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Wednesday, July 26, 2006

Medical Management of Miscarriage (non-surgical means)

Medical Management of Miscarriage
by Dr Spouse

Why You May Use Medications to Bring About Miscarriage (rather than waiting for a natural miscarriage or using surgical means)

If you've had an incomplete miscarriage or if a loss is imminent, a third option (after natural miscarriage or a D&C) is to use medications to enable the uterus to push out an remaining tissue. Medications given include RU 486 and misoprostol. Methergine may also be given.

What to Expect (My Experience)

In my 10th week of pregnancy, I noticed some spotting. I called my GP and he put me into the end-of-the-day emergency slot and booked me in for a scan later in the week. He tried to reassure me it was nothing to worry about. The next morning, I had more spotting but it was brown, so I didn't worry. By the afternoon I'd had some red spots and was starting to panic so I took myself to A&E (emergency room).

They asked me how much blood I thought I had passed, and what it was like - I now know they were trying to work out whether I'd had a complete miscarriage. The A&E doctor told me my cervix was open, but then they took me up to the gynecological ward. The gynecologist told me the other doctor didn't know what he was talking about--my cervix was closed and it could be a threatened miscarriage. We were booked for an earlier scan the following morning (Wednesday) and went home.

At the scan, we had the news that you can never forget. The sac was empty. They sent us upstairs to the ward to consider our options. They asked me when was the last time I ate and a female gynecologist came and discussed the options with us. She asked us if we'd like a little time to consider them, but it didn't take us long. They were willing to let me go away for a week to try and miscarry naturally, or to offer us medical or surgical management.

The doctor explained the "evacuation" procedure and the medical procedure. I was also told that if I chose expectant management (natural miscarriage), they would probably ask me to have surgery if it didn't work. As my cervix had been closed and the spotting hadn't gotten any worse, I didn't want to wait and possibly miscarry at work or hang around at home waiting for it to happen. I wanted some kind of connection to what was happening. So that was why we chose medical management. We were also told that, in the days before scans, women like me with a threatened, but incomplete, miscarriage would not have been able to have any confirmation of the embryo's death and could have clots travelling round their bodies etc.

The bed I'd been put in at the hospital was reserved for me; if I'd needed to come back earlier it would have been there for me. At my current stage of pregnancy (10 weeks), I was given some tablets orally, told to go home for 48 hours, then given more as vaginal pessaries. I know that it changes depending on how far along you are, so other people's treatment may be different.

The intervening 48 hours (between first dose and second dose - I believe they are different drugs but I'm not too sure) was pretty uneventful though my husband took the Thursday off to be with me at home, and take me in to hospital if necessary - it can happen pretty quickly at home before you go back. Friday morning, he took me in and went to work. My anaesthetist friend told me to take some paracetemol and codeine before going in and I'm very glad I did.

Within a few hours I had very bad cramping, slightly relieved by walking around. Around midday, I had passed the sac. I had a better idea then of what the nurses were trying to get me to look out for earlier in the week. Finally around 3pm the blood flow lessened and although my blood pressure was pretty low I started to feel a little better. Basically I had been through a very short labour.

My husband came to pick me up about 5 but they got me to stay in overnight, partly because it had only been a couple of hours since the bleeding had begun to ease off, and it had by no means stopped. I was asked to use horrible non-absorbent hospital pads, and to use a cardboard bedpan every time I went to the loo, so they could check what I had passed.

It took about a week for me to stop feeling sick and my breasts to go down. I gather that can be even longer if you have surgery. I have since had natural miscarriages as well, but at a much earlier stage.

Problems That May Arise and Ways to Troubleshoot

There are two reasons why I'm not sure I'd have this treatment again. One is that having had more miscarriages, I know they'd now offer analysis of the embryonic material if they could get any. I'm not sure they could do that if I had medical management.

The other is that I do feel that I've had a valuable experience, but you don't need to have every valuable experience more than once. I've also now had surgery (a lap and dye) which I'd never had before the first miscarriage, and so I feel a bit more confident about having a general anaesthetic than I did before.

Personal Tips

I think the worst part was the pretty ineffective pain relief. The nurses seemed to need to keep checking with each other and the doctors and then forgetting they had checked. I am very glad I did choose that method of managing the miscarriage; the only part I'm not sure about is whether I'd do it again. I am glad I did have some sense of what was happening and that it was over.

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