Medical management of miscarriage up to 10 weeks gestation

Outpatient medical management of miscarriage is a procedure which treats miscarriage. This is done by taking medication which helps your body to pass the pregnancy. It can be offered if your pregnancy ended before 10 weeks gestation (10 weeks along in the pregnancy) and allows you to be at home during the procedure.

After your miscarriage diagnosis your treatment options will be discussed. If you decide you would like medical management of miscarriage and would like to have this procedure at home, your healthcare professionals will let you know if this is possible. It may be that this can be started on the same day or at a time that suits you.

It is a two-step process involving taking different medications. There is no surgery involved in this and you are awake.

You will be provided with a pack including the first medication (mifepristone) and the second medication (misoprostol) and instructions for taking this at home.

Mifepristone, the first medication, blocks the action of progesterone.

Misoprostol, the second medication, softens your cervix (neck of the womb) and causes your uterus to contract.

This method of treatment may not be right for some people. Please let medical staff know if you have any medical conditions, if you have had a previous caesarean section or if you take any regular medication.

There are some risks of having outpatient medical management of miscarriage, these include:

• Medical management is successful in 80 to 90 out of 100 procedures. This means the procedure doesn’t work or there may still be some pregnancy remaining after the procedure in 10 to 20 cases out of 100, which may require further intervention.
• Excessive bleeding needing a blood transfusion (2 in 100 people)
• Post procedure infection (1 to 4 in 100 people)

We advise that you always have someone over the age of 18 with you during the procedure so that they can help you to get medical attention if you need it.

Day 1

The first tablet (mifepristone) should be swallowed with some water. This medication can make you feel sick or make you vomit (be sick). If you vomit within half an hour of taking this medication you will need to contact Gynae SDEC as you will need to take another dose. 

You can have light vaginal bleeding and abdominal (tummy) pain after taking the first tablet. Please only use sanitary towels, and avoid using tampons or menstrual cups. If the bleeding is heavy and / or you feel you pass the pregnancy before taking the second stage of tablets (misoprostol) please get in touch with:

• Gynae SDEC on 01709 427072 (available 8am to 4pm, Monday to Friday, closed weekends and bank holidays)
• Ward B11 on 01709 424349 (available outside of clinic hours)

Day 3 (two days after taking your first stage of medication)

Place all four of the misoprostol tablets either:

• high up in your vagina 

  or 

• swallow the tablets orally with water

  or

• place between your teeth and gum and allow to dissolve for 30 minutes. 

If the tablets have not completely dissolved within 30 minutes, you may swallow what is left with water.

Vaginal insertion

Image

Insert the four tablets as high as possible in your vagina. The exact location is not important, only that they do not fall out. 

You can do this while lying down, squatting or standing with one leg up - whatever is most comfortable for you.

Positioning the tablets in your mouth

Image

Some people describe the taste of misoprostol as unpleasant and the texture as chalky. 

Placing the tablets between your cheek and gum can make you more likely to have nausea (feeling sick), vomiting (being sick) and diarrhoea (liquid poo).

Bleeding and cramping normally starts 2 to 4 hours after taking the first 4 tablets of misoprostol. You may see other tissue and, the further on in your pregnancy, the more recognisable it may be to see an identifiable fetus (pregnancy). 

It is likely you will experience strong cramping pains during the procedure. Pain can be helped with:

• pain relief such as ibuprofen, paracetamol, codeine phosphate, or co-codamol may be used (please follow the instructions carefully). Please note co-codamol contains paracetamol - do not take it alongside any other medication containing paracetamol.
• a comfortable environment
• comfortable clothes

If the pain is severe and / or you feel unwell, dizzy or if you have heavy vaginal bleeding you should attend your nearest Urgent and Emergency Care Centre or Accident and Emergency, or call 999.

Once you have passed the pregnancy, we would expect your vaginal bleeding and pain to settle over about 10 to 14 days.

You should wear a sanitary pad to monitor your bleeding during the procedure. Do not use tampons or menstrual cups. The amount of vaginal bleeding can vary from person to person. 

If you have persistent heavy vaginal bleeding (soaking 2 maxi sanitary pads within an hour or passing blood clots larger than a 50p coin) and/or start to feel unwell you must attend your nearest Urgent and Emergency Care Centre or Accident and Emergency, or call 999.

When a pregnancy is lost sometimes we can see a baby and sometimes we see fragments of what may be placental tissue. 

It may be that you pass the pregnancy when you use the toilet. If this does happen we do not expect you to retrieve any pregnancy tissue from the toilet, you may flush the toilet as usual. If you feel unable to flush the toilet or the pregnancy passes and you have the remains, please contact Gynae SDEC or Ward B11 for further support and advice. 

You will be provided with a care pack to allow for the retrieval and storage of pregnancy remains, this will allow for histology testing and sensitive burial or cremation to take place, should you wish. Paperwork will be completed by your healthcare professional.

Please note, there are laws around personal burial of pregnancy remains 

It may be that you decide you want to bury your pregnancy at home. This is allowed however, there are certain rules that need to be followed to ensure the safe burial and further paperwork needs to be completed. The nurse caring for you can assist you further if you wish.

If this date is on a weekend or bank holiday, you will be called on the next working day.

Your healthcare professionals in Gynae SDEC will contact you to check on your wellbeing and to assess if the procedure has worked. If you have had minimal or no vaginal bleeding or feel unsure if the procedure has worked a follow up assessment will be provided on Gynae SDEC. If the procedure has not been successful, further management options will be discussed.

If we feel the procedure has been successful, you will be advised to perform a urine pregnancy test in 3 weeks. If after this time the test remains positive, or you are still having vaginal bleeding, abdominal pain or any signs of infection please contact Gynae SDEC for further assessment. The pregnancy test will be included in your pack. 

If an inpatient procedure has been recommended to you, or you have chosen to have your treatment in hospital then you will be given the first tablet (mifepristone) at a clinic appointment. You will need to return 48 hours later for the second stage of treatment (misoprostol).

When you return, you will be asked about any pain or bleeding that you may have had. If you have had any other symptoms, please tell the nurse. 

Bring any prescribed medicine or inhalers with you for this visit. You should also bring an overnight bag with you in case you need to stay overnight.

You can bring someone to stay with you at this visit. However there are no facilities for children; you will need to make alternative arrangements for childcare. Please let staff know if you have any problems with this. We advise for you to have an adult to escort you home after the procedure.

You will be in a private room where the second medication (misoprostol) will be administered. 

Once the nurse has checked your details, they will start your treatment by inserting four misoprostol tablets into your vagina.

These tablets will make your womb contract and your cervix open. This will help your body to pass the pregnancy tissue. You will be advised to rest in bed for 1 hour after administration of the vaginal misoprostol. After the first hour you will be encouraged to walk around as much as you are able. At this stage, bleeding will begin and it is likely to be heavier than a normal period. You will also start to have period like pains, and we can offer you a range of prescribed pain medication to help with this.

You may have the following side effects:

• nausea (feeling sick)
• vomiting (being sick)
• vaginal bleeding with strong abdominal (tummy) cramping pain
• diarrhoea (liquid poo)
• headache
• dizziness
• hot flushes / sweating

You must use a bedpan every time you go to the toilet so that the nurse can check your bleeding or to see if you have passed the pregnancy. 

If you are uncomfortable going to the toilet alone, please ask the nurse who will accompany you. During your stay, you may eat and drink as normal.

The nursing staff may ask to examine your vagina if:

• there is not much progress
• if the staff are unsure if everything has passed
• if there is a lot of bleeding 

however, an examination is not essential before you go home. 

If the pregnancy has not passed after the misoprostol and you are feeling well and have minimal bleeding, you may go home with an appointment for a rescan in 1 weeks’ time.

How soon after misoprostol can I go home? 

The whole process usually takes 6 to 8 hours however, it may vary. 

You may have to stay overnight if there is excessive bleeding or if you are feeling unwell.

How long will I bleed for?

Bleeding up to 3 weeks after the procedure is normal. Some people bleed for less time, while others may bleed until their next period. If bleeding continues beyond 3 weeks, or it becomes heavy, please contact Gynae SDEC. You should not use tampons or menstrual cups until the bleeding has stopped. This helps prevent the risk of infection.

When to be concerned

• Bleeding not settling after 3 weeks or passing a large palm-size clot
• Intensifying pain
• Fever
• Bad smelling vaginal discharge
• Feeling generally unwell.

Contact Gynae SDEC or see your GP.

You should not have sex until you have stopped bleeding.

People can experience a wide range of emotions following pregnancy loss. 

Counselling is available for you and your partner, please contact Gynae SDEC if you wish to be referred. 

The Chaplaincy department is also available to provide pastoral support if required, they can be contacted on 01709 424098

Contact the Gynae SDEC if you:

• have any concerns
• change your mind about having the procedure
• are sick within half an hour of taking mifepristone (day 1 medication)
• think you have passed the pregnancy without taking the second stage of tablets
• have severe side effects such as diarrhoea or vomiting
• have not had any vaginal bleeding or only had spotting
• your pregnancy test is still positive after 3 weeks
• your period has not resumed 6 weeks after the procedure – do a pregnancy test and contact Gynaecology SDEC 

Attend the Urgent and Emergency Care Centre (UECC) or nearest Accident and Emergency if you:

• have a concern that you feel is urgent
• have heavy vaginal bleeding which soaks a sanitary pad within 30 minutes
• keep passing blood clots larger than a 50p coin
• feel dizzy and unwell – attend UECC immediately
• have any symptoms of an allergic reaction from the medication, such as difficulty breathing – call 999 immediately

Gynae SDEC (including early pregnancy assessment)

01709 427072
8am to 4pm, Monday to Friday (closed weekends and bank holidays)

Ward B11

01709 424349
Please contact on weekends, bank holidays or 4pm to 8am.