This information provides information for women who have chosen to have surgical management using local anaesthetic following their diagnosis of a miscarriage.
It is also relevant for women who choose to have surgical management of pregnancy tissue or placenta that has remained inside the uterus (womb) after a termination of pregnancy, or after birth.
The purpose of this information is to:
- Describe what surgical management of miscarriage using local anaesthetic is
- Inform you how to prepare for the procedure
- Inform you what to expect before, during and after the procedure
- Explain the risks of the procedure
Date:
First appointment:
Second appointment:
EPU named nurse:
Surgical management of miscarriage (SMM) is a procedure to remove pregnancy tissue from the womb. Alternatively, it can be referred to as an ERPC (Evacuation of Retained Products of Conception), MVA (Manual Vacuum Aspiration) or a D&C (Dilation and Curettage). These terms all refer to the same procedure, although the term MVA is more commonly used to refer to the procedure under local anaesthetic.
This procedure is offered under local anaesthetic if you are:
- not bleeding very heavily
- not experiencing severe pain, and do not struggle having internal examinations due to pain
- diagnosed with a miscarriage measuring less than 9 weeks in size
The procedure can also be offered under general anaesthetic (when you are put to sleep).
Your alternative options may include expectant management (watching and waiting), medical management (using medication).
Consent
You will be seen by a doctor who will talk you through the operation, explain its risks and benefits, and ask you if you have any questions. They will then invite you to sign a consent form if you wish to proceed. If you are unsure about any aspect of the procedure, please ask to speak with a member of the team again.
Blood tests
You will usually need to have some blood tests to check your full blood count (to check if you are anaemic) and to confirm your blood group before the procedure. This will happen a few days before your procedure or on the morning of your procedure.
The day of the procedure
Please have breakfast by 8am on the morning of your appointment. We ask that you then only drink sips of water until after your procedure.
We recommend that you take painkillers before your appointments. Proving you are not allergic, please take the following medication which can be purchased at your local chemist/pharmacy counter.
8am : TWO x 500mg Paracetamol tablets and ONE x 400mg Ibuprofen tablet
1pm: TWO x 500mg Paracetamol tablets
The procedure involves two visits to our clinic on the same day. Morning appointment: Dilapan
At your first appointment you will be seen by a doctor who will be able to answer any further questions you may have. An ultrasound scan will be repeated to ensure the procedure is still needed and appropriate.
The doctor will then carry out a speculum examination and insert a small, thin dilator (called Dilapan) into the neck of the womb (cervix). Some women can find the insertion a little uncomfortable, and a numbing gel or local anaesthetic injection can be used if needed. Over a few hours, the Dilapan will expand, which will open the neck of the womb. This will make your procedure in the afternoon easier and more comfortable for you.
You will then be able to leave the unit for a few hours. It is possible the Dilapan may fall out by itself at home. Do not worry: this will not affect your procedure. Please throw the Dilapan away if this happens.
Second Appointment: Procedure
When you arrive at the clinic, a member of our nursing team will check your blood pressure and pulse.
You will be accompanied to our outpatient procedure room and be asked to change ready for the procedure. There will be a doctor and two members of the nursing team present throughout. A partner, relative or friend can also be present if you wish.
In order to keep the procedure as clean and sterile as possible we use a cleaning solution and sterile drapes placed over your tummy and legs.
The doctor will carry out another speculum examination. They will remove the Dilapan, and then inject some local anaesthetic into the cervix. This helps to reduce discomfort during the procedure. The injection can sometimes sting a little but this should last only a few seconds.
The doctor may then gently stretch the neck of your womb using instruments called dilators. This should not be painful following the local anaesthetic. A thin plastic tube will then be advanced into the womb and the pregnancy tissue be removed by suction. A member of the team will scan your tummy at the same time to help perform the procedure and to try and make sure that all the pregnancy tissue is removed.
The procedure can take up to 20 minutes to complete. Once the procedure is finished we will take you to our quiet room where you will rest for approximately one hour. You will be offered food (a snack box, but please bring your own food if you prefer) and a hot drink. Providing your bleeding is light and you have passed urine, you can then go home.
All treatments and procedures have risks, and we will talk to you about the risks of this procedure when we take your written consent. Overall the risk of serious complications is low.
Pain
All women will experience some pain or discomfort during the procedure. The vast majority of women are able to tolerate this. We hope that the painkillers you take and the local anaesthetic will make the procedure tolerable, but if the pain is severe we will stop and discuss other options with you.
Heavy bleeding
Sometimes, during the procedure, you may bleed very heavily. Very rarely, you will need a blood transfusion (donated blood given through the cannula in your arm).
Occasionally you will bleed heavily when you are at home. This can be a sign that some pregnancy tissue is left inside, and you should contact the early pregnancy unit if you are concerned, or attend A&E in an emergency.
Infection
Any procedure has a risk infection. The risk of infection for this procedure is low.
If you develop signs of infection (fever, chills, worsening tummy pain, or discharge with a strong, unpleasant smell), you should contact the early pregnancy unit or attend A&E. If infection occurs, you will need antibiotics, and you may require admission to hospital.
Injury to womb (perforation)
There is a risk of the instrument we use for the operation going too far and causing a small hole in the muscle of the womb, called a perforation. The risk is small: it happens in less than 1 in every 200 operations. Often, this hole will heal without any need for further surgery, but you might need to stay in hospital overnight for monitoring, and to have antibiotics.
Occasionally, we are worried that you may be bleeding inside the tummy, or that there may be injury to other organs, and a laparoscopy (keyhole surgery) or laparotomy (surgery through a bigger cut on your tummy) may be required.
Intrauterine adhesions
Generally the lining of the womb heals very well after surgery. Adhesions is the term for scar tissue that can form within the womb. Although mild scarring is commonly seen after miscarriage (including miscarriage managed without surgery), it rarely has any implications for the future. Severe adhesions are uncommon, but may result in difficulty getting pregnant in the future. We do not fully understand what causes some women to develop severe adhesions, and others not to.
Severe adhesions may present with absent or very light periods. If you have not had a period within six weeks of your surgery, or your period is very light, we may suggest a repeat scan or camera test(hysteroscopy) to look inside the womb and check for these.
Unsuccessful treatment
Sometimes, in spite of our best efforts to remove all the pregnancy tissue, a small amount of tissue will remain. A common sign of this could be your bleeding being particularly heavy, or continued bleeding beyond two weeks after the procedure. The risk of this is approximately one in twenty. Often this tissue will pass by itself, but sometimes you will need an additional surgical procedure to treat it.
You will have a blood test prior to your procedure that will show your blood group and your Rhesus status.
If you are Rhesus negative (eg. O negative) then you will require an Anti D injection during or after your procedure, in order to prevent you from developing antibodies which could cause problems in future pregnancies. We will provide you with more information about this should you need it.
Pregnancy tissue that is removed during a surgical procedure is handled sensitively, and in accordance with your wishes. We recommend histology examination (where the tissue is examined under a microscope) to exclude a molar pregnancy (a rare cause of miscarriage, which requires further follow-up). We do not write to you with these results unless they are abnormal. For some women with recurrent miscarriage, cytogenetic testing is recommended, and this will be discussed further with you.
After testing, many women then choose for the hospital to handle the pregnancy tissue by communal cremation. Other women prefer to take the pregnancy home with them. We will discuss your options with you, and ask you to sign a form about your choices.
You can also discuss your options with the bereavement midwife on 07539 215 484.
You can shower or take baths when you get home, but it’s a good idea to have someone nearby in case you feel dizzy. You may experience some pelvic cramps for a few days after your procedure. You can take over-the-counter painkillers (e.g. paracetamol and/or ibuprofen) for this.
After the procedure, we expect you to bleed relatively heavily for one to two days, possibly with some clots. Lighter bleeding may continue for up to two weeks. If your vaginal bleeding becomes very heavy (filling more than one large sanitary pad every hour for two consecutive hours) or your pain is unmanageable at home, or you become unwell with signs of infection, you should attend A&E.
During the first two weeks following a miscarriage, or until your bleeding has stopped, you should avoid having sex, swimming, or using tampons to reduce the risk of infection
Follow-up is not usually needed, but if your bleeding continues for longer than two weeks, or you have other concerns you should contact the Early Pregnancy Unit for advice.
When you return to work depends on you and how you feel. It is advisable to rest for a day following your operation. Although you may physically feel back to normal within a day or two, many women find they need longer emotionally.
You can ask your doctor for a sick note on the day of the procedure. If you need longer than two weeks, you should see your GP.
You will usually get your next period 4-6 weeks after surgical management of miscarriage. If you feel physically and emotionally ready, you can start trying for a pregnancy after this period. It is possible and safe to get pregnant even before this first period, but our advice is generally to use contraception in this time. This is so, when you do get pregnant, you will know how far along you are (which helps us know what to expect on scan), and also to make sure you are healthy for a new pregnancy.
For women who have had a previous miscarriage managed at UCLH, we offer a reassurance scan via our walk-in clinic at 7 weeks’ of pregnancy.
It is common to experience profound sadness and grief after a miscarriage. Some women and their partners find that these feelings persist for a long time. Other people experience anxiety, depression, and post-traumatic stress after a miscarriage. If you are struggling emotionally, it is important that you discuss this with your healthcare professional in hospital and your GP.
You may find some of the support organisations listed at the end of this helpful. You may also need more formal support or treatment, for which your GP can help or refer you.
You can also self-refer to your local counselling service, via “NHS Talking Therapies”.
You may find the following organisations helpful:
PALS
The Patient Advice and Liaison service (PALS) is a service which offers support, information and assistance to patients, relatives and visitors.
Telephone: 020 3447 9975
Email: PALS
Address: PALS, Ground Floor Atrium, University College Hospital, 235 Euston Road, London, NW1 2BU
UCLH cannot accept responsibility for information provided by other organisations.
Early Pregnancy Unit
Direct line: 020 344 76515 (please leave a voicemail) Email: uclh.
Opening Times:
Monday- Friday 09:00 – 12:30 and 14:00 – 15:00
Saturday and Sunday 09:00-12:30 (A&E referrals only)
The Early Pregnancy Unit is located in the lower ground floor of the Elizabeth Garrett Anderson Wing. Follow signs to “Clinic 3”.
Page last updated: 16 May 2024
Review due: 01 May 2025