Management of Miscarriage

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

You will 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 clinical history and ultrasound scan findings.

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.

Conservative management

Conservative management is an appropriate method for you if you have no sign of infection, excessive bleeding, temperature or abdominal pain. After the ultrasound scan confirms a miscarriage, you will return home to allow the natural process of miscarriage to occur.

It is expected that you will experience vaginal bleeding and abdominal pain over the next few days. The bleeding can last for days to a few weeks and may vary from light (somewhat like a normal period) to very heavy. 

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

 

If the bleeding is very heavy i.e. you need to change a sanitary pad every 30-60 minutes, 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,

  • a high temperature or

  • if you feel very unwell.

The pain you will experience with miscarriage and its treatment varies from woman to women. It can be similar to regular period cramps or more severe abdominal pain. Regular pain relief such as paracetamol or ibuprofen is suggested.

 

You will be asked to perform a home pregnancy test 14 days after the bleeding stops and to call the EPAU/Aislinn Suite if the test remains positive. The purpose of this test is to exclude abnormal pregnancy tissue or a pregnancy outside the womb. Patients should also contact the EPAU/Aislinn Suite if bleeding persists longer than 2 weeks.

 

You can find more information here: CUMH Leaflet ‘Conservative Management of Miscarriage’

When your miscarriage occurs at home, pregnancy remains are not identified. However, you may wish to mark your loss in a symbolic way and ideas for how to do this can be found here.

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.

Misoprostol {also called cytotec} is a prostaglandin drug and is used to soften the neck of the womb to allow the bleeding commence.

Four tablets can be administered orally or as a vaginal pessary. You will be offered a choice between having the doctor administer the tables or you can self-administer them at home. This process is repeated 48 hours later. Side effects of the medication can include nausea, vomiting, cramping, diarrhoea or hot flushes.

 

Two packs of four tables of misoprostol will be given to you in the hospital when you are seen in the EPAU/Aislinn Suite. 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. Sanitary towels are recommended instead of tampons. The abdominal pain is typically worse than period pain and regular pain relief should be taken.

Some times when the pregnancy is advanced or you live far away from the hospital and you strongly desire to have medical management you will be advised to remain in hospital throughout the duration of the medical management process.

 

You will be given an appointment to return to the EPAU/Aislinn Suite for an ultrasound scan 10 to 14 days after the first administration of the misoprostol. This is to confirm that a complete miscarriage has taken place.

 

You can find more information here: CUMH Leaflet ‘Medical Management of Miscarriage’

 

When your miscarriage occurs at home, pregnancy remains are not identified. However, you may wish to mark your loss in a symbolic way and ideas for how to do this can be found here.

Surgical management

Surgical management in the form of Evacuation of Retained Products of Conception (ERPC) will be offered to you if this is your preferred option or if clinically indicated.

 

ERPC is often referred to as a ‘D&C’. It is performed under general anaesthetic and the operation involves gently stretching the neck of the womb and removing the pregnancy tissue. The procedure takes approximately half an hour.

Some people assume that having an ERPC increases the risk of infection or haemorrhage. However this is not true and there is no evidence of difference of infection rates depending on the method of management. The rate of infection irrespective of the management chosen is very low.

 

All surgical procedures are associated with risks. The risks associated with ERPC are low but they can occur. You will be made aware of these when you sign written consent.

 

The risks include:

  • Need for repeat procedure (2%)

  • Infection (2-3%)

  • Uterine perforation (0.6-0.8%)

  • Intra-abdominal trauma (0.1%)

Other less common risks include cervical damage, haemorrhage, intrauterine adhesions and risks associated with an anaesthetic in pregnancy. If there is a concern about injury to the womb or internal organs, further surgery/treatment may be required.

 

Before admission for your ERPC, do not eat or drink from midnight the night before. This includes avoiding chewing gum, sweets and water.

 

If you have been given tablets (Cytotec) to take before your operation, we recommend that you swallow these at 6am on the morning of the operation with a small sip of water. These tablets soften the neck of the womb and make the ERPC procedure easier to perform. They may upset your stomach and you may experience some pain or vaginal bleeding.

 

On the morning of your procedure come to the main reception in CUMH. You will be admitted to Ward 4 South a designated pregnancy loss and gynaecological ward. One of the staff members will direct you to this ward. This procedure is performed in the operating theatre, which is next to the labour ward. After the operation you will be taken back to Ward 4 South.

Following a ERPC/D&C, if fetal tissue or pregnancy remains are identified at the time of the surgical procedure or on histology examination, parents have the option to consent to a hospital burial or may choose to make their own arrangements in a private burial plot. If you chose to have a hospital burial, pregnancy remains will be treated with respect and dignity at all times. The location of the burial will be documented in the cemetery records. These options will be discussed with you by your health care provider.

 

Recovery time after an ERPC is short. You will usually be allowed home within 2 to 4 hours. If your blood group is Rhesus negative you may require an Anti D injection.

 

Please arrange for someone to pick you up, as you are advised not to drive for at least 48 hours.

 

After surgical management there is no further follow up required. It is recommended you attend your GP if you experience heavy vaginal bleeding, offensive vaginal discharge or abdominal pain.

 

You can find more information here: CUMH Leaflet ‘Surgical Management of Miscarriage’

You may wish to mark your loss in a symbolic way and ideas for how to do this can be found here.

Rhesus anti-D prophylaxis

 

Rhesus negative women should receive prophylactic anti-D Immunoglobin (Ig) in the following situations:

  • Ectopic pregnancy

  • All miscarriages over 12 weeks gestation

  • Any miscarriage treated by surgical intervention

  • After 12 weeks gestation if you experience any trauma to the abdomen

  • After 12 weeks gestation if you experience vaginal bleeding

  • After delivery if the baby’s Rhesus status is positive

Administration of anti-D Ig for first trimester vaginal bleeding does not prevent maternal sensitization or development of haemolytic disease of the newborn. The risk of immunisation before 12 weeks’ gestation is negligible.

Investigations

 

Sadly, miscarriage is very common and affects 1 in 4 pregnancies. Investigations are usually not performed following one miscarriage.

 

If surgical management (ERPC) has been performed, a histological examination of the pregnancy tissue is carried out to confirm an intrauterine pregnancy and to exclude a molar pregnancy.

In the event that fetal tissue is identified during this examination, medical/midwifery staff will discuss your options and wishes with you.

If you want to read more on ectopic pregnancy or molar pregnancy please click here.

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Pregnancy Loss Research Group

Cork University Maternity Hospital

Wilton, Cork, Ireland

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