Leaflet Details
| Title | Outpatient Medical Management of Miscarriage (OMMM) |
| Department | Early Pregancy Unit |
| Author(s) | Dr Muralitharan, Miss Izuwah-Njoku |
| Review Date | May 2025 |
| Next Review | May 2028 |
| Download | A5 Booklet PDF |
| Accessibility Options | Click on the Recite Me button to show our accessibility resources |
Patient Information
Introduction
We are sorry that your scan has shown that your pregnancy has ended, and a diagnosis of a miscarriage has been made. This is not your fault or your partner’s fault and sadly, about one in four women/people lose their baby in early pregnancy. It may be that you have had very few or no symptoms at all, such as bleeding or pain, but this is not unusual in some types of miscarriage, and you will have been given verbal information on how this treatment works and what to expect. This written information is for you to take home, please keep it somewhere safe, as you may want to look at it over the next few weeks.
This leaflet should be read in conjunction with expectant management of miscarriage, surgical management of miscarriage, manual vacuum aspiration and sensitive disposal patient information leaflets.
How does the treatment work?
The medications you will be given are called Mifepristone and Misoprostol. You will be given Mifepristone, one tablet orally in EPU and you will be observed for 15 minutes in the unit. Two days later, you need to place four tablets of Misoprostol as high as possible into the vagina at home. To aid placement, you may use a tampon to push the tablets up in the vagina, but this is not always necessary.
Mifepristone is a tablet which acts by blocking the effects of progesterone, an important hormone that helps to maintain a pregnancy. It makes the uterus (womb) more sensitive to contractions and helps in the next stage of medical miscarriage management using Misoprostol.
Misoprostol relaxes the neck of the womb and causes the muscles of the womb to contract. The pregnancy should come away in the bleeding that follows. If you do not wish to insert the tablets into the vagina, you can put them under your tongue or swallow them. Taking Misoprostol orally is equally effective, but you are more likely to have side effects.
Is the treatment safe?
Serious complications with Mifepristone are rare. Vaginal bleeding (like a menstrual period) can start 1 to 2 days after taking mifepristone, though some women may start bleeding earlier.
Mifepristone and Misoprostol have been extensively studied and are commonly used for the treatment of miscarriage but the use of misoprostol for miscarriage management is off license (the drug company did not originally market it for this purpose). It has proved to have a very good safety record. Some other side effects associated with medical management of miscarriages include nausea, vomiting and diarrhea.
Each type of treatment for a miscarriage has some risk or side effect. A recent study has shown that the combination of Mifepristone and Misoprostol is more effective than Misoprostol alone in inducing a miscarriage. 85% of women will successfully miscarry using this method. Based on a single local audit we have carried out, our success rate for medical management is about 60-65%, which is lower than the success rate quoted in the national study. If the treatment is successful, you can avoid surgical treatment. Please refer to the surgical management of miscarriage leaflet.
A small number of women will have problems with heavy bleeding, incomplete miscarriage or infection. If this happens, then a surgical procedure may be needed. The risk of developing an infection is approximately 2%. If you develop a fever or offensive smelly discharge, then please contact your GP, the Early Pregnancy Unit (EPU) or attend A & E if you feel extremely unwell.
Length of time for treatment
The medical management treatment happens in three stages:
The first stage of the treatment takes place in EPU
The second stage of the treatment takes place at home at a time more suitable for you.
The third stage is a repeat pregnancy test, three weeks after your treatment. See details below please.
First stage of the treatment:
You will need to attend the hospital to take your first medication (Mifepristone) and to collect your second medication (Misoprostol). You will be seen by one of our clinical nurse specialists or doctors.
At this appointment a clinical nurse specialist or doctor will take a medical history from you and get your consent for the treatment.
Blood tests will be taken to determine your blood group and iron level. In keeping with NICE guideline, we don’t offer Anti D to Rhesus negative women or person having medical management of miscarriage.
You will be advised to take the first medication orally in our unit and we will prescribe and give you Misoprostol tablets, Codeine pain relief and anti-sickness medication. You may need additional pain relief such as paracetamol and/or ibuprofen which you can purchase over the counter.
Second stage of the treatment:
You will start the next stage of treatment at home; two days after taking Mifepristone.
We would advise that you stay at home for the day and arrange for someone responsible to be with you. It is advisable to commence the treatment in the morning or at a time that suits you. You should commence the second stage of treatment by inserting the Misoprostol tablets, as high as possible into the vagina. Some women may find it easier to push the tablets higher into the vagina using a tampon. If using a tampon, please remember to remove it no longer than four hours after insertion.
We advise that you rest on the bed for 45 minutes following the insertion of the tablets, to allow time for them to be absorbed. After this time, you can move around as normal.
After administration of Misoprostol, you can expect bleeding and menstrual type or moderate crampy abdominal pain to start within 24 hours usually. Please contact EPU if bleeding has not started 48 hours after treatment. It is difficult to say when the pain will start and finish, or how much pain you will feel, as everyone’s experience is different. If you have taken the pain relief that we provided and your own pain killers and the pain is still not controlled, you should call the EPU for advice or attend A & E if you feel your pain is unmanageable.
Most women miscarry within 48 hours of taking Misoprostol, however it is important to understand that not everyone does.
The amount of bleeding also varies but it is likely that you will experience heavy bleeding which is usually heavier than a normal period and you may pass clots and / or pregnancy tissue. These clots may be as big as the palm of your hand. We would advise that you use sanitary towels instead of tampons to reduce the risk of infection.
Some people may find hot water bottle comforting but this must be used with caution to avoid any burns.
Get in touch with the EPU or attend hospital if:
- The bleeding is significant enough to make you feel unwell, dizzy, faint, or if you soak more than 2 heavy sanitary pads per hour for over 3 hours.
- You develop a high temperature
- You experience severe pain or cramping that cannot be controlled with the pain killers provided by EPU and over the counter pain killers.
Please contact the EPU clinic after 24 hours of Misoprostol or the next working day (if weekend or bank holiday) so we can find out how you are. We are open Monday to Friday (excluding bank holidays) from 0900-1700. If you feel you require emergency treatment outside of the hours above, please attend A&E.
The use of Misoprostol for management of miscarriage is an off-license indication. If you require a second dose, you will need to return to EPU to get a further dose. If you don’t use this medicine, please don’t offer it to someone else or flush it down the toilet or put it in the bin. Kindly return any unused Misoprostol to EPU or your local chemist / pharmacist for disposal.
Third stage of the treatment
The third stage is a repeat pregnancy test, three weeks after your treatment. If the test result is positive, you must contact the Early Pregnancy Unit to arrange a follow-up scan and plan further treatment. If the pregnancy test is negative, we still recommend you contact EPU with the result so we can update your records. If the pregnancy test is negative after three weeks but you continue to bleed, please contact our unit for further advice.
What if I don’t bleed or the bleeding is light after 48 hours of Misoprotol?
If there is no bleeding or minimal bleeding after 48 hours of Misoprostol, this may mean the treatment has been unsuccessful. Please contact EPU so we can discuss further options for treatment which may include repeat treatment with Misoprostol, surgical treatment or rarely, expectant (watching and waiting) management.
What happens after successful treatment with Misoprostol?
Bleeding will be most intense during the first few days and should stop within 2-3 weeks, and you may have period type pains. You will have been given suitable painkillers by the hospital, take them as prescribed.
If your periods are regular, you will usually expect your period within 4-8 weeks, although you may find that it is heavier than usual. Your periods should return to their normal pattern for you, but it may take a few cycles for this to happen.
What happens to the pregnancy tissue?
During the miscarriage you will pass pregnancy tissue that may not be recognizable; however, you may see a small sac or fetus. If you are at home, you can use the toilet as you would with a heavy period. If you prefer, you can bring the pregnancy tissue into EPU, in a clean dry container, which we can provide if you request it. The pregnancy tissue could then be sent to the laboratory for examination and/or we can sensitively dispose of the pregnancy remains for you. If you would like more information about this, please speak to a nurse or request the sensitive disposal patient leaflet. You may choose to arrange a private funeral or cremation. Please discuss your wishes with your local undertaker. You may also bury the pregnancy remains in your private garden. If you plan to do this, please contact your health authority for specific requirements.
Returning to work and impact of early pregnancy loss on your psychological well-being
The time you can return to work varies from person to person and the type of work that you do, as well as how you feel physically and emotionally. You may have feelings of anxiety, distress, sadness and loss. These are all common after a miscarriage and for many women/people these feelings should improve with time. Please accept the help and support of your family and friends.
If these feelings are more prolonged and you or your partner are finding it difficult to cope with, you may benefit from talking to someone. Please contact your GP to discuss counselling or contact the Miscarriage Association using the details below for further support. The EPU can also support you with self or clinician referral to our local counselling service e.g. mind matters or occasionally our Ashford and St Peters Midwife counsellors.
The optimal time to try for your next pregnancy
This is an individual decision. Waiting for at least one normal period will help accurate dating. If you conceive before your period, this isn’t harmful and will not increase the risk of miscarriage. Please take folic acid, avoid smoking, alcohol, caffeinated drinks, eat a balanced healthy diet, exercise regularly and ensure any chronic medical conditions are well controlled before you try to conceive again. If you don’t wish to conceive again, please ensure you get contraceptive advice from your GP or your local Family planning clinic.
What happens if I get pregnant again?
Getting pregnant after an early pregnancy loss may bring back feelings of anxiety and fear. Please be assured that most miscarriages are a one-off event and may not happen again. If you notice pain and/or bleeding after a positive pregnancy test, your healthcare professional may refer you or you may self-refer to the EPU by visiting our website and filling the self-referral form on https://www.ashfordstpeters.nhs.uk/early-pregnancy-unit.
Further information or queries?
For any other problems relating to your treatment or for further advice and support, please contact the Early Pregnancy Unit on 01932 722662.
For all our leaflets and other information about our unit, please visit our website above. Your feedback is invaluable to us and there are QR codes in the unit and on this leaflet, you can scan to offer your feedback. Thank you.
You can get further information and advice from:
Early Pregnancy Unit
Ashford and St Peters Hospital NHS Foundation Trust website;
https://www.ashfordstpeters.nhs.uk/early-pregnancy-unit
Association of Early Pregnancy Units (AEPU)
https://aepu.org.uk/
Miscarriage UK
https://www.miscarriageuk.org
https://www.youtube.com/watch?v=hoSrLtRbB5A
(YouTube video on miscarriage association discussing counselling after miscarriage). Please note that this video content is hosted by YouTube, and they will collect visitor information such as viewership data. An "incognito mode" is available on mobile devices, while desktop users may wish to enter the private mode on their browser.
National Institute for Health & Care Excellence (NICE)
Ectopic pregnancy and miscarriage: diagnosis and initial management
https://www.nice.org.uk/guidance/ng126
NHS 111 Service
https://111.nhs.uk
Royal College of Obstetrics and Gynaecology
https://www.rcog.org.uk/for-the-public/browse-our-patient-information/early-miscarriage/
https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/diagnosis-and-management-of-ectopic-pregnancy-green-top-guideline-no-21/
