Medical Management of 1st Trimester Miscarriage

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Medical Management of 1st Trimester Miscarriage

We are sorry that you are having a miscarriage and realise that this is a distressing time for you and your family. This leaflet intends to set out in more detail the protocol which we follow to manage your miscarriage with medical therapies.

It is our intention that you make a fully informed decision for the management of your miscarriage and this leaflet sets out some of the benefits and risks associated with this procedure. You may wish to read in detail our other leaflets on the management of first trimester miscarriage.

Please ask your medical team about anything you do not fully understand or want to be explained in more detail.

We recommend that you read this leaflet carefully. You and your doctor (or other appropriate health professional) will also need to record that you agree to have the treatment by signing a consent form, which your health professional will give you.

Medical Management of Miscarriage

Sadly miscarriage affects between 10 and 20% of all pregnancies and we appreciate that there will be an impact on both your physical and psychological wellbeing.

Managing your miscarriage with medical treatments may involve you taking some oral tablets (Mifepristone, an anti progestogen) which help to reduce the effects of some of the pregnancy hormones. The mifepristone will make your womb more receptive to the subsequent hormone tablets (Misoprostol, a synthetic prostaglandin) which you will be given to bring on your miscarriage.

If you have an incomplete miscarriage with some retained products of conception you will NOT need to take mifepristone – just misoprostol.

If you have a missed, silent or delayed miscarriage or early foetal demise (previously called an embryonic pregnancy or blighted ovum) it is usual to take mifepristone on the gynaecology ward and go home shortly afterwards. Then after 36 – 48 hours you will be admitted to the gynaecology ward for the misoprostol tablets which will cause the womb to contract and expel any pregnancy tissue that remains in the womb. Approximately 1/3 of women will bleed or miscarry in the priming phase after the mifepristone and before misoprostol.

If you have an incomplete miscarriage you will only need misoprostol.

Misoprostol is given vaginally by one of the nurses or doctors to cause the womb to contract and expel any pregnancy tissue that remains. Some patients will need additional oral doses of this hormone after 3 hours if the miscarriage has not completed.

Attending the Gynaecology Ward

Initially you will be referred to the gynaecology ward after the diagnosis of your miscarriage.

When you have decided to proceed with medical management of your miscarriage you will have your general observations (pulse, blood pressure, temperature etc) taken by the nursing staff. You will be asked a few questions about your medical history and you will need to have a blood test to check your blood group and haemoglobin (iron) level, if this has not already been done.

The procedure will be discussed with you in detail and you will be asked to sign a consent form.

You will also be given the times to attend the Gynaecology Ward for the misoprostol treatment to bring on the main part of the miscarriage. This part of the treatment will involve a short admission to hospital.

Mifepristone Treatment

If you are having mifepristone, you may be given the tablets to take on the ward at your initial attendance or you may be given a time to return to the ward later for a short while. You will need to stay on the ward for 20 minutes after taking the mifepristone.

You may experience some pain and bleeding at home as a result of the mifepristone treatment. Approximately 1/3 of women will have some bleeding or even miscarry during the priming phase after mifepristone treatment. You can take mild paracetamol based pain killers at home but you must not take non-steroidal based drugs (such as Aspirin, Ibuprofen, Brufen, Neurofen, Voltarol, etc.) as they can stop the mifepristone from working properly. If you require stronger pain killers these can be obtained from the Gynaecology Ward.

If the bleeding is heavy or the pain is severe we want you to phone the ward for advice. We may need to arrange for you to return to the ward and we will ensure that you have the telephone number for the Gynaecology Ward before you leave.

You will also be given the times to attend the Gynaecology Ward for the misoprostol treatment to bring on the main part of the miscarriage. This part of the treatment will involve a short admission to hospital.

Admission to hospital

When you arrive we will settle you in to the ward, check your details and fasten an armband containing your hospital information to your wrist. The nurse will also take your blood pressure, temperature and pulse and these will be recorded.

Misoprostol Treatment

Once all admission details have been completed the nurse will insert four small tablets of misoprostol into the vagina. This will cause the womb to contract and expel any pregnancy tissue that remains in the womb. You will need to stay lying down on the bed for 30 minutes after this so that the tablets are properly absorbed.

You will probably be aware that you are miscarrying as the discomfort becomes more severe with ‘contraction like’ pains. The vaginal bleeding is likely to increase from a brownish discharge to a heavier blood loss as the remaining clots and tissue are passed from the womb.

You will be advised to inform your nurse of any pain or bleeding and you must show all pads and bed pans to the nurse before disposal. This is so that the nurse can confirm whether you have passed any pregnancy tissue or not.

You may drink freely and have a light diet and pain relief will be readily available if required.

Sometimes patients will not miscarry after the vaginal tablets and it is then necessary for them to be given another dose of misoprostol tablets by mouth after 3 hours. This can be repeated up to a maximum of 4 oral doses (total 5 doses if including the vaginal tablets).

Although misoprostol is not licensed for use in this way it is safely used in this way in many centres in the UK. Misoprostol is used widely under licence for the treatment of peptic ulcer disease. Please feel free to discuss this with your health care professionals.

Delays before treatment

We appreciate how upsetting it is to have a miscarriage. Unfortunately, this treatment cannot always be ‘planned’ as there are sometimes other emergencies that are more life threatening, leading to a delay in time before your treatment can be performed. We will try to keep you informed of any possible delays but please understand that such delays can be unexpected and unavoidable.

Benefits of the treatment

The aim of your treatment is to remove any remaining tissue and blood clot in the uterus (womb) after a miscarriage.

In other units the success rates of this procedure vary widely but may be as high as 96%. We are committed to an ongoing audit of our own success rates but these are not available at the time of writing. A recent audit of results at our unit at WRH (2007) showed a 56% success rate using a single dose of misoprostol and it is anticipated that the success rates will be improved with the regimen described above.

Success rates have been shown to be improved in women in their first pregnancy, with active bleeding and with an incomplete miscarriage.

One benefit of medical treatment to empty your uterus is the possibility of avoiding an operation and anaesthetic. Other surgical complications such as perforation or trauma to the womb may also be avoided.

Some studies have shown that there may be a lower chance of pelvic infection after medical management of miscarriage when compared with surgical management.

Serious or frequent risks

Everything we do in life has risks. Complications are rare with medical management of miscarriage but with advanced gestation (length of pregnancy) and increased sac size pain and vaginal bleeding may be more severe.

Most pain can be easily controlled with pain killing tablets but occasionally it is necessary for patients to have injections (2 – 32%).

Some patients will have side effects directly related to the medication given. This includes a fever (9%), sickness and / or vomiting (1.4 – 30%) and diarrhoea (4 – 65.3%).

More rarely, patients may have excessive vaginal bleeding requiring a blood transfusion. Sometimes patients need to undergo surgery to treat their miscarriage if bleeding is severe.

You will be cared for by a skilled team of doctors, nurses and other health-care workers who are involved in this type of treatment every day. If problems arise, we will be able to assess them and deal with them appropriately.

It is estimated that a small number of patients will need to be readmitted to hospital after discharge following their treatment (3.6 – 6%).

Sometimes the procedure will not be successful. If this procedure is not successful and there is some remaining tissue within the womb you may wish to manage this without treatment (expectantly) or surgically.

Failure of treatment

The success rate of a medical evacuation in emptying the uterus is traditionally lower than the surgical approach. If medical treatment does not work you may still need an operation.

If the procedure is not successful you will be examined by a doctor to check that there is no pregnancy tissue within the vagina that has not been seen.

If it seems that you have not miscarried despite the medical treatment outlined above you will be allowed to go home. There would be a chance that you will miscarry at a later date at home.

If your miscarriage is not completed you will be given an appointment for the Early Pregnancy Assessment Unit after 7 – 10 days for a follow up review with a scan and you will be given the telephone number of the ward as a 24-hour contact if needed before this appointment.

You may however prefer to make arrangements to have surgical management of your miscarriage. If this is your preference you will be given a date to return to the gynaecology ward for this to take place as a short day case procedure.

Other procedures that are available

If the bleeding is not excessive, you may wish to wait and give the womb chance to expel the remaining tissue without assistance. This may work in a proportion of patients but the time frame may be longer than other treatments. Please ask for the patient information leaflet on Expectant Management of First Trimester Miscarriage.

There is also a surgical option to remove any pregnancy tissue that remains in the womb. This is called evacuation of retained products of conception (ERPOC) and was previously known as a ‘D and C’ (dilatation and curettage). Please ask for the patient information leaflet on Evacuation of Retained Products of Conception or Surgical Management of First Trimester Miscarriage

A member of the gynaecology team can discuss these options with you.

After the procedure

You will be allowed to go home approximately 1 to 2 hours after your miscarriage seems complete.

If any pregnancy tissue has been identified during the procedure it will routinely be sent for microscopic examination in the laboratory and disposed of sensitively thereafter. You will need to sign a form detailing your wishes before this takes place. The tissue cannot be processed without the completed appropriate form.

It is likely that there will still be a mild discomfort and slight vaginal bleeding after you go home from the ward. The bleeding may be like a normal period with small clots or possibly a small amount of pregnancy tissue. The vaginal bleeding usually settles within the first week. If this is the case and all is well then we would not need to see you for routine follow up.

If you have bleeding persisting at the seventh day after the miscarriage we would like to see you for follow up at the hospital. In this situation please phone the Gynaecology Ward to make an appointment to be seen at the Early Pregnancy Assessment Unit at approximately 10 days after the procedure. If the bleeding is still persisting at this time you will need to be reviewed and have an ultrasound scan to see if there is still some tissue within the womb.

If the procedure has not been successful or been partially successful then further options will be discussed at that stage. Essentially you will be counselled regarding expectant management, surgical management or repeat medical management.

Anti D

Anti D injections are not given after this procedure unless bleeding has been very heavy.

What do I need to bring to hospital?

Wear loose, comfortable clothes and bring spare pants with you. You cannot use tampons but you can provide your own sanitary towels if you prefer, though please do not use the highly absorbent type (for example Always ultra) as they make it difficult to check on how much you are bleeding. Please bring in items such as a toothbrush and nightwear in case you need to stay in overnight.

You will have access to your own television and telephone via a pay card and the radio is free. Bring with you some magazines or something else to help pass the time. Cold water will be provided and hot drinks throughout the day but feel free to bring in cold drinks if you would prefer.

Can I bring someone with me?

You can bring your partner or one friend with you, and they are very welcome to stay throughout the day. Please note that we do not have the facilities to care for children on the ward so please make your own arrangements for childcare before attending the hospital.

Leaving hospital

Convalescence
How long it takes for you to fully recover varies from person to person. You should plan to rest at home for the next 24 hours. After this you should be able to resume normal activities, but if you have a physically demanding job you may want to arrange a further day off work.

How will I feel emotionally?
It is to be expected that you will feel low after this treatment and that you will feel sad and upset over the whole episode. It is helpful to discuss this with your partner and friends. The nurses will be able to give you information for support groups and information leaflets prior to leaving the hospital.

A nurse will explain to you about the Bereavement Services and options for remembrance available in the hospital. The Hospital Chaplains offer you sympathy in your loss and keep a remembrance book where you may make an entry for the baby you have lost.

A multi-faith prayer room can be found in the main reception area at Worcestershire Royal Hospital and the Alexandra Hospital. The prayer room at Kidderminster Hospital is located in ‘C’ Block. If you would like to see the Hospital Chaplain please ask the ward staff to organise this for you.

If you feel you would like to talk, need support or counselling the Miscarriage Association and Cedar Tree offer confidential help, information, counselling and support. Contact details can be found in Other Information on page of this leaflet.

Personal hygiene
You can bathe or shower as normal. You should use sanitary towels but not tampons whilst you are bleeding.

Diet
You do not need to follow a special diet.

Exercise
You should do light exercise, such as walking and light housework, as soon as you feel well enough.

Sex
You can continue your usual sexual activity as soon as you feel comfortable. We advise that you do not try to get pregnant until your periods have returned to normal.

You can fall pregnant again very soon after having this procedure so it is important that you discuss contraception prior to leaving hospital or visit your GP soon after. They can discuss what options are available and how they can be administered.

Work
How long you will need to be away from work varies depending on:

  • How quickly you recover;
  • Whether or not your work is physical; and
  • Whether you need any extra treatment.

Most women prefer to take the following day off work, and sometimes a few days, both for their emotional and physical recovery. Please ask us if you need a medical sick note.

Contact your GP if you have:

  • Increased bleeding or pain;
  • You develop a smelly vaginal discharge

These could be symptoms of an infection. You should see your GP immediately if you develop any of these symptoms, as you may need antibiotic treatment. If your GP is concerned you will be referred back to our team for further management. When you are discharged from the ward you will be given a letter to give to your GP about your treatment.

Contact details

If you have any specific concerns that you feel have not been answered and need explaining, please contact the following:

  • Worcester Royal Hospital
    Early Pregnancy Assessment Unit (phone 01905 733060)
    Gynaecology Nursing Staff, Lavender Ward (phone 01905 760586)
    Hospital Switchboard (phone 01905 763333)
  • Alexandra Hospital
    Early Pregnancy Assessment Unit (phone 01527 512100)
    Gynaecology Nursing Staff, Ward 14 (phone 01527 512100)
    Hospital Switchboard (phone 01527 503030)
  • Kidderminster Treatment Centre
    Early Pregnancy Assessment Unit (01562 823424, Bleep 3461)
    Hospital Switchboard (phone 01562 823424)

Other information

The following internet websites contain information that you may find useful.

Support also offered through:

  • Miscarriage Association 01924 200799
  • Cedar Tree Phone: 01905 616 166
    E-mail: cedartree@connectfree.co.uk
  • National Careline: 0800 028 2228

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: wah-tr.PALS@nhs.net
Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.
If you are unable to understand this leaflet, please communicate with a member of staff.

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