Treatment, Management and Support

Unfortunately, no single treatment for every type of miscarriage is available. There are many causes and risk factors for miscarriage, it would be very difficult to target them all. Additionally, most miscarriages occur by chance due to chromosomal abnormalities that happen at the very earliest stages of pregnancy, so it cannot be predicted or prevented.¹

In some women and birthing people, there may be an underlying condition that puts them at a higher risk for miscarriage. In these cases, there may be some treatments available that may help improve pregnancy outcomes.¹ Your healthcare provider will be able to discuss these options if they are suitable for you.

Progesterone is a naturally occurring hormone that has a pivotal role in supporting pregnancy.² Some women and birthing people produce lower levels of progesterone, which is associated with threatened miscarriage and pregnancy loss.³

Vaginal progesterone may be offered to women with a history of recurrent miscarriage (three or more previous losses) who are experiencing bleeding in the first trimester of their current pregnancy.⁴

If a pregnancy loss has been confirmed with an ultrasound scan, but you have not yet physically miscarried, this is referred to as a missed miscarriage. You may also be diagnosed with an incomplete miscarriage if you have had some bleeding, but a scan confirms some of the pregnancy tissue remains in the womb.

In these scenarios, you will be given options on how to manage your pregnancy loss.

This is likely going to be an extremely distressing time, and the thought of making decisions can be overwhelming. But it is important to know the options available to you.

Sometimes, having options can help you feel more in control of the situation. You can choose what may best help you navigate the loss, with the support of your healthcare provider.

There are three ways to manage your miscarriage; expectant (natural), medical, and surgical.^5,6

Expectant management (or natural management) refers to waiting for the miscarriage to happen naturally, without medical intervention. It may be an appropriate option for you if you do not wish to take medicine or have surgery. However, there is no way to know when it will happen. If nothing has happened within 14 days, it is important to contact your healthcare provider.⁵

What will happen during expectant (natural) management?

If you choose expectant management, you are likely to begin to experience cramping, which is usually more intense than typical period pains.⁶

Bleeding should follow; this may start as spotting, but will usually progress to heavy bleeding, and can last between 1 to 3 weeks. You may also notice large clots and tissue, or you may pass your baby’s body. This can be very upsetting and may feel traumatic, so it is important when discussing expectant management, you consider how you will cope with this.⁷

If you feel you want to have your baby’s body for a burial, your healthcare provider will be able to offer you support and guidance to do this

A repeat pregnancy test is advised 3 weeks after symptoms subside. If the test remains positive, contact your healthcare provider for further guidance.⁶

If pain with or without bleeding persists or worsens, you should seek medical attention, as this may indicate there is some retained tissue remaining (an incomplete miscarriage). If this happens, you may have to consider medical or surgical management.⁶ However, this only affects ~20% of women and birthing people who choose expectant management,⁸ and many women still choose this method despite the risk.⁹

Are there any risks to consider with expectant (natural) management?

Expectant (natural) management can result in retained pregnancy tissue. This is referred to as an incomplete miscarriage. This tissue needs to be removed to reduce the risk of infection and will likely be done surgically.^5,10

Infection occurs in 1 in every 100 people. Your healthcare provider may prescribe you antibiotics as a precaution, but usually they will describe the signs of infection to be aware of:¹¹

To reduce the risk of infection, tampons are not recommended, and people should avoid sexual intercourse until bleeding has stopped.

Approximately 2 in every 100 women and birthing people who choose expectant management experience severe bleeding known as a haemorrhage. If this happens, it is likely you will require a blood transfusion, or in very rare cases, surgery to stop the bleeding.¹¹

The risks may appear scary, and this may impact your decision making, but your healthcare provider will ensure you are aware of any risks and will advise against this option if it is not suitable. Additionally, you can change your mind at any time if you feel unable to cope with this form of management.

Seek urgent medical help if:¹²

Medical management is an option for those who do not wish to wait for their miscarriage to happen or where expectant management is not clinically appropriate.^5,6,11 It involves taking medication orally and/or vaginally (pessaries) to start or complete a miscarriage.^5,11 Success varies, typically 54–80% of cases,¹³ similarly to expectant management.⁸

What will happen during medical management?

Treatment will vary dependant on whether it is to manage a missed miscarriage, or an incomplete miscarriage.

For missed miscarriages:

• A medication called mifepristone will be given as an oral tablet.⁶            
  Mifepristone blocks the hormone progesterone and triggers the release of prostaglandins, which help soften the cervix.¹⁴         
  You may be able to go home, as it may take a day or two for the physical symptoms of miscarriage to begin.¹¹
• After 48 hours, you will be prescribed misoprostol, either as an oral tablet, vaginal pessary, or a tablet that dissolves under your tongue.^5,6           
  Misoprostol is a synthetic prostaglandin that helps the uterus contract to expel the pregnancy tissue.¹⁵

For incomplete miscarriages:

• Treatment is with a single dose of misoprostol, either as an oral tablet, vaginal pessary or a tablet that dissolves under your tongue.^6,15

Are there any risks to consider with medical management?¹¹

Similarly to expectant management, there is a small risk that some pregnancy tissue is retained in the womb and surgery may be offered.

Infection may occur in 1—4 cases out of 100. To reduce the risk of infection, tampons are not recommended, and people should avoid sexual intercourse until bleeding has stopped.

The risk for haemorrhage for medical management is the same as expectant management (2 in 100 people).

You should be monitored in hospital during the latter stages of medical management, therefore the healthcare team supporting you will be aware of the symptoms for infection and severe bleeding and will be able to provide you with prompt treatment, if required.

Surgical management will require you to have a small operation, whereby the pregnancy tissue is manually removed. This can be done whilst you are asleep using general anaesthetic, or alternatively, whilst you are awake using local anaesthetic.^5,6,11

During the procedure, the surgeon will slowly dilate the cervix. Once dilated, a narrow suction tube is then inserted into the uterus to remove any pregnancy tissue. The whole procedure only takes approximately 5-10 minutes.¹¹

You may have slight cramping, and some bleeding following the procedure, but these should subside within a few days, with bleeding subsiding within 3 weeks.¹¹

Some people find the heavy bleeding associated with expectant and medical management distressing. Others have other children, or work commitments to consider and therefore feel like surgical management is the most appropriate option for them.16 Surgical management offers a more convenient option, as you will know when, where and how it will happen. It may also bring some comfort as you can choose to be asleep during the procedure, and do not have to be aware when passing the pregnancy sac with your baby.¹¹

Are there any risks to consider with surgical management?¹¹

Surgical management has a slightly higher risk of infection compared to expectant and medical management (occurring in 2—3 in 100 people). Surgical management also comes with additional risks, although these are very rare.

They include:

• Perforation of the uterus (<1 in 200 cases)
• Haemorrhage and scarring (<1 in 200 cases)
• Severe allergic reaction (1 in 10,000 cases)
• Death (<1 in 100,000 cases)
• Hysterectomy (<1 in 30,000)
• Very rarely, someone may develop Asherman's syndrome. This is a condition that results in severe scar tissue in the womb and may cause difficulty getting pregnant in the future

There is also the risk of retained tissue, despite surgical intervention (occurring in 5 in 100 cases). Therefore, an additional surgery may be required to remove any retained tissue.¹¹ Despite this, surgical management has the highest success rate for complete miscarriage (>90% of cases).

It may be helpful to your decision making to gain more information from your healthcare provider. You may consider asking:

Miscarriage and pregnancy loss is a life-changing event. It is common to feel depressed and anxious following a pregnancy loss, and for some time after, especially if this was your first pregnancy. There is no rule book for grief, therefore it is pivotal you have support available to you to help you.

Your healthcare team should provide you with any supportive measures necessary to help you navigate your loss.

Be kind to yourself. Make time to rest, heal and engage in activities you enjoy.¹⁷

There are also a number of charities that work with people who have experienced pregnancy loss and are available to contact yourself. Your healthcare team should be able to provide you with the relevant information for these locally to you.