EARLY PREGNANCY LOSS A Patient Guide to Treatment

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1 EARLY PREGNANCY LOSS A Patient Guide to Treatment You have a pregnancy that has stopped growing, or you have started to miscarry and the process has not completed. If so, there are four ways to manage your care. 1. Waiting or EXPECTANT management You can wait for the tissue in your uterus to pass on its own. 2. MEDICAL management You can use a medication called MISOPROSTOL (Cytotec ). This will make your uterus contract which pushes the pregnancy tissue out. 3. Manual Vacuum ASPIRATION (MVA) Manual vacuum aspiration procedure is a method of removing the tissue from the uterus after a miscarriage. This is done in the ambulatory clinic with oral pain medication. 4. DILATATION & CURETTAGE (D&C) You can have a surgical procedure called a Dilatation and Curettage (D & C). This is an outpatient procedure done in the OR. It can be done with local or general anaesthetic. ****All four of these options have been shown to be safe - a Health Care Professional will review these options with you during your appointment in the Early Pregnancy Loss Clinic **** The main differences between the options are in the following: how fast they work whether you are treated at home or in hospital There does not appear to be any differences between the options for the following: how you may cope with your loss your future fertility (as long as there are no complications) Waiting or EXPECTANT management It could take a few weeks for your body to know that the pregnancy is not growing properly. If you choose to wait, expect cramps and bleeding (stronger than a heavy menstrual period, with increased cramping). There may be clots or pale-colored solid tissue passed. This could begin at any time. It could begin early or after many weeks. For the cramping pain you can use any of the over-the-counter pain killers except ASA (Aspirin ). Do not use ASA because it may increase your bleeding. Page 1

2 You can manage pain with acetaminophen (Tylenol ), ibuprofen (Advil or Motrin ), or naproxen (Aleve ). However, do not be alarmed if you need to use a stronger pain medication. This is normal for some women. Your doctor may choose to give you a prescription for stronger pain medication. You will need a follow-up by phone conversation. This is to confirm that you have passed all of the pregnancy tissue from your uterus. If you have not passed all of the pregnancy tissue from your uterus, you can choose to repeat Misoprostol or to change to one of the other treatment options. You can do this at any time if waiting becomes too difficult for you. If you make this decision, we will arrange another appointment time for you. Possible problems (complications) with waiting or expectant management are: Heavy bleeding (soaking a pad every hour or more for 3 hours) and /or severe abdominal pain (abdominal pain which does not go away with the prescribed medication) which requires immediate medical attention - proceed to your closest Emergency Room NOTE: The IWK does not have an adult emergency room Infection: you should report a fever (temperature over 38 C that lasts for 4 or more hours after taking acetaminophen (Tylenol ) and/or a foul smelling vaginal discharge Miscarriage does not occur or incomplete emptying of uterus Any of these complications may require the use of medications or surgical treatment, such as MVA or a D&C. MEDICAL Management of Miscarriage using MISOPROSTOL (Cytotec ) Misoprostol is a medication that is usually taken by mouth in tablet form to treat and prevent stomach ulcers. However, it also causes your uterus to contract by softening the cervix and will help finish a miscarriage that has started on its own. Misoprostol is taken at home. When taken for a miscarriage, misoprostol works for most women (80%). If misoprostol does not work the first time, then it may be tried a second time You will be instructed to place the medication into your vagina. The medication generally starts to work about 2-6 hours after it is in place. You can expect to experience uterine cramping and bleeding while the uterus is emptying itself. The cramps can be quite strong and you will be given a prescription for pain medication to use as necessary. The majority of the cramping and bleeding will occur in the first 24 hours, therefore you should plan to be at home during this time and have someone with you. Many patients will have lighter cramping and bleeding for a number of days past this. This will be more like the bleeding and discomfort experienced with a heavy menstrual period. You will be supplied with a second dose to use 24 hrs after the 1 st dose if needed. 24 hours after each dose, contact the clinic with an update of your progress. If this 2 nd dose is not effective, we would meet with you again, review your treatment options and decide on repeat dose of misoprostol, MVA or D&C. Misoprostol should not be used if: You are allergic to Misoprostol or similar medications You are allergic to other prostaglandins You have an ectopic pregnancy (pregnancy outside of the uterus) You have a pregnancy that is still progressing normally Page 2

3 Common side effects of the medication are: Mild fever (if you have a temperature higher than 38º for more than 4 hours, seek medical attention Diarrhea Nausea (vomiting is rare) Uterine cramping Possible problems (complications) effects of medical management using misoprostol are: Heavy bleeding and /or severe abdominal pain, which requires immediate medical attention (soaking a pad every hour or more for 3 hours or abdominal pain which does not go away with the prescribed medication - proceed to your closest Emergency Room. NOTE: The IWK does not have an adult emergency room Infection you should report a fever (temperature over 38 C that lasts for 4 or more hours after taking acetaminophen (Tylenol ) and/or a foul smelling vaginal discharge Incomplete emptying of the uterus Any of these complications may require the use of medications or surgical treatment, such as MVA or a D&C. However, this is uncommon. Misoprostol Instructions 1. You are supplied with 8 tablets of misoprostol 200-microgram strength and prescription for a pain medication. 2. You should plan to start the process when you have hours in which you can be close to home and have someone stay with you. 3. You may plan to start this process anytime that is convenient for you. Insert 4 misoprostol tablets into your vagina. They can be pushed in with your fingers. You should then lie down for 60 minutes after insertion to allow the tablets to start to be absorbed. After this you may resume your activities until the process begins. 4. You can use the pain medication prescribed by the clinic doctor. If this is not sufficient, it can also be combined with an anti-inflammatory such as ibuprofen (Advil ) mg every 6 hours or naproxen (Aleve ) mg every 6 hours. 5. Call the clinic the following morning after your 1 st dose of Misoprostol to update the nurse with your progress. If you do not have uterine cramping and bleeding 24 hours after inserting the first 4 misoprostol tablets, you will be instructed to insert another 4 tablets of misoprostol vaginally. Even if you have some cramping and bleeding after insertion of the first dose of misoprostol tablets, the second dose is usually recommended to ensure the miscarriage finishes. We ask you to contact the clinic the day after your 2 nd dose of misoprostol at or after you have started to miscarry. 6. You will be given a urine pregnancy test to complete three weeks after your miscarriage. If the pregnancy test is positive, please call the clinic at Page 3

4 Manual Vacuum ASPIRATION (MVA) This procedure is done for pregnancy losses of less than 9 weeks by ultrasound. You will not have a general anaesthetic. Pain medication is given by mouth approximately one hour before and sometimes after the procedure. You will be lightly sedated, but awake. There are less risks and complications than with a D&C. There is a short recovery time (24 to 48 hours). You may need to take medications before the procedure. You will be given information about how and when to take them. On the night before your procedure (from midnight on), you should only drink clear fluids. The entire procedure should take minutes. On the day of the procedure, you will register in the admitting department on the main (2 nd ) floor. The procedure is done with a speculum in your vagina. The cervix and vagina are cleansed with an antiseptic preparation. Your doctor may use a needle to inject local anesthetic (freezing) around the cervix (opening into the uterus). The cervix is then dilated or opened. This is done by putting small rods into the cervix (starting with a very small one and increasing the size of each rod) until the cervix is opened approximately 1cm. Once the dilation is finished, a plastic suction tube is placed within the uterus. This tube is attached to a manual suction device. Suction is used to remove the pregnancy tissue from the uterus. You may have cramping at this time. Your doctor may then use a spoon-shaped instrument called a curette to gently check the cavity of the uterus to remove any remaining tissue. Gentle suctioning often needs to be done more than once to remove all of the pregnancy tissue. When the procedure is finished, your doctor will do a pelvic exam (internal examination) to ensure the uterus has decreased in size. All tissue removed at the time of MVA is sent to the pathology laboratory for examination. After your procedure, you must have someone pick you up at the health centre (the procedure will not be performed if this is not arranged). Someone must take you home and stay with you for 6 hours. During this 6 hour rest time, you should not drive a car, operate machinery, sign any legal documents, drink alcohol, or be responsible for the care of another person. You may have mild cramping for 24 to 48 hours after the procedure. This is normal. You may continue to use pain medication as necessary. You should rest over the next few days after the procedure. You may go back to most of your usual activities when you feel well. Possible problems (complications) with manual vacuum aspiration (MVA) are: allergic reaction to medications a tear of the cervix perforation of the wall of the uterus retained tissue after the procedure (some pregnancy tissue not removed) infection in the uterus: you should report a fever (temperature over 38 C that lasts for 4 or more hours after taking acetaminophen (Tylenol )) and/or a foul smelling vaginal discharge Heavy bleeding (soaking a pad every hour or more for 3 hours) and /or severe abdominal pain (abdominal pain which does not go away with the prescribed medication), which requires immediate medical attention - proceed to your closest Emergency Room NOTE: The IWK does not have an adult emergency room A small number of women may require a D & C in the operating room because some pregnancy tissue may not be removed. Page 4

5 DILATATION & CURETTAGE (D&C) The day of your surgery: You must make arrangements for someone to take you home (the procedure will not be performed if this is not arranged). You need to have someone at home with you for 24 hours. You will not be permitted to walk home, or drive for 24 hours after your surgery. You must have someone accompany you home by car or taxi You must not eat or drink food after midnight the night before your surgery. Please bring your health card, but leave valuables at home. Register at Admitting on the main floor (level 2) of the IWK Health Centre. Admitting is to the right of the Security desk in the Women s site. D&C Procedure For this procedure, you could be put to sleep with general anesthetic; or you could stay awake using medications given intravenously for pain reduction and relaxation called conscious sedation. The procedure is done with a speculum in your vagina. The cervix and vagina are cleansed with an antiseptic preparation. Your doctor will use a needle to inject local anesthetic (freezing) around the cervix (opening into the uterus). The cervix is then dilated or opened by putting small rods into the cervix (starting with a very small one and increasing the size of each rod) until the cervix is opened. Once the dilation is finished, a plastic suction tube is placed within the uterus attached to an aspirator or suction machine. Gentle suction is used to remove the pregnancy tissue from the uterus. Suctioning often needs to be done more than once to remove all of the pregnancy tissue. Your doctor will then use a spoon-shaped instrument called a curette to gently check the cavity of the uterus to remove any remaining tissue. When the procedure is finished, your doctor will do a pelvic exam (internal examination) to ensure the uterus has decreased in size. All tissue removed at the time of D & C is sent to the pathology laboratory for examination. The procedure usually takes minutes. After your procedure you will stay in the recovery room for approximately one hour, to make sure your cramping and bleeding have settled. Possible problems (complications) with Dilatation and Curettage (D&C) are: allergic reaction to medications a tear of the cervix perforation of the wall of the uterus retained tissue after the procedure (some pregnancy tissue not removed) infection in the uterus: you should report a fever (temperature over 38 C that lasts for 4 or more hours after taking acetaminophen (Tylenol )) and/or a foul smelling vaginal discharge heavy bleeding (soaking a pad every hour or more for 3 hours) and /or severe abdominal pain (abdominal pain which does not go away with the prescribed medication), which requires immediate medical attention - proceed to your closest Emergency Room Page 5

6 DISCHARGE INSTRUCTIONS for all treatments If you are Rh negative, you will receive an antibody infusion (WinRho) Get plenty of rest over the next few days Avoid vaginal intercourse until your bleeding has stopped Use sanitary pads for any bleeding you may have over the few days; wait until your next period to use tampons Do not douche It may take time for your menstrual cycle to return to normal. Ovulation can occur within 2 weeks of your miscarriage or may take as long as 6 weeks. It is possible to get pregnant again within a month. Wait until you have had a normal period before attempting to get pregnant. During this time you should use birth control. After the procedure, you may have tenderness or swelling of your breasts, occasionally with drainage from your nipples. This feeling may last several days or a week. You may go back to most of your usual activities - except for: - sports (wait 24 hours) - swimming (wait 2 weeks) Call your family doctor or the clinic ( ) Monday Friday 8:30-3pm if: bleeding lasts for more than 2 weeks the cramping increases and continues for more than 2 days you develop a fever or chills you have foul-smelling vaginal discharge over the counter or prescribed medications are not relieving your pain or cramping **Any questions or concerns after hours call the IWK switchboard at and ask to speak with the on-call gynaecology resident** IWK Women s Ambulatory & Community Clinics, Halifax, N.S. PL-0757 Last Update: 10/14 Next Review: October 2017 Page 6

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