Medical management of miscarriage

Information for patients

We are sorry that you have suffered a miscarriage.   A Specialist Nurse or Doctor will be discussing the management options available to you.

There are 3 ways in which we can manage miscarriage:

 This information sheet describes ‘Medical Management’ of Miscarriage.

What does Medical Management of Miscarriage involve?

You will be given a tablet called Mifepristone to take with water when you sign the consent form for medical management of miscarriage.  Mifepristone works by blocking the action of the hormone which makes the lining of the womb hold onto the fertilised egg.  You may start to experience some abdominal cramping or discomfort and can take some paracetamol for this.  A very small number of women will miscarry after this first part. 

You will be given a prescription for a second tablet called Misoprostol. This is a type of medication called a prostaglandin which works by relaxing the cervix (neck of the womb) and making the uterus contract. This process is similar to what happens in a natural miscarriage.

The dose of misoprostol used for medical management of miscarriage is 4 tablets (800 micrograms). 48 hours after the mifepristone these 4 tablets are inserted into the vagina and usually start to work within 4‐6 hours.

Success Rate

Medical management of miscarriage is likely to work in 52 ‐ 92% of women and it is more successful in women who have already started bleeding before the tablets are given (70 ‐ 96% success).

Risks

• Up to 23 in 100 women will need to have an operation to surgically manage the miscarriage (sometimes called an SMM, surgical management of miscarriage). This may be required if vaginal bleeding becomes extremely heavy or there is tissue left behind in the womb after the treatment.
• 3-4 in 100 women, the medicines will not work. If this happens, we may offer you a second misoprostol or advise you to have a surgical management of miscarriage (SMM).
• Infection  –  symptoms  are  a  discoloured  or  smelly  discharge,  lasting  pain  or  a temperature. You should contact us if you have any signs of infection.
• Other side effects which can occur include diarrhoea, dizziness, headaches, nausea, vomiting and rash. All these symptoms are self-limiting and do not last long.
• Intrauterine adhesions occur in 19 in 100 women regardless of the option chosen to manage your miscarriage. Most adhesions are mild (58 in 100 women). Current evidence suggests long term fertility also does not appear affected by the management option chosen.
• At  any  stage,  if  you  want  to  change  your  mind  and  want  to  have  a  surgical evacuation of the pregnancy (SMM), you would be able to do so.

The Treatment

Medications

Following your consultation you will be given:

• A tablet of Mifepristone 200mg to take with water (use to start the miscarriage)

A prescription for the following medications:

• Misoprostol 800 micrograms (4 x 200microgram tablets): the medication used to induce miscarriage
• Co‐dydramol 10/500 2 tablets (pain relief): this is a pain medication which can be taken 4 times a day. It may cause drowsiness or nausea.

You should also buy Ibuprofen for pain relief which is available at most supermarkets and pharmacies, to be taken as 400 milligrams (2 x 200mg tablets) up to three times daily. It should be taken with food as it can irritate the stomach lining. Some women may not be able to take this type of medication if they have had gastritis, a stomach ulcer or have asthma.

The process

48 hours after taking the initial Mifepristone tablet in hospital you should insert the 4 Misoprostol tablets into the vagina as high up as possible. Once you have placed the tablets in the vagina you should then insert a tampon. This should be removed after 3 hours and sanitary pads used thereafter during the process.

You will usually start to have cramping lower abdominal pain (like bad period pains) and heavy bleeding within 4‐6 hours although it may sometimes take longer for things to start. You should expect to have very heavy bleeding and pass clots and tissue. We advise that you have another adult with you at home during the process to provide support. You should start taking the pain relief tablets (both types) at the time you insert the Misoprostol into the vagina.  Other simple things such as a hot water bottle may help. You can eat and drink as normal, although you may experience some nausea.

The heaviest bleeding will usually last for no more than 12 hours. You may however continue to have some lighter bleeding afterwards for several days and up to two weeks. If you are experiencing extremely heavy bleeding please contact us (details below) for advice. In general you should come to the hospital (Accident and Emergency) if you are soaking more than 4 large sanitary pads an hour or if you feel unwell, dizzy or lightheaded.

If you have not had heavy bleeding within 48 hours of inserting the misoprostol tablets then please contact us and we will see you again and prescribe a second dose of the tablets. If heavy bleeding does not occur after this second dose then we will discuss with you whether you would like to proceed with alternative (surgical) treatment.  You should seek medical attention if you experience any symptoms of infection at any time during the process (such as fever, offensive discharge or shivering).

After Care

You will be required to do a home urine pregnancy test 3 weeks after treatment. This is to check that the pregnancy hormone level has returned to normal, suggesting that all of the pregnancy tissue has been passed and the womb is empty.  Please let us know the result of the test is positive, we will see you again for a review and ultrasound scan. If there is some retained tissue we may discuss surgical management with you depending on the amount and clinical situation. If there is some retained tissue we may discuss surgical management with you depending on the amount and clinical situation.

After a miscarriage, you should expect your next period after 4‐6 weeks. If you want to try for another pregnancy, we usually advice you wait for one normal period before trying, although it will not affect the pregnancy if you conceive before this. If you have not had a period within 6 weeks of the miscarriage you should contact the Early Pregnancy Unit for advice.

Emotional Recovery

You may feel low for a while after the miscarriage, but as your body returns to normal this usually settles. Look after yourself and give yourself time to recover. If you feel it would help to talk to someone about it, you may like to talk to our EPU Specialist Nurse or your GP. The Miscarriage Association is also a useful source of information and support - (www.miscarriageassociation.org.uk)

How to contact us:

If you have any concerns immediately after your treatment (the same evening or overnight), if you are worried about the amount you are bleeding, or if you don’t feel well, you should contact us as follows:

Chelsea and Westminster Hospital

Elizabeth Suite (EPAG):

Tel: 020 3315 5073 (admin queries only 9-12pm & 2-4pm Mon-Fri).

020 3315 5070 (clinical queries only 12-2pm Mon-Fri).

Annie Zunz (Gynaecology Ward): Tel: 020 331 53906 (Out of Hours from 5PM)

West Middlesex Hospital

EPU 0208 321 6070 / 6506 - Mobile  07920020800  8AM – 5PM Monday to Friday.

Out of hours (on the day of the medication) 07879445042