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Surgical Management of Miscarriage with General Anaesthetic

Patient Information

Staff in the early pregnancy assessment unit is 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.

Sadly your scan shows that your pregnancy is not continuing. You may have a number of mixed emotions from disappointment and sadness to anger and guilt. If a pregnancy is going to miscarry at this stage, there is nothing that you could have done to stop it so try not to blame yourself by thinking of things that you should or should not have done. The staff caring for you is aware that this is a stressful and upsetting time for you and your family. They will support and advise you. After discussion with your midwife or nurse you may have chosen to have surgical management of your miscarriage.

The procedure is known as an evacuation of uterus similar to a D and C (dilatation and curettage).


What are the risks of surgery?
The procedure is safe and the risks of complications are low. However the following are the possible complications which will be discussed with you before the procedure:

• Infection risk (3 in 100 women).
• Blood loss requiring transfusion risk (1-2 /1000 women).
• Injury to cervix (neck of the womb) or the uterus (1 in 200 women).
• Incomplete procedure (5 in 100 women)
• Nausea and vomiting.
• Scar tissue in the womb.
• Need for other surgery including laparoscopy (‘keyhole surgery’ to put a camera inside your abdomen to see inside better) or laparotomy (an open operation through a cut in the tummy).
• Complications related to the anaesthetic.


Greater Glasgow and Clyde Gynaecology day surgery service
We are now able to provide planned urgency lists across all sites. Our aim is to book you onto the next available list, which may be at any of the sites within 7 days of deciding that you wish to go ahead with a surgical management, or we will book you on to the list most convenient to you but this may take longer than 7 days.


Pre-operative assessment
In order to have surgery safely we require to complete a pre-operative assessment (often call a ‘pre-op’), where we will ask you about any past medical and surgical history. It will also be necessary to take some blood tests to check your blood count and determine your blood group to establish whether your blood group is Rhesus positive or negative. If you are Rhesus negative you will require a single injection a medication called Anti-D. Anti-D is given to women with Rhesus negative blood groups following miscarriage to prevent your body from developing antibodies that could potentially affect future pregnancies.

The pre-op will usually be completed at the site where your procedure will take place and should be completed 24-72 hours before your admission date for surgical management. You will be given an appointment for this and details of where to attend.


Consent
We must by law obtain your consent to any operation. The staff will explain the risks and benefits of the surgery. You will be asked to sign two consent forms. The first will be to confirm that you agree to surgical treatment and will be completed with a doctor.

The second is for histological examination of pregnancy tissue to determine if there is a need to follow up any abnormal findings. However, it may not be possible to establish the cause of your loss.In rare instances you will be contacted if the result of the pathology investigation indicates that there was evidence of a molar pregnancy, a condition which requires follow up.


What happens next?
It is very important that you do not have anything to eat or drink for at least 6 hours before your operation. This includes sweets and chewing gum. You may be allowed water up to two hours before surgery – your nurse or doctor will confirm this with you at your pre-op appointment.

You should have a bath or shower prior to coming into hospital for the operation. Please remove any body piercings, fake nails/acrylics and nail varnish from fingers and toes. Valuables and jewellery should be left at home.


What will happen on the day of surgery?
You will remain as an in-patient for approximately 6-8 hours when admitted to the hospital. However this may be longer depending on the daily activity in the emergency theatre or you may need to stay overnight if you require any further monitoring.

We advise that you bring toiletries, sanitary towels (not tampons) and wear comfortable clothes on the day. You should also bring any regular medications that you take. You should arrange for a friend or a relative to be available to take you home following surgery.


Where do I go on the day of surgery?
You will be admitted to the site that has been chosen for you to have your surgery, either:

• Stobhill ACH
• Victoria ACH
• Royal Alexandra Hospital
• Vale of Leven Hospital
• Inverclyde Hospital

You will be given a specific time to arrive and it is important that you arrive on time so that your operation is not delayed.


Please note: the time you are asked to arrive is your admission time only and not the expected time of your surgery; this will be estimated with you during the admission process.

You will be seen by a nurse, also a doctor performing the procedure and the anaesthetist (the doctor who will administer the general anaesthetic).

Depending on your circumstances it may be necessary for you to take some medication called Misoprostol orally 1 – 2 hours before the procedure. This is to prepare your cervix for the operation. In some women this may cause period type pain, bleeding, headaches, dizziness, diarrhoea or a skin rash. Please inform your nurse if you develop any of these symptoms.

You may be required to wear a theatre gown, some anti-embolus socks (‘flight socks’ – to prevent blood clots in your legs), and disposable underwear. When it is time you will be escorted to theatre and put to sleep with a general anaesthetic. Antibiotics may be administered to you rectally whilst you are asleep. This will be discussed when completing your consent form. A member of the theatre team will be with you at all times. Your operation is only a short procedure, when you wake up from your anaesthetic you will be in the theatre recovery area. As you have had an anaesthetic you may still be sleepy. However you should be physically well and after approximately two hours if all of your observations remain within normal limits you will be fit to be discharged home.

If you have Rhesus negative blood group you will receive an injection of Anti D to prevent the development of antibodies which can have a detrimental effect on subsequent pregnancies.


What happens after you go home?
You may experience abdominal cramp for 24 hours or a little longer after the procedure. It is not unusual to bleed for 10 to 14 days, but this bleeding should be noticeably lighter, and more period like. It is advisable to use sanitary towels rather than tampons, as this reduces the risk of any infection. It is advisable to avoid intercourse whilst you are bleeding to reduce the risk of infection.


Hygiene
Avoid hot baths whilst you are bleeding, 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 The Emergency Gynaecology Unit (EGU) or your GP immediately if you develop any of these symptoms as you may require antibiotic treatment.

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.


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- noted above staff will have written to your GP and community midwife and any scans or appointments will have been 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 and you should therefore arrange to do this to avoid reminder letters and appointments being sent to you. A letter will still be sent to your GP.


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.


Will I need a follow up appointment?
Not at the hospital, although you may wish to see your GP in 4-6 weeks to check that your body is getting back to normal.


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 - Email: www.miscarriagesupport.org.uk
The SCIM provides counseling 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 - Email: 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 sees couples in this situation who sees 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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