What happens in a medical management of miscarriage?

Should I have a medical management?

When a miscarriage is not complete, for example if the embryo is still in situ in the uterus after failing to develop, many women opt for a medical management in order to speed up the process. This is usually arranged fairly quickly by NHS hospitals, however you may have to wait a few days due to practical limitations within the service. The procedure usually takes place over two appointments, the second of which may take several hours.

At the first appointment, which may be on a hospital ward or may be within an EPAU clinic, you will be given an oral tablet called Mifepristone. This is a drug which blocks your progesterone, an essential hormone needed in maintaining a pregnancy. You may also be given some blood tests just to check your blood group and a full blood count to see if all of your levels are in normal ranges. If you are to be admitted to hospital for the second part of your procedure you may also be given an MRSA swab to test for infection (this is standard for anyone being admitted to hospital). If you are sick within a couple of hours of taking the oral tablet you will need to inform your clinicians.

Sometimes this oral tablet can encourage bleeding to start, and some women even pass the pregnancy at home before their second appointment, however for the majority of women they experience little change in symptoms before their procedure. Your clinic will give you contact details and advise regarding how to seek help if you do begin heavy bleeding, and you may even be given an open access telephone number to the gynaecology ward so that you can speak to a clinician 24 hours a day.

After 48 hours, women return to hospital and are admitted. This appointment may take several hours and you will be given a hospital bed with easy access to a bathroom. Many hospitals try to ensure women who attend for miscarriage procedures are given a private room with en suite to ensure privacy, however this is dependent on each individual service and the demands it is under. Be reassured that the ward you are on will be away from maternity departments and you should not be placed on a ward near pregnant women or new babies. Hospitals also often allow partners to stay with you during this time, and will try to make your admission as manageable as possible for you both physically and mentally.

Once you have been admitted you will be given some medication called misoprostol. This is usually administered in the form of vaginal pessaries but sometimes it may be given orally. Misoprostol encourages your body to pass the pregnancy by softening the cervix and stimulating the uterus to contract. Usually this medication is highly effective quite quickly; you will begin to bleed and will feel some contractions of varying degrees. The hospital will offer you pain relief if you need it and most women pass the pregnancy within a few hours. The amount of pain and bleeding experienced may be more significant if you are further along in your pregnancy.

The nurses will usually put a bed pan over the toilet in your bathroom because they will need to look at the tissue which you are passing. When you pass the pregnancy, depending how far along you are, you may be aware of a significant lump or sac being expelled. You do not have to look at it if you don’t want to, however the nurses will be guided by your wishes and show you the pregnancy if you would like to see it or hold it. Sometimes in very early miscarriage it may be hard to distinguish an obvious sac, either because the embryo stopped developing at an extremely early stage, or because it has already started to disintegrate or even parts of it may already have been passed prior to the procedure. The nurses do have to look at the tissue you are passing so they can assess whether the miscarriage is complete and the procedure has been effective. Once the pregnancy has passed, bleeding and pain usually start to settle.

What happens if misoprostol doesn’t work?

Occasionally the misoprostol is not effective, in which case the nurses may administer further doses after a few hours. If this is still not effective, clinicians may recommend surgical management. However in the majority of cases, medical management is highly effective and most women make a quick recovery.

How long do you bleed for after a medical management?

After you have been discharged from hospital you will continue to bleed for a few days, or even a couple of weeks. You may continue to pass clots or small pieces of tissue, and you may have some mild cramping pains. The bleeding may also tail off but then start again; this is usually not a cause for concern unless you start to feel very unwell. If you start to develop a temperature or a smelly discharge then that could be a sign of an infection so speak to your GP or EPAU.

Can I have a medical management at home?

Some healthcare providers offer an option of a medical management at home. You would still need to attend the hospital for your first appointment for the oral mifepristone, but you will be given a bag of take home medication to self administer. As well as the vaginal misoprostol, you may be given painkillers such as diclofenac and antibiotics such as doxycycline (oral) and metronidazole (rectal). If you are given diclofenac then you will be advised not to take ibuprofen at home, although usually you may take the recommended dose of paracetamol.

Not all hospitals offer an option to have a home medical management, and those that do have strict guidelines related to who is eligible. For example you would need to ensure you had an adult with you, you live within a set distance of the hospital, and your pregnancy was measuring under 9 weeks at the time of your miscarriage diagnosis. Clinicians will also put a plan in place for how you would seek help if you become too uncomfortable at home and bleeding or pain is severe. You also will probably be offered a follow up appointment which may be a telephone consultation to see how it went.

How quickly should I recover from a medical management?

Following your medical management you will be advised to take a urine pregnancy test, usually two or three weeks later. It is expected that this will be negative as your hormones will have reverted to pre pregnant levels, however if after 3 weeks you are still testing positive, please speak to your EPAU department as occasionally this can be a sign of retained tissue. If that is the case you may be scanned again to assess your uterus, and further treatment may be advised. Occasionally women take longer to test negative despite having no retained tissue, and as long as you remain well this is not usually a cause for concern. Every woman’s body is different and some women’s hormones just take longer to adjust.