After your miscarriage

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1 After your miscarriage Information for you Follow us on Find us on Facebook at Visit our website: All our publications are available in other formats

2 ...Information for you...information for you...information for you 2

3 ...Information for you...information for you...information for you We are sorry that you have had a miscarriage. Most people feel upset and anxious when they are told that their pregnancy has not progressed. You may have had some warning signs that things were not going well, such as pain or bleeding. However, sometimes there are no warning signs. Either way you may well be feeling shocked at the news. Everybody reacts differently to the loss of their pregnancy. You may be surprised at your feelings and need time to grieve. Some women feel sad, depressed, guilty or angry. Others can accept the loss and recover quickly from their miscarriage. There is no right or wrong way to feel. Why has this happened? Miscarriage is common. One in every four or five pregnancies ends in miscarriage. The majority of early miscarriages occur because there has been a problem from the time of conception, which means that the baby does not develop properly. This is a matter of chance, and there is no increased risk of miscarriage in the next pregnancy. It is very unlikely that you did anything to cause the miscarriage, or that there was anything you could have done to prevent it. It is important that neither you nor your partner blame yourselves. As miscarriage is most often due to chance events, we will only carry out investigations if you have had two or more miscarriages in a row. 3

4 ...Information for you...information for you...information for you What happens now? Complete miscarriage A complete miscarriage is when there is little or no pregnancy tissue left in the womb. If you have had a complete miscarriage, there is no need for any intervention. Your bleeding should not be heavy, but may continue for up to two weeks. You should contact the Early Pregnancy Assessment Suite (EPAS) if this does not settle or if you begin to bleed heavily. Incomplete miscarriage If the pregnancy ends and is not miscarried, or if there is some pregnancy tissue left in the womb, there are three options for you to choose from: 1. Natural miscarriage / expectant management If you do not want to have any intervention, you may be able to go home and allow the miscarriage to proceed naturally. We do not advise this kind of management if you were more than nine weeks pregnant at the time of the miscarriage. It is not possible to describe exactly what this experience will be like for you as each miscarriage is different. However, most miscarriages follow a similar pattern. When a pregnancy ends, the level of pregnancy hormone in your body gradually starts to fall and you will begin to bleed vaginally. The bleeding gradually increases and is accompanied by cramping pain. The pain is likely to be worse than your normal period pain. Painkillers, such as paracetamol or ibuprofen, may help at this time. At the time the pregnancy tissue is about to pass you may have heavier bleeding and pass blood clots. Once the tissue 4

5 ...Information for you...information for you...information for you has passed, the bleeding should gradually become lighter and the pain should settle. Most women will miscarry within two to three weeks. You are advised to use sanitary pads rather than tampons when you are bleeding. If you think the bleeding and pain are excessive or if you begin to feel faint or dizzy, call a member of the EPAS team for advice. You may need to attend hospital for assessment. We will give you a pregnancy test for you to do three weeks after the miscarriage. If the test is negative and you feel well, no further follow up will be required. If the test is positive, we will arrange an appointment for you to attend EPAS for an ultrasound scan. 2. Medical management of miscarriage This is where medication is used to encourage or speed up the natural miscarriage process. This method is not suitable for everyone. We may not offer this method if you have certain underlying medical conditions or do not have easy access to hospital. The treatment method varies depending on how far the pregnancy has progressed when the miscarriage occurs. Medical management of miscarriage in pregnancies up to nine weeks You will be given an appointment time to attend EPAS. This visit may last from two to six hours. This depends on whether you are suitable for, and want a rapid discharge home. You should wear comfortable clothing; have an adult with you for support; and you should not travel 5

6 ...Information for you...information for you...information for you home by public transport after the treatment. The treatment involves four small tablets (misoprostol) being placed high in the vagina. This medication is to make your womb contract, causing cramp or period type pain and vaginal bleeding, and encourages the pregnancy tissue to pass. It may take a few hours for this process to start. Therefore the miscarriage usually takes place once you are home. We will also give you a supply of painkillers to take home. Before you go home, your midwife will talk to you and give you written instructions on what to expect, with details of when you should contact EPAS. You should contact the unit if your bleeding is excessive, if you are unable to control the pain or if you feel unwell. With your permission, the midwife will call you at home a few days after the procedure to make sure you are well and give you the opportunity to ask any further questions you may have. We will give you a pregnancy test for you to do three weeks after the procedure. If the test is negative and you feel well, no further follow up will be required. If the test is positive, we will arrange an appointment for you to attend EPAS for an ultrasound scan. Occasionally (around one in ten women) the treatment is not successful. You may have bleeding but not pass the pregnancy tissue. In this situation, we will offer you the treatment again, or you may prefer surgical management. 6

7 ...Information for you...information for you...information for you Medical management of miscarriage in pregnancies over nine weeks This treatment option uses two types of medication, given 48 hours apart. For the first part of the management, we will give you a tablet (mifepristone) to swallow. This drug stops the effect of the hormone progesterone and prepares women for the second part of the treatment. Once you have taken this tablet, you can go home with an appointment to return to the unit 48 hours later. Occasionally this drug causes vaginal bleeding, and there is a small chance you may miscarry before the second appointment. You should contact EPAS if you develop heavy bleeding. When you attend EPAS 48 hours later, you will stay in hospital until the miscarriage takes place. You should wear comfortable clothing; have an adult with you for support; and you should not travel home by public transport following the procedure. The treatment involves four small tablets (misoprostol) being placed high in the vagina. This medication is to make your womb contract, causing cramp or period type pain and vaginal bleeding, and encourages the pregnancy tissue to pass. A smaller dose of this medication is administered orally every three hours, until the miscarriage takes place. In rare cases, this may involve an overnight stay. You will be allowed home approximately one to two hours following the miscarriage, as long as you are comfortable and well. 7

8 ...Information for you...information for you...information for you. 3. Surgical Management of Miscarriage This short procedure aims to remove any pregnancy tissue that is still in your womb after a miscarriage has been diagnosed. It is carried out in an operating theatre under general anaesthetic. While you are asleep the opening of your cervix is gently stretched and the pregnancy tissue is removed by use of suction. You will usually be allowed home later that day. If you choose this method of management, we will arrange an appointment for you to attend EPAS. This will be at 8.15am Monday to Friday. You should have nothing to eat from midnight. However, you can drink water, black tea or coffee, or diluting juice up until you are admitted. Please bring any regular medication with you. Before the procedure, the midwife will insert a small pessary into the vagina to soften the cervix and make it easier to open. Occasionally this can cause bleeding and pain, in which case we will give you painkillers. Every surgical procedure has risks and possibly complications. There is a very small risk of damage to the womb with the surgical instrument used in the procedure. Occasionally not all of the pregnancy tissue is removed at the time of the operation. This may cause either heavy bleeding or infection. 8

9 ..Information for you...information for you...information for you Following the procedure: You will need a responsible adult to accompany you home and stay with you overnight. You will be unable to drive or use electrical equipment for 24 hours. You should not drink alcohol for 24 hours. It is normal to have light period type bleeding and cramp. To reduce the risk of infection you should use pads and not tampons. You should avoid sexual intercourse while the bleeding continues. If the bleeding becomes heavy, you develop an offensive smelling discharge, or you feel feverish or unwell, you should contact your family doctor (GP). Which option is best for me? Sometimes the choice will be clear, for example, if you are bleeding heavily and are unwell then surgical management is best. Occasionally, we may recommend one option over another based on your individual circumstance. More often it is your own personal choice. 9

10 ...Information for you...information for you...information for you. Disposal of pregnancy tissue We can assure you that all pregnancy tissue is dealt with sensitively. There is a separate leaflet which explains this in more detail. Ask your midwife for a copy. Advice following miscarriage Your period should return four to six weeks following the miscarriage. For some people however it can take longer, particularly if you have an irregular cycle. Please ask your family doctor (GP) for advice if you have any concerns. We recommend that you have at least one normal period before trying for your another baby. Physically your recovery should be quick. Emotionally it may take longer - only you can decide when the time is right for you to try again. You should be aware that it is possible to become pregnant before your next period arrives. Please consider using contraception until you feel ready to cope with another pregnancy. 10

11 ..Information for you...information for you...information for you Further information Early Pregnancy Assessment Suite (EPAS) Open Monday to Friday 8am to 6pm, and on Saturday from 8am to 4pm Outwith these times, calls will be diverted to Maternity Outpatients, or you can call Support Miscarriage Association Association of Early Pregnancy Units 11

12 All of our publications are available in different languages, larger print, braille (English only), audio tape or another format of your choice. Tha gach sgrìobhainn againn rim faotainn ann an diofar chànanan, clò nas motha, Braille (Beurla a-mhàin), teip claistinn no riochd eile a tha sibh airson a thaghadh Tell us what you think... If you would like to comment on any issues raised by this document, please complete this form and return it to: Communications Department, 28 Lister Street, University Hospital Crosshouse, Crosshouse KA2 0BB. You can also us at: comms@aaaht. scot.nhs.uk or comms@aapct.scot.nhs.uk. If you provide your contact details, we will acknowledge your comments and pass them to the appropriate departments for a response. Name Address Comment Last reviewed: November 2013 Leaflet reference: AMU GD 12