If you have recently been diagnosed with a miscarriage, I am very sorry for your loss and am absolutely committed to helping you through this difficult time – Dr. Hugh Porter.
What are the symptoms of miscarriage?
The hallmark symptoms of a miscarriage are crampy lower abdominal pain and vaginal bleeding. Please note that not all pain and/or bleeding in early pregnancy means you are having a miscarriage. Sometimes women may have no symptoms and have a miscarriage diagnosed at a routine ultrasound scan.
How is a miscarriage diagnosed?
In very early pregnancy, miscarriage is diagnosed by a declining pregnancy hormone called Beta HCG (blood test). After that time, serial ultrasound scans are used to diagnose miscarriage.
What is a ‘missed miscarriage’ vs. an ‘incomplete miscarriage’ vs a ‘complete miscarriage’?
- If you have not had any pain or bleeding, and your miscarriage was diagnosed on an ultrasound scan, this is called a ‘missed miscarriage.’
- If you have been diagnosed with a miscarriage, have crampy abdominal pain and bleeding, but have not yet passed any pregnancy tissue, it is called an incomplete miscarriage.
- If you have had pain and bleeding, passed pregnancy tissue, and the bleeding has settled, you have likely had a complete miscarriage. An ultrasound scan can confirm there is no pregnancy tissue left inside.
Why did this happen?
Miscarriage is far more common than most people realise. After a positive pregnancy test, almost one in five pregnancies end in miscarriage. Miscarriage is most common during the first three months of your pregnancy (the first trimester), and the chance of miscarriage increases with age.
It is thought that over 90% of all miscarriages happen because something was wrong with the pregnancy (a mistake of nature).
What should I do if I’m having difficulty coping with the diagnosis?
Feelings of sadness, guilt, anger, and frustration are common after a miscarriage. Be assured the miscarriage is almost never your fault, and there is nothing you could have done to prevent it. If you or your partner have concerns for your mental health, please advise Dr Porter ASAP. Dr. Porter can arrange social work, counselling, or psychological help as required.
What are the treatment options after a miscarriage?
- Surgical (D&C)
- ‘Watch and wait’ approach, let your body pass the tissue naturally
- Tablets taken to help pass the tissue
- Products gently removed from the uterus under general anaesthesia (patient asleep)
- Missed MC: 20-50% at 2 weeks
- Incomplete MC:80- 90% at 2 weeks
- Missed MC 80-90% at 2 weeks
- Incomplete MC 90-95% at 2 weeks
How long does it take to work?
- Variable as above
- The average time to pass tissue is 6-18 hours after taking meds
- Infection, 30% have not passed tissue at 6 weeks
- Crampy pain, Diarrhea, Shivering, Nausea, Vomiting Heavy bleeding requiring surgical intervention
- Bleeding/Infection Perforation 1:300, 2% require 2nd curette Asherman’s disease
- Recommend another method if MC is not complete by 2 weeks
- 5% of women will present to the emergency department with significant pain or heavy bleeding
- Ultrasound at 2 weeks if tissue passed. Pregnancy hormone level at 5 weeks.
- Phone call 2-3 days after meds.
- Ultrasound at 2 weeks.
- Pregnancy hormone level at 5 weeks.
- Face-to-face appointment 2 weeks after your surgery.
What should I expect if I choose medical management?
Within a few hours of taking the Misoprostol tablets, you will likely start feeling crampy lower abdominal pain and experience moderate to heavy vaginal bleeding. The average time taken to pass pregnancy tissue is 6-18 hours. Dr. Porter will provide you with anti-nausea and pain relief medications to take as required.
When should I worry about pain or bleeding?
During expectant or medical management of miscarriage, the combination of crampy pain and bleeding is considered NORMAL.
PAIN: If you are unable to control your pain with the combination of Panadol/Nurofen and Endone, you should seek medical attention.
BLEEDING: If you soak through two thick maternity pads in an hour and two more in the following hour, you should attend your local emergency department. You may require surgical treatment (Dilatation and Curettage).
NOTE: Use the above thresholds as a guideline only. If you are concerned at any time, you can call Dr. Porter or present to your local emergency department.
Do I need to collect the pregnancy tissue when I pass it?
Dr. Porter will give you a pathology form and a small container to collect any tissue you pass. You do not need to do this if it makes you uncomfortable or it is difficult/not possible.
The advantage of collecting tissue is:
- To confirm the diagnosis
- To rule out abnormal/malignant tissue called a ‘Molar pregnancy’ (rare).
- To test the tissue for possible genetic causes of miscarriage (usually performed in the context of recurrent miscarriages and should be discussed with Dr. Porter)
If you do collect any tissue, put the container in the fridge, and drop it off at your local pathology provider when convenient, preferably within 12 hours.
Do I need ‘anti-D’?
Women with a negative blood group (e.g., AB negative) require an injection of ‘anti-D’ to prevent problems in subsequent pregnancies. Dr. Porter will arrange the injection if you need it.
What do I need to know if I am having surgical management (dilatation and curettage of the uterus)?
- You will need to be fasted for your operation (If your operation is in the morning – Do not eat or drink anything from midnight. If your operation is in the afternoon, eat nothing after 8 am).
- Some patients will be asked to take a medication (Misoprostol) two hours before their procedure. This medication makes the procedure safer by softening and opening the cervix. If you require misoprostol, Dr. Porter will explain how and when the medication should be taken.
- The procedure is a ‘day case.’ I.e., you will go home on the same day as your surgery. Arrange someone to drop you off and pick you up from the hospital.
- Dr. Porter can provide you with a medical certificate for time off work.
- You should avoid using tampons, baths/swimming, and sexual intercourse for 2 weeks after the procedure.
- Dr. Porter will see you in his rooms two weeks after the procedure to give you the pathology results and check your recovery.
When can I fall pregnant again?
Medically you can try to conceive again after your very next period. From a psychological standpoint, you may not feel ready, and that’s ok. The chance of falling pregnant again after a miscarriage is the same regardless of your management option.
INSTRUCTIONS FOR MEDICAL MANAGEMENT OF PREGNANCY:
The best time to take your tablets is in the morning after breakfast. Unless otherwise directed by Dr. Porter, instructions are as follows:
Misoprostol (Medication to help pass the tissue)
- Take 3 misoprostol tablets to start the process. There are two ways to take the tablets: insert them into your vagina (as far as possible) or dissolve them under your tongue. The vaginal route has fewer side effects (diarrhea, shivering, gastric upset), but many women feel uncomfortable with this method. The treatment is similarly effective either way. If you take the tablets under the tongue, they take about 20 minutes to dissolve. Do not eat or drink while the tablets are under your tongue, and don’t worry if you swallow them; they will still work. You can eat/drink or rinse your mouth after 20 minutes. If you put the tablets in your vagina, lie down for 20 minutes afterward. Do not have a bath or sexual intercourse on the day of your treatment.
- Showering is ok.
- If you have not passed any tissue in 3 hours, take the next 3 misoprostol tablets.
- 3 hours later, if you are still yet to pass any tissue, repeat the process (take 3 more tablets). Do not take any more Misoprostol after the 3rd dose. If you have not passed any tissue within 24-48 hours, contact Dr Porter for further instructions.
Maxolon/Zofran (Anti-nausea medication)
- Dr. Porter will prescribe you one of two anti-nausea medications. You can wait and see if the misoprostol makes you nauseous, then take the medication. Or you can take them pre-emptively.
- Zofran: Dissolve one 4mg wafer under your tongue every 8 hours as required.
Swallow one 10mg tablet every 8 hours as required.
- Dr. Porter will prescribe you Panadol, Nurofen, and Endone for pain. You should take Panadol and Nurofen regularly from the beginning, and Endone only if you need it.
- Panadol: Take 1g (2 tablets) every 4-6 hours. The maximum dose is 4g (8 tablets) in 24 hours. Nurofen: Take 400mg (2 tablets) every 6-8 hours. The maximum dose is 6 tablets in 24 hours.
- Endone: Take 5mg (one tablet) every 3 hours, only if needed. The maximum dose is 25mg (5 tablets) per day.
If you experience significant pain after taking the above medications, you should contact Dr. Porter or attend the emergency department.