Management | Cork Miscarriage

Management of Miscarriage

Once a miscarriage has been diagnosed and the type of miscarriage is identified, there are options for how to manage the miscarriage. You should be provided with verbal and written information regarding treatment options, and advised of the risks and benefits associated with each approach.

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

You should take your time when making this 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 waiting for the miscarriage to happen by itself, without doing anything medically to cause it to happen. With this option you may experience some bleeding and discomfort over the next few days.

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 number of weeks in the pregnancy
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 scan in around 2 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 3 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.

Toy may be asked to come back to the EPU in 2 weeks for a blood test or ultrasound scan to ensure that the miscarriage process is complete. You will need to take a home pregnancy test 3 weeks after the bleeding stops, and you will need to contact the EPU if the test result is positive.

For information about identifying pregnancy tissue, please see here.

Are there any risks with conservative management?

All managements of miscarriages carry some risks. The risks associated with conservative management of miscarriage are low, but they can happen, including:

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

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

When should I go to the hospital during conservative management?

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) that has filled with blood clots every 15 minutes for over an hour (or 4 soaked pads in the course of 1 hour), you need to go to 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.

If the pain and bleeding do not settle after you go to the hospital, there is a small possibility that you may require treatment with antibiotics, or an emergency operation.

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 will need to take a home pregnancy test 3 weeks after the bleeding ceases, and you will need to contact the EPU if the test result is positive.

You should contact the EPU for re-assessment if:

You have bleeding lasts longer than 2 weeks, or
You have no bleeding at all after 2 weeks.

In cases where a letter for work is needed, the EPU will be able to provide one. Please see the section 'Aftercare at home following miscarriage' for more information.

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

Medical management

The most common method for inducing miscarriage is through medications that speed up the process of passing the pregnancy tissue. About 80–90% of women will have a complete miscarriage with the use of these medications.

What happens during medical management?

Medical management uses 2 medications: mifepristone and misoprostol. Mifepristone is taken by mouth first, in the presence of a doctor. It may cause nausea, for which anti-sickness medicine is available. If you vomit within 1 hour after taking mifepristone, you must contact the EPU for a new dose.

It is uncommon that miscarriage starts after mifepristone alone. Even if it does start, you must take misoprostol to complete the miscarriage process.

Misoprostol works by softening the neck of the uterus (womb), and it is taken at least 24 hours - but no more than 48 hours - after mifepristone, ideally at around 36 hours. 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.

Misoprostol tablets generally work better if taken by buccal administration. This means the tablets are placed between the gums and the inner lining of the cheek and left to dissolve for 30 minutes, without eating, drinking, smoking, or chewing gum during this time. You then rinse your mouth and swallow. Vaginal administration os also possible. Pain medication (a non-steroidal anti-inflammatory drug) is advised, to be take 1 hour before the misoprostol tablets. If no bleeding occurs 24 hours after taking the misoprostol tablets, you should contact the EPU.

Depending on the size of the pregnancy, and how far you are from CUMH, healthcare providers may recommend a hospital stay during the process.

Complete miscarriage is confirmed either through a home pregnancy test or an ultrasound scan in the EPU after 3 weeks. If the home pregnancy test is positive, you should contact the EPU.

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 people
Heavy bleeding: 1 in 100 people
Heavy bleeding requiring a blood transfusion: 1 in 1000 people
Incomplete emptying of the uterus (womb) or retained pregnancy tissue, requiring further treatment: 1-10 in 100 people (an estimate, depends on the type of miscarriage)
Infection: 1-3 in 100 people.

Does the medication have any side effects?

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 7-10 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?

During the miscarriage, 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) that has filled with blood clots every 15 minutes for over an hour (or 4 soaked pads in the course of 1 hour), you need to go to the Emergency Room.

You should also go to the hospital if you:

Develop severe abdominal pain that is not relieved by painkillers
Develop a high temperature
Feel very unwell.

You will be given the choice of a home pregnancy test or a follow up ultrasound scan in the EPU within 3 weeks of 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 2 weeks, as this may indicate retained pregnancy tissue or infection.

In cases where a letter for work is needed, the EPU will be able to provide one. Please see the section 'Aftercare at home following miscarriage' for more information.

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

Surgical management

An operation may be offered to you, depending on how far along you may be in the pregnancy.

Surgical management means vacuum aspiration of the uterus (womb). There are two procedures:

Electrical - Evacuation of Retained Products of Conception (ERPC), or
Manual - Manual Vacuum Aspiration (MVA)

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 performed in the case of miscarriage.

What happens during an ERPC procedure?

The ERPC procedure is performed in the operating theatre, under a general anaesthetic. It involves gently widening the neck of the uterus (womb) and removing the pregnancy tissue, and it takes approximately half an hour. 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.

Your medical team should meet you 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 will be advised what time to swallow these with a small sip of water on the day of the operation. You may also take them by buccal administration (between your gum and your cheek) or sublingually (under your tongue) 1 hour before the operation; they work faster when taken buccally or sublingually. These tablets soften the neck of the uterus and make the surgical management procedure easier to perform. They may upset your stomach, and you may experience some pain or vaginal bleeding.

What happens during a MVA procedure?

MVA is a medical procedure used to remove pregnancy-related tissue from the uterus (womb). Before the procedure begins, you will receive an injection to numb the neck of the uterus, which the doctor will gently open just enough to pass a small suction tube into it to remove the contents. Sometimes, an ultrasound scan machine might be used during the procedure to make sure the uterus 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 an outpatient procedure done while you are awake. The procedure takes about a half an hour, 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?

MVA is suitable for those who are less than 12 weeks pregnant, and prefer this method over taking medication or having surgery with a general anaesthetic.

Potential advantages:

There is no need for general anaesthesia, so it may be possible to return to ordinary activities on the same day, if you wish to do so.
Because the procedure empties the uterus quickly, your body can recover and return 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 hospital surgery appointment.

Potential disadvantages:

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

Are there any risk with surgical procedures?

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

The risks include:

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

*Sticky scar tissue may form inside the uterus, potentially causing menstrual and fertility problems due to the walls of the uterus sticking together.

** Pain and fainting after an outpatient procedure could signal complications and hinder recovery, with prompt medical attention needed to ensure well-being and recovery.

In the rare event that the medical team suspect injury to the uterus or to the internal organs during surgical management, additional surgery or treatment may be needed. Your medical team will discuss this with you.

It is a common misunderstanding that having surgical management increases infection or bleeding risk. In fact, infection rates stay very low regardless of which management method is chosen.

Take any regular daily medications with a small amount of water on the morning of the operation. For blood thinners like aspirin or heparin, you may need to stop these before surgery - check with your medical team at CUMH or GP if unsure about any medications.

What is the physical recovery time after surgical management?

The physical recovery time after surgical management of miscarriage is short. You will usually be allowed home within 2 to 4 hours, and it may be possible to go back to work after a few days, if you wish to do so. If you experience complications, your medical team can offer treatment; for example, if the complication is an infection, they can offer antibiotics.

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 the 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, there is usually 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 2 weeks after you have stopped bleeding.

In cases where a letter for work is needed, the hospital will be able to provide one. Please see the section 'Aftercare at home following miscarriage' for more information.

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 a person 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 providers to figure out the best way to manage a miscarriage in your personal situation. For example, conservative or outpatient management may not be recommended if you are living a distance from the hospital, or if you do not have childcare supports or transport.