Miscarriage – what happens next?

Miscarriage – what happens next?

Outpatient medical management of first trimester miscarriage
We are sorry that you are having a miscarriage and we do understand that this a very
difficult and distressing time for you and your family. This leaflet intends to explain in
detail the process for outpatient medical management of miscarriage.

This information sheet is designed to fully inform you about the whole procedure and
its risks and benefits in comparison with conservative or surgical management of
miscarriage.

Outpatient management gives you a choice to go through the treatment at home in
familiar surroundings avoiding a hospital admission and surgical intervention. 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 it carefully so you can fully understand what to expect
during this treatment. To ensure we have covered all the aspects of your treatment we
will get you to sign a consent form detailing the pros and cons of this treatment.

What is an early miscarriage?
Early miscarriage is when a woman loses her pregnancy in the first three months.
Once you have had a positive pregnancy test, there is around a one in five (20%) risk
of having a miscarriage in the first three months. Most miscarriages occur as a ‘one-off’ (sporadic) event. Most women who have suffered a miscarriage will go on to have
successful pregnancy outcomes in future.

Procedure of Medical management

Attending EPAU/Gynaecology ward
You will be seen at EPAU (Early Pregnancy Assessment Unit) or Gynaecology
Assessment Unit after the diagnosis of your miscarriage. Nurse and the doctor will
assess your fitness to proceed with the medical management. Some important
questions will be asked regarding your health including details of your previous
pregnancies. Blood test will be carried out to check your blood group and to make sure
you do not have significant anaemia (which may make you unsuitable for medical
management).

The procedure will be discussed in detail and you will be asked to sign a consent form.
Following this, misoprostol tablets will be administered into the vagina by performing
internal examination by the nurse/doctor and you will be observed for another 15-30
min to ensure you do not encounter any side effects. You will then be given an
information pack and pain killer medication pack to take home.

The emergency contact details, in case you need further advice and help, are given at
the end of the leaflet.

Benefits of treatment
The aim of treatment is to remove any remaining tissue and blood clot in the uterus
(womb) after a miscarriage. The tablet stimulates the womb to expel any pregnancy
tissues left behind.

According to research, the success rate for completing a miscarriage after using
misoprostol (synthetic prostaglandin) is roughly 75 to 85% and the majority of women
who choose medical management are satisfied with the choice when interviewed later.
Success rates are higher if you have already started the process of miscarriage in
form of bleeding associated with passage of pregnancy tissues and blood clots.

Risk of infection is similar with surgical and medical management.

Surgical management carries a small <1% risk of injury to uterus requiring further
surgery which is avoided if miscarriage happens naturally or by using medical methods

Serious or frequent risks
Complications are rare with medical management but with advanced gestation (length
of pregnancy) and increased size of pregnancy sac, pain and bleeding may be more
severe.

Most pain is easily controlled with oral pain killers but occasionally it is necessary for
patients to be admitted for stronger pain relief (2-32%). Some patients may experience
side effects of the medication (misoprostol).

Common side effects include fever, shivering, nausea (1.4-30%) or diarrhoea (4-65%).
Most of these side effects are self-limiting.

Rarely, patients may have excessive bleeding requiring a blood transfusion. The
commonest cause for unexpected hospital admission is pain and excessive bleeding.
Sometimes it is required to carry out emergency surgical treatment to avoid further
bleeding and pain.

Misoprostol Treatment-What to Expect
Misoprostol is a medication which helps the womb to contract and expel any
pregnancy tissue that remains inside the womb. As the tablet starts to work the pain
will gradually increase from mild period type pains to stronger cramping feeling in the
lower part of you tummy. The amount of pain and discomfort can vary from patient to
patient and also depends on the size of the pregnancy. 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. To get good pain control you should continue to
take the pain killers prescribed at regular intervals even in the absence of significant
pain; this will avoid buildup of pain which is harder to control. Once the pregnancy
tissue has been expelled, pain and bleeding will settle down. You may experience
bleeding similar to a heavy period.

In the presence of the following symptoms please contact the hospital:

• Excessive bleeding
• Severe pain and the pain-relieving drugs are not helping
• Smelly vaginal discharge
• Shivers or flu-like symptoms with temperature
• Feeling faint and unwell

Follow up

Day 3- Following administration of first dose of vaginal tablets you will be contacted by
one of the Medical Staff members via telephone. If symptoms suggest that you have
passed the pregnancy tissue and bleeding is settling, you would be advised to do a
home urine pregnancy test in 4 weeks’ time.

If by 3rd day you have not responded to the medicine we will ask you to attend the
EPAU to discuss administration of a second dose or to discuss alternative options like
surgery. Surgical treatment will be scheduled on the first available list which may take
few days.

Following 2 doses of misoprostol 84% of patients will not require any further treatment.
Approximately 16% patients will need surgical intervention either as an emergency or
a scheduled procedure. Choices of treatment will be discussed with you at every step.

After the procedure
It is likely that you will have bleeding like a normal period with small clots or possibly a
small amount of pregnancy tissue. The bleeding can take up to 2-3 weeks to settle.

How will I feel emotionally?
Apart from the physical effects of miscarriage some women may find miscarriage to
have a deep psychological and emotional impact in their life. The EAPU nurses will
provide you with support and also give you contact numbers for the support groups.

Personal Hygiene
You can bathe and shower normally. To avoid risk of infection it is advised that you
should use sanitary towels instead of tampons.

Sex
To avoid risk of ascending infection it best to avoid sexual activity till the bleeding
settles down.

Work
How long you will need to be away from work varies from a day off to few days
depending upon

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

Please ask if you need a sick note to sign you off work.

Contact details
If you have any specific concerns that you feel need to be addressed please contact
the following:

Worcester Hospital

• Early Pregnancy Unit (Tel: 01905 733060 )
• Hospital Switchboard ( Tel: 01905 763333)

Alexandra Hospital

• Early Pregnancy Unit (Tel: 01527 512100)
• Hospital Switchboard (Tel: 01527 503030)

Kidderminster treatment Centre

• Early Pregnancy Unit (Tel: 01562 823424, Bleep 3461)
• Hospital Switchboard ( Tel: 01562 823424)

Useful organisations

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

Miscarriage Association
Clayton Hospital Northgate
Wakefield
West Yorkshire
WF1 3JS
Helpline: 01924 200799
Website: www.miscarriageassociation.org.uk

Wellbeing of Women
27 Sussex Place
Regents Park
London
NW1 4SP
Tel: 020 7772 6400
Email: wellbeingofwomen@rcog.org.

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.PET@nhs.net

Opening times:
The PALS telephone lines are open Monday to Thursday from 8.30am to 4.30pm and
Friday: 8.30am to 4.00pm. Please be aware that a voicemail service is in use at busy
times, but messages will be returned as quickly as possible.

If you are unable to understand this leaflet, please communicate with a member of
staff.

Version 4.7