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Medical Management of Miscarriage

We are very sorry for your loss and understand that this can be a very difficult time. This leaflet aims to tell you what to expect during and after your medical management of miscarriage. If you have any further questions, please speak to the doctor or nurse caring for you.

Approximately 20% of all pregnancies miscarry and, in many cases, the miscarriage happens naturally without intervention. In some cases though, the ultrasound scan may show that the baby has stopped developing, or that the pregnancy sac has not grown, but spontaneous miscarriage has not yet occurred.

Sometimes the symptoms of a miscarriage are not immediately obvious. You may have had a scan that showed that the pregnancy stopped developing some time ago. Alternatively, your scan may have shown that a miscarriage has started but some of the pregnancy tissue remains inside the womb.

Missed miscarriage (also called ‘delayed’ or ‘silent’ miscarriage)

This term is used when a pregnancy has stopped developing but natural miscarriage has not yet occurred. This term is also used if the pregnancy sac in the womb is empty with no evidence of a baby. You may still have the symptoms of pregnancy. You may or may not have other symptoms like bleeding or pain. In many cases, because a physical miscarriage has not yet happened and the pregnancy remains in the womb, you may still be experiencing the usual symptoms of pregnancy such as nausea and breast tenderness.

Incomplete miscarriage

This is where some but not all of the pregnancy tissue has miscarried. You may still have pain or bleeding which can be heavy.

Methods of Management

In all situations described above, a full miscarriage is likely to happen naturally in time (‘conservative’ or ‘expectant’ management) and some women choose this option. The process can be sped up or ‘managed’ by medical treatment (medication) or surgery (an operation). Whatever your choice, we will help to support you through what is an understandably very difficult time. You should remember that there are no right or wrong choices and that once you have been given all of the information, you must decide which option feels right for you. You can change your mind about your preferred method of treatment at any point. Our early pregnancy staff will help you to reach a decision that you feel comfortable with. It may help to know that research comparing natural, medical and surgical management found that:

  • The risks of infection or other harm are very small with all three options
  • Your chances of having a healthy pregnancy next time are equally as good- whichever method you choose.
  • Women tend to cope better when they are given clear information, good support and a choice of management methods.

Your nurse or doctor will discuss any alternative treatments that may be available to you following your scan. Leaflets are available explaining these options:

  • Expectant/ Conservative management – letting nature take its course so that the miscarriage happens naturally.
  • Surgical management of miscarriage – a short operation during which gentle suction is used to remove the remains of the pregnancy under general anaesthetic (while you are asleep).

What is medical management of miscarriage?

Medical management of missed miscarriage is carried out using two medications called mifepristone and misoprostol.

If you have an incomplete miscarriage you will NOT need to take mifepristone – just misoprostol.

Mifepristone is a medication which is given as a tablet by mouth approximately 48 hours before misoprostol. The mifepristone works by reducing the effect of the pregnancy hormone progesterone in order to make the misoprostol more effective. It does this by helping to break down the lining of the uterus (womb). Approximately 1/3 of women will bleed or miscarry after the mifepristone and before the misoprostol. If you have heavy bleeding after taking Mifepristone, you should contact EPAU who will assess whether the second part of the treatment (Misoprostol) is still required.

Misoprostol is usually given vaginally and works by preparing your cervix and making your womb contract to help expel the remains of the pregnancy. Miscarriage usually happens within a few hours of taking the medication, but sometimes this can take a few days. This treatment can be carried out at the hospital as a day case, or if the pregnancy was less than ten weeks at the time of your scan appointment, you may choose to have your treatment at home, as long as you have another adult who can be with you during this process.

Why should I have medical management of miscarriage?

Medical management of miscarriage allows you to be more in control of how and when and, in many cases, where the miscarriage will happen, allowing you to feel more prepared for this.

Some studies have shown that there may be less risk of developing a pelvic infection when you choose to have medical rather than surgical management of miscarriage. Another benefit of medical treatment is the possibility of avoiding an operation and anaesthetic. Potential surgical complications such as, perforation or trauma to the womb may also be avoided.

Research has shown that medical management will be effective for approximately 80-90% of women, resulting in a complete miscarriage without the requirement for any further intervention or treatment.

What are the risks?

Complications are rare with medical management of miscarriage, however advanced gestation (length of pregnancy) and increased pregnancy size may result in pain and vaginal bleeding being more severe.

Many women worldwide have used this treatment and it is proven to have a very good safety record. Every treatment or procedure has some potential risk or side effect, and you must therefore provide your consent once these have been fully explained to you. The main risks associated with medical management of miscarriage, though small, are:

  • Heavy bleeding occurs in around 1-2 in 100 women. Although rare, if bleeding is too heavy and you become anaemic, you may require a blood transfusion.
  • The process of miscarriage can be painful. Most women have strong period-like pain and cramps and can find the process very painful, especially as the pregnancy is expelled.
  • The tablets do not work for everybody. They fail to work in around 10-20% of women. The doctor or nurse looking after you will be able to advise you about your likelihood of this treatment being successful.
  • If the treatment does not completely empty the womb, there is a risk that hospital admission or surgery may be required.
  • Bleeding can continue for up to three weeks after the treatment and some women may need several follow-up scans to monitor progress.
  • Infection rate is low occurring in 1-4 in 100 people. Antibiotics are not routinely prescribed as evidence has shown this not to be necessary in most cases. 

What happens during medical management of miscarriage?

You may be given the option to have treatment at home if the pregnancy is less than ten weeks, when measured on the ultrasound scan.

How can I prepare for medical management of miscarriage at home?

  • If you have children at home, we recommend that you organise childcare during the treatment.
  • It is important to have another adult with you whilst you are miscarrying and for at least 24 hours following.
  • Ensure that you have a good supply of large sanitary pads. Do not use tampons as this may increase the risk of infection.
  • Ensure that you have an adequate supply of pain medication. Your practitioner will offer you codeine tablets for pain relief, please take these if you are able to, alongside regular paracetamol if needed. If you are taking these medications at home, check the instructions on the packaging for the correct dose. Paracetamol and ibuprofen are available from your local pharmacy or supermarket without prescription.
  • You can eat and drink normally on the day of your treatment.
  • It is advisable to wear loose, comfortable clothing and, if you are having your treatment in the hospital, to bring a change of clothing with you.

Treatment in hospital

If you are having your treatment in the hospital, you are welcome to bring one supporting adult with you on the day. The ward staff will provide meals and drinks for you but you are also welcome to bring your own snacks / drinks. There is a cafeteria, shops and vending machines in the hospital for anyone who accompanies you to use.

  • Treatment will take place on Ward 26. All rooms are private with their own bathroom facilities to ensure your privacy and comfort.
  • Routine blood tests will be carried out within 48 hours prior to your admission.
  • You will be given four misoprostol tablets, which we recommend are inserted vaginally. You can choose to do this yourself, or if you prefer, the nurse or doctor caring for you will be able to do so for you. It is possible to take the medication orally, but there is an increased risk of vomiting when taken this way, which may reduce the chances of the treatment being effective. Dissolving the medication under your tongue (sub-lingual) or between your lip and gum (buccal) is also proven to be effective. It is recommended that whichever route you choose, the tablets are kept in place for one hour to allow them to be fully dissolved and effective.
  • Usually 2-4 hours after you will start bleeding and have pains similar to period cramps. Once the miscarriage starts, most women liken this to quite strong period-like pain. Some women find this process to be very painful, especially as the pregnancy passes through the cervix (neck of the womb). It is difficult to say when the pain will start and finish, or how much pain you will have, as this varies from woman to woman. For some women it is felt to be quite mild, while for others it can be very painful. Pain relief medication will be prescribed for you, please let the staff know if you are beginning to experience any pain, as the sooner we are able to give you some pain relief medication, the sooner it is likely to take effect.  
  • The amount of bleeding also varies from woman to woman, but we expect this bleeding to be fairly heavy and that you will pass some clots. It is not unusual to soak four to six pads in the first hour. You may be able to see the pregnancy sac once the miscarriage has happened, but it is not likely that you will see a recognisable baby dependant on how early into the pregnancy you were at the time of the miscarriage. You should use sanitary towels not tampons, so that you can observe how much bleeding you are having and also to reduce the risk of infection.
  • You will be asked to use bedpans when you go to the toilet so that the progress of the miscarriage can be monitored by nursing staff who are experienced in assessing this.
  • You can expect to stay on the ward for up to 6-8 hours or until the doctor or nurse is happy that you are well enough to go home. In rare cases, you may need to stay overnight.
  • Sometimes, bleeding or pain may not happen in the first few hours after taking the Misoprostol. If you are feeling well, we may offer you further medication, usually four hours after your first dose. If symptoms still don’t occur, following assessment from the medical team, we may offer you repeat doses of the misoprostol, or, if you feel comfortable to go home, we may discharge you, knowing that the miscarriage may start to happen in the next few hours or even days.
  • If you do not have any bleeding within 48 hours of taking the misoprostol, or experience only minimal bleeding within 72 hours- please contact the hospital using the contact details provided in this leaflet.

Treatment at home

If you have decided to have this treatment at home, you should take the day off from work.

Self-administering misoprostol tablets vaginally:

  • We recommend starting your treatment in the morning so that you are able to access care and contact us through the day if you have any questions or concerns.
  • Ensure that you have passed urine and put on a clean sanitary pad, prior to insertion of the misoprostol.
  • Prior to inserting the tablets, you should ensure your hands have been washed and dried thoroughly.  Push each tablet as far up as you can into the vagina,
  • Once the tablets have been inserted, you should lie down for one hour. This prevents the tablets from falling out and allows time for absorption to occur.

If there is little or no bleeding within 48 hours please contact EPAU or the ward for advice. Some women require a second dose of misoprostol which can be prescribed by the hospital doctor.

Are there any side effects of the misoprostol medication?

We need to inform you that, although misoprostol has proven to be safe and effective in the treatment of miscarriage for a long time, it is not specifically licensed for this use.

  • Some women feel sick and may vomit. This normally settles within 2-6 hours. If you are having your treatment in hospital, you may be prescribed anti sickness mediation.
  • Diarrhoea may occur. This usually resolves within a day.
  • Chills are a common side effect but these should not last for very long. Fever is a less common side effect and does not mean that you have an infection. Symptoms of fever should not last longer than a day.
  • Side effects are fairly common. Most last between 2 and 24 hours. If you are at home, and you are not coping with the side effects, or they last for more than a day, please contact us using the details provided in this leaflet.

What happens to the pregnancy tissue?

If you miscarry in hospital:

All pregnancy tissue will be sent to the pathology department to confirm under the microscope that it is indeed pregnancy tissue. Unless this is your third consecutive miscarriage there will be no further tests performed.

All babies and pregnancy tissue will be treated with care and respect. We have arrangements in place for sensitive disposal (unless you request otherwise) and all pregnancy tissue will be sent for cremation to Saltwell Crematorium in Gateshead. If you would like more information about this, or if you wish to make alternative arrangements, please speak to the nurse or doctor caring for you. Staff can also provide you with information about the monthly service held at the Crematorium, which you are very welcome to attend. 

If you miscarry at home:

If you miscarry at home or outside of the hospital setting you are most likely to pass your pregnancy into the toilet. You may want to retrieve your pregnancy to have a closer look, or you may flush the toilet (many people do this automatically). There is no right or wrong answer. It is important that you do what you feel is best for you.

You are unlikely to pass anything recognisable if you were less than 7 weeks pregnant. It is possible that you may see a small gestation sac or a tiny baby. If you are at home you can use the toilet as you would with a heavy period.

If you prefer, you can bring the pregnancy tissue to Women’s Health Clinic, in a clean dry container. It will be sent to the pathology lab and the same process will be followed as to if you were to miscarry in hospital. It is important to note that the examination within the pathology department will not provide an answer for why your pregnancy miscarried.

What happens afterwards?

You may continue to have some cramps for the next few days.  You can take Paracetamol and codeine (if able) as directed on the package. If the pain is severe or prolonged please seek advice from your GP.

You can expect to have some further bleeding, which should gradually stop over the next three weeks. If the bleeding continues to be heavy, you have severe pain or an unpleasant / offensive smelling vaginal discharge / high temperature – contact your GP as soon as possible. These may be signs of infection. You should use sanitary towels, not tampons, to reduce this risk of infection, even after the miscarriage has happened, until bleeding stops. 

You should contact the Early Pregnancy Assessment Unit if you still have a positive pregnancy test three weeks after your treatment.

If your periods normally occur every month, the first period usually occurs within six weeks, it may be heavier than usual. Your periods will return to their normal pattern but it may take a few cycles for this to happen.

When do I need to worry or contact a health professional?

  • If you have very heavy bleeding and it does not seem as though it is getting better.
  • If you feel light-headed or dizzy.
  • If the pain medication you are taking is not working and you are still in significant pain.
  • If you have signs of infection, such as a raised temperature, flu-like symptoms or vaginal discharge that looks or smells offensive.
  • It is normal to bleed for up to two weeks afterwards with additional spotting for a further week. If you have continuous bleeding for more than two weeks please contact us.
  • If any of the side effects mentioned above have not resolved within the specified time.

If you are concerned that you may be developing any of these symptoms you should contact us (using the numbers in this leaflet) for immediate advice or attend your nearest A&E department.

Do I need to inform anyone about my miscarriage?

When a miscarriage is confirmed, staff in the early pregnancy clinic will complete a form to alert your GP and Community Midwife. This will ensure that any scans or appointments are cancelled, so that you do not need to worry about doing this. Unfortunately, if you have booked care at another hospital we are unable to cancel appointments but a letter will be sent to your GP.

When can I go back to work?

You are likely to feel quite tired after a miscarriage. You may feel physically low for a week or so and need to take it easy during this time. Most women start to feel better within a few days, however, it may take a few weeks until you feel fully recovered from a physical perspective.

Returning to work varies from person to person and on the type of work that you do, as well as how you feel physically and emotionally. You may prefer to be among colleagues and friends. Some women find it helpful to have a routine, others may want to take some time off until they feel ready to see people and feel able to concentrate on work. If you need time off work to recover, your GP can provide you with a sick note. We can also provide this for you in the early pregnancy clinic if required and you should be offered a sick note when miscarriage is diagnosed.

What about my emotions?

Reaction to a pregnancy loss is very variable. In addition to the grief that you may feel, your body will be undergoing many hormonal changes. It is completely normal to feel a variety of emotions during this time, and it may take time for you to get back on your feet again. Feelings of anxiety, distress, sadness and loss are common after miscarriage. For many women these feelings may pass quite quickly and normal routines will resume. For some however, these feeling are more prolonged and difficult to cope with. Your baby has died and it is understandable if you need time to grieve. Friends and family can help but you may want to talk to someone about how you are feeling. The early pregnancy team can provide you with information about counselling support. Alternatively, you can speak to your GP or contact the Miscarriage Association.

When can I start trying for another baby?

It is perfectly safe to start trying for another pregnancy once you and your partner feel ready to, providing that you feel well and have stopped bleeding. It is recommended that you wait until you have a negative pregnancy test before trying to conceive again; however, if you do conceive before your next normal period, there is no evidence to suggest that there is an increased risk of miscarriage. You should continue recommended preconception care such as:

  • Taking folic acid
  • Reducing your alcohol and caffeine intake
  • Stopping smoking

If you wish to wait before trying for a future pregnancy, it is advisable to use contraception prior to your next period. You can discuss this with the EPAU nurse, GP or Family Planning Clinic.

Admission details for treatment in hospital:

Please attend: Ward 26 – Peter Smith Surgery Centre (Yellow Zone)

Time: 09:00am   

Contact Number: 0191 445 3004

Contact Details

Early Pregnancy Assessment Unit (EPAU)

Monday – Friday –
0191 445 2742
Early Pregnancy Assessment Unit

Ward 26

Specialist Gynaecology Ward

Open 24 hours –
0191 445 3004
Ward 26

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