Management of a Miscarriage

Patient Information

Obstetrics & Gynaecology Department

Introduction

If you are reading this leaflet, you are probably in the process of dealing with a miscarriage – or perhaps supporting someone else in this situation.  You may be facing difficult choices at a difficult and distressing time, or perhaps you are trying to find out more about what has happened so far.  Whatever your circumstances, we hope that you find this leaflet helpful.

Background

In some miscarriages, the womb (uterus) empties itself completely.  In some cases though, an ultrasound scan shows that the baby has died or not developed, but has not been physically miscarried.  This leaflet explains some of the medical terms that are used in this situation and describes the different ways in which the miscarriage process can be managed in these circumstances.

Medical Terminology

There are several ways that doctors might describe a miscarriage where the womb does not empty itself completely.  Unfortunately, not everyone uses the same terminology, so it can be difficult to understand what they mean.  We explain the main terms below:

Missed miscarriage

(Also called delayed or silent miscarriage)

This is where the baby has died or failed to develop, but your body has not physically miscarried the pregnancy.  There may have been little or no sign that anything was wrong and this may have been diagnosed at a routine scan.  You may still feel pregnant, though your symptoms may be weaker than before and a pregnancy test may still show positive.

Blighted Ovum

Now more often called missed or delayed miscarriage, the term Blighted Ovum is still sometimes used when an ultrasound scan shows a pregnancy sac with nothing inside.  This may be because the fertilised egg does not divide and develop as it should and although the pregnancy sac develops, the baby does not.  Alternatively, it may be that the baby stops developing at such an early stage that it is absorbed back into the surrounding tissue.  You may still feel pregnant, as with a missed miscarriage.

Incomplete miscarriage

Sometimes when a miscarriage occurs, not all the pregnancy tissue in the womb comes away.  Although the pregnancy is over, symptoms of pain and heavy bleeding continue.

Methods of management

In all of these situations, the pregnancy will fully miscarry in time and waiting for this to happen is preferable, but the miscarriage may also be managed medically or surgically.  You will usually be offered a choice, or the doctor might make a recommendation.  In most cases, you should be able to have time to think about which method to choose.  This can be difficult – not least because you would almost certainly prefer not to have to consider any of these options at all.

It may help to know that a large research study comparing surgical, medical and expectant (natural) methods came to three very important conclusions:

The risk of infection or other harm is very small with all three methods.

Your chances of having a healthy pregnancy in the future are just as good whichever method you choose.

Women interviewed for the research study generally coped better when they were given clear information, good support and were able to choose the management method that they felt they could best cope with.

We hope that the following information might help you in making a decision and/or in understanding more about the process.

Natural Management

Some women prefer to wait and let the miscarriage happen naturally – especially in the first 8 or 9 weeks of pregnancy.  Doctors tend to call this expectant or conservative management, though they may also call it a “wait and see” approach.

What happens?

The process of a natural miscarriage will vary depending on the size of the pregnancy and the findings of the ultrasound scan.  There is wide variation and it may take days or several weeks before the miscarriage begins.  Once it does, you are likely to experience abdominal cramps.  Bleeding can continue for two or three weeks.  It can be very difficult to predict what will happen and when.  In some women, the small sac in the womb will re-absorb without much bleeding at all.

You will be invited to attend for another scan or scans over the next few weeks to monitor progress and ensure that the womb has emptied.

Does it hurt?

It varies, but most women will experience abdominal cramps, possibly quite severe and painful, especially as the pregnancy tissue is expelled.  As with medical management, this is because the womb is contracting and pushing (imagine tightly clenching and then relaxing your fist a few times), rather like the contractions of labour.  You are also likely to have heavy bleeding and pass blood clots.  You may see the pregnancy sac and it may be larger (or smaller) than you expect.  You might see an intact fetus, which may look like a tiny baby, especially if you are miscarrying after 10 weeks.  The nurse will give you some guidance as to what to expect and provide or recommend pain-relief.

Are there any risks?

The risk of infection with expectant (natural) management is low, at around 1 in 100.  Signs of infection are a raised temperature and flu-like symptoms, a vaginal discharge that looks or smells offensive and/or abdominal pain that gets worse rather than better.  Treatment is with antibiotics.  In some cases you may be advised to have an ERPC (Evacuation of Retained Products of Conception – see page 6).  You will also be advised to use pads rather than tampons for the bleeding and not to have sexual intercourse until the bleeding has stopped.

There is a small risk of haemorrhage (extremely heavy bleeding); a recent study reported that 2 in 100 women had bleeding severe enough to need a blood transfusion and some women will need an emergency ERPC.  If you have very heavy bleeding or severe pain and/or feel faint or unwell, or if you just find it hard to manage, you may wish to contact Ward 2 at Leigh Infirmary telephone 01942 264252 or telephone 01942 264857, out of hours Billinge Ward, Royal Albert Edward infirmary on telephone 01942 822072.

In rare cases, pregnancy tissue may become stuck in the cervix and will need removing during a vaginal examination: this can be painful and distressing.  If there is still pregnancy tissue remaining in the womb after several weeks, you may be advised to have an ERPC.

What are the benefits?

The main benefit is in avoiding hospital treatment – medication or an operation and general anaesthetic.  Some women feel strongly that they want their miscarriage to be as natural a process as possible.  They prefer to be fully aware of the process of miscarriage and may want to see the pregnancy tissue and perhaps the fetus.  Some feel this helps them to say goodbye, though they may want guidance on what to do with the remains of their baby.

It may be helpful to know that if you reach a point where you no longer want to wait, you can request an ERPC.

Disadvantages

Some women find it very difficult not knowing when – and therefore where – the miscarriage might start.  Sometimes it can take several weeks before the womb empties itself.  Women may worry about starting to bleed heavily when they are least prepared and perhaps in public (though carrying or wearing sanitary pads can help).  Some women are anxious about how they might cope with pain and bleeding, especially if they are not within easy reach of a hospital.  Some fear seeing the fetus.

For some women, waiting can become intolerable after a time; though they may have mixed feelings about having follow-up scans to monitor progress.  They may decide to request an ERPC.  Others will need an ERPC because of heavy bleeding or infection.

Medical Management

This is treatment with pills and/or vaginal tablets or pessaries to start or speed up the process of a delayed or missed miscarriage.  This treatment can also be used to help empty the womb after an incomplete miscarriage.  It isn’t suitable for women with certain health problems.

What happens?

Medical management involves a single visit to the hospital. During this time, you will have pessaries (tablets) inserted inside your vagina, or you may be given the tablets orally if you are having vaginal bleeding.  These work by making your womb contract and push out the pregnancy tissue.  You may need more than one treatment with pessaries or oral tablets before the miscarriage happens.  You may choose to stay in the hospital or go home following the administration of medication.  If you prefer you may take the tablets home and take them yourself at home.  Bleeding may continue for up to 3 weeks after treatment.

Does it hurt?

Once the miscarriage starts, most women have quite strong period-like pain and cramps and some find the process very painful, especially as the pregnancy tissue is expelled.  This is because the womb is contracting and pushing (imagine tightly clenching and then relaxing your fist a few times) rather like the contractions of labour.  You are also likely to have heavy bleeding and pass blood clots.  You may see the pregnancy sac and it may be larger than you expect.  You might see an intact fetus, which may look like a tiny baby, especially if you are miscarrying after 10 weeks.  You may take Paracetamol or Co-codamol for pain relief, but you should not take Aspirin or Ibuprofen as they may make the treatment less effective.

Some women react to the medication with nausea and/or diarrhoea.

Are there any risks?

The risk of infection after medical management is low, at around 1 in 100.  Signs of infection are a raised temperature and flu-like symptoms, a vaginal discharge that looks or smells offensive and/or abdominal pain that gets worse rather than better.  Treatment is with antibiotics.  In some cases you may be advised to have an ERPC.  You will probably also be advised to use pads rather than tampons for the bleeding and not to have sexual intercourse until the bleeding has stopped.

There is a small risk of haemorrhage; a recent study reported that 1 in 100 women had bleeding severe enough to need a blood transfusion.  If you have very heavy bleeding or severe pain and/or feel unwell, or if you just find it hard to manage, you may ring Ward 2, Leigh Infirmary telephone 01942 264252 or telephone 01942 264857, out of hours, Swinley Ward, Royal Albert Edward Infirmary on telephone 01942 822072.

Medical management is effective in approximately 80 to 90% of cases.  Where it is not, women may be advised to have surgical management – an ERPC.

What are the benefits of medical management?

The main benefit is in avoiding an operation and general anaesthetic.  Some women prefer to be fully aware of the process of miscarriage and may want to see the pregnancy tissue and perhaps the fetus.  Some women feel this helps them say goodbye.

Some women see medical management as a more natural process rather than having an operation, but more manageable than waiting for nature to take its course.  It may be helpful to know that if the treatment doesn’t work, you may be able to opt for ERPC.

Disadvantages?

Some women find the process painful and frightening, though good information about what to expect can help.  Some women are anxious as to how they might cope with the pain and bleeding, especially if they are not in hospital at the time.  Some fear seeing the fetus.  Bleeding can continue for up to three weeks after the treatment and women may have to have several follow-up scans to monitor progress.  This can be upsetting.  Some women will end up having an ERPC as well as medical treatment.

Surgical Management: ERPC

This is an operation to remove the remains of your pregnancy and it is usually done under general anaesthetic (you are asleep).  ERPC is an abbreviation for Evacuation of Retained Products of Conception, which means the removal of the remains of the pregnancy and surrounding tissue.  Some people call it a D & C, which means Dilation and Curettage, but this is a slightly different procedure, usually carried out for women with period problems.

What happens?

The cervix (neck of the womb) is dilated (opened) gradually and a narrow suction tube is inserted into the womb to remove the remaining pregnancy tissue.  This procedure takes about 5 to 10 minutes.  The tissue will then be sent to the mortuary for appropriate disposal. (You will be asked to consent for this before the operation).

Does it hurt?

The ERPC is usually carried out under a general anaesthetic.  It is done vaginally and you will have no cuts or stitches.  You may have some abdominal cramps (like strong period pain) when you wake up and for a few days afterwards.  You are likely to have vaginal bleeding for up to two or even three weeks.  Bleeding may stop and start but should gradually tail off during that time.  If bleeding continues to be heavy or gets heavier than a period, it is best to contact your GP.

Are there any risks?

There is a small risk of infection or injury with any surgical operation and more rarely, a risk from having a general anaesthetic.

The risk of infection after ERPC is low (about 2 to 3 cases per 100).  There is a very small risk (less than 1 in 200) of uterine perforation (making a small hole in the wall of the womb) and in rare cases, damage to the bowel or other internal organs.  The risks of haemorrhage (extremely heavy bleeding) or of scarring (adhesions on the lining of the womb) are also very low (less than 1 in 200 cases).

Very occasionally, if there is still pregnancy tissue remaining in the womb, a second ERPC may be needed.

What if I get an infection?  Will I know?

Signs of infection are a raised temperature and flu-like symptoms, a vaginal discharge that looks or smells offensive and/or abdominal pain that gets worse rather than better.  Treatment is with antibiotics.  In some cases you may need a second ERPC.

You will be advised to use pads rather than tampons for the bleeding and not to have sexual intercourse until the bleeding has stopped.

What are the benefits of an ERPC?

For many women, the main benefit is that their miscarriage is over and done with and they feel they can move on more easily.  They may be shocked to find out that their baby has died and may not be able to tolerate “carrying a dead baby” once they find out.  With surgical management, they know when the miscarriage will happen and can plan around that.  Some women prefer not to be aware of the process of miscarrying.

Disadvantages of ERPC

Some women are frightened of having an anaesthetic, surgery or a hospital stay or of something going wrong during the operation.  Some prefer to let nature take its course and to be aware of the whole process.  Some women worry that the diagnosis might be wrong and refuse surgery in case there is a chance that their baby is still alive. Don’t be afraid to ask for another scan if you need to be sure before making a decision.

Surgical management under local anaesthetic (MVA):

This is also called MVA, which stands for Manual Vacuum Aspiration. A small hand held device is used to empty out the contents of the uterus after some local anaesthetic has been applied to the cervix (neck of the womb).

This procedure offers an additional choice to women who want surgical management of miscarriage but want to avoid having a general anaesthetic.

What happens?

If you decide to have the MVA, you will be given an appointment.  You can eat and drink normally before you attend. You may be given tablets or vaginal pessaries before the procedure to soften the cervix, along with pain relief. The doctor will meet you and go through any questions that you may have. You will be asked to sign a consent form. A nurse or a health care assistant will stay with you throughout the procedure. They will assist the doctor and provide reassurance and support.  A local anaesthetic is injected into the cervix and/or the cervix may be numbed with a gel. The cervix is then dilated (stretched) gradually. A narrow suction tube is then inserted into the uterus to remove the pregnancy tissue. At this stage you will experience a period like pain. The whole procedure will take about 10 to 15 minutes. Once the procedure is complete, an antibiotic (Metronidazole) is given rectally or orally (by mouth).

After the procedure

After the procedure, you can rest in a recovery area with refreshments until you feel able to go home (usually you are fine to leave within an hour, but you may need to stay longer).

You may experience some period like pains after the procedure.  Pain killers are available if you need them

Does it hurt?

If you are given tablets or vaginal pessaries before the operation, you might feel discomfort as the cervix opens. Most women have period type pain during the procedure. You will be given painkillers if necessary and the discomfort probably won’t last long. You may have some light vaginal bleeding afterwards. If it becomes heavy, you need to contact us (you will be given contact numbers prior to discharge).

Are there any risks?

These are mostly the same as for surgical management of miscarriage under general anaesthetic. There is a very small risk of having a reaction to the local anaesthetic.

What are the benefits?

MVA has been shown to be:

99.5% effective

Associated with less blood loss

No risks of general anaesthetic

Shorter length of stay in hospital than general anaesthetic

What are the disadvantages?

Some women prefer not to be aware of the procedure.  You may worry about coping with pain or anxiety.

After the miscarriage

In hospital

When a baby dies in pregnancy before 24 weeks, there is no legal requirement to have a burial or cremation. 

You will be offered respectful disposal of fetal tissue.  The choices are as follows:

Hospital cremation

The hospital arranges for all fetal remains to be transferred to Wigan Crematorium for cremation, unless the mother indicates an alternative choice.

The hospital is responsible for the funding of and making arrangements for the cremation service.

Private arrangements normally incur a cost.

Private Burial/Cremation

A funeral director of your choice may be approached to arrange a private burial/cremation.

Burial outside a cemetery

There is no legal prohibition to a woman taking fetal remains home.

Arrangements can be made for burial outside a cemetery, but the following should be taken into consideration:

The burial should not take place near to water supplies or a water course.

There must be no chance of bodily fluids leaking into or onto adjoining land.

The fetal tissue must be buried at a depth of at least 18 inches (45 centimetres).

Permission must be obtained from the landowner if the woman does not own the land.

Careful thought must be given when considering burial in a garden, taking into account what would happen if the parents moved house or the land is used for new purposes in the future.

At home

If you miscarry at home or somewhere other than a hospital, you are most likely to pass the remains of the pregnancy into the toilet (this could happen in hospital too).  You may look to see what has come away and you might see a pregnancy sac and/or fetus, or perhaps something that you think might be the fetus.  You may decide simply to flush the toilet – many people do that automatically – or perhaps to remove the sac or fetus for a closer look.  That’s also a very natural thing to do.

Whether or not you see a recognisable fetus, however tiny, you may wonder what to do with it.  Flushing it down the toilet may seem right or it may not.

You might decide to bury the remains at home, in the garden or in a planter with flowers or a shrub.  Or you may want to see if they can be buried in a local cemetery.  You may want to put the remains into a container and take them to your GP or Ward 2, Leigh Infirmary, Monday to Friday or Billinge Ward, Royal Albert Edward Infirmary at weekends and on Bank Holidays.  Do be aware that they probably won’t be able to do any tests on the fetus or tissue, though they may be able to confirm that you have passed pregnancy tissue.

You are welcome to contact The Miscarriage Association if you have any questions about what to do.

Counselling Services

Ward 2 Counselling Service was set up in August 1977.  It is based at Leigh Infirmary and provides a confidential service, Monday to Friday 8:00am to 5:00pm.

What does it offer?

It doesn’t offer advice, but it was set up to help you in the following ways:

To provide emotional support.

To help you become aware of your emotions and to come to terms with them.

To reduce the stress you are experiencing surrounding your situation.

Who do we help?

Obstetric and Gynaecology patients attending either as an out-patient or an in-patient.  You can be seen individually or as a couple.

The service is run by qualified counsellors and has additional trainee counsellors on placement.  If you have any questions or worries you can call them on 01942 telephone 264308.  If they are unavailable, there is a confidential answering machine and if you leave your name and telephone number, they will call you back.

Summary

There are several ways of managing a miscarriage.  All have advantages and disadvantages but risks of infection or other harm are low and the chances of having a healthy pregnancy in the future are just as good whichever method you choose.

The processes are different and personal experience varies, so if you are given options, you may find it hard to decide between them.  We understand that you would almost certainly prefer not to be making these choices at all.

We hope that this leaflet provides the information to help you make decisions at what may be a difficult and distressing time.

Useful resources

The Miscarriage Association

Clayton Hospital, Northgate, Wakefield WF1 3JS

Telephone 01924 200799

e-mail: info@miscarriageassociation.org.uk

www.miscarriageassociation.org.uk

Association of Early Pregnancy Units:  www.earlypregnancy.org.uk

Royal College of Obstetricians & Gynaecologists: www.rcog.org.uk

Comments, Compliments or Complaints

The Patient Relations/PALS Department provides confidential on the spot advice, information and support to patients, relatives, friends and carers.

Contact Us

Telephone 01942 822376 (Monday to Friday 9:00am to 4:00pm)

The Patient Relations/PALS Manager

Wrightington, Wigan and Leigh NHS Foundation Trust

Royal Albert Edward Infirmary

Wigan Lane

Wigan

WN1 2NN

In addition to the Patient Relations/PALS Service, you can contact HELPline on telephone 01942 822111.

This leaflet is also available in audio, large print, Braille and other languages upon request. For more information telephone 01942 773106.

Call 1 1 1, for health advice and reassurance when it’s less urgent than, 9 9 9.

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