Miscarriage in Early Pregnancy Obstetrics & Gynaecology Women and Children’s Group This leaflet has been designed to give you important information about your condition / procedure, and to answer some common queries that you may have. Introduction What has happened? This booklet has been written to give help Bleeding from the vagina in early pregnancy and guidance to parents who lose a baby in is very common. Most pregnancies will the early stages of pregnancy. continue as normal but sadly other Parents who have suffered such a loss by pregnancies will end in miscarriage. miscarriage find that they need to make a Miscarriage is the term used to describe the number of choices within a short space of sudden ending of a pregnancy, most often time, choices that they may rather not think within the first 12 weeks. about. With the help of the staff and the information in this booklet, we can help you Inevitable miscarriage through your period of grief, making this Some women find that the initial bleeding stressful time easier to cope with. becomes heavier, sometimes with blood At the moment you may be experiencing clots. There may also be severe period-type feelings of anxiety, distress and sadness. pains or cramps. What is happening is that Grief is a very natural reaction to the loss of the uterus is trying to push out, or expel, the your baby, and grief following a miscarriage pregnancy. may be just as strong as that occurring after the loss of someone we have known and Incomplete miscarriage loved. How a particular person copes with This is when the pregnancy is partially grief is unique to that person. There is no set expelled from the womb. This is associated pattern to the way grief is dealt with on an with continuous vaginal bleeding and an individual level. Allow yourselves time to open neck of the womb (cervix). grieve. Some will recover more quickly than others. Remember - grieving is part of the Complete miscarriage healing process. When the uterus totally expels the Following a miscarriage you may have quite pregnancy, the condition is described as a number of questions you wish to ask. You 'complete'. After the initial heavier bleeding, may want to know what exactly has the loss settles down and stops like the end happened, and why. You may want to know of a normal period. There is no further how you are likely to feel after the treatment needed. miscarriage, and whether it may happen again. Missed miscarriage / Early Fetal We hope that the information in this booklet Demise will be of value in answering your questions, about both the physical and emotional Another type of miscarriage is a condition aspects of recovery, and where extra support called a missed miscarriage. This is when is available. the embryo develops but then fails at an early stage. In this situation the mother may have no indication that there was anything wrong with the pregnancy, and would carry on thinking all was well. Eventually she may start to loose blood from the vagina or experience tummy pains. A pelvic or Choices for management of the transvaginal ultrasound scan will confirm that miscarriage the pregnancy is no longer viable. There are 3 ways of managing a miscarriage. Anembryonic Pregnancy Guidance from the National Institute of Care & Health Excellence (NICE) suggest that This type of miscarriage is used to describe miscarriages should be managed in the the condition where the placenta grows following order of priority: around an empty sac of fluid. This sac is called the gestation sac and would normally 1. Conservative management contain the developing embryo but in this 2. Medical case it is absent. Eventually the mother would experience bleeding from the vagina. 3. Surgical Investigations done for the bleeding would However, we know that experiencing a then confirm the diagnosis. miscarriage is a very distressing time and you may already have a preferred option of Diagnosis of miscarriage management. We will always try to support your request for any of these options which If you are experiencing life threatening are explained in more detail below. bleeding it may not be safe to wait for a scan to diagnose a miscarriage. However, miscarriage is usually diagnosed by an Conservative management ultrasound scan. It may be necessary to Conservative management is effective in perform an abdominal scan and an internal 80% of cases. Conservative management vaginal scan to diagnose an early means ‘letting nature takes it course’, as miscarriage. Internal scans are used in early sooner or later your uterus will expel the pregnancy because they are much more pregnancy. When this happens you may find accurate than an abdominal scan. Internal that you start to have abdominal pains or vaginal scans are safe in pregnancy and do cramps, and some vaginal bleeding. Some not cause miscarriages. women describe their miscarriage as like a Diagnosis of miscarriage using 1 ultrasound heavy, painful period. Others describe it as scan cannot be guaranteed to be 100% being like labour with severe pain and heavy accurate, especially in early pregnancy. It is bleeding with clots. Every miscarriage is possible for a second opinion scan to be different and it is impossible to predict what it performed after your miscarriage has been will be like for you. diagnosed to act as a second opinion and If you decide that conservative management confirm the diagnosis. We would is the right choice for you, you will then be recommend for this to be performed 7 – 14 offered an appointment to return to EPAU in days after your first scan. If you would like a 2 weeks’ time where your condition will be second opinion scan please ask the nurse, reassessed. doctor or midwife to arrange this for you. At this time we will discuss with you what needs to be done next. It could be that the pregnancy has been expelled completely, or you may have changed your mind about continuing with conservative management. a bad reaction, or allergy to previous We will be able to support advice and answer prostaglandin treatments any questions you may have. cerebrovascular disease If your bleeding becomes very heavy with clots and you have abdominal pains that are cardiovascular disease not relieved by simple pain killers, then you inflammatory bowel disease should go to your nearest Accident and If so, please tell the doctor. Also let the Emergency Department. doctor know of any other conditions you Medical management suffer from, and any medicines you are taking. You are usually cared for on Ward 19 or Ward 28 at Scunthorpe or Ward B1 at How does the treatment work? Grimsby. The doctors on the ward will If you are 8 weeks & 6 days pregnant or prescribe medication that will help you during under, you will be given four Misoprostol your miscarriage. tablets vaginally. You will also be given What is the treatment? some antibiotics both orally and rectally. If there is no vaginal bleeding after 2 to 3 hours Medical treatment is effective in 85% of you may be given two more tablets, this time cases. A medicine called Misoprostol is orally. You will need to stay in hospital for used to induce the miscarriage to happen on approximately 6 hours. Sometimes the a chosen day. tablets will not take full effect until after Misoprostol is similar to the prostaglandin discharge from hospital. If this is the case, hormone, which works by causing your you will be asked to re-attend in 2 weeks for uterus to contract and your cervix to open; a scan to make sure that the miscarriage is this then helps your body to expel the non- complete. viable pregnancy. Misoprostol will be given Between 9 weeks and 19 weeks +6 days vaginally in pessary form or orally in tablet pregnant you will be given four misoprostol form. tablets vaginally then a further 3 doses of two Please note that Misoprostol is unlicensed tablets at 3 hourly intervals orally. You will for this use by the manufacturer but also be given some antibiotics both orally recommended by the Royal College of and rectally. You may need to stay in Obstetricians & Gynecologists (RCOG 2004). hospital overnight, as the nurses will need to European Community regulations permit make sure that the miscarriage is complete doctors to prescribe unlicensed regimens before you can be discharged. and permit nurses to administer medicines prescribed outside of a product license. What are the effects of the treatment? Will the treatment suit me? After taking the medication you may feel This treatment suits most women. However, unwell - perhaps a little faint or sick - during the treatment may not be suitable if you have the first few hours. any of the following health conditions: If you are not already bleeding from your The operation will be carried out under vagina, you will start to bleed. It is likely that general anaesthetic, which means that you you will have some stomach pains and will be asleep during the procedure. cramps that may be quite strong. In some After the operation you should be well cases the bleeding will be very heavy. In a enough to go home after a few hours. You small number of cases, it is necessary to may find that you have a slight blood loss give a blood transfusion and carry out a from your vagina and you may have slight simple operation (ERPOC Evacuation of period type pains. retained products of conception) to stop the bleeding. If you continue to bleed heavily from your vagina, have a smelly discharge, or If you have a lot of pain you will be given increasing abdominal pain contact your GP pain relief, which may be tablets or an or the ward.