Tuesday, 5 March 2019

Medical Management of a Miscarriage: Trigger Warning

This is not my usual kind of post but as it has changed my life, changed the way forward, I feel like I want to share my thoughts and experience. I feel like I want to share some information as I couldn't find enough out there written about the process I went through, it would have been helpful to me at the time to know more.

Trigger warning, content is graphic.

I previously wrote about how I found out about the missed miscarriage, also called a silent miscarriage. It was at a private clinic where I was having a scan on a Saturday morning. The baby had not developed past 7 weeks and there was no heartbeat. The sonographer did the referral there and then to the Early Pregnancy Unit at the hospital, it was scheduled for Monday morning. I was impressed with how joined up the service was, I wasn't left to do this myself, at the time it really did help out. I didn't expect the private baby scan clinics to be so linked in and so efficient. I was given leaflets about the different ways to manage a miscarriage and my referral letter before I went home.

Different Ways to Manage a Missed Miscarriage

So I knew the baby had no heartbeat and now I had to consider the practical options of what next. There are three options and I am going to say shortly what was told to me from the nurse as opposed to detailing what was on the handouts I received:

  • Conservative management  - basically wait for the miscarriage to happen naturally
  • Medical management - tablets/pessaries to bring the miscarriage on
  • Surgical management - surgical removal of the pregnancy
Monday morning I went to the hospital and had a repeat scan. There was a male student there and they asked if I minded him being in the room, I didn't. I had another internal scan with the vaginal wand and it was explained that they would also need to get a second opinion to confirm there was no heartbeat.  Within a few minutes another nurse arrived and I had another internal scan. Confirmed.

From here I saw another nurse in another room to discuss the options.

Waiting and watching - conservative management

I was told that conservative management carries some risks in that it may take some time (several weeks)  to happen and there is a risk of infection. They would contact me though and not let me disappear off because the process may need to be changed for another management type. The nurse said to me - time is not on your side though if you are wanting to try for another!! That was all I needed to hear. She also mentioned that sometimes the ' products of pregnancy', a term they use, clinical but factual, may start to calcify and it can be extra painful to pass. 

Pushing things along - medical management

This would be done by putting pessaries into the vagina, a drug called misoprostol which would speed the miscarriage along, cause the cervix to open so 'products of pregnancy' could pass. I was told it doesn't always work and some women have to have a second dose on another day. The hospital only booked one treatment a day that would be administered at lunchtime and I'd need to stay in for 4 hours and have somebody drive me home - this is especially because I live in a rural area so the stay times reflect the distance and ease with which to get back to hospital. 

The pain would be intense, a steady climb that would peak. I would pass clots and tissue, would struggle for a while, probably end up ill in bed and would require help. I may even recognisably pass the embryo sac. If everything isn't passed then surgical management can be arranged as the next step. 

Quick and less physical pain- surgical management

Sometimes see this referred to as a D&C but in my NHS trust at least, it's an ERPC (Evacuation of retained products of conception) The nurse said although this was quick and would be less painful, being surgical it did carry more risks - infection mainly and of course reactions to anaesthetic. Also a risk of Asherman's Syndrome which can affect future chances of getting and staying pregnant as scar tissue is formed in the cervix/uterus. However, the nurse said this is very rare and in her career she could only remember two cases of it but then she was very straight to the point in saying that of course the surgery is done 'blind' and referred to it as they swishing about and clearing the uterus, so occasionally fragments of tissue get left etc.

My decision

I spent a while discussing with her, practical considerations too such as looking after Little Bird back home. She thought perhaps the surgical option might be better considering being able to look after my son - surgery would be over and done in a day, the other options I'd be in a lot of pain at home and perhaps unable to cope with a child with autism. However, I felt like I'd manage ok with help and so I decided to opt for medical management and this was scheduled in for the next day.

The nurse told me I'd pass clots and tissue that would look like liver. I would pass the gestational sac and this could be visibly distressing. I could flush down the toilet, save in a plastic tub to put in the fridge as the tissue would decompose quickly and take to the hospital to be cremated or (informally advised) bury deep in the garden (although you're not really supposed to do this). The pregnancies lost at less that 12 weeks are cremated together each month and the ashes scattered at the local garden of rest in the cemetery, there would be a group memorial service arranged at the hospital if we wished to attend.

Going through medical management for a missed miscarriage

12 noon 22nd January I was scheduled to be admitted onto the Early Pregnancy Unit and had a bed on a ward with just two other beds, I think the ward also had ladies with other gynaecological issues. My lovely OH was with me all the time and was a comfort throughout. A doctor came to see me and we ran through the process and the risks. Then the nurse brought the pessaries and these were inserted. Now I had to wait and had to stay on the ward or in the vicinity of the ward for the next four hours. Some people apparently miscarry all at hospital but I got the impression that most start hours later and the miscarriage will happen over the next few days.  If you go to the toilet, you pee into one of those cardboard bowl thingies in case you pass anything so the nurse can check. We pottered to the hospital coffee shop and tried to giggle at things and keep in a good frame of mind.

It wasn't until after three hours that I started to cramp in my lower back and I had to get some painkillers from the nurse. At four hours I was ok to be discharged but at any point I was able to return if I felt worried that I was passing too much blood. I had to have an Anti D injection die to me having rhesus negative blood. Walking across the car park, well I was hobbling now as the pain had ramped up considerably. The journey was hideous and I felt like I was in early labour, having to breathe out the pain through contractions. By the time I got home I was crippled in pain and hardly able to stand at some points. I had asked Little Bird's dad to come to look after him after school for which I am so grateful as we are 90 minutes drive away.

So we took over with Little Bird and I tried in between contractions to go about the usual with a lot of help from OH. By 7pm I was really passing a lot of blood, it was pouring out of me. I collapsed in the bathroom and was weak with nausea and blood loss. Then I started to vomit. The pain was intense and I was passing blood, blood clots and tissue.

The pain peaked by 9pm and one visit to the toilet passed a mass of clots, tissue and grey material that made me shriek. I think this was the embryo. I wrapped into tissue and in that moment I knew I'd bury by my favourite rose, to stay with me. At this point I fell asleep from exhaustion.

The severe pain stopped and for the next ten days it was like a medium - heavy period. Some days nothing and some days the bleeding would return. After two weeks I took a pregnancy test and it was negative. All over and now to think of the future and heal. Finishing this post today on the 5th March I still haven't had a period as yet and haven't a clue when it will return. We are both in a positive happy place, I feel I was able to emotionally heal very quickly, I know not everyone is the same.

I hope to write more about the quest for a child after 40, we have changed our diets and are much healthier than we were, these positive elements keep me going.

Further help - Miscarriage Association

Article on miscarriage


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