How to Get the Best Possible Care for Your Miscarriage
Miscarriage is the most common complication of pregnancy, ending in about 20 to30 percent of all pregnancies, most often in the first trimester. I knew about these chances even before it happened to me, but still I was taken by surprise – not only because of the emotional losses from the loss, but also because of the decisions I had to make about how to complete the physical the process of miscarriage.
Loss of pregnancy can happen in many ways. Sometimes it ends naturally, without any intervention. Sometimes bleeding starts but then stops. And many miscarriages are diagnosed, like mine, when a conventional ultrasound does not show a heartbeat. It was clear that pregnancy was not viable, but I did not have bleeding and there were no signs of tissue ejection on my body.
We are usually offered three options for completing a first trimester miscarriage:
- Wait for this to happen naturally (what doctors call “wait and see”).
- Ask your doctor to remove the tissue (“surgery,” often called dilation and curettage, or D&C).
- Take medications to cause a complete miscarriage (“medical treatment”).
None of these are perfect and it can be difficult to assess the risks and benefits of each while processing bad news. This is how I felt when faced with this decision a few years ago, so I turned my attention to a study published this summer showing how to improve medical management. The catch is that the best treatment regimen includes a commonly used abortion drug, and restrictions on its use not only limit women’s access to abortion, but also evidence-based care for miscarriages.
Before we look at the new research, let’s take a quick look at other treatment options for miscarriage.
Waiting for control is natural, but also slow and unpredictable.
A miscarriage on its own can take several weeks. One study of expectant management found that 40 percent of miscarriages were completed within a week, 70 percent within two weeks, and 81 percent after about 7 weeks. The success rate was lower if bleeding was absent or the cervix was still occluded (commonly diagnosed as miscarriage or anembryonic pregnancy), and only 52% of these miscarriages are completed within two weeks using expectant management. …
Meanwhile, we remained in limbo, hoping that the bleeding would not start at the wrong moment. “Most patients say that just waiting for this period of time and feeling pregnant, knowing that this is not a successful pregnancy is really difficult,” said Sasha Krieg, assistant professor of obstetrics and gynecology at the University of Oregon Health and Science.
If the process is taking too long, your midwife will likely recommend a different approach to try. Otherwise, there is a risk that “you are left with products of conception, and you will need several procedures to remove these calcified products of conception from the uterus.” It’s rare, but I’ve seen it happen, ”said Krieg.
After I was diagnosed with a miscarriage, I spent two sad weeks waiting for the bleeding to begin – still feeling nauseous during pregnancy and sore breasts – but my body was holding on to the pregnancy. At this point, my obstetrician recommended D&C, which brings us to our next option.
Surgical treatment is fast and predictable, but more invasive and expensive
A second approach to managing a miscarriage is the surgical removal of pregnant tissue from the uterus. This can be offered in the doctor’s office using a small suction apparatus or in the surgical center as dilation and curettage (D&C) , the latter option requiring stronger anesthesia and more cost. Surgery has traditionally been the most common approach to completing a miscarriage, and in cases where there is already heavy bleeding or signs of infection, this may be necessary.
The advantage of a surgical approach is that it resolves quickly and predictably, which means you do not need to experience the bleeding and cramping that accompanies pregnancy. However, you may have to skip business hours for the procedure, and this is usually more expensive than other options, depending on your insurance situation. (With my high deductible insurance plan, my D&C medical bills were over $ 2,800. Otherwise, it was a simple, quick recovery procedure, and I was glad I could move on.)
There are also some real – albeit very rare – risks to D&C , including problems with anesthesia, uterine perforation, and the development of scar tissue or uterine adhesions. This latter problem is of greatest concern for women who have intermittent miscarriages and have multiple D&Cs, Krieg said, as adhesions can cause infertility.
Medical management offers some control and less cost if it works
Medical management allows you to end a miscarriage in the privacy and comfort of your home, but with more control than expectant management. The most commonly used misoprostol (brand name Cytotec), a synthetic prostaglandin that causes the cervix to soften and the uterus to contract. (It’s also commonly used to help start labor and treat postpartum haemorrhage, and to treat peptic ulcers.) Misoprostol is inexpensive, can be stored at room temperature, and your doctor can call you for a prescription at your local pharmacy. …
Ideally, you can take misoprostol on Friday night and end the miscarriage on the weekend. As with expectant management, you can expect heavy bleeding that lasts longer than usual and is often accompanied by cramping. Your doctor will usually prescribe pain relievers and explain how to tell if the bleeding is too much. More than three night pads per hour for two to three hours guarantees an emergency room visit, Krieg said, but this is rare, and “most women know when it’s too much.” She also said that misoprostol can reduce the chance of heavy bleeding because it restricts blood flow to the uterus.
The downside of misoprostol is that, like expectant management, it does not always work. For example, in one large study, 71 percent of women had a complete miscarriage within three days of taking misoprostol. The rest took the second dose, resulting in an overall success rate of 84% by day eight. If that doesn’t work, patients get D&C.
New Research Shows How To Improve Medical Management
Courtney Schreiber, associate professor of obstetrics and gynecology at the University of Pennsylvania, said in an email that this success rate disappointed her and her patients, so she designed a trial to see if taking another medication, mifepristone, could improve the well-being of misoprostol. process. Schreiber and his colleagues randomly divided a group of 300 women, racially and socioeconomically diverse, who took either misoprostol alone or mifepristone followed by misoprostol 24 hours later. The study excluded women who already had significant bleeding or an open cervix, as in these cases it is already known that misoprostol alone is highly effective. The results were published in June in the New England Journal of Medicine .
The study found that adding mifepristone to the miscarriage treatment protocol significantly improved this process. Among women taking misoprostol alone, 67 percent had a successful miscarriage within four days and one dose of misoprostol. Among those who took mifepristone and misoprostol, the process was completed at the same time in 84%.
The remaining women in both groups were given a choice of how to proceed: either give the process more time, take a second dose of misoprostol, or undergo uterine aspiration. Overall, only 9 percent of women who started with a dose of mifepristone ultimately chose (or ultimately needed) surgical aspiration, compared with 24 percent of women in the misoprostol-only group.
There were no differences between groups in the intensity of pain or bleeding, and the frequency of infections and the need for blood transfusion were very low and did not differ between groups. Those taking mifepristone were more likely to vomit than the misoprostol group (27 percent versus 15 percent), but the frequency of other symptoms (fatigue, headache, dizziness, chills, nausea, diarrhea, cramping, and fever) was similar.
In an editorial published alongside the study, Caroline Westhoff, professor of obstetrics and gynecology at Columbia University Medical Center, wrote that although the study did not estimate cost, “faster treatment success is expected to lower costs (for additional office visits, ultrasound ). examinations and aspiration procedures), as well as to reduce the associated inconvenience. “
For my part, I chose D&C over medical management because I didn’t want to deal with high expectations and uncertainty. If we knew then about the increased chances of success with mifepristone and if it were available to me, I would choose this path. I think I would rather save money, avoid surgery and miscarriage at home, crying with my husband.
Why is access to mifepristone limited?
However, there is an important obstacle to the use of mifepristone. It is also used to terminate pregnancy (again, in combination with misoprostol) and is regulated by the FDA under the so-called risk assessment and mitigation strategy, or REMS . The REMS restrictions for mifepristone, designed to protect patients from serious side effects, mean that it is not sold as a prescription drug in retail pharmacies, but can only be supplied by healthcare providers who must apply for and be certified as providers of mifepristone .
Krieg said most obstetricians currently do not store mifepristone unless they also have abortions, and under the current system, they may not want to start doing so. “If there is a practitioner who doesn’t want to be labeled as terminating a pregnancy, simply for safety or other reasons, they may hesitate to do so,” she said. Some doctors may also be limited by their institution or health care system to become providers of mifepristone. And if mifepristone is only available from abortion providers, it would simply not be available to many women coping with miscarriages, as six states have only one abortion provider and in many parts of the country it takes 12 hours or more to get to the nearest one. … …
In an editorial accompanying Schreiber’s article, Westhoff argued that forcing patients and healthcare providers to jump through the REMS hoop to access mifepristone is unwarranted. “This limitation places a burden on both women and doctors, who are delaying care and undoubtedly reducing the use of this safer and more effective treatment regimen,” she wrote.
The American College of Obstetricians and Gynecologists agrees. After the FDA approved REMS in 2016, ACOG issued the following statement :
REMS “is no longer required for mifepristone due to its safe use. The REMS requirement is incompatible with requirements for other drugs of similar or higher risk, especially in light of the significant patient benefits of mifepristone. ”
In arguing for lifting the restrictions, other authors have indicated that the mortality rate associated with mifepristone is lower than that of erectile dysfunction drugs that do not require a REMS plan. Safety data for mifepristone indicate that complications such as infection and heavy bleeding are rare, treatable, and also occur with other obstetric and gynecological procedures . There is no evidence that forcing women to get the medicine from a provider rather than from a pharmacy even reduces the risks of these complications – only that it increases the cost of distributing the medicine and limits its access to women who may need it.
“Mifepristone offers a better and more effective way to complete a miscarriage. Ideally, we could make the rules for prescribing mifepristone less stringent, ”said Krieg. She added that many of her patients living in rural areas travel for hours to see her, and forcing them to come to her office for medicines is a barrier to help.
All of this means that if you have a miscarriage and choose medical treatment, you may have to defend yourself if you want evidence-based care in today’s restrictive environment. If your healthcare provider doesn’t offer you mifepristone, ask why they don’t and if they can refer you to someone who can. (Find a supplier of mifepristone here – although these listings may not be complete.)
“I believe that all doctors who care for women who may have a miscarriage should register and be able to prescribe mifepristone to their patients. Women seeking this treatment should be aware that mifepristone is only available in the doctor’s office, and they must also protect themselves by making sure it is available wherever they seek help, ”Schreiber said.