The leaflet is detailed below, or you can download 'Management of your Miscarriage' leaflet in PDF.
What is this leaflet about?
We would like to offer our sincere condolences for your pregnancy loss. This leaflet contains information about how we manage your miscarriage here at the Liverpool Women’s. We understand that this is can be an extremely distressing time and we are here to support you.
Every miscarriage is different and how we manage it is based on your thoughts and wishes.
Although this leaflet is about the management of miscarriage there are also leaflets available on the support available for you and your family at this difficult time.
The term ‘pregnancy remains’ is used throughout this leaflet for consistency in reference to cases of pregnancy loss up to and including 23 weeks and 6 days gestation. This leaflet has been devised in accordance with Human Tissue Authority guidance.
If after reading this leaflet you have questions or queries please contact us at the Gynaecology Emergency Department (GED)on telephone 0151 7024140
What are the options available to me?
There are three broad options for management of miscarriage and in most cases there is no one “right” answer. It may be that you, or someone you know, have experienced this before and you may already know what you want to do. However if not, we hope this leaflet will help you understand your options.
The 3 options are
- Conservative management
- Medical management
- Surgical management
In all 3 options it is reassuring to know that
- The risk of infection or harm are very small with all 3 methods
- Your chance of a healthy pregnancy next time are the same with all 3 methods
- Women cope better when given clear information, good support and a choice of management options
Natural management (also known as conservative or expectant management)
In this option we allow time for your body to complete the miscarriage itself. This can take days or weeks and the amount of bleeding or pain that you experience is difficult to predict. The further on in pregnancy you are may mean that you have heavier bleeding or stronger cramps but this is not always the case.
You will be provided with painkillers to help with the period cramps that can be associated with miscarriage.
A follow up scan in the Early Pregnancy Assessment Unit (EPAU) will be booked for you for two weeks after your miscarriage is diagnosed. This way we can advise you whether your miscarriage is complete. If the miscarriage has not completed we can advise you on your next options.
There is a chance you will experience heavy bleeding you should contact the Gynaecology Emergency Department (GED) on 0151 7024140 if you are worried about the bleeding. The general advice is to contact us if your bleeding is so heavy that you need to change pads every half hour or if you are feeling unwell, such as feeling dizzy or faint.
We are here for you throughout your natural management should you wish to contact us sooner for advice or if you wish to discuss alternative management.
What are the risks?
- Infection can occur in about 1 in 100 women. Signs to look out for are
- Raised temperature or flu-like illness
- Vaginal loss that changes colour to be darker or smells bad
- Pain that gets worse rather than better
- Bleeding that gets heavier rather than lighter
If you develop any of these symptoms please contact us at the Gynaecology Emergency Department. We will need to assess you and you may need antibiotics.
- About 1 - 2 in 100 women will have heavy bleeding bad enough to require blood transfusion. Some of these women need to undergo emergency surgery to stop the bleeding and complete the miscarriage. This is why we ask you to contact us should the bleeding become heavy or you feel unwell.
- Sometimes during a natural miscarriage, the pregnancy does not completely pass even within two to three weeks. This is why we see you for a follow up scan so we can advise on further management options for you.
What are the benefits?
The main benefit is that you are in control of your miscarriage and can avoid intervention. Some women feel that this helps them deal with the miscarriage better however this is not how everybody feels. Natural management can be successful in up to 9 out of 10 women therefore avoiding any medical intervention.
What are the disadvantages?
There is an element of waiting for things to happen and some women find this difficult. Some women do not want to be at home during their miscarriage because they don’t want to worry about getting into hospital if they have heavy bleeding or if they have other children at home who they do not want to be around while miscarrying.
Although over 9 out of 10 women who chose natural management miscarry within 3 weeks it may not happen on its own. This could mean you require medical or surgical management despite waiting for nature to take its course.
Most women are suitable for medical management of miscarriage at home. There are certain circumstances when we would advise you to have your management with us. You may already have been made aware of this. If you have any concerns about management at home please speak to a member of the medical or nursing staff.
What does medical management involve?
Medical management is made of up two parts. Initially you will receive a medicine called mifepristone that prepares the womb for the miscarriage. This will be given to you in the GED. You will be given the second part of the medical management to take home with you along with pain killers. We ask you to take this medication 48 hours after your first medication. This medication is called misoprostol and it causes the pregnancy to pass.
We ask you to contact us at the GED after 48 hours if you have not had any bleeding. This is so we can review you to see if you need a further dose. If after this second dose there is no bleeding or minimal bleeding after 7 days we will ask you to contact the GED to arrange review.
You can sometimes pass your pregnancy before the second part of the medical management. If this happens, please contact the GED and tell the nurse that you have had bleeding and think you have passed the pregnancy. They may ask you further questions about what you have passed and may invite you in for a review. They may also ask you to bring the pregnancy remains with you if you still have it. Some women instinctively flush the toilet after passing the pregnancy but some women prefer to remove the remains for a closer look. We will provide you with an appropriate receptacle at the start of your miscarriage management to bring the remains into us if this is what you wish.
How will the management be different if I need to stay in hospital?
If you need to stay with us for your miscarriage management you will be given a date to attend. This will be 48 hours after taking your first medication. There can be a slight delay getting this date as we try and plan your stay at times when the ward is quieter for your privacy. You will be given the misoprostol medication is separate doses 4 hours apart. If after two doses you have not passed the pregnancy a member of the team will review you and offer you a third dose. At this point they will have a discussion about what will happen next. This will be based upon your circumstances and your wishes.
What are the risks?
- Infection is common affecting about 1 in 10 women
- Bleeding that lasts up to 2 weeks is common but heavy bleeding is uncommon, about 1 in 1000 women
Medical management is successful in 80-90% of women however if it is not successful you may require a further dose of the medicines or be offered surgical management.
What are the benefits?
The main benefit is avoiding a surgical procedure and the associated general anaesthetic.
Some women prefer this option as they feel more in control by choosing when the miscarriage will happen.
As with natural management some women find acknowledging the passing of the pregnancy helps with the grieving process of a miscarriage.
What are the disadvantages?
There are side effects to the medication most commonly tummy cramps and diarrhoea. Sometimes these pains and the associated bleeding can be quite distressing.
If you chose to manage your miscarriage at home some women worry about having to get back to the hospital if they have heavy bleeding.
Some women have concerns about seeing the baby, particularly if they are more than 10 weeks when the miscarriage occurs.
Bleeding can last for up to 3 weeks. Sometimes this is due to small amounts of tissue remaining and in some cases, it may be necessary to consider surgical management
This can be done in one of two ways
- Under local anaesthetic while you are awake also known as Manual vacuum aspiration (MVA)
- In theatre with sedation
Both procedures are very similar. You may have heard it referred to as a D&C which means dilatation and curettage. Although this is technically a procedure done for heavy periods some people use this term to explain surgical management of miscarriage also. .
What does and MVA involve?
A doctor will see you and discuss the procedure.
You will be given a medication (misoprostol) to soften the cervix (neck of the womb) prior to the procedure. Some women will experience side effects with these misoprostol tablets. Possible side effects include nausea, vomiting, diarrhoea, abdominal pain, headache, hot flushes and an unpleasant taste in the mouth. These side effects are reduced by giving the tablets vaginally (ask a member of your healthcare team for more information about this). You may experience some bleeding.
You will have a speculum examination (similar to that at a smear test) by a doctor or nurse with the assistance of another nurse or healthcare assistant. This will allow the doctor or nurse to assess the cervix, which will be numbed with a local anaesthetic injection.
When you feel comfortable and ready, the pregnancy tissue will be removed with a small tube attached to a syringe. The pregnancy remains will be sent to histopathology . This examination will not provide an answer for why your pregnancy miscarried. For more information on this please see the section below on how my pregnancy is cared for after I have passed and our Histology patient information leaflet.
You will feel some discomfort during the procedure (similar to period pain). Entonox (‘gas and air’) will be available for you to use if you wish.
If you feel pain please let the nurse or doctor know. Additional local anaesthetic may be possible but if you find the procedure too uncomfortable it can be stopped and the treatment abandoned.
Sometimes an ultrasound scan may be repeated to check that all of the pregnancy tissue has been removed.
How long will the MVA take?
The actual procedure takes about 15 minutes. You will stay for about 30 minutes after the procedure.
What happens afterwards?
We will monitor you for 30 minutes after the procedure. This includes reviewing vaginal bleeding and any pain you are having. You can leave the hospital once you feel well enough to go home.
You can expect some vaginal bleeding after the MVA. This usually settles within seven days but can persist for two weeks. If you are worried about your bleeding because you feel it is too heavy please contact the GED.
We recommend you use sanitary towels instead of tampons and do not have sexual intercourse until the bleeding has settled. This reduces the risk of infection. You may return to work when you feel able. If your blood group is Rhesus (Rh) Negative you will require anti D
How is the theatre management different?
The procedure is very similar but for the surgical management you will ask to be fasted. You will be asked to attend the gynaecology unit either early morning or early afternoon depending on what time of day the procedure is to be performed. You will meet the anaesthetist who will explain the sedation. You will also meet your surgeon who will explain the procedure.
Once you are sedated in theatre the cervix is gently dilated (stretched) and a narrow suction tube is inserted into the uterus to remove the pregnancy. The operation only last about 5-10 minutes however you could expect to be in the theatre department for over an hour due to the time taken for the anaesthesia and recover afterwards.
After the procedure you should be able to go home the same day. You may have some period pains afterwards. You may bleed for up to 2-3 weeks which may stop and start but should gradually tail off. If it ever gets heavier than a period or you are concerned please contact the GED.
What are the risks?
- In 1 in 20 women some of the pregnancy can remain in the womb after the procedure. This may require a second operation or a dose of the medical management to complete the miscarriage
- About 1 in 30 women can develop an infection
- Bleeding that lasts for up to 2 weeks is common but heavy bleeding is uncommon, less than 1 in 500. It is rare that a woman would require a blood transfusion
- Scarring to the inside of the womb can occur rarely, less than 1 in 100 women. The clinical significance of this scarring is unknown.
- Injury to the cervix or rarely – in less than 1 in 200 women the womb can be perforated (a hole made). If this happens there can be injury to the bowel, bladder or blood vessels inside your tummy. If there is a concern that this has happened the surgeon may perform a laparoscopy (key hole surgery) to look inside the tummy and if necessary they may need to perform a laparotomy (cut on the tummy) to repair any injury. This is extremely rare. In most cases if there is a small perforation it will heal itself with some antibiotics to prevent infection and should not affect future pregnancies.
- Very rarely the anaesthetic can cause a severe allergic reaction, about 1 in 10,000 or even death, 1 in 100,000
What are the benefits?
Some women prefer this method of management as they know when the miscarriage will happen and they can plan around it. Some women also prefer that the miscarriage happens while they are sedated.
What are the disadvantages?
Some women are frightened of going to theatre or staying in hospital. The anaesthetic may make you feel groggy afterward for a day or so.
What happens after your miscarriage?
How is my pregnancy cared for once I have passed it?
All pregnancy remains are transferred to the care of the honeysuckle bereavement team.
If an embryo/ tiny baby is identified visually by staff caring for you it will not be necessary for any examination to take place. With your signed consent The Honeysuckle Team will then arrange for a communal cremation to take place at a local crematorium. If you wish to discuss the communal cremation in more detail or think you would like to make your own arrangements please contact The Honeysuckle Team on 0151 702 4151 / firstname.lastname@example.org
If an embryo/ tiny baby is not identified by staff caring for you histopathological testing will be requested by medical staff. For more information please see enclosed patient information leaflet
Histology patient information leaflet
If you miscarry at home or outside of the hospital setting you are most likely to pass your pregnancy loss into the toilet.
You may want to retrieve your pregnancy to have a closer look or flush the toilet (many people do this automatically). There is no right or wrong answer. It is important you do what you feel is best for you.
What does miscarriage mean for future pregnancies?
Because miscarriage is sadly a common occurrence in early pregnancy, 1 in 4 early pregnancies is believed to miscarry, it is unlikely that there is any significant medical cause for you miscarriage that would increase your chances of it happening in your next pregnancy. It is highly likely that your next pregnancy will not end in miscarriage. We do however, investigate women who have had 3 miscarriages in a row through our recurrent miscarriage clinic. If this is something you have experienced please ask about referral to this service.
There are no rules about when you can start trying for a baby again and every couple has different feelings about this. It is best to wait for your next period as it helps us to date the next pregnancy but there would be no harm if you got pregnant before then.
In order to ensure we can offer early pregnancy scans in our EPAU to women who have bleeding or pain in early pregnancy as soon as possible we cannot provide a reassurance scan for women who have suffered a miscarriage unless they have suffered two miscarriages in the last two pregnancies. We do offer a private service for early pregnancy reassurance scans when you are over 6 weeks that can be booked via the imaging department. Please contact them at 0151 702 4483
This leaflet has been produced from the Miscarriage Association ‘Management of miscarriage: your options’ leaflet 2016.
Gynaecology Emergency Department
GED telephone: 0151 702 4140
Telephone number: 0151 702 4151 (Monday to Friday, 8am to 4pm)