Miscarriage

Have I made the right decision?

Many women feel they have enough information and are happy with their choice. This can be an emotional time that you may change your mind about your treatment. If you have any concerns please call us (our phone number is at the end of the leaflet).

What happens next? 

For a miscarriage to happen, anything that is inside the womb must come away. This will mean that you will bleed. The amount of bleeding and/or pain can vary. 

How soon will a miscarriage happen? 

50% of people miscarry within a week of their diagnosis, but the time it takes does vary from woman to woman. 

What sort of bleeding should I expect? 

• The amount of bleeding can depend on how many weeks pregnant you are and what was recently seen on your scan. 
• In very early pregnancy the bleeding may be like a period. 
• For many women the bleeding will be much heavier than this. 
• It is normal to pass some clots. Blood clots can vary in size. 
• There can be a lot of small clots and heavy bleeding. Some women pass clots from the size of a 50p piece, a golf ball, or even a few clots the size of a tennis ball. 

Will I see the pregnancy? 

In early pregnancy you may miscarry a small sac with the pregnancy inside. Most women cannot tell exactly what has ‘come away’. 

Once the pregnancy increases in size 

As pregnancy goes on, the sac becomes larger the pregnancy forms more. Bleeding from the miscarriage can be heavier too. Some women find seeing the pregnancy traumatic. For others, seeing it can help them understand and process what is happening. 

Will I have pain? 

Most women will have tummy pain – like strong period cramps. Some women describe it like feeling ‘contractions’. You should have painkillers at home in case you need them. 

Start with paracetamol, then add ibuprofen (Nurofen) if needed. You can also use codeine if the pain is stronger. Every women is different and the painkillers needed varies. 

What do I do if the bleeding is very heavy or the pain is very bad? 

Very few women come into hospital. However, there is a 24-hour ward contact number at the back of this booklet. 

• If you bleed much more than we have explained or your pain is too strong to manage (but you feel well), contact the ward for advice. 
• If you feel unwell and have lots of clots (the size of a tennis ball or the palm of your hand), feel faint/dizzy, call an ambulance. 
• If you start to feel unwell, and need advice, ask someone to stay with you. Then call the 24-hour ward number.

Medical management of miscarriage is successful in about 85% of women. It is most successful in women with early pregnancy who have had bleeding and pain within the last 24 hours.

The medicines used are called mifepristone and misoprostol. Most people cope well with these. 

What will happen today? 

• We will fully explain the treatment to you, and you will need to sign a consent form to agree to go ahead. 
• You will have blood tests to check your blood group, and your haemoglobin (to make sure you are not anaemic). 
• You may need a swab taken and may need antibiotics before starting treatment. 
• You should have someone to take you home from hospital in case you feel unwell. You should arrange for a responsible adult to stay with you overnight. 

How is the treatment given? 

We start today with one tablet of mifepristone, and we send you home with 4 tablets of misoprostol to be inserted into the vagina after 48 hours. Usually one dose of misoprostol is enough, but if nothing has happened within 48 to 72 hours of using the misoprostol more can be prescribed. 

What happens next? 

Some women start to miscarry after the first medicine is taken by mouth. We still advise you to continue with the misoprostol. 

For a miscarriage to happen, everything inside the womb has to come out. This will mean that you will bleed. This is heavier than a period. 

Strong period-like cramps are common, and women often describe them as contraction like pain. 

We will send you home with codeine tablets. You can also use ibuprofen if you need it. 

The amount of bleeding and/or pain varies as with an expectant miscarriage. But bleeding does tend to be heavier with medical management. It can start quickly and with little warning.

More women who have medical management need to see us with pain or heavy bleeding than with expectant management. Most women do not need to come into hospital. 

What side effects are there to the medication? 

The main side effects are: 

• Nausea and vomiting - usually stops in 6 hours of the medication. Anti sickness medication can be used. 
• Headaches are common. Paracetamol can help. 
• Diarrhoea - often resolves within 24 hours. 
• Chills - ‘chills’ are common, and usually pass quickly. 
• Fever (less common) does not indicate infection. If this continues after 24 hours seek medical advice. 
• Skin rash – usually goes away in 24 hours. Contact the clinic or ward if you are worried. 
• Most people do not have any side effects. 

What do I do if the bleeding is very heavy or the pain is very bad? 

If you bleed much more than we have explained or your pain is too strong to manage (but you feel well), contact the ward for advice. 

If you feel unwell and have lots of clots (the size of a tennis ball or the palm of your hand), feel faint/dizzy, call an ambulance. 

If you start to feel unwell, and need advice, ask someone to stay with you. Then call the 24-hour ward number. If you cannot reach the ward, call 111. 

After medical or expectant management of miscarriage 

• If we think a miscarriage has happened, lighter bleeding can continue on and off for up to 3 weeks. This gets less over time. 
• If not much bleeding or no bleeding has happened, we will discuss with you what to do next. We will make a plan over the phone. You may need a further scan to review your situation. 

Do I need to come back and see you after expectant management or medical management of my miscarriage? 

Most women do not need to return to hospital for follow-up. We know it can be difficult returning to a busy clinic. 

You should do another pregnancy test after 3 weeks to make sure it is negative. Your bleeding and pain should have settled by this time. 

If your test positive or you still have symptoms of pain and/or bleeding, we will need to see you. We will scan you to make sure the lining of the womb is back to normal.

If you feel that you need a follow-up visit, tell us and we will arrange to see you face-to-face.

If you book a follow-up appointment but do not attend, we will contact you by phone.

This means removing a pregnancy or tissue (under local or general anaesthetic) relating to the pregnancy from the womb. We do the surgery carefully and as soon as possible. 

What are the benefits of the operation? 

You do not need to go through the natural process of miscarrying the pregnancy. 

You will know exactly when the operation can happen instead of waiting to see when a natural miscarriage will occur. 

It helps some women have closure/end point to a pregnancy that has sadly failed. 

How quickly we can book you for surgery does vary. If we cannot book you as soon as you had hoped, please feel free to contact the Gynaecology Coordinators to see if your date can be brought forward. 

• Phone 0117 414 6791 

How is it done? 

The operation can be done local or general anaesthetic. Careful examination helps to assess the size and position of the womb. The cervix (entrance to the womb) is then gradually opened. The pregnancy or pregnancy tissue is then removed.

What is the benefit of having the procedure done under a local anaesthetic (while you are awake)? 

Many studies show that doing the procedure under local anaesthetic is safe and women cope well. 

• You can eat and drink normally. 
• You avoid the risks of a general anaesthetic. 
• You recover from the procedure more quickly. 
• You can return home very quickly after your operation.

How is the procedure done under local anaesthetic? 

• You will arrive in the Cotswold Clinic two hours before the procedure and you will be asked to take some tablets called misoprostol. These help to soften the neck of the womb and to open more easily.
• We recommend that you bring someone with you who can come home with you afterwards. 
• You should take paracetamol or ibuprofen one hour before the start of the procedure. (Please bring these in with you so you can take them at the right time). 
• Wear comfortable clothes and you will need to remove all clothing below the waist. 
• You will lie on a couch and your legs will be supported using special leg supporters. 
• When you are ready, the doctor doing the procedure will do an internal examination and insert a speculum (similar to having a smear test). 
• The doctor inject local anaesthetic in the neck of the womb. As you will be awake, you will be aware of sensations like touch, pressure, and temperature. Some women have period-like cramps. The local anaesthetic does not completely remove the cramping and if severe we can use Entanox (gas-and-air) as well. 
• The neck of the womb will be gently opened and the contents of the womb removed using a hand-held suction device. 
• The procedure only takes about 10 minutes. 
• A nurse will be at your side through the whole procedure. If at any time the procedure is too uncomfortable you can ask the doctor to stop. Alternative treatment can the be reviewed. 
• When the procedure is complete you will be observed in the recovery area next door for a short time before being allowed home. 

What happens when the procedure is done under general anaesthetic? 

• You are usually in hospital as a day case and stay about half a day. 
• You should not have anything to eat for 6 hours before the procedure; you can drink water until you arrive. 
• 1 to 2 hours before the procedure you will have some medication in the vagina to soften the neck of the womb. 
• Before your surgery, you will see the doctor and the anaesthetist. You will be transferred to the theatre where a small plastic tube will be placed in the back of your hand to give the medicines to put you to sleep. 
• The operation will be through the vagina and suction is used to remove the pregnancy/sac from the womb. 
• You will wake up in the recovery area and when you are properly awake you will return to the ward. You may feel drowsy from the anaesthetic, but this will wear off. 

What will I need to bring into hospital with me? 

• An overnight bag is a good idea (although you probably do not need it). 
• Books/magazines to occupy time. 
• Sanitary towels. 
• Wash thing (soap). 
• Dressing gown and slippers. Comfortable clothing for going home. 
• Make sure you have basic painkillers at home, like ibuprofen and paracetamol. 

How soon can I go home after a general anaesthetic? 

After the operation we keep you for a few hours to make sure that you feel well. Before going home you need to: 

• have something to eat and drink (without feeling sick)
• be up and about without feeling light-headed/faint
• pass urine (pee) without any problems
• have stable blood pressure, pulse, temperature, breathing, and oxygen levels
• have minimal bleeding after the operation
• have a lift home and somebody with you overnight

After surgical management of miscarriage, it is essential that your pregnancy test comes back to negative. We will give you a pregnancy test and a letter about the pregnancy test to go home with. We advise you to do this 3 weeks after your surgery. 

You should not have unprotected intercourse (sex) until it is negative. 

If you are still bleeding or having pain, or if the test is positive, it is important to contact us. We will need to review you in hospital to make sure that the lining of the womb is back to normal. 

What are the risks of surgical management of miscarriage? 

Risk of general anaesthetic (and other medicines used) are rare. 

• Heavy bleeding is uncommon - very occasionally a blood transfusion is needed. 
• Infection (3 in 100) - symptoms are temperature and a nasty smell to any bleeding or discharge. This would require review with your GP and antibiotics. 
• Perforation (a small hole made in the womb) (5 in 1000). This sometimes requires further surgery, which is usually keyhole surgery to assess any damage to the womb (laparoscopy). Rarely a laparotomy is needed where a bigger cut is made in the tummy. 
• Need for repeat procedure due to failure of the original operation (up to 5 in 1000). 

After a perforation, will I have a problem in the future? 

• Usually the womb heals well without any long-term problems. There are some cases where it can affect future fertility but this is not common. 

Will I bleed or have pain after the surgical management of miscarriage? 

• It is normal to have some bleeding like middle or end of a normal period. We do not expect you to bleed heavily. 
• Some period-like cramps are normal. Paracetamol and ibuprofen tablets will usually help. 

Our aim is continuity of care, however this is not always possible, and when you are in hospital you will be looked after by a team of doctors and nurses.

Normally up to 7 to 10 days. It is not usual to bleed or have pain for longer than 3 weeks. If you still have symptoms after 3 weeks, seek advice. If the bleeding gets heavier or smells bad, you should speak to your GP. You should use sanitary towels and not tampons during this time to avoid infection. 

In early pregnancy it is not possible to tell you.

If a miscarriage happens in hospital, one of our chaplains oversees the cremation of any pregnancy. This makes sure it is done with dignity. Cremations happen every few month. The chaplain oversees the process, but there is no religious element to the cremation. 

We wish to be sensitive when we talk about miscarriage - but we also want to make sure you know all the choices you have. 
Some women choose to bury the pregnancy remains in their garden or arrange for a plant pot to be a memory with a plant.  

You can choose to take the pregnancy (or any pregnancy tissue) home. Individual cremation or burial can then be arranged yourself or with the help of the hospital chaplain who will help with practical steps. 

Cremation at the hospital is also available for women who miscarry at home.  

Please call us if we can provide any further information or support. 
 

If you have a regular cycle, you can expect your periods to return in 4 to 5 weeks. It is then safe to use tampons if you wish. However, some women find their periods take longer to return to normal.  

50% of women will miscarry due to a one-off genetic problem with the pregnancy.  

If you have had one miscarriage, you have an 85% chance of a successful pregnancy next time. There is a 10% increase of further miscarriage if you have had one already.  

People react to miscarriage in different ways. Some people take time to feel normal again. Partners/family can also react in many ways.   
If you work, you may choose to take some time off, and we will happily provide a sick note. 

You may go through many emotions such as anger, sadness, depression, feelings of guilt, tiredness and asking “why me?” All of these emotions are normal and a part of the grieving process.  Be aware that some women do not experience all of the emotions above - miscarriage is a personal experience. 

It will take a couple of weeks for your body to settle down, wait till bleeding has stopped. Wait until you have had a negative pregnancy test. 
 

We have free items to help memory making - these include candles, hearts, and memory boxes. You can see these at any point. We can also offer a picture of the scan you had if this was in the early pregnancy clinic. These are not right for everyone – but important to let you know they are here for you.  
A Book of Remembrance is kept in the Hospital Chapel and there is an annual memorial service (usually in May). If you would like a page in this book please ask to speak to one of the Chaplains or contact them after you have gone home on 0117 414 3705.  

Your body will return to normal quickly, and this means you could conceive quickly. Trying again is a personal decision, and waiting for one normal period is often suggested. But there is no evidence to say you should wait a specific amount of time. 
 

A well balanced, healthy diet is important before and during pregnancy. 

This is a naturally occurring substance in many foods. It has been shown that women who have enough folic acid reduce the chance of having a baby with a condition like spina bifida. 

Foods with lots of folic acid include breakfast cereals and leafy green vegetables. Folic acid tablets are available from the chemist and should be taken prior to conception until 12 weeks into pregnancy. 

Smoking is a health hazard to both mother and baby. If you smoke you may also find it more difficult to conceive. Women who smoke have more complications in pregnancy, and it is good advice to give up smoking if possible. At the very least start cutting down. Your GP can give advice and support with this. 

Medicines should only be taken in pregnancy after discussion with your doctor.

• The Early Pregnancy Clinic Southmead Hospital Monday to Friday, 8:30am to 3:30pm (Not available weekends or bank holidays).  
  Phone: 0117 414 6778 
• Cotswold Ward – 24 hour phone number 
  Phone: 0117 414 6785 
• The Miscarriage Association  
  Phone: 0300 003 6464  
  E-mail: info@miscarriageassociation.org.uk  
  Website: www.miscarriageassociation.org.uk  
• North Bristol NHS Trust Chaplaincy 
  Phone: 0117 414 3700 
• The Ectopic Pregnancy Trust 
  Address: PO Box 485 Potters Bar EN6 9FE 
  Phone: 02077 332 653 
  Website: www.ectopic.org/trust 
• Bristol Cruse – Bereavement Care 
  Free, confidential help to bereaved people in Bristol and Weston super-Mare. 
  Phone: 0117 9264 045 
• British Association for Counselling and Psychotherapy (BACP) 
  To find accredited counsellors in your area.  
  www.bacp.co.uk 
• Bereavement midwives 
  Phone: 07867196995 
  Email: bereavementmidwives@nbt.nhs.uk 
• To give feedback including compliments, concerns, complaints, and suggestions  
  www.nbt.nhs.uk/patients-carers/feedback 
  Phone: 0117 414 4596 
   

Ectopic pregnancy and miscarriage: diagnosis and initial management. Reference number:NG126 Published: 17 April 2019. Last updated: 23 August 2023

Mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomised, double-blind, placebo-controlled trial Volume 396, Issue 10253 p770-778September 12, 2020

Mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomised, double-blind, placebo-controlled trial Volume 396, Issue 10253 p770-778September 12, 2020