Management of

miscarriage:
your options
 Need to talk to someone who understands?
Call our support line on 01924 200799. Monday to Friday, 9am-4pm
Or email info@miscarriageassociation.org.uk

2
If you’re reading this leaflet, you are probably dealing with
a miscarriage right now – or supporting someone else
through the process. You may be facing difficult choices at a
difficult and distressing time; or you may be trying to find
out more about what has happened already.
Whatever your situation, we hope you will find this leaflet helpful.
We have separate leaflets on the management of ectopic and molar pregnancy
(see page 15).

What this leaflet is about Blighted ovum

In some miscarriages the uterus (also called ‘early embryo
(womb) empties itself completely. loss’ or ‘missed’ or ‘delayed’
But in others an ultrasound scan miscarriage)
shows that the baby has died or not This is where an ultrasound scan
developed but has not been shows a pregnancy sac with nothing
miscarried. This leaflet describes the inside. This is usually because the
different ways these kinds of fertilised egg hasn’t developed
miscarriages can be managed. It also normally so the pregnancy sac grows
explains some of the medical language but the baby doesn’t. Sometimes the
you might hear or read. baby stops developing at such an early
stage that it is absorbed back into the
surrounding tissue. As with a missed
miscarriage, you may still feel pregnant.
Understanding the
medical language
Doctors have different ways of
describing miscarriages where the
Incomplete miscarriage
This is where some but not all of the
uterus does not empty itself pregnancy tissue is miscarried. You may
completely. The main terms used are: still have pain and heavy bleeding.

Missed miscarriage
(also called ‘delayed’ or
‘silent’ miscarriage)
This is where the baby has died or
failed to develop but is still in your
uterus. You might have had no idea
that anything was wrong until a
routine scan. You may still feel
pregnant and have a positive pregnancy
test.

3
 It may help to know that research
1
Methods of
comparing natural, medical and surgical
management found that:
management
In all the situations described above, a
full miscarriage will happen naturally in • the risks of infection or other harm
time and some women choose this are very small with all three
option. But the process can be speeded methods;
up, or ‘managed’ by medical treatment
• your chances of having a healthy
(drugs) or surgery (an operation).
pregnancy next time are equally
If you choose to have one of these
good whichever method you
treatments, you may be asked to wait
choose;
for a week or more for a second scan
to make sure the pregnancy has ended • women cope better when given
before treatment begins. clear information, good support and
a choice of management methods.
Ideally you should be able to choose
what treatment to have and be given We hope the information that follows
information to guide your decision. will help you to understand the
You may find it easy or difficult to different options better and make it
make a decision depending on your easier to decide.
situation. Unless you need emergency
treatment, you should be given time to
choose the right way forward for you.

“ I was told I had a missed miscarriage and was then

sent home to think about the various options.
“
I went to see my GP who was very helpful and
explained that the choice was mine and all options
were right.

4
Natural management
(also called ‘expectant’ or
‘conservative’ management):
letting nature take its
course
“ I decided to wait for
things to happen
naturally as I wanted
to keep control of
Some women prefer to wait and let “
what was happening
the miscarriage happen naturally. to me, as much as
Doctors often recommend this, you can...
especially in the first eight or nine
weeks of pregnancy. National (NICE)
guidance2 also states that natural Or you may be asked to do a
management should be the first pregnancy test at home and come back
method to consider. However, your only if it is still positive after 2-3 weeks.
choice will be important in deciding At this point you may be offered
the best and safest option for you. medical or surgical management.
What happens?
This can vary a lot depending on the
Does it hurt?
size of the pregnancy and the findings Most women have period-like cramps
of the ultrasound scan. It can take that can be extremely painful, especially
anything from days to weeks before when the pregnancy tissue is being
the miscarriage begins. Once it does, pushed out. This is because the uterus
you are likely to have strong period- is tightly squeezing to push its contents
like cramps and bleeding. The bleeding out, much like it does in labour.
may go on for 2-3 weeks; or the small You are also likely to bleed very
pregnancy sac in the womb may be heavily and pass clots. These can be as
reabsorbed without much bleeding at big as the palm of your hand. You may
all. It can be very difficult to predict see the pregnancy sac, which might
exactly what will happen and when. look different from what you
expected. You may – especially after 10
You will probably be asked to visit or weeks – see an intact fetus that looks
contact the hospital over the next few like a tiny baby. The hospital team
weeks. You may be offered a scan to should prepare you for what to expect
check whether the uterus has emptied. and advise you about pain relief.

“ I had small cramps, which I had been having for

some time and then severe period cramps. The pain
“
was uncomfortable but in my experience you soon
forget that and in the scheme of what has happened
to you, it is not the worst thing.

5
 What are the risks? Haemorrhage
Infection (extremely heavy bleeding)
This affects about 1 woman in every About 2 in 100 women have bleeding
100, so some hospitals give antibiotics bad enough to need a blood
routinely to prevent it. Signs include: transfusion. Some of them need
emergency surgery to stop the
• a raised temperature and flu-like bleeding. If you are bleeding very
symptoms heavily – or feel otherwise unwell or
• vaginal discharge that looks or unable to cope – it may be best to
smells bad contact the hospital where you were
treated or your nearest Accident &
• abdominal pain that gets worse Emergency Department.
rather than better
• bleeding that gets heavier rather
Retained tissue
than lighter. Sometimes a natural miscarriage
doesn’t complete itself properly –
Treatment is with antibiotics. You may even after a few weeks – and some
need an operation to remove any pregnancy tissue remains in the uterus.
remaining pregnancy tissue. You may need an operation to remove
it.
You will probably be advised to use
pads rather than tampons for the In rare cases, pregnancy tissue gets
bleeding and not to have sex until it stuck in the cervix (neck of the
has stopped. uterus1) and needs to be removed
during a vaginal examination. This can
be very painful and distressing.

fallopian tubes

ovary ovary

uterus (womb) cervix

1
The cervix is a cone-shaped passageway, about an inch long, that connects the vagina and the uterus
(womb). It is normally closed, but dilates (opens) during labour. It may also dilate naturally during
miscarriage.

6
What are the benefits? And the disadvantages?
The main benefit is avoiding hospital • You may find it difficult not knowing
treatment. You may want your when or where the miscarriage
miscarriage to be as natural as might happen. This can take anything
possible and to be fully aware of what from days to weeks. You may worry
is happening. You may also find it easier about starting to bleed heavily in
to say goodbye to the pregnancy if you public when you are least prepared
see the tissue and maybe the fetus as – although wearing sanitary pads as
it passes. You may still want advice, a precaution can help;
though, on what to do with the
remains of your baby (see After the • You may be anxious about how you
miscarriage on page 14). will cope with pain and bleeding,
especially if you are not within easy
If you choose natural management, it reach of a hospital;
may help to know that you can change
• You may be frightened about seeing
your mind at any stage and ask to have
the remains of your baby;
medical or surgical management.
• You may find it upsetting or
inconvenient to have follow-up
scans or blood tests to check on
“ After my second
missed miscarriage
I opted to let nature
take its course.
progress – although some women
find this reassuring;
• You might be too upset to wait for
the miscarriage to happen naturally
once you know your baby has died.
It took two weeks
until I had a
miscarriage and
although those Be prepared
weeks were very If you decide to manage the
difficult, I found that miscarriage naturally, being prepared
I managed to accept with sanitary pads, pain-killers and
the situation much emergency contact numbers can help
quicker than you cope with what happens. You may
previously. I also want to make sure you have people on
found my body got hand to support you.
“
back to normal in a
much shorter period
of time.

7
 Medical management You may need more than one dose of
This means treatment with pills and/or this medication before the miscarriage
vaginal tablets (pessaries) to start or happens. If you are taking it at home
speed up the process of a missed or you should also be given pain relief,
incomplete miscarriage. Not all along with emergency contact
hospitals offer this option and it isn’t numbers to use in case of problems.
suitable for women with some health Your first period after the miscarriage
problems, including severe asthma or may be heavier than usual.
anaemia.
Does it hurt?
Most women have period-like cramps
What happens?
The exact form of treatment your that can be extremely painful,
hospital offers will vary according to especially when the pregnancy tissue
local practice and your type of is being pushed out. This is because
miscarriage. And you may be treated the uterus is tightly squeezing to push
as an in-patient or out-patient – again, its contents out, much like it does in
this differs from hospital to hospital. labour. You are also likely to bleed very
You may start with tablets to help heavily – more than with a normal
break down the lining of the uterus, period – and pass clots. These can be
then be asked to come back two days as big as the palm of your hand. You
later for the next stage of treatment. may need to use extra-absorbent pads,
A small number of women miscarry possibly even more than one.
after the first stage. You may see the pregnancy sac, which
The 2012 NICE guidance recommends might look different from what you
that the first stage tablets may not be expected. You may – especially after 10
necessary, so you may go straight on weeks – see an intact fetus that looks
to the second stage: tablets or like a tiny baby.
pessaries to make your uterus The hospital team should prepare you
contract and push out the pregnancy for what to expect. They should make
tissue. These are usually inserted into sure you have strong pain relief. They
the vagina. You may have this may offer anti-sickness medication too.
treatment in hospital or be given the
medication to use at home.

The medication may make you feel

sick and can cause diarrhoea and
flu-like symptoms.

8
What are the risks?
Infection affects about 1-4 women in
every 100. Haemorrhage affects about
2 in 100 – the same as for natural
miscarriage (see page 6).
“ I felt I needed to go
through the process
to get closure. I was
lucky not to

Medical management is effective in

experience too much

80-90 per cent of cases. If it is not, or

pain although I was

if you have an infection, you may be

regularly offered

advised to have surgical management

pain relief. The

to complete the miscarriage.

hospital gave me a

What are the benefits?

side room and my
husband stayed with
“
The main benefit is avoiding an
me throughout.

operation and the anaesthetic (general

or local) that goes with it.
And the disadvantages?
Some women see medical • You may find the process painful
management as more natural than and frightening, although good
having an operation, but more information about what to expect
controllable than waiting for nature to can help;
take its course.
• You may be anxious about how you
As with natural management, you may will cope with pain and bleeding,
prefer to be fully aware of what is especially if you are not in hospital
happening, to see the pregnancy tissue at the time;
and maybe the fetus.
• You may be frightened about seeing
the remains of your baby;
• Bleeding can continue for up to
three weeks after the treatment
and you may need several follow-up
scans to check on progress;
• Some women end up having an
operation anyway.

“ I was told it would be like a heavy period with

cramps and may go on longer than usual. Because I
“
had never had a miscarriage before, I did not know
what to expect. I was unable to cope with the pain
and needed strong pain-killers.

9
 Surgical management of Does it hurt?
miscarriage: SMM If you are given tablets or vaginal
This is an operation to remove the pessaries before the operation, you
pregnancy tissue. It is usually done may have cramping pain and perhaps
under general anaesthetic which puts some bleeding as the cervix opens.
you to sleep. But in some hospitals it Having a general anaesthetic means
can also be done under local you will not feel anything during the
anaesthetic, when you stay awake. operation itself; and there are no cuts
or stitches.

You may have some abdominal cramps

(like strong period pain) when you
SMM under general
wake up and for a few days afterwards.
anaesthetic
This used to be called called ERPC or
ERPoC, which stands for Evacuation of You may bleed for up to 2-3 weeks
Retained Products of Conception. You after the operation. Bleeding may stop
might hear it called it a D & C, which and start but should gradually tail off. If
means dilatation and curettage; but it stays heavy, gets heavier than a
that is a slightly different procedure, period or makes you worried, it is
usually carried out for women with best to contact your GP or the
period problems. Both of these terms hospital.
are still used occasionally.

What happens?
The cervix (neck of the uterus) is
dilated (stretched) gradually. This is
usually done under anaesthetic but
“ I only bled for a
short time after
the operation

you might be given pills or vaginal

(about 4-5 days like

pessaries before the operation to

a period). I only had

soften the cervix. A narrow suction

tube is then inserted into the uterus
“
mild aching and
soreness the next

to remove the remaining pregnancy

morning.

tissue. This takes about 5-10 minutes.

A sample of the tissue removed is

usually sent to the pathology
department to check that it is normal
pregnancy tissue. It is not usually
tested further unless you are having
investigations after recurrent
miscarriage.

10
What are the risks? What are the benefits?
• About 2-3 women in every hundred With surgical management you know
get an infection. For signs of when the miscarriage will happen and
infection and treatment, see under can plan around that. With a general
‘natural miscarriage’, on page 6; anaesthetic you won’t be aware of
what’s going on.
• Rarely – less than 1 in 200 cases –
the operation can perforate (tear) It may be a relief when the miscarriage
the uterus; damage to other organs is ‘over and done with’ and you can
is rarer still; move on.
• Haemorrhage (extremely heavy And the disadvantages?
bleeding) and scarring (adhesions) Some women are frightened of
on the lining of the uterus are also anaesthetics, surgery and staying in
rare – less than 1 in 200; hospital. Some prefer to let nature
• Very occasionally some pregnancy take its course and to remain aware of
tissue remains in the uterus and a the miscarriage process.
second operation is needed to
The anaesthetic might make you feel
remove it;
groggy or unwell for a few days.
• Very rarely, the general anaesthetic
can cause a severe allergic reaction Some women refuse surgery because
(about 1 in 10,000 cases) or even they worry that the diagnosis might be
death (fewer than 1 in 100,000 wrong and their baby is still alive. If
cases); this is your concern, don’t be afraid to
ask for another scan just to be sure.
• Very rarely (less than 1 in 30,000
cases) it can result in a
hysterectomy; this would only be if
there is uncontrollable bleeding or
severe damage to the uterus.

“ When I was told I had lost the baby I just wanted it

to be all over as soon as possible. I was booked in
immediately and had the op the following day. I was
treated with great kindness and informed all the“
way along of what would be happening. I recovered
physically within a couple of weeks.

11
 SMM under local Does it hurt?
anaesthetic If you are given tablets or vaginal
This is also sometimes called MVA, pessaries before the operation, you
which stands for Manual Vacuum might feel pain as the cervix opens.
Aspiration. It may be carried out in a Most women have cramps (like strong
hospital ward, a day surgery unit or an period pains) as the pregnancy remains
out-patient clinic. are removed. But you will be given
painkillers and/or nitrous oxide (‘gas
and air’) if necessary and the pain
probably won’t last long.
What happens?
You may be given tablets or vaginal
pessaries before the operation to You may have some light vaginal
soften the cervix, along with pain relief. bleeding afterwards. If it becomes
A local anaesthetic is injected into your heavy, it is best to contact the team
cervix, or the cervix may be numbed that treated you.
with a gel and the cervix is then dilated
(stretched) gradually. A narrow suction
tube is then inserted into the uterus to
Are there any risks?
These are mostly the same as for
remove the remaining pregnancy tissue.
SMM under general anaesthetic. There
You will be offered further pain relief
is a very small risk of having a reaction
during the procedure and may have a
to the local anaesthetic.
scan afterwards.

This all takes about 10 minutes.

Afterwards you will probably be
advised to wait for an hour or two to
make sure you are well enough to go
home.

As with SMM under general

anaesthetic, a sample of the tissue
removed may be tested afterwards to
check that it is normal pregnancy
tissue.

“ I had the surgery done under local anaesthetic

(just with gas and air). It was painful, but very
quick. The actual removal took less than 5 minutes
and just happened on the ward. Within an hour I
walked home with my husband (though I am sure
they expect you to be driven home), bleeding only
a little bit and in no pain (just feeling empty).
“
12
What are the benefits? And the disadvantages?
As with SMM with general anaesthetic, Some women prefer not to be aware
you will know when the miscarriage of the process of miscarrying. And you
will happen and may then feel you can may worry about coping with pain or
move on. The procedure is quick and anxiety.
you will recover more quickly than
from a general anaesthetic.

You may actually prefer to be awake

and aware of what is happening.

“ I was worried about whether the

MVA would be painful, but the
consultant talked to me all the way
through, which was very reassuring.
It only hurt for a few minutes and
I felt in control of the pain and what
was going on. The pain and bleeding
stopped very quickly afterwards and
the next morning I felt fine.
“

13
 After the miscarriage
In hospital At home
When a baby dies before 24 weeks of If you miscarry at home or
pregnancy, there is no legal somewhere else outside a hospital,
requirement to have a burial or you are most likely to pass the
cremation. Even so, most hospitals remains of the pregnancy into the
have sensitive disposal policies and toilet. Actually this can happen in
your baby may be buried or cremated, hospital too. You may look at what has
perhaps along with the remains of come away and see a pregnancy sac
other miscarried babies. Some and/or, the fetus – or something you
hospitals treat the remains of an early think might be the fetus. You may want
loss as clinical waste, which is sent for to simply flush the toilet – many
incineration, but this is changing. people do that automatically – or you
may prefer to remove the remains for
If you want to find out about what a closer look. That’s natural too.
happens at your hospital, you could
ask a nurse or midwife on the ward or You may decide to bury the remains at
unit where you are or were cared for. home, in the garden or in a planter
The hospital chaplain, the hospital with flowers or a shrub. Or you may
bereavement service or the PALS prefer to arrange burial in a local
(Patient Advice and Liaison) officer cemetery. You may want your GP or
may be able to provide further hospital to look at the remains. Be
information or advice. aware, though, that while they may be
able to confirm you have passed
Even if you miscarry in hospital, you pregnancy tissue, they probably won’t
may want to make your own be able to carry out any tests on it.
arrangements for burying or cremating
the remains of your baby. You can do If you have any questions about what
this through a funeral director or to do or would just like to talk it
carry out your own burial at home. through, you are welcome to contact
the Miscarriage Association.
There are a few things to think about
and you may want to contact the
Miscarriage Association for further
information.

“ It wasn’t what I’d intended, but a friend said

“Just think about your baby being swept through
“
the system and then floating out to sea, bobbing
about under the stars.” I found that really
comforting.

14
Summary Useful reading
There are several ways of managing a Leaflets from the Miscarriage
miscarriage. Each has its pros and cons. Association, especially:
But the good news is that the risks Ectopic pregnancy
associated with all of them are low;
Molar pregnancy (hydatidiform mole)
and your chances of having a healthy
pregnancy in future are equally good Patient information from the National
whichever you choose. Institute of Health and Clinical Care
(NICE), available online at
Each method is different and affects
http://publications.nice.org.uk/ectopic-
people differently. This can make it
pregnancy-and-miscarriage-in-early-
hard to choose between them –
pregnancy-ifp154
especially when you wish you didn’t
have to choose at all.

We hope that this leaflet provides the

Thanks
information to help you make Our sincere thanks for their help in
decisions at what may be a difficult writing this leaflet go to Mr Kim
and distressing time. Hinshaw, Consultant Obstetrician and
Gynaecologist at Sunderland Royal
Hospital, and Ms Manjeet Shehmar,
Consultant Obstetrician and

“ The one thing all

these methods have
in common is that
Gynaecologist at Birmingham
Women’s Hospital, and her team.
We are also grateful to everyone who
they are all unhappy shared their thoughts and experiences
experiences to go with us.
through. But if you

References
feel informed with the
J Trinder et al: Management of miscarriage:
correct information 1

then at least you have expectant, medical or surgical? Results of a

randomised controlled trial (miscarriage
treatment (MIST) trial). BMJ 2006;332:1235-
some control of a
“
situation where you 1240 (27 May)
feel horribly out of 2
NICE guidelines {CG154] Ectopic pregnancy
and miscarriage: Diagnosis and initial
management in early pregnancy of ectopic
control.
pregnancy and miscarriage (December 2012).
https://www.nice.org.uk/guidance/cg154

The Miscarriage Association is a registered charity with a telephone helpline, an

online support forum and a range of helpful leaflets on pregnancy loss.

15
The Miscarriage Association
17 Wentworth Terrace
Wakefield WF1 3QW
Telephone: 01924 200799
e-mail: info@miscarriageassociation.org.uk
www.miscarriageassociation.org.uk

© The Miscarriage Association 2016

Registered Charity Number 1076829 (England & Wales) SC039790 (Scotland)
A company limited by guarantee, number 3779123
Registered in England and Wales

Mgt/07/16