Surgical Management of Miscarriage

Surgical Management of Miscarriage

Department of Gynaecology

We are sorry that you have had a miscarriage. We have to recommend that you have
surgery to empty your womb (this usually happens following a miscarriage, but may
happen after any pregnancy). There is some tissue and blood clot left in your uterus
(womb) and although this might pass naturally, sometimes an operation is required to
remove this. The operation is called surgical management of miscarriage and was
previously known as evacuation of retained products of conception (ERPC).

This leaflet explains some of the benefits, risks and alternatives to the operation. We
want you to have all the information you need to make the right decision. Please ask
your gynaecology team about anything you do not fully understand or want to be
explained in more detail.

We recommend that you read this leaflet carefully. You and your doctor (or other
appropriate health professional) will also need to record that you agree to have the
procedure by signing a consent form, which your health professional will give you.

Before your procedure

Most patients are seen on the Early Pregnancy Unit when you will meet a nurse or
doctor. Other women may be admitted via accident and emergency, the gynaecology
ward or the post-natal ward.

At this time, we shall ask you for details of your medical history and carry out any
necessary clinical examinations and investigations. This is a good opportunity for you
to ask us any questions about the procedure, but please feel free to discuss any
concerns you might have at any time.

You will be asked if you are taking any tablets or other types of medication – these
might be ones prescribed by a doctor or bought over the counter in a pharmacy. It
helps us if you bring details with you of anything you are taking (for example, bring the
packaging with you).

This procedure is a day case procedure and most women are able to go home a few
hours after the operation.

During the procedure

Before your procedure, you will be given the necessary general anaesthetic (see
below for further details).

Once you are asleep under the general anaesthetic, a speculum is inserted into your
vagina so that the cervix (the opening of the uterus) can be seen. The cervix is gently
opened using some dilators, and a hollow tube is passed through it. Some suction will
be used to remove the retained pregnancy tissue and any blood clot. The whole
procedure usually takes less than 15 minutes.

An experienced member of the gynaecology team will perform this procedure.

Disposal of products of conception

Prior to commencing the procedure, you will be asked if you would consider a
histological examination of the products of conception to rule out a rare condition
called molar pregnancy that can affect your health and may need further treatment and
follow-up. There will be an additional consent form for this, which you must sign stating
if you would like this examination to take place or not.

Please note that it is not usually possible to determine the cause of your miscarriage
by this test.

A nurse will explain to you about the remembrance garden. The Hospital Chaplains
offer you sympathy in your loss and keep a memorial book where you may make an
entry for the baby you have lost.

A multi-faith prayer room is located in the main reception area at Worcester Royal
Hospital and the Alexandra Hospital. The prayer room at Kidderminster Hospital is
located in ‘C’ Block. If you would like to see the Hospital Chaplain please ask the ward
staff to organise this for you.

If you feel you would like to talk, need support or counselling The Cedar Tree is a
pregnancy crisis centre, which offers confidential help, information, counselling and
support. Contact details as follows:

Phone: 01905 616 166

E-mail: [email protected]

National Careline: 0800 028 2228

Website: www.careconfidential.com

The fetal tissue taken will be disposed of in accordance with appropriate ethical, legal
and professional standards. Disposal is by means of cremation.

Benefits of the procedure

The aim of your surgery is to remove any remaining tissue and blood clot in the uterus
(womb) after a miscarriage.

Serious or frequent risks

Evacuation of retained products of conception (ERPOC) is a very safe operation,
however, as with all surgical procedures there are some risks associated with it.

The general risks of surgery include problems with:

• Breathing (for example, a chest infection);
• The heart (for example, abnormal rhythm or, very occasionally, a heart attack);
• Blood clots (for example, in the legs or occasionally in the lung);

The risks specifically related to surgical management of miscarriage include:

• Heavy bleeding at the time of surgery;
• Infection of the lining of the womb;
• Tear in the cervix, which may require a stitch;
• There is a chance some of the retained tissue will be missed, but this is rare;
• Small risk of uterine perforation. This means a hole is made in the uterus because the wall of the recently pregnant womb is very soft. If this happens, it might be necessary to check that there is no internal bleeding using a laparoscopy (a procedure in which a laparoscope [or telescope] is passed through a small cut below the navel). If there is internal bleeding, we might be able to control this using this ‘key hole’ surgery or you might need a larger ‘open operation’, which will take longer to recover from;
• Sometimes, more surgery is needed to put right these types of complications.

Most people will not experience any serious complications from their surgery. The
risks increase for older people, those who are overweight and people who already
have heart, chest or other medical conditions such as diabetes or kidney failure and
women that smoke. As with all surgery, there is a very small risk that you may die.
You will be cared for by a skilled team of doctors, nurses and other health-care
workers who are involved in this type of surgery every day. If problems arise, we will
be able to assess them and deal with them appropriately.

Other procedures that are available

If the bleeding is not excessive, and you prefer not to have surgical treatment, you
may wish to wait and give the womb chance to expel the remaining tissue without
assistance. This may work in up to two out of 10 cases but the majority will require
further treatment (in other words you may still need an operation eventually).

Another option is to have medical treatment. This is when you will take some tablets,
which help the womb to contract and empty itself. The success rate of a medical
evacuation in emptying the uterus is lower than the surgical approach but does have
the benefit of possibly avoiding an anaesthetic. If medical treatment does not work you
may still need an operation.

A member of the gynaecology team will discuss these options with you.

Pre-operative clerking

You will have a medical assessment and clerking before your operation to gather
information about your current symptoms, past medical history, history of any
operations and details of any medications you are taking. This will take place in the
Early Pregnancy Assessment Unit, Gynaecology Assessment Unit, or on admission to
the ward.

Being admitted to the ward

You will usually be admitted on the day of your surgery. We will welcome you to the
ward and check your details. We will fasten an armband containing your hospital
information to your wrist.

If you are at high risk of blood clots in your legs after surgery, we may ask you to wear
support stockings before and after your surgery. Sometimes you may have a drip
inserted to give you fluids straight into your veins before your operation.

We will usually ask you to continue with your normal medication during your stay in
hospital, so please bring it with you. Some patients will need a small tablet to be
inserted in the vagina to soften the neck of the womb and make the procedure easier.

Your pre-surgery visit by the anaesthetist

Once you are admitted to hospital the anaesthetist will come to see you and ask you
questions about:

• your general health and fitness;
• any serious illnesses you have had;
• any problems with previous anaesthetics;
• medicines you are taking;
• allergies you have;
• chest pain;
• shortness of breath;
• heartburn;
• problems with moving your neck or opening your mouth; and
• any loose teeth, caps, crowns or bridges.

On the day of your operation

Nothing to eat and drink (nil by mouth)
It is important that you follow the instructions we give you about eating and
drinking. We will ask you not to eat or drink anything (including chewing gum or
sucking sweets) for six hours before your operation. This is because any food or
liquid in your stomach could come up into the back of your throat and go into
your lungs while you are being anaesthetised. You may have a few sips of plain
water up to two hours before your operation so you can take any medication
tablets.

Your normal medicines
Continue to take your normal medicines up to and including the day of your
surgery. If we do not want you to take your normal medication, your surgeon or
anaesthetist will explain what you should do. It is important to let us know, before
you are admitted, if you are taking anticoagulant drugs (for example, warfarin,
aspirin or clopidogrel).

We will need to know if you do not feel well and have a cough, a cold or any
other illness when you are due to come into hospital for your operation.
Depending on how urgent your surgery is, we may need to delay your operation,
as it may be better for you to recover from this illness before your surgery.

Delays prior to the operation
We appreciate how upsetting it is to undergo surgical treatment and a pregnancy
loss. Unfortunately, the majority of these operations cannot be ‘planned’ so they
take place on the ‘emergency operating list’. As other emergencies are
sometimes more life threatening, and some days are extremely busy, there may
be necessary delays in the time before your operation can be performed. We will
try to keep you informed of any possible delays but please understand that such
delays can be unexpected and unavoidable.

If you condition allows we would also make an effort to put you on a planned
operating list in Kidderminster. Going on a planned list avoids unpredictable
waiting times. This option is only considered for patients who clinically well and
comfortable and do not have major health problems.

Your anaesthetic
We will carry out your surgery under a general anaesthetic. This means that you
will be asleep during your operation and you will feel nothing.

When it is time for your operation, a member of staff will take you from the ward
to the operating theatre. They will take you into the anaesthetic room and the
anaesthetist will make you ready for your anaesthetic. To monitor you during
your operation, your anaesthetist will attach you to a machine to watch your
heart, your blood pressure and the oxygen level in your blood. General
anaesthesia usually starts with an injection of medicine into a vein. A fine tube
(venflon) will be placed in a vein in your arm or hand and the medicines will be
injected through the tube. Sometimes you will be asked to breathe a mixture of
gases and oxygen through a mask to give the same effect.

Once you are anaesthetised, the anaesthetist will place a tube down your airway
and use a machine to ‘breathe’ for you. You will be unconscious for the whole of
the operation and we will continuously monitor you. Your anaesthetist will give
you painkilling drugs and fluids during your operation. At the end of the
operation, the anaesthetist will stop giving you the anaesthetic drugs. Once you
are waking up normally, they will take you to the recovery room.

Pain relief after surgery
Pain relief is important as it stops suffering and helps you recover more quickly.
We will usually give you tablets, suppositories or injections to make sure you
have enough pain relief. Once you are comfortable and have recovered safely
from your anaesthetic, we will take you back to the ward. The ward staff will
continue to monitor you and assess your pain relief.

It is important that you report any pain you have as soon as you experience it.

What are the risks of anaesthetic?
Your anaesthetist will care for all aspects of your health and safety over the
period of your operation and immediately afterwards. Risks depend on your
overall health, the nature of your operation and how serious it is. General
anaesthesia is safer than it has ever been. If you are normally fit and well, your
risk of dying from any cause while under anaesthetic is less than one in 250,000.
This is 25 times less likely than dying in a car accident. Side effects of having a
general anaesthetic include drowsiness, nausea (feeling sick), muscle pain, sore
throat and headache.

After your surgery

• Once the medical team are happy with your progress, we will usually take you from the recovery room to the general ward. You will need to rest until the effects of the anaesthetic have passed. You may have a drip in your arm to keep you well hydrated.
• Your anaesthetist will arrange for you to have painkillers for the first few hours after the operation, as we mentioned earlier.
• We will encourage you to get out of bed and move around as soon as possible, as this helps prevent chest infections and blood clots.

Special measures you need to take after the procedure

If you have surgical management of miscarriage and your blood group is rhesus
negative, we will give you an injection of anti-D immunoglobulin. This will help prevent
antibodies forming and affecting later pregnancies.

Leaving hospital

Length of stay
How long you will be in hospital varies from patient to patient and depends on
how quickly you recover from the operation and the anaesthetic. Most patients
having this type of surgery will go home the same day. If your operation can only
take place late in the evening, it may be most sensible to stay in overnight.

Medication when you leave hospital
Before you leave hospital, the pharmacy will give you any extra medication that
you need to take when you are at home.

Convalescence
How long it takes you to recover from your surgery varies from person to person.
This type of operation requires time for both physical recovery and often for
emotional recovery. After you return home, you will need to take it easy and
should expect to get tired to begin with.

Stitches
There should be no stitches following your operation unless another procedure
has been performed at the same time.

Personal hygiene
You may bathe or shower normally while you are in hospital, and this can
continue as normal after you leave hospital.

Diet
You do not need to follow a special diet.

Exercise
You should do light exercise, such as walking and light housework, as soon as
you feel well enough.

Sex
You can continue your usual sexual activity as soon as you feel comfortable. We
advise that you do not try to get pregnant until your periods have returned to
normal.

Driving
You should not drive until you feel confident that you could perform an
emergency stop without discomfort – probably at least a few days after your
operation. It is your responsibility to check with your insurance company.

Work
How long you will need to be away from work varies depending on:

• how quickly you recover;
• whether or not your work is physical; and
• whether you need any extra treatment after surgery.

Most women prefer to take the following day off work, and sometimes a few
days, both for their emotional and physical recovery. Please ask us if you need a
medical sick note.

Outpatient appointment

Most patients do not require an outpatients appointment after surgical management of
miscarriage.

Contact details

If you have any specific concerns that you feel have not been answered and need
explaining, please contact the following:

Patient Services – 0300 123 1733

Worcestershire Royal Hospital

• Early Pregnancy Assessment Unit (phone 01905 733060)
• Gynaecology Nursing Staff, Lavender Ward (phone 01905 760586)
• Hospital Switchboard (phone 01905 763333)

Alexandra Hospital

• Early Pregnancy Assessment Unit (phone 01527 512100)
• Gynaecology Nursing Staff, Ward 14 (phone 01527 512100)
• Hospital Switchboard (phone 01527 503030)

Kidderminster Treatment Centre

• Early Pregnancy Assessment Unit (01562 823424, Bleep 3461)
• Ward 1 Nursing Staff (phone 01562 512356)
• Hospital Switchboard (phone 01562 823424)

Other information

The following internet websites contain information that you may find useful.

www.patient.co.uk
Information fact sheets on health and disease

www.rcoa.ac.uk
Information leaflets by the Royal College of Anaesthetists about ‘Having an
anaesthetic’

www.nhsdirect.nhs.uk
On-line Health Encyclopaedia

www.careconfidential.com
Pregnancy Crisis Support

www.miscarriageassociation.org.uk
The Miscarriage Association

www.worcestershirehealth.nhs.uk/acute_trust
Worcestershire Acute Hospitals NHS Trust

If your symptoms or condition worsens, or if you are concerned about anything,
please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you
and your loved ones. If you have any questions or concerns, please do speak with a
member of staff on the ward or in the relevant department who will do their best to
answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well
and where improvements can be made. There are lots of ways you can share your
experience with us including completing our Friends and Family Test – cards are
available and can be posted on all wards, departments and clinics at our hospitals. We
value your comments and feedback and thank you for taking the time to share this with
us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the
nurse in charge or the department manager in the first instance as they are best
placed to answer any questions or resolve concerns quickly. If the relevant member of
staff is unable to help resolve your concern, you can contact the PALS Team. We offer
informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf,
if you feel unable to do so, to resolve your problems and where appropriate refer to
outside help.

If you are still unhappy you can contact the Complaints Department, who can
investigate your concerns. You can make a complaint orally, electronically or in writing
and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:
The PALS telephone lines are open Monday to Thursday from 8.30am to 4.30pm and
Friday: 8.30am to 4.00pm. Please be aware that a voicemail service is in use at busy
times, but messages will be returned as quickly as possible.

If you are unable to understand this leaflet, please communicate with a member of
staff.

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