Medical management of miscarriage

Medical management of miscarriage (also known as MMM) involves using tablets to help speed up the process of a miscarriage. It involves the insertion of small tablets called misoprostol into the vagina. The misoprostol causes your uterus (womb) to contract and helps you expel the pregnancy tissue. An extra tablet taken by mouth, mifepristone, can be given two days before misoprostol to increase the chances of medical management working.

Consent

You will talk to a doctor who will explain medical management, its risks and benefits, and ask you if you have any questions. They will then invite you to sign a consent form if you choose to proceed.

We will give you a prescription for strong painkillers, anti- sickness medication and misoprostol (see below), which you can pick up from the hospital pharmacy on the ground floor of the main hospital.

Optional stage: Mifepristone tablet

The doctor will explain the option of an extra oral tablet called mifepristone. This may make medical management more successful, but it does mean that you will need to wait 48 hours before putting in the vaginal tablets (misoprostol), which is usually what starts off the heavy bleeding and cramping.

In one study, mifepristone increased your chances of having passed the pregnancy after 7 days from 75% to 83% (the

You must take mifepristone while in the clinic. You swallow this tablet with some water. It can sometimes make you feel a little sick, and if you vomit you may need to take another tablet (please call us for advice if you are already at home).

Sometimes a miscarriage will happen after mifepristone alone (and it may have happened even if you hadn’t taken any treatment). If you think you may have miscarried after mifepristone alone, you should call the department and talk to us, as you may then not need to put in the misoprostol.

Misoprostol vaginal tablets

If you have taken mifepristone, we recommend waiting two days (approximately 48 hours) before starting the next step and putting in the misoprostol. If you have decided not to take mifepristone, you can put in the misoprostol straight away.

We generally suggest putting in the misoprostol in the morning. This means it is likely that the most intense symptoms will be during the day, when it is easier to get advice and support.

Using your finger, you should put the 4 tablets of misoprostol into the vagina as high as you can push them. It doesn’t matter exactly where the tablets are, so long as they don’t fall out. You may prefer to put them in while lying down, squatting or standing with one leg up – whatever is easiest for you. You should then rest for 30-60 minutes to let the tablets start to absorb. Do not be surprised if you see a bit of tablet substance when you go to the toilet. If any tablets fall out into your underwear, you can push them back inside.

The miscarriage

When the miscarriage happens, the pregnancy tissue will come out with blood. It is hard to say exactly when exactly this will happen because it is different for everyone.

Usually bleeding starts within four hours of putting in the tablets but can sometimes take up to 24 hours to start. The bleeding usually starts light and gradually gets heavier. It may get very heavy and involve blood clots. You might see the pregnancy sac as it comes out (often greyish colour). You should use large sanitary pads (not tampons).

Pain control during medical management

You will probably have strong period ‘cramps’ during medical management. We suggest using regular pain medicine as soon as any pain starts, and to carry on using it until the pain has stopped completely.

Paracetamol and ibuprofen, which can be bought in any pharmacy, are recommended if you are able to take these (i.e. you do not have an allergy or intolerance to them). You should follow the instructions on the packet. It is best to take the paracetamol and ibuprofen at different times (rather than taking both at the same time) to make sure you always have some pain relief working. We can give you a prescription for stronger pain tablets, usually dihydrocodeine, which can be taken alongside paracetamol and ibuprofen. It might make you drowsy, dizzy or nauseous, and make you constipated – so we suggest you use it only when the pain is not controlled with the other painkillers. You should not drive or operate machinery after taking dihydrocodeine.

All treatments have risks of complications, and we will talk to you about this before you give your written consent. Overall the risk of serious complications is low.

Unsuccessful treatment

This treatment does not always work. A study has shown that medical management is effective in around 8 out of every 10 cases after two weeks (2). Some women may wait longer for their miscarriage to complete, while others will choose surgery instead.

Sometimes during MMM you may bleed very heavily. If you are fully soaking a large pad more than once an hour for two consecutive hours, or feel dizzy, we advise you come into hospital. If you are losing too much blood during a miscarriage, you might need an urgent surgical procedure to remove any pregnancy tissue that is left and to stop the heavy bleeding.

Very rarely, you may need a blood transfusion (donated blood given through the cannula in your arm).

Infection

Occasionally you can develop infection within the womb. If you have symptoms of infection (persisting fever, ‘chills’, worsening tummy pain, or discharge with an unpleasant smell), you should contact the early pregnancy unit or go to A&E. If there is an infection, you will need antibiotics, and you may need to be admitted to hospital and need evacuation of pregnancy tissue which might be infected.

Intrauterine adhesions

Adhesions is the term for scar tissue that sometimes form within the womb. Mild scarring is commonly seen after miscarriage, and usually has no implications for the future. Severe adhesions are uncommon, but may result in difficulty getting pregnant in the future. We do not fully understand what causes some women to get severe adhesions, and others not to.

We would suspect severe adhesions if you have absent or very light periods after your miscarriage. If you do not have a period within six weeks of your miscarriage, or if your period is very light, we would suggest a scan or camera test (hysteroscopy) to look for adhesions inside the womb and treat them.

Bleeding is usually heaviest on the first day after misoprostol, and then decreases. Some bleeding may continue for up to two weeks.

If your vaginal bleeding becomes very heavy (filling more than one large sanitary pad every hour for two consecutive hours) or your pain is unmanageable at home, or you become unwell with symptoms of infection (such as fever or smelly discharge), you should attend A&E.

It is common to experience profound sadness and grief after a miscarriage. Some women and their partners find that these feelings persist for a long time. Other people experience anxiety, depression, and post-traumatic stress after a miscarriage. If you are struggling emotionally, it is important that you discuss this with your healthcare professional in hospital and your GP.

You may find the following organisations helpful:

The Miscarriage Association: www.miscarriageassociation.org.uk

Saying Goodbye: www.sayinggoodbye.org.uk

SANDS: www.sands.org.uk/support-you

If you have questions or concerns about the care you received, you can contact PALS:

The Patient Advice and Liaison service (PALS) is a service which offers general support, information and assistance to patients, relatives and visitors.