Leaflet Details
| Title | Surgical Management of Miscarriage (SMM) |
| Department | Early Pregnancy Unit / Obstetrics and Gynaecology |
| Author(s) | Dr Krishanna Kathirgamanathan, Miss Ngozi 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
About the Leaflet
This leaflet is intended to give you additional information to that received from your healthcare professional.
Early Pregnancy Unit opening hours:
| Open: | Monday to Friday | 0900-1700 |
| USS scanning hours: | Monday to Friday | 0900-1300 |
Phone: 01932 722662
Early Pregnancy Unit website:
https://www.ashfordstpeters.nhs.uk/early-pregnancy-unit
Early Pregnancy Unit email:
Contents
- Introduction
- What are my options if a miscarriage is confirmed
- What is Surgical Management of Miscarriage (SMM)
- Why might SMM be appropriate for me?
- What are the risks involved?
- Do I have to decide now?
- What happens if I think I have miscarried before the procedure?
- What do I need to do to prepare?
- What happens following the procedure?
- How will I feel after my operation?
- How to reduce the risk of blood clots?
- When should I seek help?
- When can I try for another baby?
- Returning to work
- Further questions and feedback
- Further information and support
Introduction
We are deeply sorry to hear about your loss. Sadly, miscarriages are common and occur in 1 in 4 pregnancies and it is not caused by anything you have or haven’t done. We don’t always know why miscarriages occur but one of the most common causes of miscarriage is chromosomal abnormalities and this happens by chance. Other factors that may affect the risk of miscarriage include your age, the biological age of the father, previous pregnancy history, ethnicity, some medical conditions and lifestyle choices.
https://www.tommys.org/baby-loss-support/pregnancy-loss-statistics
(Miscarriage Statistics and Rates in the UK - Tommy's)
This leaflet will provide you with additional information from that received from your health professional. This leaflet should be read in conjunction with leaflets on other options for miscarriage management e.g. expectant or medical management of miscarriage, manual vacuum aspiration and sensitive disposal patient information leaflets.
What are my options if a miscarriage is confirmed?
If you have had a scan confirming a miscarriage and some or all of the pregnancy is still inside your uterus (womb), there are three options that we can recommend for you.
- Conservative Management - waiting for the pregnancy to pass naturally
- Medical Management - taking medications to help the pregnancy pass from your womb
- Surgical Management - having a procedure to remove the pregnancy tissue
This leaflet will focus on the surgical management of miscarriage (SMM).
What is Surgical Management of Miscarriage (SMM)
SMM is a minor operation that involves removing the pregnancy tissue from your uterus through the vagina. The procedure is done under general anaesthetic and so you will be asleep during the operation. The neck of your womb is gently stretched to allow a plastic suction tube to be inserted into the womb to remove any remaining pregnancy tissue. The operation takes about 10-15 minutes, and you can usually go home on the same day depending on how you feel and if the procedure has been uncomplicated.
Why might SMM be appropriate for me?
Sometimes SMM might be recommended to you if you are experiencing heavy vaginal bleeding or severe pain, you have signs of an infection or if other management has been unsuccessful. You may also choose an SMM without trying other treatments if you find it to be the most suitable option for you. We may also advise SMM if you are diagnosed with a molar pregnancy, have medical conditions that may make you ineligible for other options or if you have had a poor experience with other methods for treating a miscarriage previously.
The intended benefits of the procedure include:
- A high success rate of 95 in 100 women
- More predictable as you will have a confirmed date for the management of miscarriage and some people may find this helps them to manage the feelings they may experience after a pregnancy loss
- Pain and bleeding are usually less in comparison to other methods of treating a miscarriage
- Not having to stay awake during the procedure
- Re-admission for heavy bleeding or severe pain is less likely after SMM compared with non-surgical options of miscarriage management
What are the risks involved?
As with any operation there are some risks involved:
- Heavy bleeding requiring a blood transfusion (up to 3 in 100 women)
- Infection (4 in 100 women) which we can treat with antibiotics
- Retained pregnancy tissue (5 in 100 women) - this may require a repeat procedure depending on your symptoms and wishes.
- Scar tissue (adhesions) forming in your uterus (16-18 in 100 women).
- Damage to the cervix (1 in 1000 women)
- We may unintentionally make a perforation (hole) in your womb - this is very rare (1 in 1000 women). We will usually perform an operation to check and repair any damage either through keyhole (laparoscopy) or open (laparotomy) surgery depending on the extent of the injury
- Uterine perforation and or damage to internal organs may not be immediately recognised at the time of surgery and so if you are feeling increasingly unwell, worsening abdominal pain, abdominal distension, vomiting, not passing flatus or stools, please seek urgent medical review
- Risk of general anaesthesia which will be discussed during the pre-op review with the anaesthetist.
Do I have to decide now?
Please take as much time as you need and remember no decision is final. It is acceptable to change your mind on how you want to manage your miscarriage. Please contact our Early Pregnancy unit on Monday to Friday 0900-1700 on 01932 722662 should you wish to discuss your options further
What happens if I think I have miscarried before the procedure?
This can happen sometimes, so it is useful to have some sanitary pads and pain relief available at home. If you think you have miscarried, you may no longer require an SMM. Please contact us to discuss your symptoms and next steps. If you have experienced light bleeding only, you should keep your appointment as planned. If you have experienced heavy bleeding with clots, it is advisable to ring EPU for advice. You may be advised to attend for a scan to confirm that your miscarriage is complete.
If pain and bleeding becomes unmanageable while waiting for your operation, you should attend the Accident and Emergency department.
What do I need to do to prepare for SMM?
We will book you in for an appointment at the early pregnancy unit to go over the procedure and sign the consent form with you and answer any questions you may have. We will also discuss what you would like to happen with the pregnancy tissue after the procedure. This will involve signing a sensitive disposal consent form so that we can carry out your wishes. In addition, we will take some blood tests to check your blood count and blood group during your pre-assessment appointment.
You will be given fasting instructions, which is avoiding food for 6 hours before your procedure. At Ashford and St Peter’s hospital, we practice sip till send to avoid the risk of dehydration prior to your surgery. You can have sips of water and clear fluid till your procedure. Clear fluids include black tea or coffee without milk, squash and drinks like Lucozade boost. Please don’t eat any food including sweets and chewing gum within 6 hours of your procedure.
Please shower as usual prior to attending for your procedure.
Please take any regular medication unless you have been advised not to do this.
Once you arrive you will be asked to change into a hospital gown, and you will be shown to your bed. Avoid bringing any valuables with you. You will be seen by the surgeon who will go through the consent process with you and the anaesthetist will give you further information about general anaesthesia. It is usually necessary to soften the cervix prior to SMM, and the nursing team will ask you to insert two tablets called Misoprostol as high as possible into the vagina. This can usually cause mild abdominal cramping and bleeding as the medication starts to work. Please inform the nurses if you experience severe to moderate pain or bleeding after using Misoprostol so we can expediate your operation.
What happens following the procedure?
It is normal to still feel sleepy after the procedure and after you return to the ward as the anaesthetic wears off. We will continue to monitor you, and you can start eating and drinking once you are able to. You will usually be allowed to go home after a couple of hours once you have eaten and passed urine. During the first 24 hours you may feel more sleepy than usual, and your judgement may be impaired.
If you drink any alcohol, it will affect you more than normal. You should have an adult with you during this time and you should not drive or make any important decisions
You may experience vaginal bleeding up to 2 weeks after your procedure, with the bleeding being worst on the first day and getting lighter progressively. The bleeding should not be heavier than a period. It is best to use sanitary towels rather than tampons and avoid sexual intercourse until the bleeding stops completely to reduce the chance (risk) of infection. You may have abdominal cramps after the procedure, but you can relieve this with a simple painkiller, such as paracetamol or ibuprofen if you are okay with these drugs.
How will I feel after my operation?
It is normal to feel tired after your operation. You may want to take a nap during the days as your body is healing. Please eat a balanced diet and try to stay active. You may shower or bath after your operation. Establishing a daily routine may help you recover both physically and emotionally following your pregnancy loss and operation.
A miscarriage affects every woman differently. Some women come to terms with what has happened within weeks, while for others it takes longer. Many women feel tearful and emotional for a short time afterwards. Some women experience intense grief over a longer time and your family and friends may offer support in lots of different ways. This could be in terms of practical support with things such as shopping, housework or preparing meals.
Having company gives you a chance to say how you are feeling after your miscarriage, and this may help lift your mood as well as bring comfort.
If you live alone, you may wish to have someone stay with you for the first few days after you go home. If these self- help strategies are not helping, please contact your GP for referral for counselling. You may also contact us for referral if you are having difficulty assessing counselling referral from your GP.
You can find further information and support from the Miscarriage Association, Tommy’s (the pregnancy and baby charity) and the Royal college of Obstetricians and Gynaecologists.
How to reduce the risk of blood clots
After any operation there is a higher risk of forming blood clots in the legs called a Deep Vein Thrombosis (DVT).
This can sometimes travel up to the lungs forming a Pulmonary Embolism (PE). You can reduce the risk of this by being as mobile as much as you can after the procedure and trying leg exercises. These can be as simple as bending and straitening your knees, ankles and rotation your feet.
Staying well hydrated is also recommended to reduce this risk.
Depending on your risk you may also be given blood thinning injections to be taken daily to go home with. We will teach you on how to administer them and advise for how many days to continue them for.
When should I seek help?
If your bleeding is extremely heavy and not settling, you notice an offensive vaginal discharge, burning or stinging when you pass urine, painful red swollen leg or difficulty bearing weight on your leg (may suggest a DVT), chest pain, shortness of breath or coughing up blood (may suggest PE), raised temperature or flu-like symptoms, you should contact your GP, NHS 111, the Early Pregnancy Unit on 01932 722662 or attend A&E if out of hours or acutely unwell.
If you develop signs and symptoms of a DVT or a PE including leg pain or swelling, breathlessness, chest pain then please call 999 or attend A&E.
If you develop increasing abdominal pain, abdominal swelling, inability to pass wind or stool, please seek urgent medical review.
If your bleeding lasts longer than 2 weeks after the procedure, please contact the Early Pregnancy Unit on 01932 722622. You should do a home pregnancy test after 3 weeks of SMM and please contact the early pregnancy unit if this is positive.
When can I try for another baby?
The decision to try for another pregnancy and when to try is personal and will vary from person to person. Your periods should resume in 4-8 weeks after the procedure if your periods are usually regular. It may be heavier and last longer than expected. We recommend waiting until both you and your partly feel ready before trying to get pregnant again. We advise you to wait till after your next period before trying to conceive as this will help to date your pregnancy. If you get pregnant before your next period, this isn’t dangerous, and it will not increase the risk of another miscarriage.
Please ensure any medical conditions are treated as some poorly controlled medical conditions may increase the risk of a miscarriage. Use pre-conceptual folic acid, be active, stop smoking and practice healthy eating.
If you have not had your period within 8 weeks and this is unusual for you and you are not pregnant, you should seek advice from your GP.
If you don’t want to get pregnant again, please contact your GP or local family planning clinic for contraceptive advice.
Returning to work
The time you return to work depends on you, how you feel and the type of work that you do. It is advisable to rest for a few days following your operation and you can self-certify for seven days. You will not be harmed by getting back to normal work within a day or two of the operation, particularly if you can work from home. You may need a longer time to recover emotionally. If so, it may be helpful to talk with your GP or occupational health adviser. We can support you by provide you a sick note or you could get this from your GP.
Further questions and feedback
We realize that this is a very sad and emotional time for you and your family. We hope that we can support you through this. Please feel free to ask us any questions or contact us while you are under our care for any further advice.
We value your feedback, and you can use the QR code displayed in the unit to offer us feedback.
Further information and support
You can get further information from:
Association of Early Pregnancy Units (AEPU)
https://aepu.org.uk/
Miscarriage UK
https://www.miscarriageuk.org
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/
NHS Better Health:
https://www.nhs.uk/better-health/quit-smoking/
Tommy's
Miscarriage Statistics and Rates in the UK:
https://www.tommys.org/baby-loss-support/pregnancy-loss-statistics
Royal College of Obstetrics and Gynaecology
https://www.rcog.org.uk/for-the-public/browse-our-patient-information/bleeding-andor-pain-in-early-pregnancy/
RCOG video on recovering well after surgical management of miscarriage.
Please click link or scan QR code below
https://www.youtube.com/watch?v=2q0F3_I4vVA
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.
