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Expectant Management of Miscarriage - Incomplete and Missed


Patient Information

Staffs in the early pregnancy assessment unit are aware that individuals will react to complications or the loss of a pregnancy in different ways. We will endeavour to provide you with information and support in a sensitive manner, taking into account your individual circumstances and your emotional response. Staffs are sensitive to the significant distress for some women and their partners and we will ensure there is sufficient time available to discuss your care and arrange an additional appointment or telephone consultation if more time is needed.

We understand this may be a very distressing time and we are sorry for your loss.

You have opted for expectant management following your diagnosis of incomplete or missed miscarriage. This leaflet aims to give you some general information about what this method will involve, and help to answer some of the questions you may have. It is intended only as a guide and there will be an opportunity for you to talk to your midwife / doctor about your care and treatment.


What is expectant management?
Expectant management means that we expect your miscarriage to happen naturally without any intervention. You will be monitored by the hospital over the next few weeks and attend a follow up appointment instead of having immediate treatment. It may also be known as ‘conservative’ or ‘letting nature takes its course’ management / treatment.


Why have I been offered this treatment?
There are several reasons why this treatment may be appropriate for you:

• You have been diagnosed with a missed miscarriage.
• You have been diagnosed with an incomplete miscarriage.
• Your general health is good and your condition is stable.
• You do not wish any medical or surgical intervention at this time.


What are the risks?
Risk of infection
Approximately 1 in 100 (1%) of women will develop an infection. Signs of infection are a raised temperature and flu-like symptoms, a vaginal discharge that looks or smells offensive and/or abdominal pain that gets worse rather than better. Treatment is with antibiotics. In some cases, you may be advised to have an operation to remove any remaining pregnancy tissue. This is known as an Evacuation of Retained Products of Conception (ERPC). You may be given a course of antibiotics routinely to prevent infection.

Risk of haemorrhage (extremely heavy bleeding)
Research suggests that 2 in 100 women (2%) had bleeding severe enough to need a blood transfusion and some women will need an ERPC to remove any remaining pregnancy tissue.

Risk of tissue being retained
In rare cases, pregnancy tissue may become stuck in the cervix and will need to be removed during a vaginal examination: this may be painful and distressing. If there is still pregnancy tissue remaining in the womb after several weeks, you may be advised to have an ERPC.


What are the advantages of expectant management?
• You do not have to stay in hospital.
• Avoids medications or surgery with a general anaesthetic and the possible associated risks and side effects of both.
• It is seen as a more ‘natural’ process – which some women may prefer.
• You may wish to be fully aware of the process of miscarriage and may want to see the pregnancy tissue and perhaps the fetus. Some women feel this helps them to say goodbye, though they may want guidance on what to do with the remains of their baby (see leaflet – Sensitive disposal of pregnancy loss).

Please note that if you reach a point where you no longer want to wait, you can change your mind and request medical or surgical management.


What are the disadvantages of expectant management?
• It can take a few weeks before the uterus (womb) empties itself.
• You may find it difficult not knowing when (or where) the miscarriage might start.
• You might be anxious about coping with pain and bleeding and not knowing when the miscarriage is complete.
• You may be concerned about the possibility of seeing the pregnancy tissue, in particular the fetus.
• Further visits to the hospital are required which may include blood tests or scans.
• Medical or surgical management may be required if the miscarriage doesn’t occur after 3 weeks, or you experience persistent heavy bleeding and / or pain.


Is the treatment suitable for everyone?
Expectant management is not an option for all women. It may not be suitable if you are anaemic; you have a high risk of bleeding or suffer from an underlying medical condition that would increase the risk to your health. Your healthcare provider will advise you . It is usually possible when:
• You have experienced a missed miscarriage – where the pregnancy tissue remains in the uterus even though it is no longer developing.
• You are experiencing an incomplete miscarriage, and don’t want any medical or surgical intervention.
• Your general health is good and your condition is stable.
• Pain levels are considered to be acceptable.


How successful is it?
Expectant management is successful in 50 out of 100 women (50%). It can take time before bleeding starts and it is normal for the bleeding to continue for up to three weeks. Bleeding may be heavier than normal and you may experience cramping pain. Very occasionally emergency admission for heavy bleeding or severe pain is necessary. If bleeding does not start or the miscarriage has not completed you will be offered the option of taking tablets or having an operation.


What can I expect to happen?
Pain
Having a miscarriage can be quite painful, with cramping type pains and lower backache occurring at any time, but especially when the miscarriage is imminent.
It is advisable to be prepared with a suitable type of pain relief which you are able to tolerate.
The following types of painkillers are all useful:
• Paracetamol
• Ibrufen
• Codeine based painkillers
Please ensure you read the label/instructions carefully before taking them and do not exceed the maximum daily dose. If these types of pain relief are insufficient, please do not hesitate to contact us.

Bleeding
Be prepared for when the bleeding starts, or becomes heavier it is advisable to use sanitary towels rather than tampons, as this reduces the risk of any infection.
It is difficult to predict how heavy the bleeding might be, but most probably it will be heavier than a normal period, and you may pass blood clots, tissue or even a recognizable fetus, which can be alarming.

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

Once you have actually miscarried (passed clots of blood or tissue) the bleeding will ease and it will become much lighter. Any cramping pain will also cease. It is not unusual to bleed for 10 to 14 days after a miscarriage, but this bleeding should be noticeably lighter, and more period like. It is advisable to avoid intercourse whilst you are bleeding, again to reduce the risk of infection

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.

Signs of infection
Increased bleeding or pain, or developing an offensive smelling vaginal discharge may be symptoms of an infection. You should contact your GP immediately if you develop any of these symptoms as you may require antibiotic treatment.

Work
Going back to work during or following a miscarriage is a very individual decision. It also depends on how heavy your bleeding is, and how you feel generally. Having a miscarriage can be a very distressing event in a woman’s life. Many women feel that at least a few days off work may be necessary. Most work places allow you to self-certify for up to 7 days, but please let staff or your GP know if you require a sick note (a medical certificate).

What if the miscarriage does not happen?
If there has not been any bleeding, and you do not think the miscarriage has happened, you may decide that you would prefer to consider managing the miscarriage by medical or surgical intervention, depending on your individual circumstances. Please telephone staff in EPAU who will be able to make suitable arrangements for you.

What follow-up will I need after expectant management has been agreed?
You will be given a date and time for a follow-up scan before you leave the hospital. If required your pregnancy hormone levels may also be monitored to assist diagnosis. The scan will confirm when the miscarriage is complete.

When can I expect a menstrual period?
Every woman is different regarding how soon after a miscarriage to expect a period, however sometime in the next 4- 6 weeks is considered usual. Often this first period may be different than normal (heavier or lighter). Again this is nothing to be concerned about, unless the bleeding is very heavy in which case, contact your GP or EPAU directly.

Do I need to inform anyone of my miscarriage?
If you have booked your antenatal care at one of the maternity units within Greater Glasgow and Clyde staff will have written to your GP and community midwife and any scans or appointments already arranged will be cancelled so you do not need to worry about doing this. Unfortunately if you have booked care at another hospital we are unable to cancel appointments so please make arrangements to cancel these appointments to avoid receiving reminder letters.

Emotions
Reaction to a pregnancy loss is very variable and in addition to the grief you may feel, your body will be undergoing lots of 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. You may experience days when you feel completely ‘back to normal’, but you may also have days when you feel sadness or a sense of loss. We are all different and we all react and recover in different ways—there is no right or wrong way. It is however important to give yourself, time to recover on a physical, psychological, and emotional level. It is important to remember that miscarriage is a very common occurrence, and in most cases the cause of the miscarriage is unknown.


If you wish to talk to someone about your feelings and are unable to do so with a partner, close friend or family member, you may wish to contact a confidential counselling service.

The Scottish Care and Information on Miscarriage Association (SCIM)
Telephone number 0141 552 5070
www.miscarriagesupport.org.uk
The SCIM provides counselling for women and couples in Scotland who have suffered miscarriage, stillbirth or neonatal loss. They connect with NHS and community organizations to assist people to access services in their community to ensure they receive the best quality care. Their aim is to help you to discover your own recourses for self coping, to find new ways forward and to make new plans so that you feel more optimistic about your future.

Miscarriage Association
Telephone number: 01924 200799
www.miscarriageassociation.org.uk
The Miscarriage Association (M.A.) works to ensure that everyone affected by miscarriage, ectopic pregnancy or molar pregnancy receives the care, support and information that is right for them. As well as providing information they provide telephone counselling and online support.


When can I start trying to become pregnant?
It is perfectly safe to start trying for another pregnancy once you and your partner feel ready to (providing you feel well and have stopped bleeding). For dating purposes, there may be some advantage in waiting until your next normal period. However, if you do conceive before your next normal period there is no increased risk of miscarriage.
Any preconception care you have been following should continue, such as:
• Taking folic acid
• Reducing your alcohol and caffeine intake
• Stopping smoking

If you are unsure whether you wish to try for a future pregnancy, it is advisable to consider your contraceptive needs during this time.

If this is your third consecutive miscarriage, staff will discuss with you and your partner if you wish to be referred to one of the consultant gynaecologists, who counsels couples in this situation for investigation and support.


Early Pregnancy Assessment Service (EPAS) – Contact Details:

Princess Royal Maternity
Phone Number: 0141 211 5317
8:30am – 4:30pm Sunday - Friday
Closed on Saturday

Queen Elizabeth University Hospital
Phone Number: 0141 201 2331
8:00am – 4:00pm Monday - Friday
8:30am – 4:30pm Saturday
Closed on Sunday

Royal Alexandra Hospital
Phone Number: 0141 314 6953
9:00am – 5:00pm

Vale of Leven
Phone Number: 01389 817 232
9:00am – 5:00pm

Inverclyde Royal Hospital
Phone Number: 01475 504 619
8:00am – 8.00pm

Referral to the service is made via NHS 24; Accident and Emergency; Local GP, Sandyford, Community Midwife or Out of Hours Service only.


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