Patient Information

Information about miscarriage

Author:Women and children’s services Produced and designed by the Communications Team Issue date Apr 2016 - Review date Apr 2019 - Expiry date Apr 2020

Version 4 Ref no. PILCOM1504

Contents

Information about miscarriage

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What is a miscarriage? What causes a miscarriage? Types of miscarriage

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Treatments

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Threatened miscarriage

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Miscarriage if you are less than 12 weeks pregnant

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Miscarriage if you are more than 12 weeks pregnant

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Manual Vacuum Aspiration (MVA)

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Evacuation of retained products of conception (ERPC)

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Anti-D Immunoglobulin

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Tests and investigations

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Postmortem examination

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Laying your baby to rest

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If your baby was under 12 weeks gestation

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If your baby was over 12 weeks gestation

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Further information

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Bereavement support

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Information about miscarriage We are so sorry you have lost your baby. Please accept our sympathy and condolences at this very sad and distressing time. We understand this is a very emotional time for you and your partner, and making decisions and choices is understandably not what you wish to be doing at this time. The leaflet explains what is known about miscarriage, what treatments are available at this hospital, and what choices are available to you about how your baby is laid to rest. As there are many reasons for miscarriage, not all of the information in this leaflet will be relevant to you. If you have any questions about your particular circumstances, please speak with a member of staff.

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Information about miscarriage One in four pregnancies will end in a miscarriage. There is still a great deal unknown about the causes of miscarriage and it is often difficult to pinpoint an exact cause in individual women. It is important to know that it is most unlikely to have been caused by anything you did or did not do. A miscarriage is rarely anyone’s fault. What is a miscarriage?

What causes a miscarriage?

Miscarriage is the term used to describe the spontaneous loss of a baby. This can occur at anytime, from around the date of a missed period, to 24 weeks of pregnancy (after 24 weeks the loss of a baby is referred to as a stillbirth and is registered as a birth).

In 60% of cases, a miscarriage before the 12th week of pregnancy is likely to be because of an abnormality of the growing baby. However, it is often very difficult to determine the cause. Many women are left asking questions, and find it hard to accept that no cause can be given.

A miscarriage can be a very distressing time. Apart from the emotional trauma of expecting a baby and then losing it, your body has been adapting to the changes of pregnancy. Your hormone levels will fall suddenly and the lining of your womb, including the blood supply which has been supporting the pregnancy, will be lost.

Please be reassured, it is unlikely to have been caused by anything you did.

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Types of miscarriage Threatened miscarriage

Inevitable miscarriage This is when the pain and bleeding of a miscarriage continue and increase. The cervix will open and the pregnancy will be lost.

This is when there is spotting or bleeding. However many women do not go on to miscarry and the bleeding may settle and stop. This bleeding can be caused by hormones, particularly around the time of the missed period at 8 and 12 weeks.

Complete miscarriage This means the pregnancy has ended and all the pregnancy tissue in the womb has come away and is lost.

Missed miscarriage or delayed miscarriage Often a pregnancy comes to an end with little or no sign that anything is wrong. The baby dies or fails to develop, but your body does not expel the pregnancy.

Late miscarriage After 14 weeks, a scan may reveal the baby has died or the pregnancy begins to be lost. You may experience painful contractions, dilation of the cervix, bleeding, and the water sac surrounding the baby may rupture (break).

You may hear medical staff use the term ‘early foetal demise’, which means that the baby has died in the womb at an early gestational age.

Hydatidiform mole In rare cases (1 in 1200 pregnancies) an abnormal egg cell is fertilised and develops for a while as if it were a normal pregnancy, but only the placenta develops; there is no embryo. The hormones of pregnancy are produced which make a woman feel pregnant. This type of pregnancy will be picked up by a scan. Once diagnosed, specialised follow-up care is essential and you will be referred to a specialised centre in the UK.

Blighted ovum This is the name given to a fertilised egg that does not divide and develop as it should. The normal pregnancy sac develops but the baby fails to develop within the sac. Incomplete miscarriage This happens when the pain and bleeding of miscarriage continue, but not all of the pregnancy tissue is expelled.

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Ectopic pregnancy An ectopic pregnancy is a pregnancy outside the womb. About 1 in 100 pregnancies is ectopic. 95% of ectopic pregnancies occur in one of the fallopian tubes. Signs of an ectopic pregnancy include pain and bleeding. The bleeding can be a scanty irregular brown / red discharge. Pain in the shoulder or rectum can also be a symptom. An ectopic pregnancy is usually caused by a problem with the fallopian tubes, and not the developing baby.

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Treatments Threatened miscarriage

Expectant management You may be given the option of returning home to let nature take its course, and the loss to occur naturally. This is called expectant management.

If you have a threatened miscarriage, your GP should refer you to our Gynaecology Emergency Unit (GEU) Unit for the gynaecology doctor to review and arrange a scan. A scan will not be carried out until after the sixth week of pregnancy. Often it is difficult in early pregnancy to detect the baby’s heartbeat and a second scan will be offered to you a week later.

This is one of the preferred methods of treating a miscarriage when the baby is less than 12 weeks gestation. This method will be selected when: z An ultrasound scan has confirmed your pregnancy is no longer viable (no longer capable of maintaining life).

An internal vaginal examination is not usually required at this stage, but in some circumstances the doctor may wish to examine your cervix (neck of the womb). This will not cause any harm to the pregnancy. The doctor may take a vaginal swab to exclude any infection.

z You are not bleeding heavily. z You are less than 12 weeks pregnant. z You are otherwise generally well, and not experiencing signs of shock, dizziness, nausea, vomiting or severe pain.

We realise that, because of the time needed to make a clear assessment, you may feel anxious as you remain uncertain about the progress of your pregnancy.

z There is no evidence of infection. z There is no evidence of anaemia. z You have / may have medical disorders, which may be complicated by an anaesthetic.

Miscarriage if you are less than 12 weeks pregnant To diagnose a miscarriage, you will have a full examination and an ultrasound scan. This may be a shock, as you may still feel pregnant.

If you agree to this method of care you will be allowed home with the contact numbers listed in this booklet to call for advice and support.

You will fully miscarry with time; however there are different ways to manage the situation: 7

a miscarriage and are unprepared for this. We hope this information will help you manage your pain and miscarriage without feeling frightened about what is happening.

What will happen when I go home? If you are not bleeding already you may start to bleed within the next few days, and experience periodlike pains, rather like a heavy period. Often this discomfort and bleeding last a short time – one to two days or less. Eventually the womb will expel the pregnancy.

When you go home you may wish to take strong pain relief every four hours to ease the discomfort. Like labour pain this is a natural process to dilate the cervix and expel the pregnancy and we do understand that this can be very frightening especially as you will have some bleeding. The bleeding is a normal process of miscarriage and should not be excessive (excessive is if you are passing large blood clots and the loss is continuous and is increasing rather than decreasing). If you start to feel light-headed, faint and your pulse / heart rate is racing you need to call us for advice.

Women experience varying degrees of pain and bleeding before, during and after miscarrying. In some women the pain may be quite acute and sudden, and the pain can become intense for some women as the uterus contracts and attempts to dilate the cervix (the opening to the womb). This acute pain normally occurs at the latter stages of miscarriage as the cervix opens and the uterus gives a final contraction to expel the pregnancy.

The pain may not start straight away until hormone levels start to fall in your blood stream and the body starts to realise the pregnancy is no longer ongoing.

Miscarriage pain usually starts with a period cramping pain, and backache with a heavy uncomfortable feeling in the bowel like a colic pain. As the uterus continues to contract and the cervix dilates this pain intensifies.

Should you feel overwhelmed with the pain and what is happening while you are at home please do not hesitate to contact the Gynaecology Emergency Unit (or Elsdon Ward when GEU is closed), for advice and support.

Some women can feel quite unwell, nauseous and faint. Whether your miscarriage is being managed conservatively or medically or you are waiting for a scan - you will be allowed home. Coping with the pain and discomfort can be distressing and upsetting if you are unaware of the process of

We know that this can be a very unpleasant and upsetting time for you and your family. There is no easy way to relieve the distress and

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grief you may experience. Many women now prefer this method of care so they can be at home with their partner and/or family and share the grief and offer each other love and support throughout this difficult time.

Will I be seen again? You may be seen again after three weeks if you are still bleeding and a pregnancy test is still positive. A nurse will call you to discuss your progress and make an assessment over the telephone, to save you coming to the hospital again.

What should I do when I miscarry? You may telephone one of these numbers for advice:

If the bleeding has stopped, you are feeling well in yourself and the early signs and symptoms of pregnancy have gone, our nurse may decide that you do not need to be contacted again.

z Gynaecology Emergency Unit 01268 524900 ext 8030 Weekdays 8am - 8pm Weekends 9am - 5pm.

In some cases, you may be asked to return to the Gynaecology Emergency Unit for a trans-vaginal scan where your observations will be recorded and you will need a repeat blood test.

z Elsdon Ward 01268 524900 ext 4528 when GEU is closed. (Please note:blood results will not be available on this telephone number. Blood results can only be obtained from GEU).

Medical management Medical management of miscarriage is similar to expectant management, with the assistance of a drug called Misoprostol.

The bleeding may continue for up to three weeks, but should lessen over this time. You may continue to experience cramp-like pains and you may need to take your normal pain relief.

Medical management may be selected if: z An ultrasound scan has confirmed your pregnancy is no longer viable (no longer capable of maintaining life).

If you experience sudden heavy bleeding (a continuous flow) and severe pain, passing clots or develop an unpleasant smelling discharge, high temperature or feel unwell and feverish you must contact us on the numbers above.

z No gestational sac can be seen intact. z You are not bleeding heavily.

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z You may experience side effects, such as nausea or diarrhoea, if the drug is given orally. The drug can be given orally, vaginally, or rectally if there is vaginal bleeding.

z Your pregnancy date and expected gestational size is below a certain level. z There is no evidence of infection. z There is no evidence of anaemia. z You have no known liver or kidney disorder.

z You must attend the Gynaecology Emergency Unit three weeks after taking the medication for a repeat urine pregnancy test or repeat ultrasound scan, even if the bleeding has stopped.

z You have no sensitivities to the drug prescribed. This treatment may take 8-10 days to complete, with small repeated doses of Misoprostol.

z You must contact the Gynaecology Emergency Unit and speak to a nurse if you experience severe pain, that is not relieved with your regular pain relief, and is getting worse.

If this method is chosen, you must comply with the following for your own safety and wellbeing: z A consent form must be signed by you and your gynaecologist. z You must have an adult to accompany you home and remain with you for 48 hours.

z You must contact the Gynaecology Emergency Unit if you have sudden heavy bleeding with clots.

z You may not drive yourself home, travel on public transport or ride a bike.

z You must have access to a telephone at all times and not live more than 20 miles from your nearest hospital with an accident and emergency department.

z Please be aware that there is a small chance that the drug will not work, repeat dose of Misoprostol may be given or surgical evacuation may be required.

Surgical evacuation In some cases, when bleeding in early pregnancy becomes a cause for concern, an operation may be needed to empty the womb. This is called a surgical evacuation.

z There is a small risk of haemorrhage, which may require an admission to hospital.

However, there are possible complications such as: z Risks associated with a general anaesthetic. 10

z Perforation of the uterus (this is rare).

The two hormones are used one after the other to give the best possible chance for the treatment to work.

z Infection. z Bleeding.

You will be asked to return to the hospital within 36 - 48 hours.

z Trauma to the cervix - which can result in long term damage to the cervix and problems may arise in subsequent pregnancies.

The treatment and how to take the medicine Your gynaecologist will discuss your treatment with you, and you will be asked to sign a consent form to confirm that you understand and agree to the treatment. If you have any questions or concerns, please ask.

Because of the complications above, you will be offered expectant or medical management where possible. Miscarriage if you are more than 12 weeks pregnant If you start to miscarry after 12 weeks of pregnancy you will need to be admitted to hospital to ensure that the bleeding is controlled, and for an induction or acceleration of your labour.

Mifepristone (Mifegyne) Most women can tolerate this medication. However you should NOT TAKE this treatment if: z You are not pregnant or this has not been confirmed.

Before you are admitted to hospital, your doctor will prescribe the medication Mifepristone (Mifegyne) and Gemeprost.

z You have an ectopic pregnancy (where the egg has implanted in your fallopian tubes or outside the womb).

Mifegyne tablets contain 200mg of a drug called Mifepristone. Mifepristone acts by blocking the effects of progesterone, a hormone needed for pregnancy to continue successfully.

z You have had a reaction or allergic response to either of these drugs. z You smoke and are over 35 years old. z You are taking any corticosteroid treatments.

Gemeprost is a pessary inserted into the vagina. This is given 48 hours after the Mifepristone and contains prostaglandin, a different type of hormone, which will help expel the pregnancy.

z You have any illness or you are taking any treatment that may stop your blood clotting.

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z You have known liver or kidney disorder.

You will be given one Mifepristone tablet to swallow at the hospital. You will need to remain at the hospital for one hour in case you experience any side effects from the medicine. You will be able to go home after one hour if you are feeling well.

z You have a heart complaint or are receiving treatment for high blood pressure. z You suffer from severe asthma which is poorly controlled on medication.

z You have an artificial heart valve fitted.

Gemeprost Gemeprost is produced from prostaglandin, a natural chemical which helps to make the cervix (the neck of the womb) softer by slowly causing contractions of the womb, and softening of the cervix which will then open up.

z You should advise the doctor if you have high cholesterol.

Before receiving Gemeprost you must inform the doctor if:

Giving the doctor this information will enable them to discuss with you whether you should take the medication.

z You are allergic or sensitive to any drugs known as prostaglandins.

z You have bronchitis or diabetes. z You are suffering from any other conditions or taking medicines of any kind, prescribed or otherwise.

z You have any kidney, heart or liver disorders.

After taking the Mifepristone tablets you may experience nausea and dizziness, or more severe side effects including fainting, headache and uticaria (skin rash). You may develop period-like cramps and vaginal bleeding.

z You have any blood clotting disorders. z You have any inflammation or known infections in the genital tract - particularly on the cervix (neck of the womb).

Some medicines may interfere with the treatment and should not be used until it is completed. These include:

z You have any medical conditions, allergies, glaucoma or asthma. Gemeprost can produce some of the following side effects which may only last for a short time. However you should tell your doctor if these side effects cause you distress.

z Aspirin z Ibuprofen z Mefenamic acid 12

z Bleeding with period-like abdominal pain.

What are the effects of the treatment? It is not unusual for nothing to happen until you have had your first Gemeprost pessary. If you have not already started to bleed, this will commence shortly after your pessary.

z Nausea or vomiting. z Headache / dizziness. z Muscle weakness / backache. z Palpitations, chest pain, shortness of breath (very rare).

The bleeding will be accompanied by cramping pains, like a bad period pain. The pains will become quite strong and similar to early labour pains. The pain can be worse in women who have never been pregnant and given birth, or who normally have painful periods. Our staff will be able to offer you pain relief if you need it.

The pessary is short acting and has no known long-term effects to the cervix or vagina. If you would like any further information please ask a nurse who will give you the drug manufacturers information sheet enclosed in the product packaging. One Gemeprost 1mg pessary will be administered into your vagina at three hourly intervals, to a maximum of five pessaries. Bleeding from the vagina may occur soon after the first pessary.

What pain relief will I be given? Should you experience pain, our staff can give you pain relief tablets, or if you have severe pain, an injection such as pethidine can be given. Gemeprost can sometimes cause nausea. If so, an antiemetic (anti-sickness) drug can also be given.

If you experience severe pain, vomiting or bleeding with clots, please call a nurse. You are advised to empty your bladder before the pessary is administered.

What happens if the treatment is not successful? If the procedure is not successful, we must wait for twelve hours before starting a second course of Gemeprost pessaries.

If you go to the toilet after the pessary is inserted and the pessary passes out, please inform a member of staff.

In the unlikely event of that the treatment is still not successful; your gynaecologist will discuss the further options available to you. 13

Are there any possible complications? Should your bleeding become heavy, and if the treatment is not progressing, a blood transfusion may be necessary. Surgery may be needed to stop the bleeding.

It is possible for you to become pregnant immediately after the treatment is complete, so you will need to start using a reliable contraception within three to nine days of taking the Mifepristone tablet.

You may experience diarrhoea, sickness, hot flushes and chills. On rare occasions women experience a severe headache or chest pain.

Manual Vacuum Aspiration (MVA) What is MVA? MVA is a procedure to remove the pregnancy tissue inside the womb. The procedure will be carried out in the clinic, with pain relief and local anaesthetic. It is an alternative procedure to ERPC, which is a similar procedure done under general anaesthetic.

Very rarely, heart and circulatory problems may be a concern. An infection may develop requiring antibiotic treatment. In very rare circumstances, especially in women who have had an operation on the womb or have had a baby by caesarean delivery, there is a small risk that the womb may split or rupture.

What are the differences between MVA and ERPC? 1. MVA is carried out under local anaesthetic with pain relief. Therefore you will feel some pain during the procedure, but in most cases it is not severe and wears off quickly afterwards.

What if I change my mind about the procedure? You should be sure of your decision before consenting to the procedure. Therefore please discuss any anxieties with your doctor before taking the drug.

ECRP is carried out under general anaesthetic. 2. Both techniques are very similar and both result in 98-99% chance of removing all tissue from the womb.

What else should I know? You should not drink alcohol, smoke or take any unprescribed medication once you have taken Mifepristone, and for at least two days after you have been given the Gemeprost pessary.

3. Both techniques result in reduced bleeding compared with medical or conservative management.

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a dental injection) and the neck of the womb will be opened up gently. A plastic tube will be placed inside the womb and suction applied. The tissue will be gently removed from the womb. You will feel a cramp like sensation, similar to period pain, during this part of the procedure. Once all the tissue is removed you may be scanned to check the womb is empty.

4. There is a reduced risk of womb perforation (accidentally making a hole in the womb) with MVA compared with ERPC. 5. There is similar chance of other complications such as infection. What does the procedure involve? You will come to the Gynaecology Emergency Unit (GEU) and will need to stay for 2-3 hours. You will be given some pain relief (paracetamol, codeine/Tramadol, ibuprofen/ Voltarol). Misoprostol tablet may be given. This can be taken orally or inserted into the vagina and is given to soften the womb to make the procedure easier.

How will I feel afterwards ? You will have light bleeding and the cramps will wear off gradually. What happens after the procedure? We will observe you for about half an hour afterwards to check you are well enough to go home. You will be given pain relief for ongoing discomfort. If your blood group is Rhesus negative, you will be given an injection of Anti-D. If you have had any infection in the past or if you are likely to have an infection currently, you may be given antibiotics to take home.

Do I need any special preparation? You do not need to be nil by mouth, so can eat prior to coming for the appointment. If you have any allergies to medications let us know. Please arrange for someone to pick you up in case you are unable to travel home alone.

What should I expect at home? Lower abdominal cramps and light bleeding may last for a couple of days. If you continue to have light bleeding for 3-4 weeks following the procedure, please contact us.

How long does the procedure take? The procedure takes about 10 minutes. A speculum will be inserted into the vagina to see the neck of the womb. You will have local anaesthetic injected (similar to

The risk of complications following this procedure is very small. If you experience severe abdominal

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This may include a small foetus, the pregnancy sac, placenta or blood clot.

pain, heavy vaginal bleeding, offensive vaginal discharge, or have any other concerns following the procedure, please seek medical attention earlier.

ERPC is sometimes referred to as a D&C (dilation and curettage), although this is a very imprecise term and usually refers to a diagnostic test for other problems.

What shall I do if I have a problem or concern? The risks of complications are very small, but if you have heavy bleeding, severe abdominal pain, a fever or offensive vaginal discharge, then please contact the following:

Will I need an ERPC? You will be offered an ERPC if it is not clear whether your womb is empty, and / or you are bleeding heavily. However, if there is very little tissue or blood clot in your womb, you may be advised to wait until you pass the contents of your womb naturally - letting nature take its course.

z Gynaecology Emergency Unit 01268 524900 ext 8030 Weekdays, 8am - 8pm Weekend, 9am - 5pm Public holidays, 9am-5pm z Contact your GP

You may be offered medicine to accelerate the miscarriage. Our staff will be able to provide advice and information to help you decide.

z Call Elsdon Ward on 01268 524900 ext 4528 z Call NHS 111 and speak to a specially trained nurse

Some people find that having an ERPC helps them to come to terms with the loss of their pregnancy.

z Go to your nearest accident and emergency (A&E) department or call 999 in the event of an emergency.

Some find relief following an ERPC, especially if it has taken a long time to confirm that the pregnancy is no longer continuing.

Evacuation of Retained Products of Conception (ERPC)

Others will prefer to let nature take its course, or to use medical treatment.

What is an ERPC? Evacuation of retained products of conception (ERPC) is the medical term for the surgical removal of the parts of the pregnancy that may remain in your womb following a miscarriage.

What happens before an ERPC? To minimise the risk of damage to your cervix during the operation, a Gemeprost pessary will be inserted 16

z Nausea or vomiting z Headache / dizziness z Muscle weakness / backache z Palpitations, chest pain, shortness of breath (very rare) If you would like any further information please ask a nurse to give you the drug manufacturer’s information sheet enclosed in the product packaging.

into your vagina one hour before your surgery. Gemeprost is a medicine produced from prostaglandin (a natural hormone) which helps to make the cervix softer, which will then open up. This will allow surgical instruments easier access to the womb. This is usually not necessary if you have already given birth to a child vaginally. However, if you have only had a caesarean delivery or early miscarriage, you may need the pessary.

Should your operation be delayed for more than three hours you will be supervised. Bleeding from the vagina may occur following insertion of the pessary. This bleeding is nothing to be concerned about, however should you start bleeding heavily please tell a member of staff.

Before receiving Gemeprost you must tell the nurse or doctor if: z You are allergic to any drugs known as prostaglandins. z You have any kidney disorders, heart or liver disorders.

You should not leave the ward once the pessary has been inserted.

z You have any blood clotting disorders.

If you experience severe pain, vomiting or start to bleed heavily (passing clots from the vagina) please tell a nurse. The pessary is short acting and has no long-term effects to the cervix or vagina. If you go to the toilet after the pessary is inserted, and the pessary is passed out, please tell a member of staff.

z You have any inflammation or known infections in the genital tract - particularly on the cervix (neck of the womb). z You have any medical condition, allergies, glaucoma or asthma. Gemeprost can produce some of the following side effects which may only last for a short time. Please tell the doctor if these side effects cause you any distress:

What happens during an ERPC? You will be taken to an operating theatre and given a general anaesthetic.

z Bleeding with period-like abdominal pain

The neck of your womb will be gently stretched to allow a surgical 17

You can expect your next period any time up to six weeks after the ERPC. It may be heavier and last longer than normal. If you have not had your period by this time, you should seek advice from your GP.

instrument to remove any remaining tissue from your womb. If the pregnancy sac is complete, this is often performed with a suction tube, which is more effective at emptying the womb, preventing any tissue being left behind.

Are there any side effects or possible complications? As with any surgical procedure, there is a very small risk involved.

The procedure takes 5-10 minutes. What happens following the ERPC? When you return to the ward you will still be feeling sleepy, and you may experience abdominal cramping.

Occasionally the introduction of a surgical instrument into your womb can cause infection or bleeding. Very rarely a perforation of your womb can occur.

If you have your operation during the day, you are likely to be allowed home after approximately four hours. If you have your operation in the evening or at night, you are likely to have to remain in hospital overnight.

Will having an ERPC affect future pregnancies? You can ovulate (produce an egg) at any time after your ERPC and so you may become pregnant before you have a period. If you have intercourse you may conceive, so it is worth reviewing contraception as soon as possible if you want to wait before trying again.

You may continue to bleed for up to a fortnight, perhaps on and off. The bleeding should not be heavier than a period and it is best to use sanitary towels rather than tampons to avoid infection.

Most doctors advise that you wait until you have had at least one period before trying to conceive again. This allows time for you and your partner to recover emotionally and physically, and will also help with accurate dating of the next pregnancy.

You may have abdominal cramps for up to eight hours after the procedure. You can relieve this with pain relief such as paracetamol. If your bleeding is heavier than a period; if the bleeding or vaginal discharge smells offensive; if you develop a raised temperature or have flu-like symptoms, you should contact your GP. 18

Anti-D Immunoglobulin

Giving an injection of Anti-D within 72 hours of miscarriage prevents the production of harmful antibodies. A nurse will give you the injection before you go home.

What is Anti-D Immunoglobulin? During pregnancy, blood cells from your baby can sometimes pass into your blood. If you are rhesus negative and your baby is rhesus positive, your body will react by producing antibodies.

Normally Anti-D is only given after eight weeks of pregnancy, as before this time the foetal / maternal blood mix is so small that it should not cause any problems with future pregnancies.

This can affect any future pregnancy if the baby is rhesus positive, as the antibodies you have produced can destroy the baby’s developing blood cells.

Are there any side effects? z You may have some slight discomfort at the injection site for a short time.

Anti-D immunoglobulin is a protein contained in blood, which can be used to stop the formation of antibodies, preventing harm to future pregnancies.

z Allergic reactions are rare. If you experience any continuous pain, itching, rash or unusual reaction, please call Elsdon Ward on the telephone number at the back of this leaflet.

It is given by injection into a muscle. As Anti-D is a blood derivative you may wish to discuss this further if you have a religious belief or objection to the administration of a blood product.

Are there any risks? All blood donors used in making Anti-D are tested for Hepatitis C and HIV. There is no evidence that Anti-D can cause these infections.

When is Anti-D given? z All miscarriages over 12 weeks of pregnancy.

Are there any drug interactions? If you have recently had a vaccination, or are due to have a vaccination, please tell a nurse.

z Ectopic pregnancy. z All miscarriages where the womb has been evacuated, either surgically (ERPC) or medically (with tablets).

It is important that you let us know if you have had any drug reactions in the past, particularly to vaccines.

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Tests and investigations z TORCH - Screen - This is an investigation into Toxoplasmosis, Rubella, Cytomegally virus and Herpes.

If this is your first or second miscarriage, and your baby was less than 12 weeks gestation, you will not be offered any tests or investigations. This is because it is unlikely that any investigations would detect a clear cause, and often a subsequent pregnancy will be straightforward and successful.

z Lysteria z Karyotyping for both partners – this may be carried out, depending on your doctor’s recommendation, for women aged over 37 years, or patients at known risk.

The Royal College of Obstetrics & Gynaecology Guidelines recommend women should be offered investigations following three or more miscarriages. Even after several miscarriages, a successful pregnancy is always possible without medical intervention. When treatment is recommended the aim is to improve the chance of a successful pregnancy.

All women who miscarry over 14 weeks will be asked for their consent to have tests and investigations carried out. This can be very upsetting, and we apologise for the distress caused. If you have given consent to any tests and investigations being carried out, it may take up to six weeks before you receive the results. At a very early stage of pregnancy, histopathological examinations can be very limited in offering any answers to specific abnormalities you may have concerns about.

The following blood tests are carried out for women with recurrent miscarriages to exclude infections and certain conditions in pregnancy loss over 12 weeks gestation. z Full blood count

Unfortunately in many instances no cause for the miscarriage is found.

z Clotting screen z Lupus anticoagulant z Blood glucose z Thyroid function z Anti-cardiolipids antibody

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Postmortem

is designed to help you understand what is involved and answer any questions that may help you make your decision.

If your baby was over 12 weeks gestation, you may be offered a postmortem.

Unless instructed by the Coroner, a postmortem can only be carried out with your written permission.

A postmortem is only possible for babies over 12 weeks gestation, when body systems are developed and intact. Below 12 weeks, baby structures are very frail and weak, and it is very difficult to establish the cause of death.

The benefits of a postmortem A postmortem examination can give valuable information about an illness, and may explain why your baby died. This information may make it easier for you and other family members to come to terms with the death. Postmortem examinations can also provide valuable information that can help doctors to treat other babies with the same kind of illness and help provide vital information for research.

What is a postmortem? A postmortem is an examination of a body after death. It is performed by a Pathologist, a specialised doctor. A postmortem may help to: z Identify a medical condition that caused the death. z Identify a problem, that could affect another baby in the family. z Exclude a suspected cause of death.

What happens at postmortem? The postmortem is carried out with the same care that is used in an operation.

z Provide knowledge that can be used to help other babies in the future.

The Pathologist will examine all the major organs. They will need to make cuts into the body to do this. Small samples of tissue may be taken and examined under a microscope and tested for infection. X-rays and photographs may be taken. In some circumstances, it may be necessary for the Pathologist to carry out further examination of certain organs, such as the heart or brain. This may

Please be aware that a postmortem might not provide answers to all questions. The cause of death cannot always be determined with certainty. It can be very difficult to think about a postmortem so soon after your baby’s death. Please do not worry if you don’t take in everything that the doctor explains to you. This leaflet

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Consenting to a postmortem will not delay the issuing of a death certificate or a non-viable foetus certificate.

mean that the organ concerned needs to be removed and retained. If this is thought to be the case, the doctor will explain the reasons to you and you will be asked to give your consent for an organ to be retained. It is possible to delay the funeral until the tests are completed and the organ can be returned to the body.

We hope this information helps you to make a decision. If you feel you need any further help or information, please contact the Bereavement Support Midwife on 01268 524900 ext 1516.

After the postmortem, your baby’s body will be carefully restored. If you would prefer, your baby can be dressed in his or her own clothes a high-necked item of clothing and a bonnet or cap are most suitable.

The Trust Bereavement Office can help and advise you about what you will need to do after you have suffered a loss. They can be contacted on 01268 524900 ext 4850, or by making an appointment to visit the office.

The Pathologist will prepare a report and send this to the Consultant involved in your care, who can discuss the findings with you. You may, if you wish, ask for a copy of the postmortem result. The doctor will discuss all of the above with you in more detail when your consent to a postmortem is requested. Before a postmortem is carried out, we will need your informed consent. If you give your permission, we will ask you to complete and sign a consent form. Should you have any questions at all, please ask the doctor before signing the consent form.

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Laying your baby to rest If you have given your written consent to a postmortem or clinical tests and investigations, the funeral may be delayed if you have requested that any organs or tissue removed are returned to the baby’s body before burial or cremation. Your nurse will discuss this in more detail with you and assist you with the completion of the consent forms for these procedures.

Once again, please accept our deepest sympathy at this very sad and difficult time. We would like to reassure you that all babies, regardless of how many weeks pregnant you were, are treated in a dignified, sensitive and respectful manner. If your baby was less than 12 weeks gestation If your baby was under 12 weeks gestation, you will be asked for your permission to cremate your baby’s remains at a shared cremation. The service will be conducted by the hospital Chaplain, at the local crematorium. Parents are not able to attend this service.

Giving your consent The staff caring for you will require your written consent on a designated consent form, for the cremation or burial and internment of your baby. We understand that this is a very difficult and distressing time for you. However, it is unlawful to dispose of any baby remains without permission and we apologise if this causes you distress.

The nurse caring for you will explain the shared cremation arrangements to you, together with the necessary forms which have to be completed. Once the forms are completed, the hospital will undertake all the arrangements on your behalf. You may discuss these arrangements further with the hospital Bereavement Support Midwife who can be contacted on 01268 524900 ext 1516.

The consent form has two sections. Section A requires your decisions regarding a histopathological examination. This examination should be considered to exclude any abnormality that may require treatment.

Should you wish to make alternative arrangements, you must tell a member of staff.

Section A also requires your consent for any tissue samples in the form of blocks and slides to be retained for hereditary disease and scientific research purposes.

The identity of any baby remains, cremated or buried, is strictly confidential to the hospital. 23

Section B must be completed for the necessary arrangements to be made by the hospital for the cremation of your baby. A copy of the consent form will be given to you by staff. Should you not understand any part of the consent form please ask a member of staff caring for you.

service, unless this is declined. The service will normally be held in the morning, beginning around 9am, when it is more private. The date and time of the funeral is set by the funeral director and is at their discretion. If you choose a burial for your baby, this will be a communal grave with other babies of a similar loss. The grave cannot be marked. The cost of the funeral, excluding flowers or additional cars, would be met by the Trust.

If your baby was more than 12 weeks gestation If you were more than 12 weeks pregnant, your baby will be buried or cremated according to your wishes, following any tests and investigations which you have given consent to.

Should you not wish to attend the funeral, the Trust would arrange for your choice of a cremation or burial, and the same standards as above would apply. Again, there is no cost to you.

The following options are available:

Your written consent is required before funeral arrangements can proceed, and we apologise for the distress this may cause.

Private funeral You may wish to make your own funeral arrangements for a private burial or cremation. Please be aware that the funeral directors and church will charge a fee for their services. Most funeral directors do offer significantly reduced fees for baby funerals.

We offer spiritual and pastoral care at times of bereavement such as this. A Chaplain can be contacted via the hospital switchboard at any time.

A funeral arranged by the hospital The hospital will arrange, with a local funeral director, to undertake your choice of either a burial or a cremation. A member of the Chaplaincy Team will preside at the

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Further information Contact Numbers: z Hospital Switchboard 01268 524900 z Bereavement Support Midwife 01268 524900 ext 1516 z Gynaecology Emergency Unit 01268 524900 ext 8030 Monday – Friday, 8.30am – 5pm When the GEU is closed, please contact Elsdon ward for advice.t z Elsdon Ward 01268 524900 ext 4528 z Hospital Chaplain The pastoral office telephone number during normal working hours 01268 524900 ext 3503. Out of hours please contact them via the hospital switchboard on 01268 524900. z Bereavement Office 01268 524900 ext 4850 z NHS 111 You can call 111 when you need medical help fast but it’s not a 999 emergency. Calls are free from landlines and mobile phones. www.nhs.uk z Miscarriage Association www.miscarriageassociation.org.uk

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Bereavement support Bereavement support recognises the need to support and offer guidance for both relatives and staff who are involved with the loss of a child / baby / foetus at any gestational age. Bereavement support recognises the diversity of needs of the bereaved and their right to choice, compassion and dignified care, taking into account their physical, emotional, cultural, religious and spiritual needs before, during and after the bereavement. Those experiencing loss deserve informative, supportive care to make them fully aware of the choices involved and to help them create the memories they will need to enable them to cope with the grieving process. As midwives and nurses we can help to ensure that, what could have been a devastating time can, with our help, become one of treasured memories, pride and love.

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Not to be photocopied

Basildon University Hospital Nethermayne Basildon Essex SS16 5NL 01268 524900 Minicom 01268 593190

The Trust will not tolerate aggression, intimidation or violence directed towards its staff.

Patient Advice and Liaison Service (PALS) 01268 394440 E [email protected]

This is a smokefree Trust. Smoking is not allowed in any of our hospital buildings or grounds.

W www.basildonandthurrock.nhs.uk

This information can be provided in a different language or format (for example, large print, Braille or audio version) on request.