a home pregnancy test three weeks after, or follow up ultrasound scan in the EPU two weeks after, the first administration of the misoprostol tablets. This is to confirm that a complete miscarriage has taken place. If the home pregnancy test is positive, you should contact the EPU.
You should also contact the EPU if bleeding persists longer than two weeks as this may indicate retained pregnancy tissue or infection.

Sometimes taking time off work or normal activities to recover physically and mentally is beneficial. If you need a certificate for work, the EPU will be able to provide you with one.

You can find more information in the CUMH Leaflet ‘Medical Management of Miscarriage’.

Surgical management

Surgical management is an operation that may be offered to you depending on the how far along (how many weeks) you may be in the pregnancy.

Surgical management is called vacuum aspiration of the uterus. It can be electrical (ERPC: Evacuation of Retained Products of Conception), or manual (MVA: Manual Vacuum Aspiration). You may hear people refer to surgical management of miscarriage as a D&C (Dilation and Curettage) but this not the correct term for the operations done in pregnancy.

These operations are performed in theatre using general anaesthetic or regional anaesthetic (spinal), or you can have the operation as an outpatient, using local anaesthetic. Surgical management involves gently widening the neck of the womb and removing the pregnancy tissue. Procedures take approximately half an hour.

What happens during an ERPC procedure?

The ERPC procedure is performed in the operating theatre at CUMH. You will be given information about where to go for admission to CUMH, where you will be directed to Ward 2 South. This is the gynaecology and pregnancy loss ward at CUMH.

You should meet your medical team before your procedure. Before admission for your surgical management, you might be asked not to eat or drink from midnight the night before. This includes avoiding chewing gum, sweets, and water.

If you have been given tablets (misoprostol) to take before your operation, you may swallow these at 6am on the morning of the operation with a small sip of water. You can also take them by buccal administration, which means that the tablets are placed in the mouth between the gums and inner lining of the cheek, or sublingually (under your tongue) one hour before your operation, as they work faster when taken like this. These tablets soften the neck of the womb and make the surgical management procedure easier to perform. They may upset your stomach and you may experience some pain or vaginal bleeding.

ERPC is usually performed under general anaesthetic. It involves gently widening the neck of the womb and removing the pregnancy tissue. The procedure takes approximately half an hour.

What happens during a MVA procedure?

Before the procedure begins, you will receive an injection to numb the neck of your womb. Then, the doctor will gently open the neck of your womb just enough to pass a small suction tube into the womb. The tube is used to remove the contents of the womb. Sometimes, an ultrasound scan machine might be used during the procedure to make sure the womb is completely empty. During this part, you may feel some period-like pain, which can be uncomfortable.

It is important to note that MVA is done while you are awake, and you can usually return home shortly afterwards.

MVA procedures are currently done in the Ambulatory Hysteroscopy Clinic on 4 South at CUMH on a Wednesday morning.

Who might be offered a MVA procedure?

Manual Vacuum Aspiration (MVA) is a medical procedure used to remove pregnancy-related tissue from the womb. It is suitable for individuals who are less than 12 weeks pregnant, and prefer this method over taking medication or having surgery with a general anaesthetic.

Advantages:

No need for general anaesthesia, so you can return to your regular activities on the same day•
It quickly empties the womb, allowing your body to recover and get back to a normal menstrual cycle
You won't have to wait for hours for medication to take effect
You won't have to wait for a long time for a hospital surgery appointment.

Disadvantages:

You will be awake and aware during the procedure
You may experience some discomfort during the procedure, similar to period pain
For some women, the procedure may be challenging due to pain or discomfort, and it might not be completed.

Are there any risk with surgical procedures?

All surgical procedures are associated with risks. The risks associated with surgical management of miscarriage are low, but they can occur. You will be made aware of these when you sign written consent for the operation.

The risks include:

Anaesthesia-related complications: < 1 in 1000 women
Ashermans Syndrome/Uterine adhesions: 1 in 100 women
Cervical tear/injury: 1 in 100 women
Feeling faint: 1-2 in 100 women (only if awake during surgery, otherwise not applicable)
Heavy bleeding: 1 in 100 women
Heavy bleeding requiring a blood transfusion: 1 in 1000 women
Incomplete emptying of the womb/retained pregnancy tissue which requires further treatment: 1-3 in 100 women
Infection: 1-3 in 100 women
Injury to womb/need for further surgery: 1-4 in 1000 women.

If there is a concern about injury to the womb or internal organs, further surgery or treatment may be required. Your medical team will discuss this with you.

A common misunderstanding is that having surgical management increases the risk of infection or haemorrhage. However, this is not true. Infection rates remain very low whichever method of management is chosen.

If you have been prescribed regular daily medication, take this on the morning of the operation with a small amount of water. If you are taking medication to thin your blood (such as aspirin or heparin) you may have been advised to stop this before your operation. If you have any queries about your medication, you should speak to the medical team at CUMH or your GP.

What is the physical recovery time after surgical management?

The physical recovery time after surgical management of miscarriage is short. It is usually possible to go back to work after a few days, if that is what you want to do. You will usually be allowed home within two to four hours. If you experience any complications (for example, an infection), contact your medical team may who can offer antibiotics to settle the infection.

If your blood group is Rhesus negative, you will require an anti-D injection. This is done because there is a possibility that small quantities of fetal cells will enter your bloodstream during the surgical procedure.

Please arrange for an adult to pick you up from CUMH and stay with you that night after surgical management, as you are advised not to drive for at least 48 hours.

You may feel some cramps and pain similar to what you experience during your period. If you need something to help with the pain, you can take ibuprofen or paracetamol. You can take both of these medicines together for better pain relief.

You will also have bleeding that is a lot like your period, and it will last for about 7 to 10 days. During this time, it is best to use sanitary towels (pads), not tampons. And it's important to avoid having sex until the bleeding has stopped.

After surgical management of miscarriage usually there is no need for routine follow up to CUMH. However, it is recommended you contact your GP if you have heavy vaginal bleeding, vaginal discharge with a bad smell, abdominal pain, or if you have a positive pregnancy test three weeks after you have stopped bleeding.

Why might I have one form of management over another?

Your doctor or midwife might recommend one form of management over another. For example, if this is your second (or more) miscarriage, they may recommend surgical management so that pregnancy tissue can be collected for genetic testing.

Surgical management may also be more appropriate if you are further along in your pregnancy, for several reasons:

As the pregnancy progresses, the size of the pregnancy tissue gets bigger, and it becomes more difficult for the body to remove it naturally
If a miscarriage happens later in the pregnancy, there is a higher chance of problems like heavy bleeding or infection. The controlled surgical environment is better able to manage these issues
When the woman is already unwell, e.g. bleeding very heavily from a miscarriage that is already happening
Sometimes there is a need to examine the pregnancy tissue or do genetic testing. Surgery provides a controlled and precise way to collect the tissue, which allows for more accurate analysis and diagnosis
It might be your preference to have surgical management.

It is important to talk to your healthcare professionals to help you decide the best way to manage your miscarriage. Factors such as how far along your pregnancy was, and your personal situation are likely to inform the decision making process.

Conservative or outpatient medical management may not be recommended if you are living a distance from the hospital or if you do not have childcare supports or transport.