Expectant management of miscarriage

Sadly your pregnancy has resulted in a miscarriage. We are very sorry that this has happened, and hope that the information in this leaflet will be of some help to you and your partner.

This leaflet aims to help you understand more about expectant of a miscarriage, where to seek more support to help you and your partner come to terms with losing your pregnancy, and about planning future pregnancies.

Miscarriage in early pregnancy is very common, with as many as one in four confirmed pregnancies ending this way. It is also something that families and friends often find difficult, awkward or uncomfortable to talk about.

The staff on EPU, (Clinic 24), will talk through the issues with you and hope to help you through this distressing time by:

• Explaining expectant management of a miscarriage to you.
• Describing possible events, in order to help prepare you.
• Being available to give you advice over the telephone. (If the unit is closed please contact Daphne Ward, the inpatient gynaecology ward). Contact telephone numbers are found at the end of this leaflet.
• Providing written information for you, in the form of this leaflet, to help you understand what is happening to you and to give you more information about expectant management of miscarriage.

About miscarriage

You may have what is termed an inevitable miscarriage this means you have had, or are still having pain and bleeding, however, on examination the cervical os is open. Sadly the pregnancy will be lost and no intervention will prevent the miscarriage. An ultrasound scan is not indicated.

Or:

You may have a delayed / missed miscarriage this means the pregnancy has ended, and either the fetus has died or the embryo never developed, but you have not expelled the pregnancy. You may have begun to feel a lessening of any pregnancy symptoms, such as breast tenderness and nausea, but you have not had any further symptoms of the miscarriage, such as bleeding or cramping pelvic pain.

Or:

You may have a blighted ovum or anembryonic pregnancy. This means a pregnancy without an embryo. This is the name given to a fertilised egg that does not divide and develop as it should. The normal pregnancy sac develops but a fetus does not develop within the sac.

Or:

You may have an incomplete miscarriage in which you have passed some, but not all, of the pregnancy tissue.

Although miscarriage happens to many women, it is a very individual experience, characterised by common symptoms: bleeding, (this may be the passing of blood clots, tissue or even a recognisable fetus, or just some brown spotting), discomfort/pain and the loss of the pregnancy.

Depending on the circumstances, including how clinically well you are at the time you were seen in Clinic 24, you will have been offered the following choices to help you with the next part of your inevitable miscarriage:

• Expectant management- allowing the pregnancy tissue and / or blood clots to pass naturally through the vagina, without any intervention.
• Medical management of miscarriage - a two stage procedure with use of medication to begin or speed up the process of miscarriage, causing the pregnancy tissue and / or blood clots to pass. The second part of the treatment involves your being admitted as a day case.
• Home management of miscarriage- as per medical management with the second part of the procedure in your own home.
• Manual vacuum aspiration for management of miscarriage (MVA) - a procedure to remove pregnancy tissue and / or blood clots under local anaesthetic.
• Surgical management of miscarriage (SMM) - a procedure to remove pregnancy tissue and / or blood clots under general anaesthesia.
• You have chosen expectant management.

About expectant management of miscarriage

Expectant management of miscarriage means letting nature take its course, with no intervention to affect the miscarriage (such as drug therapy or surgery).

This certainly means experiencing some heavy bleeding, and probable cramping pains.

Advantages of expectant management of miscarriage

• There is no need to be in hospital
• You may feel more in control of the process because you are not in hospital.

Disadvantages of expectant management of miscarriage

• You cannot predict when the miscarriage will occur, or be complete.
• You may experience pain and certainly heavy bleeding.

What to expect

Bleeding

Be prepared that at some point the bleeding will be heavy. It is difficult to predict how heavy the bleeding will actually be, but most probably it will be heavier than a normal period with you passing blood clots, tissue and even a recognisable fetus. This can be alarming.

It is advisable to use sanitary towels rather than tampons as this lessens the risk of infection.

It may be advisable to have an adult with you when you are actually miscarrying.

Ensure that you keep your fluid intake up for the duration of the miscarriage.

If you are concerned the bleeding is excessive (requiring you to change a sanitary pad every 30 minutes), you feel faint / dizzy / unwell, please call Clinic 24 / Daphne ward on the contact numbers below. You are also able to attend the Emergency Department (ED) at any time.

We understand that bleeding heavily at home can be frightening – please do not hesitate to contact us at any time if you are unsure what to do.

Once you have actually miscarried (passed blood clots or tissue) the bleeding will ease and it will become much lighter. Any accompanying pain will also settle.

It is not unusual to bleed for 10 to 14 days after a miscarriage, but this bleeding will be noticeably lighter and more period-like. Some women can have a blood-stained discharge (like the end of a period) that can start and stop for up to three weeks. This is nothing to be concerned about, however, should the bleeding last longer than three weeks, become heavy once settled, smell offensive or you have ‘flu-like symptoms, then please either contact Clinic 24 (see contact number later in this leaflet) or see your General Practitioner (GP).

It is advisable to avoid intercourse or swimming whilst you are bleeding, again to reduce the risk of infection.

Anti-D

Ordinarily women whose blood group is rhesus negative will be given an injection called Anti-D to prevent rhesus incompatibility harming future pregnancies, however, as you have not had any intervention and the pregnancy is under 12 weeks gestation Anti-D is not required.

Discomfort / pain

Having a miscarriage can be painful, with cramping-type pains and lower backache occurring at any time, but especially when the miscarriage is imminent. You may have period-like pain for a few days, this is normal.

It is advisable to be prepared with suitable pain relief which you are able to tolerate. The following types of pain relief are useful and available over the counter from chemists / supermarkets:

• Paracetamol
• Ibuprofen (brand name Nurofen)
• Codeine-base painkillers

If these types of pain relief are insufficient, please do not hesitate to contact us on the contact numbers below, or attend the ED.

Hygiene

Avoid hot baths whilst you are bleeding heavily, as you may feel faint. Otherwise it is safe for you to have a warm bath or shower. We recommend you do this whilst there is an adult in the house and do not lock the door.

Signs of Infection

Increased bleeding or pain once settled or as previously mentioned, developing an offensive smelling vaginal discharge may be symptoms of an infection.

You should see your GP immediately if you develop any of these symptoms as you may require antibiotic treatment. If your GP is concerned, you will be referred back to the EPU for further management.

If you are unable to see you GP, please contact us on Clinic 24 and we will be happy to advise, and if necessary, see you.

Work

Going back to work during or following a miscarriage is a very individual decision. Everyone is different, but many women find that it can take them anything from a few days to a few weeks or even months to recover physically from a miscarriage. You may find that you are particularly tired or feel generally run down. Or you may feel better or simply relieved once the process has happened, especially if it took a long time or if there was a long period where it was not clear if you were miscarrying or not.

All sorts of things can have an impact on your recovery, including how much bleeding you have had, how you feel generally, and how long the process has taken. There are no absolutes, but if you are worried that it is taking you a long time to recover physically, please see your GP. Having a miscarriage can be a very distressing event in a woman’s life.

You can self-certificate for the first week off work, thereafter your GP should be able to provide you with a fitness for work certificate. We are also able to provide these is you feel this is necessary. If you have not told your employer you were pregnant and you do not wish for them to know your GP will respect your confidentiality and will discuss with you what you wish writing on the certificate.

You should not feel pressurised by family, friends or your employer to return to work before you feel ready. You do not need ours or your GP’s permission to go back to work. The decision is yours.

If you have parental responsibilities in the home, you may need another adult around to assist you.

It is important to get back to full activity soon, as this will help with your recovery. Keeping active can help you cope with your feelings and emotions. Build up slowly at your own pace. Listen to your body. If the exercise you are doing is causing you pain, stop and try something less active for a few days.

What is the miscarriage does not happen?

If there has not been any bleeding and you do not think the miscarriage has happened, you may decide you would prefer to consider managing the miscarriage by medical or surgical intervention, depending on your individual circumstances.

Please telephone the staff in Clinic 24 who will be able to make suitable arrangements for you.

Follow up

It is not necessary for us to see you again in Clinic 24 after your miscarriage.

In most cases it is not necessary to scan you to ensure the miscarriage is complete.

However, the staff in Clinic 24 may arrange to telephone you in approximately three weeks after you were initially seen, to discuss your progress and the enquire how you are. If you wish, this can be a formal arrangement for a scheduled date and time for us to call you. You will be asked to perform a urine pregnancy test, prior to us telephoning you. If the test is negative, this will confirm the miscarriage is complete. However, if the urine test is positive or you are concerned about on-going pain and/or bleeding, you should ring Clinic 24 for further consideration.

Following this discussion we may advise you to come back for further assessment. This might include a urine pregnancy test and/or ultrasound scan.

You may wish to see your GP two to three weeks after the miscarriage to ensure all is well.

Emotionally

It is not unusual to feel low in mood or tearful at any time during or after a miscarriage. Some women even feel quite angry, ‘why has this happened to me?’

It is quite normal for you to feel sad and upset about losing your baby. Losing a baby can be a very painful experience for partners too. Often partners can be forgotten when a woman is having a miscarriage. They are generally trying to be strong and support you, neglecting their own emotions and loss of their hopes and dreams.

Some women find it useful to discuss their feelings with their partner and together you may be able to support each other at this sad time.

If you feel that you, or your partner, need more help coming to terms with losing your baby, you will find some useful contact numbers and web address in the Further Information section.

Next period / future pregnancies

Your next period may happen in four to six weeks after the procedure. Prior to this you will have ovulated and therefore will be able to become pregnant again. You may therefore wish to consider some form of contraception if you have not already made arrangements. Please see your GP for this.

People’s feelings vary after the experience of miscarriage. You may feel that you want to get pregnant again as quickly as possible, or you may feel apprehensive and anxious at the thought of another pregnancy; there is no ‘right’ way to manage this – only you and your partner can decide when you are ready.

If you wish to try for a pregnancy immediately following the miscarriage, it is advisable to wait for at least one normal period before you try to get pregnant again. This helps you to have time to grieve for one baby before embarking on another pregnancy and allows your body time to recover.

If you are planning to become pregnant quickly we recommend you take folic acid and to stop smoking and reducing your alcohol and caffeine intake.

Remember that miscarriage is a very common occurrence and in most cases the cause of the miscarriage is unknown.

If you require assisted conception, you should liaise with your provider for further specialist advice.

Risk of future miscarriage: If you have had one or two early miscarriages you do not have a higher risk of miscarriage. Most miscarriages are one off events and you have a good chance of a successful pregnancy the next time. If you have had previous consecutive miscarriages and you meet certain criteria, you may be referred to the recurrent miscarriage clinic. This may involve additional tests for yourself and partner. The staff on Clinic 24 will discuss this with you.

Do I need to inform anyone about my miscarriage?

No. The staff in Clinic 24 will have written to your GP and community midwife and any antenatal scans or appointments will have been cancelled, so you do not need to worry about doing this.

What happens to any tissue or the fetus?

Should you wish you are able to bring in any tissue / fetus to have the miscarriage confirmed by the histology department.

No other investigations are usually carried out into the cause of the miscarriage at this time unless specifically discussed with you.

Further arrangements

There are standard procedures in place for the interment of pregnancy remains at the Arbory Trust Woodland Burial Site, Barton (Barton Glebe). Further information concerning this is available in the leaflet: Rosie Hospital arrangements for the burial of pregnancy remains please ask a member of staff to discuss this with you or to give you a copy of the leaflet.

Individual parents are able to make their own sensitive disposal/funeral arrangements, upon request, but in the majority of cases, the hospital will make these arrangements.

For further Information, please contact one of the Rosie Bereavement Team.

Contacts / further information

• Clinic 24 (The Early Pregnancy Unit)

Telephone: 01223 217636

08:00 to 20:00 Monday to Friday

08:30 to 14:00 at weekends

Closed: Bank holidays

• Daphne ward (The Inpatient Gynaecology Ward)

Telephone: 01223 257206

Any other time

You can also attend the Emergency Department (ED) at any time if you are concerned about the amount of bleeding you have and the EPU is closed.

Further Information

• The Miscarriage Association

Telephone: 01924 200799 (Monday - Friday, 09:00 – 16:00)

The Miscarriage Association (opens in a new tab)

• Association of Early Pregnancy Units

Early Pregnancy (opens in a new tab)

• The Royal College of Obstetricians and Gynaecologists

The Royal College of Obstetricians and Gynaecologists (opens in a new tab)

• Early miscarriage: information for you (pdf) (opens in a new tab)
• Stillbirth and Neonatal Death Society (SANDS) (opens in a new tab)
  Telephone: 0808 164 3332

We hope this information leaflet has been of help to you. If you have any further concerns, please contact the staff in Clinic 24.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and / or specialist one to one care is required.