We are very sorry that you are having a miscarriage. This leaflet explains more about medical management
of miscarriage, including the benefits, risks and alternatives, and what you can expect. If you have any
further questions, please speak to the nurse or doctor caring for you in the early pregnancy advisory clinic

What is medical management?

Sometimes the symptoms of a miscarriage are not immediately obvious. You may have had a scan that
showed that the pregnancy stopped developing some time ago. Alternatively, your scan may have shown
that a miscarriage has started but some of the pregnancy remains inside the womb. Instead of waiting for the
miscarriage to happen naturally, medical management uses a medication called misoprostol to speed up the
process of miscarriage. Misoprostol works by preparing your cervix and making your womb contract to help
push out the pregnancy.

What are the benefits?

  • You are more in control of your treatment
  • If successful, medical management avoids surgery and general anaesthesia
  • The risk of infection is low
  • Medical management is successful in about 80-90% of cases
  • What are the risks?
  • Bleeding can be heavy and you will pass clots. Although rare, if bleeding is too heavy and you become anaemic, you may require a blood transfusion
  • The process of miscarriage can be painful. Most women have strong period-like pain and cramps and can find the process very painful, especially as the pregnancy is expelled
  • The tablets do not work for everybody. They fail to work in 10-20% of women. The doctor or nurse looking after you will help advise you about your likelihood of success
  • If the treatment does not completely empty the womb, there is a risk that hospital admission or surgery may be required
  • Bleeding can continue for up to three weeks after the treatment and some women may need several follow-up scans to monitor progress

Are there any other alternatives?

If suitable, your nurse or doctor will discuss any alternative treatments available to you. Leaflets are available explaining these options:

  • • Expectant management – waiting for the pregnancy to pass ‘naturally’ through the vagina, without any medical intervention
  • Surgical management of miscarriage – an operation to remove the remains of the pregnancy under general anaesthetic (while you are asleep)

Giving my consent (permission)

We want to involve you in decisions about your care and treatment. If you decide to go ahead, you will be
asked to sign a consent form. This states that you agree to have the treatment and you understand what it
involves. If you would like more information about our consent process, please speak to a member of staff
caring for you.

We need to inform you that although misoprostol has been used in the treatment of miscarriage for a long time,
it is not licensed for this use. Our leaflet, unlicensed medicines explains what this means.

How can I prepare for medical management?

  • If you have children at home, we recommend you organise childcare during the treatment
  • It is important to have somebody with you whilst you are miscarrying
  • Ensure you have a good supply of large sanitary pads
  • Ensure you have an adequate supply of pain medication such as paracetamol

What happens during the medical management?

You will need to insert the misoprostol tablets into your vagina at home. We recommend you insert them in the
morning so you are able to access care and contact us throughout the day should you have any questions or
concerns. To insert the tablets you need to first pass urine, and then push each tablet as far as you can up into
your vagina. Then put on a sanitary pad and lie down for one hour. This prevents the tablets from falling out
and gives your body time to absorb them. After the hour you can get up and move around as normal.
Pain and bleeding usually occur within one to two hours of using misoprostol. If nothing happens after three
hours of inserting the misoprostol, you will have been issued with a further, smaller dose which you can again
insert into the vagina or take orally. We expect bleeding to be heavy with clots. You may see some of the
tablets come out with the bleeding, do not worry about this.

It is not unusual to soak four to six pads in the first hour. You may see the pregnancy sac, but it is unlikely you
see a recognisable baby as it is still very early in the pregnancy. Most women experience strong cramps and
abdominal pains. These pains are usually strongest while the bleeding is heavy and should ease off quite
quickly once the pregnancy remains have passed, it is also common to have some nausea and vomiting.
We advise that you use pain relief medication such as ibuprofen and paracetamol.

We understand it can be a traumatic experience to see and have to deal with your pregnancy remains.
The EPAC team will do their best to honestly explain what you may see and what to expect.

Often women have an urge to sit on the toilet whilst they are miscarrying as the position is more comfortable.
Therefore it is not uncommon for women to pass the pregnancy remains into the toilet. You must do what you
feel most comfortable to do if this happens. There is no right or wrong and everybody is different. If you wish
to flush the toilet that is perfectly acceptable. Other people prefer to retrieve the remains to organise disposal.
Alternatively EPAC could provide you with some cardboard toilet liners if you would prefer.

Disposal options:

  • Bring the remains back to EPAC where we can arrange either communal sensitive incineration or communal burial. EPAC will give you a leaflet explaining these
  • Make your own arrangements with a funeral director for private cremation/burial
  • Legally bury the remains on private land when adhering to the regulations.

Please see http://www.naturaldeath.org.uk or http://www.environment-agency.gov.uk for further information
If you would like to have the pregnancy remains tested please discuss this with a nurse. We are unable to offer
genetic testing unless this is your third consecutive miscarriage.

Are there any side effects of the medication?

  • Chills are a common side effect of misoprostol but this should not last long. Fever is a less common side effect and does not mean you have an infection. If the fever or chills last longer than 24 hours after taking the misoprostol please contact EPAC or your GP
  • Nausea and vomiting may occur but should get better within two to six hours
  • Diarrhoea may occur after using misoprostol but should get better within a day
  • Skin rash may occasionally occur after using misoprostol
  • When do I need to worry or contact a health professional?
  • If you have very heavy bleeding and it does not seem as though it is getting better
  • If you feel light-headed or dizzy
  • If the pain medication you are taking is not working and you are still in significant pain
  • You have signs of infection, such as a raised temperature, flu-like symptoms or vaginal discharge that looks or smells offensive
  • It is normal to bleed for up to two weeks afterwards with additional spotting for a further week. If you have continuous bleeding for more than two weeks, please contact us
  • If any of the side effects mentioned above have not resolved within the specified time

If you have any of these symptoms, are concerned about the amount of pain or bleeding you have, or have
any questions about medical management, contact your GP or EPAC on 01935 384385 (Monday to Friday
8.30am-8pm, weekends and bank holidays 8:00am-4pm).

In an emergency you can contact the NHS helpline on telephone number 111, or attend your nearest emergency
(A&E) department.

General advice

  • We advise you to use sanitary pads and not tampons to lessen the chance of infection.
  • We advise you to not have sex until your bleeding has stopped. This allows the neck of the womb (cervix) to close and reduces the risk of infection.
  • You can shower as normal but we advise using plain water without scented products or antiseptics.
  • Lying in a hot bath can make you feel faint, so it may be better to avoid this.

Will I have a follow-up appointment?

We do not routinely organise a follow up. You will be asked to perform a urine pregnancy test at home after
two weeks. If you are still bleeding or have a positive pregnancy test please contact EPAC clinic as we may
arrange a scan to check that you have completely miscarried.

How might I feel after medical management?

It is normal to feel tired after a miscarriage, both due to physical symptoms and the emotional impact of the
miscarriage. Miscarriage can cause a range of emotions for you and your partner. These may include anger,
guilt, frustration, despair and feelings of loss and extreme sadness. The Miscarriage Association (details
below) offers many support services, including information leaflets, online forums and telephone advice and
support. Yeovil Pregnancy Crisis Centre (see below) also offer free counselling and support

When can I try to get pregnant again?

We advise you to wait for at least one period before trying for a new pregnancy. Some people prefer to wait
longer as miscarriage can be a very upsetting time and they feel they need longer to recover. If you require
contraceptive advice please discuss this with your GP. If you are planning a pregnancy after your first period,
we advise you to take folic acid (400 micrograms daily). This is available from your local pharmacy.

When can I return to work?

This will vary for each woman. You should be able to go back to work after a week or so. However, it can take
longer than this to come to terms with your loss and your GP can provide a sick certificate if required. If you are
off work for seven days or less, you can self-certify.

Contact us
If you have any questions or concerns about medical management or your symptoms, please contact the early
pregnancy advisory clinic (EPAC) on t: 01935 384385 (Monday to Friday 08:30-8pm, Saturday and Sunday and
BH 08:00am-4pm). Outside of these hours, please contact the NHS advice number by calling t: 111, or speak to
your GP.

Useful sources of information
The Miscarriage Association
provides support and information to anyone affected by miscarriage, ectopic pregnancy or molar pregnancy.
tel: 01924 200799, Monday to Friday, 9am-4pm web: www.miscarriageassociation.org.uk
Yeovil Pregnancy Crisis Centre
web: www.ypcc.co.uk tel: 07896 630296

Ref: 14-20-175
Review Date 04/22