Medical Management of Miscarriage

What is miscarriage?
Miscarriage is the loss of pregnancy before a fetus becomes viable. It is very common (up to 1 in 5 pregnancies) in the first 12 weeks of pregnancy but can occur at any time before 24 weeks of gestation. In most cases, there is usually no identifiable cause. About half of all early miscarriages are caused by random (one-off) genetic faults in the egg or the sperm, or during the development of the fertilised egg. The exact cause of these genetic faults is unknown, but they are more common with advancing maternal age.

Other causes include infection, abnormalities in the structure of the womb, exposure to certain toxins and certain medical conditions.

A miscarriage is usually diagnosed as complete, incomplete, or missed:

• A miscarriage is complete when the pregnancy tissue has passed out completely. No further treatment is required in this situation.
• A miscarriage is incomplete when some of the pregnancy tissue has passed out, but there are some pregnancy tissues that are still retained inside the womb.
• A missed miscarriage is diagnosed when the pregnancy has stopped progressing, but the tissue has not passed and is still inside the womb.
  

What are my treatment options?
Expectant Management
Some women prefer to allow the miscarriage to happen naturally. With adequate time (up to 8 weeks), expectant management is successful in achieving complete resolution of the miscarriage in about 50-80% of women.

Medical Management
This method can be considered in women who want to reduce the time taken for a complete resolution without any signs of infection, severe bleeding or anaemia and prefer to avoid a surgical evacuation. This method is successful in about 73-91% of women.

Surgical Management
A minor surgical procedure is performed to remove the pregnancy tissues from the womb usually under general anaesthesia. This is successful in about 95-99% of women.

What does medical management of miscarriage involve?
Medications
You will be given 2 types of tablets, taken 24-48 hours apart.

1. Mifepristone – This involves swallowing the tablet, which blocks the pregnancy hormones from acting on the womb and cervix in preparation for expulsion of the pregnancy tissues from the womb. Mifepristone alone can induce expulsion in 1% of patients. This step can be omitted in certain cases (e.g., incomplete miscarriage).
2. Misoprostol – It works by causing contractions of the womb and relaxation of the cervix which helps to expel the pregnancy tissues. These tablets will be given to you every 3-4 hours until the process is complete. They can be taken by placing them inside your mouth between the cheek and teeth or under your tongue or into the vagina.

Expulsion of pregnancy tissue
Once the fetus/pregnancy tissue is expelled, you will be assessed to determine if any portion of the pregnancy tissues are still retained inside the womb. Should there be any, you may require a minor surgery under anaesthesia to remove them.

Pregnancy tissues from pregnancy (less than 12 weeks gestation) will be sent for testing to check for evidence of molar pregnancy (abnormal pregnancy tissues which can occasionally progress to a cancerous form of gestational trophoblastic neoplasia, or GTN in short).

What if I have had a womb surgery?
If you have had any surgery (caesarean section, fibroid removal) in your womb before, you are at a higher risk of experiencing rupture of the scar on your womb during the procedure (1-2%). You may be closely monitored in High Dependency Unit (HDU) during this procedure.

What should I expect?
Vaginal bleeding
You may experience vaginal bleeding within 4 hours of taking the misoprostol tablets. Bleeding can range from light to heavy and is usually heavier than a normal period. It should decrease after the pregnancy tissues have expelled. On an average, the bleeding can last for 8 to 10 days. Please use sanitary pads and avoid tampons. Excessive bleeding that may require a blood transfusion is uncommon (<1%).

Abdominal cramps
You may experience abdominal cramps within 4 hours of taking the misoprostol tablets. The cramps can range from mild to severe and is usually more than a normal period. This should reduce after the pregnancy tissues have expelled and may continue for the next few days. Painkillers, heat packs, massage and ample rest may help to relieve the pain.

Other common side effects
You may experience other common side effects like fever, nausea, vomiting, diarrhoea, and dizziness during the process.

What does medical management of miscarriage involve?

1. Painkillers are given to relieve abdominal cramps.
2. A blood test will be done to determine your blood group before the procedure. You may be given an anti-D (RhoGAM) injection within 72 hours of expulsion of the pregnancy tissues if your blood group is Rhesus negative. This is to prevent the formation of antibodies that can affect your future pregnancies.
3. If your pregnancy is more than 20 weeks gestation at the time of this procedure, you may be prescribed cabergoline tablets to stop the breast milk production.
   
   

What should I watch out for?
Please seek immediate medical attention if you experience the following signs and symptoms:

• Fever
• Foul smelling vaginal discharge
• Excessive vaginal bleeding i.e., soaking 2 pads within an hour for 2 consecutive hours
• Severe abdominal pain which is not relieved by pain killers prescribed to you
• Feeling generally unwell

Some women may experience long-term emotional problems after a miscarriage. You should talk to your doctor about these feelings.

What is the schedule like?
PART 1: You will swallow the mifepristone tablet in the clinic. You need to return to take another dose if you vomit within 1 hour of taking mifepristone.

PART 2: 24-48 hours after the mifepristone tablet, you will be admitted to the ward for misoprostol treatment.

If you prefer to have the medical treatment at home (only applicable for early pregnancy before 10 weeks of gestation), take the misoprostol tablets according to your doctor’s advice.

The next step
A follow-up clinic appointment will be arranged for your review. Your next period may return approximately 4-6 weeks after a miscarriage. After this, you can try for another pregnancy once you and your partner are physically and emotionally ready. If you are not ready for another pregnancy, we recommend using reliable contraception until you are keen to conceive. Most contraceptive methods can be started immediately after a miscarriage.

KEY CONTACTS

• Urgent O&G Centre (UOGC)
  Operating Hours: 24-hour walk-in clinic
  Location: Basement 1, Women’s Tower.
  
  
• For emotional support:
  Medical Social Worker +65 6394-1028
  Central Appointments +65 6294-4050
  
  

References:

1. Chu J, Hardy P, Beeson L, Coomarasamy A. What is the best method for managing early miscarriage? BMJ. 2020;368:l6438. Published 2020 Jan 20. doi:10.1136/bmj.l6438
2. SchreiberCA, CreininMD, AtrioJ, SonalkarS, RatcliffeSJ, BarnhartKT. Mifepristone pretreatment for the medical management of early pregnancy loss. N Engl J Med 2018;378:2161-70. 10.1056/ NEJMoa1715726 29874535 
3. H Al Wattar B, Murugesu N, Tobias A, Zamora J, Khan KS. Management of first-trimester miscarriage: a systematic review and network meta-analysis. Hum Reprod Update. 2019;25(3):362-374. doi:10.1093/humupd/dmz002
4. Dunford A, Fyfe R. Combination therapy with mifepristone and misoprostol for the management of first trimester miscarriage: Improved success. Aust N Z J Obstet Gynaecol. ;58(4):438-442. doi:10.1111/ajo.12747 
5. National Institute for Health and Care Excellence (2019). Ectopic pregnancy and miscarriage: diagnosis and initial management. NICE guideline [NG126]. Retrieved from https://www.nice.org.uk/ guidance/ng126
6. Early pregnancy loss. ACOG Practice Bulletin No. 200. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e197-207
7. Niinimäki, M., Mentula, M., Jahangiri, R., Männistö, J., Haverinen, A., & Heikinheimo, O. (2017). Medical treatment of second-trimester fetal miscarriage; A retrospective analysis. PloS one, 12(7), e0182198.
8. Saraswat L, Ashok PW, Mathur M. Medical management of miscarriage. Obstet Gynecol. 2014;16:79–85.
9. Medical management of abortion. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 2.0 IGO.

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