EPU Leaflet: Conservative Management of Miscarriage

Leaflet Details

Patient Information

Useful Details

This leaflet is intended to give you additional information to that received from your healthcare professional.

Early Pregnancy Unit opening hours:

• Monday to Friday 0900-1700, excluding bank holidays
   
• USS scanning hours: Monday to Friday 0900-1300
   
• Phone: 01932 722662.

Early Pregnancy Unit website:
https://www.ashfordstpeters.nhs.uk/early-pregnancy-unit

Early Pregnancy Unit email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Introduction

We are very sorry that your pregnancy is no longer progressing. We understand this may be a very distressing time for you. Sadly, miscarriages are known to occur in 1 in 4-5 pregnancies. In early pregnancy, the most common reason for a miscarriage is a genetic abnormality within the baby and so is out of your control.

The risk of miscarriage increases with age and is quoted as 20% (1: 5) at age 30 years and about 50% (1:2) over the age of 40 years. The incidence may be increased by medical conditions such as poorly controlled diabetes, smoking, being overweight or heavy drinking.

Following a miscarriage, the pregnancy may be completely expelled by the womb and no further treatment is needed. If this doesn’t happen or the pregnancy is not completely expelled by the womb, this leaflet is intended to discuss your options. It gives you additional information to that received from the doctors and nurses in the hospital. Please read this leaflet in conjunction with our leaflets on miscarriage management titled medical management of miscarriage, surgical management of miscarriage, information for women having manual vacuum aspiration for management of miscarriage.

We understand the word women has been used in this leaflet. This is intended to include people who may not identify as women e.g. non-binary people, transgender people.

Making your decision

Please remember that no decision about your care is final. It may be your choice to change the way your miscarriage is managed, or it may become medically necessary to perform an operation to remove the pregnancy tissue because of excessive prolonged bleeding or unsuccessful conservative management. This operation is known as surgical management of miscarriage (SMM) or manual vacuum aspiration (MVA).

What is Conservative Management?

Conservative management is one option for treating an early miscarriage. It means allowing the body to pass the pregnancy tissue naturally, without using medication or surgery.

Conservative management is recommended as a first-line treatment for early miscarriage. It is safe and effective but we require you consent to proceed.

Who Can Choose Conservative Management?

This approach is generally suitable if you have been diagnosed with a missed or incomplete miscarriage or retained pregnancy tissue and:

• The isn’t excessive bleeding, pain or signs of infection.
   
• An ultrasound has confirmed that the pregnancy is not continuing.
   
• You are well in yourself.
   
• You prefer to avoid medication or surgery.

When is conservative management of miscarriage not suitable?

• The woman is at increased risk of bleeding for example the pregnancy is advanced e.g. in the late first trimester (the first trimester is the first 12 weeks of pregnancy).
   
• The woman has a condition that increases the risk of bleeding e.g. clotting disorders or the effect of heavy bleeding e.g. women who refuse blood transfusion
   
• There is evidence of infection
   
• There has been a previous history of adverse and/or traumatic experience associated with pregnancy e.g. previous traumatic miscarriage, antepartum haemorrhage, still birth etc.

What to Expect?

• Most women will pass the pregnancy tissue within 7 to 14 days.
   
• You may experience cramping which may be moderate to severe, bleeding with/without clots, and passing of tissue like the pregnancy sac or the baby. The amount of bleeding and or pain depends on the scan findings and the stage in pregnancy when the miscarriage was diagnosed. These symptoms are usually more in the first few days of the miscarriage.
   
• Bleeding may be heavier than a normal period and last for up to 3 weeks.
   
• Pain relief such as paracetamol or ibuprofen or prescribed pain killers like codeine can help manage discomfort.

What Are the Benefits of conservative management of miscarriage?

1. Avoids Medication and Surgery

National guidance recommends we offer conservative management as a safe first line option for women with confirmed miscarriage who are well and prefer to avoid medical or surgical options for miscarriage care.

This approach avoids:

• Side effects from medications such as misoprostol (e.g. nausea, vomiting, diarrhoea, cramping).
   
• Surgical risks such as uterine perforation, infection, or anaesthesia-related complications.

2. No Need for Anaesthetic or Hospital Admission

Conservative management avoids the need for an anaesthetic:

• Allows the miscarriage to occur at home, reducing the need for a hospital admission.
   
• Avoids general anaesthesia or sedation, making it safer for women with health risks (e.g. cardiovascular or respiratory concerns).

3. Respects the Natural Process

Conservative management allows your body to complete the miscarriage naturally, which many women find emotionally and physically preferable.

• Some women feel a sense of closure and control by allowing the miscarriage to happen without active intervention.
   
• Some women may find choosing this method enhances emotional recovery.

4. Comparable Outcomes

National guidance recommends expectant management as a safe and effective treatment for most women diagnosed with a miscarriage.

• Around 50% of women who choose expectant management will complete the miscarriage naturally within 7–14 days but this may take up to 3-4 weeks in some women.
   
• The long-term outcomes e.g. future fertility is like other methods of miscarriage

What Are the Risks?

1. Uncertainty and Prolonged Waiting

• Expectant management may take several weeks to complete.
   
• Some women may find the waiting difficult emotionally or physically. Some women may find it more difficult to deal with the emotional and psychological trauma of early pregnancy loss if conservative management fails and additional treatment is needed.
   
• Bleeding and cramping may persist for up to 3 weeks.
   
• You may experience ongoing physical symptoms and emotional distress while waiting for resolution.
   
• The miscarriage may not resolve fully on its own, meaning patients may still require medical or surgical intervention later with medicine (misoprostol) or surgery; Manual vacuum aspiration (MVA) or surgical management of miscarriage (SMM).

2. Risk of Infection

• The risk of infection is about 1% (1:100)
   
• The presence of retained pregnancy tissue may increase the risk of uterine infection (endometritis). Please inform you doctor or the early pregnancy unit if you develop a fever, offensive vaginal discharge worsening abdominal pain or prolonged bleeding.
   
• If an infection is confirmed or suspected, you may require antibiotics or surgical evacuation.
   
• In rare cases, untreated infection can lead to sepsis, which may be life-threatening.

3. Unpredictable Bleeding and Pain

• Miscarriage symptoms can begin suddenly and may be distressing or overwhelming, especially if they occur without adequate preparation.
   
• Heavy bleeding, passing large clots, and intense cramping are common when the pregnancy tissue is being passed. In a minority of cases, emergency treatment may be required if the symptoms are severe. This may include emergency surgical management of miscarriage if there is excessive bleeding and/or severe pain.
   
• Around 2% (2 in 100) of women may experience bleeding severe enough to require emergency blood transfusion.
   
• When the pregnancy is being passed, this may get trapped in the cervix (neck of the womb). This may cause intense cramps, but this can often be removed by your clinician if identified during a vaginal examination.
   
• You should have access to emergency contact numbers NHS 111 or attend A&E if you experience very heavy uncontrolled bleeding, severe abdominal pain which isn’t improving with pain killers or you feel dizzy, lightheaded, unwell or collapse at home.

4. Emotional Distress

• We recognise that the emotional burden of waiting for a miscarriage to happen naturally can be significant.
   
• We also acknowledge that seeing pregnancy tissue or the pregnancy sac at home can be upsetting.
   
• Some women find expectant management emotionally difficult due to the ongoing uncertainty of what the process will feel like and if conservative management will be successful.
   
• Emotional reactions vary and some women may appreciate the privacy and time, while others may feel prolonged grief or anxiety.
   
• We will recommend assessing emotional support through your GP. We will also encourage you to seek further information and support helpful organisations like the

Miscarriage Association:
https://www.miscarriageassociation.org.uk/

Tommy’s:
https://www.tommys.org/baby-loss-support/miscarriage-information-and-support/about-miscarriage

We can also refer you for counselling to Mind matters or our women’s counsellors at St Peter’s Hospital.

5. Need for Ongoing Monitoring and Follow-Up

• There is a chance that the miscarriage may be incomplete, requiring follow-up treatment.
   
• Some women may need repeat scans to check for retained tissue. The national recommendation is that if after 2 weeks of conservative management and bleeding has not started, there is ongoing bleeding or the pregnancy test is positive after three weeks of expectant management, an USS should be performed to rule out retained pregnancy tissue.
   
• We understand that returning to our unit may be difficult emotionally, but this may be required if we suspect conservative treatment has been unsuccessful.

Follow-Up Care

• You may be offered a follow-up ultrasound (please note this isn’t required routinely for all patients).
   
• Please perform a pregnancy test after 3 weeks of conservative management. We can provide a urinary pregnancy test in our unit to for this purpose. If the test is positive, please contact our Early Pregnancy Unit for further advice.
   
• We will cancel any further midwifery, antenatal clinic and US scan appointments if you are booked in our hospital.
   
• If you are booked in another hospital, we will advice you to cancel your upcoming appointments by contacting your midwife if your pregnancy is already booked. If you feel this may be too distressing for you, please inform us and we will do our best to cancel the appointment/s on your behalf.
   
• We will share your USS report/s with your GP, and they will be informed your pregnancy is no longer progressing.
   
• If there is a short interval between your miscarriage diagnosis and your midwifery and / or scan appointments, you may still receive a message, text reminder or letter. This is because the appointment may have already been sent out to you, and we will be unable to recall the message or letter. We apologise in advance if this happens.

What Should I Do If I Miscarry at Home?

If you are managing your miscarriage at home, you may pass pregnancy tissue, including the pregnancy sac or, depending on the stage of pregnancy, a recognisable baby. This can be a deeply emotional experience, and you may wish to prepare for it in a way that feels right for you.

What might I see?

• The pregnancy tissue may look like blood clots or greyish matter.
   
• If your pregnancy was further along (usually after 8–9 weeks), you may see a small sac or even a recognisable embryo or baby.
   
• Some people choose to look at the tissue, while others prefer not to. This is entirely your choice.

If you pass tissue in the toilet or at home

You may choose to flush the pregnancy tissue away, and this is a natural and acceptable option. Please note, there is no right or wrong decision - what matters is that it feels appropriate for you.

I would like to have a memorial for my baby. How do I organise this?

There is no legal requirement to have a burial or cremation if your pregnancy ends before 24 weeks. Some women may find comfort in choosing to bury the pregnancy tissue in a private space, such as their garden. If you choose this:

• You must follow local guidance for safe and respectful burial.
   
• We recommend that you contact your local health authority (e.g. Environmental Health or your local council) for advice on regulations in your area.
   
• If you want a formal burial or cremation, you can get further advice from your local funeral director.

The hospital holds an annual baby loss memory day service as part of baby loss awareness week in October each year. Please let us know if you want more information as we can sign post you to our women’s bereavement counsellors at St Peters Hospital.

You may also get further advice and support by contacting the miscarriage association.

If you’ve been asked to bring the pregnancy tissue in for testing

Sometimes, we may ask you to return the pregnancy tissue to the Early Pregnancy Unit (EPU) for further testing. This is normally recommended after a third pregnancy loss. Some women may also choose to bring the pregnancy tissue to the hospital either for testing in the laboratory (to confirm pregnancy tissue) and/or for hospital approved sensitive disposal.

If so:

• Please place the tissue in the container we provided.
   
• If you were not given one, you can use a clean, sealable container such as a small jar or Tupperware box with a tight-fitting lid.
   
• Keep the container in a cool place (e.g. the fridge) and bring it to our unit from Mondays to Friday from 0900-1700 excluding bank holidays.

When to Seek Medical Advice?

Contact your doctor or go to A&E if you experience:

• Heavy bleeding (soaking more than 4 pads per hour and the bleeding is ongoing and not slowing down)
   
• Severe abdominal pain not responding to pain killers
   
• Fever or chills
   
• Foul-smelling vaginal discharge
   
• Feeling faint or dizzy or you collapse

When Can I Start Trying for Another Baby?

“There is no physiological reason to delay trying to conceive after miscarriage. Couples may try to conceive again as soon as they feel ready.”
Royal College of Gynaecologist and Obstetricians Patient Information, 2022

• There is no need no need to wait a specific amount of time before trying again. You and your partner can start to try for another pregnancy if this is desired when you feel ready.
   
• We advise you refrain from sexual intercourse until the bleeding has stopped to reduce the risk of infection.
   
• Once your miscarriage is fully complete and you are no longer bleeding, your period may return within 4–6 weeks if your cycles were previously regular. The first period may be heavier or lighter than usual for you.
   
• We will usually advice to wait for one period before trying to conceive. This helps us to date your pregnancy using the date of your last period. Please note that it’s not harmful if you fall pregnant before having a period. The pregnancy can be dated by ultrasound.
   
• Ovulation can occur as soon as 2 weeks after a miscarriage and so it’s possible to conceive before your next period. If you don’t want to get pregnant immediately after a miscarriage, please consider your options for contraception.

We advise the following pre-conceptual care:

Please optimise treatment for any condition (e.g. diabetes) prior to getting pregnant again.

Women with a BMI >30, have certain medical conditions or have had a previous baby affected by Neural tube defect e.g. Spina bifida require 5mg of Folic acid daily which can be prescribed by your doctor.

Please maintain a healthy weight, stop smoking, reduce alcohol and caffeine intake and eat healthily. You can get support to stop smoking: https://www.nhs.uk/better-health/quit-smoking/

Emotional Support

Miscarriage can be distressing. Support is available:

• Tommy’s:
  https://www.tommys.org/
   
• Miscarriage Association:
  https://www.miscarriageassociation.org.uk/
   
• Your GP or local Early Pregnancy Unit (EPU)

Contact Information

If you have any concerns, please contact:

• The Early Pregnancy Unit (EPU) on 01932 722662.
   
• NHS 111 (non-emergency advice)
   
• Emergency services (999) in urgent cases

You can get further information and advice from:

• EPU website ASPH:
  https://www.ashfordstpeters.nhs.uk/early-pregnancy-unit
   
• Association of Early Pregnancy Units (AEPU)
  https://aepu.org.uk/
   
• Miscarriage Association:
  https://www.miscarriageassociation.org.uk/
  01924 200799 (Helpline)
   
• National Institute for Health & Care Excellence (NICE) Ectopic Pregnancy and Miscarriage
  https://www.nice.org.uk/guidance/ng126
   
• Royal College of Obstetrics and Gynaecology
  https://www.rcog.org.uk/for-the-public/browse-our-patient-information/bleeding-andor-pain-in-early-pregnancy
   
• Early miscarriage | RCOG
  https://www.rcog.org.uk/for-the-public/browse-our-patient-information/early-miscarriage
   
• Miscarriage, what every woman should know. Professor Lesley Reagan. ISBN No. 0747530246
   
• Miscarriage, Ann Oakley ISBN No. 0140120246