I. Medical Management

1. Intrauterine pregnancy (missed abortion)

When you choose medical management, your doctor or midwife will give you medications to help your uterus contract and expel its contents. The most commonly used medication is misoprostol, which causes intense cramping of your uterus. Your doctor or midwife will also usually give you a medication for pain. Misoprostol often causes diarrhea and may cause some nausea. Let your doctor or midwife know if you aren’t able to keep the medicine down. You will usually have to take two doses of medication about 6 hours apart. Medical management of miscarriage is generally effective within 24-48 hours. You can expect less bleeding than with a natural miscarriage but you should still be prepared.

Misoprostol can also be given vaginally and less commonly, rectally. If using vaginally insert the pills as far up in the vagina as possible and lie down immediately afterward. It is a good idea to plan to do this at bedtime. You may also want to take pain medication at the same time. Try to stay horizontal so the pills stay in the right place so they can work. This dose may also have to be repeated. Some women notice less nausea and vomiting with the vaginal method.

If you are past the first trimester, expect to be admitted into the hospital for administration of the misoprostol. Otherwise, you will safely be able to do this at home. The management for the miscarriage once it starts is the same as found below in the Expectant Management section. [Note: my second loss (13 weeks) was managed by induction of labor by misoprostol in the hospital. The story is found on the “Your Stories” page at the very bottom, “Andrew”.]

2. Ectopic pregnancy

Your doctor or midwife will probably offer you several different ways to manage your miscarriage. As mentioned above, the medical term for a miscarriage is abortion. It is important to understand that there is not necessarily a right way to manage a pregnancy loss. It is also important for you to understand that your doctor or midwife may be advising you based on her personal experience and preference.

An ectopic pregnancy is a pregnancy that is “out of place” (the literal meaning of the term). Most non-medical people refer to this as a “tubal pregnancy.” Ectopic pregnancies most commonly occur in the fallopian tubes, but they may also occur in the cervix, the cornua (area of the uterus where the tube enters), ovary, or the abdomen. Ectopic pregnancies are serious and are a significant cause of maternal death in the first trimester.

I think there is sometimes a misconception that an ectopic pregnancy is somehow different in terms of what the baby looks like. All things being equal an ectopic pregnancy is the same as an intrauterine pregnancy…just in the wrong place. Below is a photo of a baby in the sac removed at 6 weeks because of implantation in one of the fallopian tubes. The baby was still moving until the sac was opened.

[I believe this may be in fact 6 weeks after conception, not 6 weeks post LMP, making this really an 8 week baby.]

Your doctor or midwife may suspect an ectopic pregnancy because of your symptoms or because she doesn’t see anything in your uterus on an ultrasound. If your pregnancy hormone (beta HCG) level is above 1500, it should be possible to see a pregnancy in the uterus. Your doctor may also order a progesterone level to help evaluate the pregnancy. A progesterone level of less than 5 indicates an abnormal pregnancy; a level greater than 25 indicates a normal pregnancy. Most women, however, have levels between 5 and 25. Your doctor or midwife may have you return in 48 hours for a repeat check of your pregnancy hormone level. In a normal pregnancy, the level should increase by two thirds in 48 hours. A hormone level that does not go up as much indicates an abnormal pregnancy. If no sac was seen in the uterus, this implies an ectopic pregnancy.

Expectant management of an ectopic pregnancy is similar to that of a missed abortion or blighted ovum. Your doctor or midwife may have you return in 48 hours for a repeat check of your pregnancy hormone level or may have you wait until the next week. You will be given strict instructions on symptoms that should lead you to call your doctor. DO NOT IGNORE THESE SYMPTOMS. A ruptured ectopic pregnancy is a true medical emergency. If your hormone levels are decreasing and you are not having symptoms, your health care provider will continue weekly checks of your pregnancy hormone level until it reaches zero.

Some women opt for medical treatment of an ectopic pregnancy. If you choose medical treatment, you will be given a shot of methotrexate. Methotrexate is a drug that prevents genes from being copied and prevents proteins from being made. It causes the placental tissues to die. Before you get methotrexate, your doctor will check to make sure that your liver and kidneys are functioning properly. Methotrexate is given as an injection into the muscle (usually the buttocks). You will have your pregnancy hormone level checked on the day you get the shot, the third day after the shot, and the sixth day after the shot. It is normal for the level to go up between days 1 and 4. Your doctor or midwife will look for the level to drop by 15% between days 4 and 7. If the hormone level does not drop enough, you and your midwife will need to discuss whether you should get another shot or whether you should have surgery. If it does drop enough, you will continue to have your pregnancy hormone level checked each week until it is negative.

Methotrexate has many side effects, including diarrhea, nausea and vomiting, and abdominal pain. There are some rare cases in which methotrexate causes the bone marrow to temporarily stop making blood cells. This only lasts for a short time and is reversible.

II. Surgical Management

1. Intrauterine pregnancies: Dilation and Curettage (D&C)

There are numerous places online that detail exactly what happens during a D&C. A good example in layman’s terms can be found here. Technically, few D&Cs (which involve scraping the uterus with a sharp instrument) are performed any more. The usual procedure for emptying a uterus because of miscarriage is called vacuum extraction or a suction D&C. D&C has come to be the generic name for all such procedures. There are also cases in which a combination of suction and curettage is used. In a nutshell, this is what to expect:

The day before the scheduled surgery you will go to the hospital for preoperative lab work and to be evaluated for anesthesia. This will probably take a few hours. You will be instructed not to have anything to eat or drink after midnight. If you are on medications, you will be discussing which ones to take and which ones to hold.

A D&C is an outpatient procedure so unless there are complications you will not be staying overnight. You will register in the preoperative department and spend some time there getting an IV placed, receiving any sedation, etc. The nurses will make sure that everything is in order, all consents are signed, and you have questions answered. Then you will be taken into the OR. Usually there are two options for anesthesia: conscious sedation and complete sedation. In the former, you are awake, but not very aware, and you shouldn’t feel any pain. You may feel some pulling sensations during the actual procedure. In the latter you are put to sleep and you wake up in the postoperative department. The anesthesiologist will have discussed these options with you and it will be your choice.

You will be positioned in the lithotomy position on the operating table (just like a regular gyn exam). Your legs will be securely propped up so you do not have to hold them there. You will be given oxygen and your vital signs will be monitored. You will have electrodes attached to your chest and arms (this doesn’t hurt) to monitor your heart. At this point you should be drifting off.

The doctor will use a speculum to open the vagina. It will stay in place the whole time. Dilators of increasing size are inserted into the cervix to widen the opening. When it is open enough a tube is passed through it into the uterus. Suction is applied through the tube to remove everything in the uterus. [Note that this is a blind procedure and the doctor stops when he ‘thinks’ he has removed everything. Sometimes this was not the case and a repeat D&C must be done.] When the doctor feels the uterus is firm enough (it will cramp very hard during the procedure) and the bleeding is within reasonable limits you will be taken to the postoperative department to recover. Everything that was removed from the uterus is collected, examined for completeness, and sent to the pathology department. The entire procedure takes only about fifteen minutes.

You will stay in recovery until you are awake, your vital signs are stable and close to the levels they were when you were admitted, you can tolerate fluids by mouth and you can urinate. Your bleeding will be monitored and if it is found to be too heavy, you may stay longer or possibly be admitted. You will be given medication for pain. You will not be able to drive yourself home so make sure you brought someone with you. You will be given detailed instructions for how to take care of yourself at home.

Bleeding may last up to two weeks (similar to that of an unassisted miscarriage) but will probably be less than a regular period since most of the superficial lining of the uterus was removed during the procedure. The rest of your care is identical to that after an unassisted miscarriage (see that section). You may be given antibiotics to take to prevent infection.

Complications are rare (less than 1 in 100) but include infection, excessive blood loss, perforation of the uterus and uterine adhesions (which may affect the ability to be pregnant again). The site I previously quoted and linked here is no longer active. Up to date information about the risks of surgical removal of retained tissue can be found in several studies, but this one published in August 2024 contains both a follow-up study and metanalysis. Here is an excerpt:

“Traditionally, curettage by manual curette or vacuum aspiration has been used for removal of RPOC in case expectant management or misoprostol fails. Although curettage is generally considered a safe procedure, it can cause intrauterine adhesions (IUAs). The incidence of IUA formation after curettage is estimated to be between 7% and 38%, and increases with each curettage. IUAs may cause menstrual disturbances, subfertility, and recurrent pregnancy loss. Obstetrical complications in the subsequent pregnancy, such as placental abnormalities and preterm delivery, are also associated with IUAs.”

2. Ectopic pregnancies: Laparoscopy

Some women choose to have surgery to remove an ectopic pregnancy so that the process will end more quickly. In other cases, the doctor will recommend surgery because of the size of the ectopic pregnancy or because she suspects that you are bleeding. If your doctor believes that you have a ruptured ectopic pregnancy, you need to have surgery. Ruptured ectopics are medical emergencies and are fatal if not treated. While no one can make you have surgery if you refuse, you should know that a doctor who uses the term “ruptured ectopic” believes that surgery is necessary to save you.

Surgery is usually with a camera that allows the surgeon to operate without making a large incision on your abdomen. This is called a laparoscopy. Laparoscopies are generally outpatient procedures. Your pre-operative experience is the same as that described above in the section about D&C.

In the operating room, you will be put to sleep. A small incision will be made in your belly button and a camera will be inserted. The surgeon will look around with the camera and then make two other small incisions in line with your hipbones and below your belly button. She will clean out the blood in your belly and then decide how to best remove the ectopic pregnancy. If the ectopic is small and the tube looks relative normal, she will make a small slit in the tube and gently extract the ectopic (a salpingostomy). If the pregnancy is large or the tube looks very abnormal, then she will likely remove the entire tube (a salpingectomy). You can still get pregnant with a single fallopian tube. Your postoperative experience is similar to that described above in the section about D&C.

Less commonly, you will have to have surgery through an large incision without a camera. This is called a laparotomy. You may have to have this type of surgery if you have too much bleeding to have surgery with the camera, if you have had abdominal surgery before, or if you have an ectopic that is outside of the fallopian tube. The surgeon will usually make a “bikini” incision and then examine your tubes and ovaries. You may have a slit made in the fallopian tube or the entire tube may need to be removed. After a laparotomy, you will be admitted to the hospital. You will usually stay for two or three days after surgery.

If you have had significant bleeding, you may need a blood transfusion. If your blood type is Rh negative, you should be given Rhogam.

III. Expectant Management

This is also known as the “watch and wait” choice and in this blog is usually referred to as “natural miscarriage”. You may wait a few days or you may wait a few weeks from the time you learn your baby has died. Most women will deliver within two weeks. Also, once the active miscarriage starts, it may start slowly and progress over a few days or it may be over in a matter of a few hours. The length of time does not correspond to the length of the pregnancy. At 12 to 13 weeks my “active” miscarriage took 3 1/2 hours from spotting to delivery of the last clot.

Especially in the first trimester this is a reasonable option for most women. While you are waiting you may be asked to go into your doctor or midwife’s office for vital sign checks and/or labwork. If you start to feel ill during this time you need to call your practitioner immediately. If after several weeks you have still not delivered you will need to talk to your practitioner and review your options because your risks of infection and blood clots have increased.

So what should I do?

Here is a list of the three management methods presented with pros and cons for each:

Expectant Management

Pros:

  1. Lower risk to you: If you are generally healthy and do not have any complicating factors (such as a bleeding disorder or preexisting infection) then this represents the lowest risk way for you to miscarry. The risk of heavy bleeding is still present.
  2. More privacy and ability to control your environment: This is also one of the reasons many women choose home birth over hospital birth. You are laboring and delivering, so this is not significantly different. This is an emotionally charged experience and many women do better with a friend or family member at their side (or within calling distance) in their own home than in the midst of bright lights and several strangers.
  3. Psychological: You have been pregnant for a number of weeks, sometimes months, and you were doing all you could to provide a safe and nurturing environment for your child. Just because you are not facing the delivery of a live infant does not mean that you have stopped being a mother. Also, for some women, going through labor and delivery provides closure. Especially for a woman for whom this is a first pregnancy, going through the entire process from conception to delivery can reinforce the fact that she was really pregnant, that this is really a child, that she is really a mother.

Cons:

  1. Psychological: If carrying a child for days or weeks after learning he has died is completely overwhelming (and in all honesty, it will not be easy), then a more rapid conclusion may be best. Whether this represents a D&C or pharmacological intervention, the physical miscarriage will be over and past in a few days (not counting recovery).
  2. Risk of infection: If it is determined that the baby died several weeks ago, or you have already been waiting several weeks, and you haven’t had any physical signs of miscarriage, then you may be approaching the point at which a D&C is indicated. If you are already showing signs of infection (fever, foul-smelling vaginal discharge, abdominal pain), then you need medical intervention without waiting.
  3. Heavy bleeding: There is a risk of heavy bleeding with this method especially if the placenta is not expelled.

Medical Management

Pros:

  1. Psychological: You don’t have to endure as long a wait as you do with expectant management.
  2. Privacy: If you are in the first trimester you will most likely be able to do this at home. (see above)
  3. [Note: if you have an ectopic pregnancy and are not in danger of rupture, this is the most likely way your medical practitioner will manage it. While some ectopic pregnancies do miscarry on their own, this is not the time for expectant management. Note that the medication is methotrexate rather than misoprostol.]

Cons:

  1. Side effects of the medication include nausea, vomiting and diarrhea. It works by inducing uterine contractions so you will experience pain that may be more than if you had not taken the medication.
  2. Hospitalization: If you are not in the first trimester (or even past 8 weeks, depending on your practitioner) you will probably be admitted to the hospital for the induction. If you are well into your second trimester expect to be admitted.

Surgical Management

Pros:

  1. Quicker resolution: This is the most rapid resolution of a miscarriage. You could be scheduled as quickly as the next day for surgery.
  2. Quicker recovery: You generally experience much less bleeding than with any other option, possibly less than a regular period.
  3. [Note: if you have developed an infection or are bleeding heavily or have retained parts, this is not an optional procedure. Similarly, if you have an ectopic pregnancy that is in danger of rupture (or is rupturing) laparoscopy is not an optional procedure.]

Cons:

  1. There are risks of infection, uterine perforation (a hole poked in your uterus) and uterine scarring that may make it more difficult to be pregnant in the future. There is also the risk of an injury to the cervix that in a small number of cases may cause difficulty carrying subsequent pregnancies to term. The risk of scarring increases with additional D&Cs.
  2. You will not have an intact body as a result. You will, however, still be able to request the remains for burial if you so desire.

*The most important thing is for you to have an honest conversation with your doctor or midwife about how you would like to manage your miscarriage, and to be willing to listen to his or her concerns about your health.

Many thanks to Dr. E. B. (ob/gyn) for contributions, suggestions and corrections!