Out-Patient Medical Management of Miscarriage

Delayed or Missed Miscarriage
This is when your baby has passed away but your body has not recognised that this has happened, which explains why you may only have had a little pain or bleeding or possibly not had any symptoms at all.

Early embryonic demise or an Empty Pregnancy Sac
This is also known as a blighted ovum or an anembryonic pregnancy. This is when the embryo has stopped developing at a very early stage of the pregnancy. Consequently, only a gestation sac can be seen, but will not yet have been passed. This is why you may have only experienced a little pain or bleeding or possibly no symptoms at all.

Incomplete miscarriage
This is when most of the pregnancy has been lost, usually with the symptoms of heavier blood loss and abdominal pain. At your scan you will have been told that you still have some pregnancy tissues remaining in your womb. The medical term for this is retained products of conception or RPOC. Or you may have been told that the lining of your womb is still thickened – this is when it is measuring over 25mm.

You have chosen to have medical management of your miscarriage. This involves taking medication to encourage a woman’s body to complete the miscarriage. This medication is in two stages. The first tablet is called Mifepristone and is one tablet taken orally. This tablet helps to reduce some of the effects of some of the pregnancy hormones and makes the womb more receptive to the second lot of medication that you will take. The second part of the process involves taking 4 tablets called Misoprostol which can be either inserted vaginally or taken orally. This medication is not specifically licensed for the management of miscarriage, but it is safe and has been used for many years in this country and abroad and is being offered as treatment at Blackpool Teaching Hospital.
When taking the medication orally, there is an increased risk of vomiting. (You will also be dispensed medication to help with any nausea or vomiting that may occur). You will also be provided with medication to help with any pain that you may experience.
Research has shown that when using medical management, approximately 90 to 100% of women with an incomplete miscarriage and approximately 80% of women with an early fetal and anembryonic demise will have a complete miscarriage without requiring further intervention or treatment.

You will be asked to attend the unit on a specific day (chosen by you). A nurse/midwife will discuss with you any symptoms that you may have experienced since we last saw you. You will have blood tests to check your haemoglobin level and blood type. A doctor will come and see you to discuss the process further and answer any further questions before obtaining written consent from you before continuing with the medical management to treat your miscarriage.
You will be given the Mifepristone when you attend Early pregnancy for your appointment. You will then be provided with a take home prescription for the Misoprostol, Anti Sickness and Pain relief.
The Misoprostol may be taken orally or inserted vaginally and should be taken approximately 48 hours after you have had the Mifepristone.
The Misoprostol causes the womb (uterus) to contract and will help to induce the miscarriage which means you will start to bleed and experience period-like pain initially.
We recommend that you take pain relief regularly during your treatment if you have pain. You can buy Paracetamol over the counter, and we can provide a prescription for Codeine if needed. You will need to buy some sanitary pads, not tampons, to use at home.
You should arrange for someone to stay with you at home during the treatment and overnight.

The miscarriage will usually take place within 24 hours of taking the tablets. In some cases, the miscarriage may happen earlier or later. During the treatment some women have very heavy bleeding and quite a lot of pain, whilst others have very little bleeding and mild pain.

It is impossible to tell you exactly when you will start bleeding, how much you will bleed, or how much pain you will have, as this varies from person to person. Most women will start to bleed within the first 24 hours.
Some women may start bleeding straight away, while others may not bleed for two to three days or even longer.
If you have not had any bleeding after 48 hours, please contact the Early Pregnancy Unit at as you may need a further dose of Misoprostol. If you have any questions or concerns, please contact the Early Pregnancy Unit.
At some stage, we do expect you to experience an episode of bleeding. This may seem heavier than a period and there may be clots of blood and/or tissue passed. There may be one episode that goes on for a few hours or repeated episodes which go on for a few days. This is normal.
You may also experience cramping type abdominal pain, similar to a period pain, sometimes ladies have described contraction type pains similar to labour. We recommend Paracetamol and stronger pain-relieving medications as you require them. It is important to always check the dosage on the boxes.
Once the miscarriage is complete (passed clots of blood and tissue) the bleeding will ease and it will become much lighter, but you could bleed on and off for up to 3-4 weeks following the treatment. Any cramping pain should also cease.

It is advisable to avoid intercourse whilst you are bleeding, to reduce the risk of infection.
Whilst at home you may also experience the following:
• Nausea or vomiting.
• Feeling dizzy.
• Temporary hot flushes or sweats.
• High temperature.
• Diarrhoea.

If you have not had any bleeding or only had light spotting after 7 days, we advise you call the department as the treatment may have been unsuccessful. It may be necessary to ask you to return to discuss further treatment.
We understand that bleeding heavily at home can be frightening. Please do not hesitate to contact us during opening hours if you are unsure of what to do.

If the amount of bleeding makes you feel unwell, dizzy, faint, frightened or if you are having to change a heavy blood-stained sanitary pad more than every hour for more than a few hours then please contact Early Pregnancy. We will give you advice on whether the bleeding you are experiencing is normal and if you need to attend the emergency department for assessment.

If you are unable to cope with the pain by taking painkillers such as Ibuprofen, Paracetamol or Codeine then please contact Early Pregnancy, it may be that you need to attend the Emergency Department for assessment.
Hygiene
Avoid hot baths while you are bleeding heavily, as you may feel faint. Otherwise, it is safe for you to take a warm bath or shower. Also avoid swimming while you are bleeding.
Work
Going back to work during and following a miscarriage is a very individual decision. Many women feel at least a few days off work may be necessary. Most workplaces allow you to self-certify for up to 7 days, but please let staff know if this is a problem and you require a sick note.
If you have any concerns regarding bleeding or pain or feel you cannot manage them at home, you must contact Early Pregnancy Unit, or attend the Accident and Emergency Department for assessment.

You will be contacted by the Early Pregnancy Unit staff a week after your treatment to check on your wellbeing and to discuss any symptoms you may still be experiencing. A pregnancy test is advised 3 weeks after your treatment.
Most women will have completed their miscarriage within 3 weeks. You will be advised to take a pregnancy test 3 weeks after your treatment. A nurse will plan with you a suitable day to call you to discuss your pregnancy test result, any symptoms you may still be experiencing and to answer any questions you may have It is important that you take the pregnancy test as planned to confirm that the treatment has worked. Sometimes it may be necessary to have a scan if you are continually bleeding heavy or your pregnancy test result is positive.
You are welcome to contact Early Pregnancy Unit for advice at any time during your care and once discharged.

Aftercare Bleeding
You may have some bleeding, on and off for up to 3-4 weeks. Please use sanitary towels and not tampons during this time to avoid the risk of infection. Your next period may occur 3-8 weeks following your miscarriage; it may be heavier or lighter than you are normally used to and may last a bit longer.
It is important to contact the Early Pregnancy Unit or your GP if you have continuous bleeding, heavy bleeding, are passing clots, have pains or a smelly discharge or fever. These may be possible signs of infection and you may require antibiotic treatment.
Sexual Intercourse
To help prevent infection, wait until your bleeding has stopped before you resume intercourse; you should also feel ready in yourself and use adequate contraception (unless you wish to try to conceive again straight away).

Everyone feels differently because we are all unique. Over the next few weeks, you may experience days when you feel completely ‘back to normal’, but you may also have days when you may feel a sadness or a sense of loss.
All these feelings are normal, but you might find it helpful to talk to someone you know and whom you feel close to. If you wish to talk to someone about your feelings and are unable to do so with a partner, close friend or family member, you might like to consider a referral to our Bereavement Support team that can be arranged via the Early Pregnancy Unit.
If you have any questions that are not covered I this leaflet, please do not hesitate to ask the staff on the Early Pregnancy Unit of your GP.
Please attend for treatment:.................................................................
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Your follow up: Pregnancy test to be performed on:............................
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