MMC - surgical/medical/expectant management - wwyd?

[EffinIneffable]

I'm 8 weeks pg, but scans show no embryo. Looks like no development beyond 5 weeks (my dates aren't out - I am an obsessive tracker since ttc from Feb 2013). I haven't mc'd naturally yet, so next week will prob have option of medical or surgical management.

For those of you with experience of this, what would you do?

I'm leaning towards surgical management (ERPC) because it will be over and done with more quickly, and hopefully less bleeding afterwards than medical management.

We were supposed to be going camping week after next, and think I'm more likely to be bleeding too much for that if I go for medical management than surgical. Also I want to get back to ttc as soon as possible so don't want to wait ages for natural mc to kick in.
BUT - additional risks with ERPC such as perforating the uterus, scarring higher risk of infection, that could further reduce fertility in the future.

I had a natural mc 6 months ago at 6 weeks, which was relatively (physically) painless, just like a very heavy period. But of course being a bit further on and having to have surgical/medical management means it could be very different this time.

Difficult one. They say naturally is good as with surgery you could have complications. However with surgery it's over and done with quickly and you tend to get your fertility back quicker as the pregnancy hormone disappears quick due to everything being removed at once.

I've only had two natural mcs and to be honest they weren't traumatic as they were very early ones and I haven't had to pass the sac or anything like that.

I had a very bad experience when my miscarriage was medically managed. If I were to miscarry again I would 100% go for the surgical option. I'm scared of anything surgical tbh, but it couldn't be any worse than what I experienced after being given the pessaries. Everyone is different though and I think my reaction was at the extreme end of the scale.

Surgical management doesn't sound too bad from what people have said about it on here.

I'm very sorry for your loss and that you're in this position. I had an ERPC a week ago tomorrow and it went fine, I was glad I had gone for that option and it was the right one for me. I had had a general anaesthetic once before so knew that I didn't react badly to them. It's a personal thing but for me I was more fearful of passing the mc naturally at home than I was of having the minor op.

However, because of the risks, and although the wait was horrible, I was glad that I'd given it a week to come out by itself (which it didn't) as I kept telling myself it would be better to avoid surgery if possible. I had to wait a week because they had to do a second scan. For me the medical management wasn't really an option because of fear of it being more painful as the meds make your womb contract.

In my case I arrived at the hospital for the ERPC at midday and left there at 5.30pm. I was pretty tired from the anaesthetic for 2 days but have had very light bleeding and immediately felt very relieved it was over.

Like IWantDogger I was also very worried about mc at home so chose surgical. My initial thoughts when I was given the options was that surgery sounded extreme & I'd go for natural. I then read lots of posts on here & was terrified by the stories about bleeding, passing big clots and the sac. I couldn't have coped with that. The ERPC was ok, a bit scary & I didn't like the feeling of coming round from the anaesthesic, but the pain wasn't too bad, more like a heavy period. I had bleeding for nearly 3 weeks afterwards but that's possible because of complications with it being a partial molar pregnancy, so this probably would have been the case with medical management too.

It's a horrible decision to make and I'm sorry you're going through this. I found the nurses at the EPU were helpful, but it was Mumsnet that really helped me decide. Look out for the thread on practicalities of miscarriage, there are LOTS of examples of people's experiences and some really useful advice.

Best wishes x

I had a mmc back in 2009 and had medical management which wasn't a good experience and had a mc last year in which I said if I needed I'd rather have surgery than go through medical management again.

Sorry your going through this it's horrible.

Thank you all so much for sharing your experiences and thoughts with me. It's different for everyone of course but I'm still leaning towards surgical I think if I don't mc naturally in the next week.

I don't get on well with the epu nurses, where i am, they spend a lot of time sympathising and not enough giving actual medical information for me, so mn is really a godsend to see what others have actually experienced.

And thanks for the tip about the other practicalities thread too. Really helpful. It's this sort of inside info it's so hard to get from hpcs who don't want to commit to saying anything.

I was diagnosed with a blighted ovum at my 9 week scan on the 7th July. I waited to miscarry naturally but just had a lot of pain and heavy bleeding with very few clots for the next few weeks. I finally decided to have a d&c which took place on Wednesday. It wasn't scary at all and the pain and bleeding stopped straight away, with just a little bit of spotting yesterday and today. I might have decided to wait a bit longer to miscarry naturally but we are flying to NY for our honeymoon next Tuesday and now that will be possible! I am sorry that this has happened to you and to so many of us. xx

Hi Effin,
I have posted in a couple of other threads but I thought I'd share my story with you. I MC yesterday naturally at 12 wks + 3. I wanted to go straight into hospital for ERPC on Friday as had my scan on thurs and baby had passed away at about 9/10 weeks. I was extremely scared of natural process especially about what I would see. I fortunately read up a lot about what I might experience with natural mc, especially being 12 wks and it was traumatic yesterday. I still have to have a scan tomorrow and possible ERPC if retained any product. I am angry at my hospital for not offering me the management method I wanted sooner, to avoid going through what I went through yesterday, but I wasn't offered medical mgmt only surgical or natural. I believe the risks with ERPC are quite low, but I may still have to go through one tomorrow so will post if it helps. Hope you are doing ok x

Thanks for asking after me tori and for sharing your experience erica. It's great to know there are people here I can talk to who understand what this is like. I hope you are both making a start on the road to recovery.

erica it is very frustrating that they can't move quicker isn't it. I can only think that their guidelines mean they are required to not take what we know about our dates into account, and that they have to make absolutely sure they're not offering a procedure if there's a chance it might be viable. Which is heartbreaking when you know that chance doesn't really exist. Your experience sounds very traumatic. Luckily (funny what starts to seem like good luck) I only have a gestational sac and no embryo or fetus to pass.

I'm still undecided about which option. I'm supposed to be going camping next week and it would be great to have everything over and done with, and not to worry about starting to bleed while in a tent with shared facilities... so I'm thinking erpc just because it's so much more convenient, and surgery itself doesn't phase me (had a straightforward laparoscopy a could of months ago). But maybe I'm just being short term and it might be better on my body to go for medical or natural. But, I read on another thread here (can't remember which one) that only about 25% of mmc are completed naturally, so I don't really want to drag this out longer than necessary.

I'm also just totally focused on getting through this physical bit and suspect I have a bit more emotional work to do once this is over. And a holiday would help with that.

Hi Effin I was advised that medical management works in 80 - 90% of cases if that helps. Although my personal experience of medical management was very bad, as said in previous post (it did work though, no retained tissue). Whichever option you go for I hope it all goes as well as it can for you.

Hi Effin,

I went into hospital yesterday for internal scan and surprise surprise there was retained tissue. Had to have the ERPC anyway (posted the details on my thread 'have to wait a week for ERPC') so won't re post here. Had to go thru trauma of seeing my tiny baby miscarried at home then still have a general anaesthetic although the ERPC was straight forward and I am now in minimal pain just dull aches, although bleeding was a lot lighter - I have gone and over done it at the supermarket this morning and now bleeding a bit heavier. A holiday will definitely help, I have my sisters 30th bday party on Saturday with all our family and will be waiting for the 'when are you having another baby' questions... Haven't prepared my answer yet, but will probably drink a lot of wine and then say 'well obviously not at the moment' to them all in a drunken stupor! Have been advised that bleeding will tail off in 7/10 days unless there's any problems from ERPC but I feel at least now there's nothing left to come out of my body and it will start to heal itself, physically. I do wonder when I'm going to lose it emotionally... I feel strong currently but I know that can all change. Are you booked in for an ERPC? X

The info I have - written so badly that I strongly suspect a lot of it is just made up - says about 80-90% of medical management is successful and 90% of surgical is successful first time. But medical has a better chance of success if you're already starting to bleed. But most mmc will need some kind of intervention rather than just waiting for nature to take its course.

Sorry you had to go through erpc as well as the trauma of a natural mc erica. I'm booked in for surgery on Friday, to be confirmed on Thursday.

The nurses wouldn't tell me what they needed to see on the scan to confirm mc when I last saw them, so there's a possibility they still won't treat me. I think there needs to be no growth between two scans a week apart. It gets a bit technical/legal because they need to make sure you're not trying to get an easy termination (at least that's the only reason I can think of why they refuse to believe your dates and insist on at least two scans). At my last scan (five days after initial private scan) there had been a tiny bit of growth of the sac so they couldn't treat (but no embryo). God I hope that it's stopped growing, because it's clearly not viable. Don't know what happens if there's been some growth again. Come on stupid body, it's over!

Tori yes, all internal scans. There's not really anything to be seen on abdominal scans except a shadow. I know my dates to within a couple of days because I've recorded ov (CBFM), sex and BFP - and for this to be OK, I'd have conceived on the day I got my BFP. But legally they're not allowed to rely on that in case you're trying to get a quickie termination (I think).

At my last scan (not in my dream!), I also remembered the sonographer saying I had a heart-shaped uterus, but that this didn't affect anything. But doing a bit of research, it seems (depending on how severe it is) it can be associated with miscarriage, and may also make EPRC less likely to be successful as they can miss material in the 'other half' of the uterus.

I woke up in the middle of the night having an anxiety dream about surgery. In my dream everyone was very casual and disorganised and didn't know what they were doing and I was having to tell the doctors what to do and they weren't interested in my circumstances. They were very rough and I thought they would scar me. I was scared of the GA because I couldn't keep an eye on things, scared of the operating theatre and being in hospital. So perhaps I'm not as OK with the idea as I thought!

I think it reflects my mistrust of doctors and medical professionals in general. I know lots of people feel they have had good care in these situations, but I constantly seem to be given misinformation, fobbed off, only told half the story and generally treated like a child who should shut up and take her medicine without asking awkward questions.

Hi effin

My impression regarding the extra scans is more to protect themselves - they don't want you saying "I was pushed into a termination" or "you didn't give my baby a chance to grow" or whatever.

How did you manage to go from private to NHS? I had a private scan last week at 8wks to find that the baby is small and has a very slow heartbeat. They're getting me to do followup private but then I'd prefer to move back to NHS. Is that possible?

Effin I have now experienced both natural (7w) and surgical (6w twins) management. I'm not sure there's too much difference to be honest. I also have a heart-shaped uterus. It does make you more prone to miscarriage but I have one daughter to prove it's not impossible. Generally the pregnancy implants in one half of your uterus and much of the material stays there before dropping down towards the cervix.

My natural mc took about two weeks in total and wasn't physically painful, no more than a period but substantially more blood loss. Not sure how I would have coped camping, but I managed to work through it (didn't realise what was happening initially - long story!).

My twins are more complex as they have been querying a partial molar pregnancy so I needed the surgical management to ensure histology was done - otherwise I would have let nature take its course again. Foetal poles were 4.8/4.7mm first scan then 3mm second and the HBs had gone. The op itself was straightforward and post-op pain hasn't been an issue at all. I'm told to expect to continue to bleed for up to 10 days or so afterwards.

Tori that sounds like an awful experience for you, I'm so sorry

Hi Tori

That's horrible for you, sorry.

I spent last night reading NICE guidelines on MC (I know, rockin Saturday night!) It seems like they always wait 10-14 days to confirm that the embryo has died before intervention. For mine I had HB just very very slow, so it will go one of two ways. Either there will be no HB at my Friday scan or there will, in either case I'll get my GP to refer me to EPU, as I'll then have to keep having scan until the heart stops. As far as I understand they still prefer you to wait another 7-10 days to see if you'll MC naturally before intervention. I'm seeing GP this morning, I will ask her what I need to do.

So, thought I would update. Apologies for the long post, but I really need somewhere to tell the rest of this story.

At my last scan (31 July - two weeks after first scan and a week after the second), the sac had grown again, so they still wouldn't offer surgical or medical management as it is against the EPU guidelines. Their guidelines state they can only confirm, and therefore treat, a mmc if there is no growth at all 7-10 days apart, or the sac is over 25mm with no fetal pole. This is for those 'just in case' moments where maybe it would have been viable and because they can't trust your dates in case you're trying to get an easy termination. The EPU nurses did say they could get a consultant to confirm and sign off treatment against guidelines if I really wanted.

But after terrifying myself about (the small) risks of ERPC and knowing that medical management is only about 80% effective when mc hasn't already started, I decided I was happy to give it another couple of weeks to see if things resolved naturally. When I initially realised it wasn't a healthy pregnancy I wanted it over and done with immediately, but by this point I think I'd accepted it and another couple of weeks didn't really make much difference.

So I went off camping armed with mahoosive pads and lots of ibuprofen and paracetamol. Had a great time for five days, then I started having normal period-like cramps and brown blood, not very heavy. Then in the early hours while the hurricane raged around the tent, I had strong cramps - I think like the early stages of labour - regular, sharp contractions that made me feel wrung out from the inside. Lasted about two hours, ibuprofen and paracetamol did not begin to touch the pain, I was panting through them. In a tent, on Saturday night, an hour from the nearest hospital. Then cramps passed, and I started bleeding heavily, red blood, and passed a large golf ball size clot/tissue which I think was probably the sac. Since then, just steady bleeding.

I mc'd before at 6 weeks, and it was just a heavy period. Although the pregnancy didn't really develop past 5 weeks this time, I was nearer 10 weeks and it was totally different, much more painful and more blood.

I'm hoping I'll avoid medical or surgical interventions now and have another scan on Thursday.

charlieis30 so sorry to hear you're going through the horrible waiting game. Those NICE guidelines sound like what my clinic were following. They won't do anything at all when there's a heartbeat, even if it looks as though it's not going to survive. Have you found a resolution? My EPU said a consultant could potentially sign off treatment against guidelines if you insist.

After my private scan, I just said I wanted to be referred to the nhs (we couldn't afford a follow up) and the consultant gave me a letter, I phoned my GP told him what the letter said and he referred me to the EPU.

chatenouef (great name btw) thanks for the heart-shaped reassurance. Apparently I'm more arcuate than properly birconuate - just a slight dip. I hope you're recovering from the surgery and you don't also have molar pg to deal with.

I had a miscarriage at 9 weeks and opted for medical management. I wasn't given a surgical option and was quite nervous as had read some horror stories, but it was fine. No real pain, though I took the cocodomol they offered as a preventive measure. I passed the tissue about six hours after taking the tablets and after that bleeding was heavy period level for about three days and normal period level for a further week. I was back at work (although a little shaky) the following week. I'd advise having childcare and support to take it very easy for a couple of days though.

Effin. In some ways I'm glad it's happened naturally for you. I hope that it will be relatively painless at least physically from here on. I'm fully recovered abd bleeding has pretty much stopped so I feel, aside from random bouts or tearfulness, pretty normal now. Mercifully histology was normal so I've nothing else to contend with.

Tori, hope you are recovering too.

Hi Effin,
Well done for making it through a mc, in a tent, in hurricane conditions, you deserve a medal but these will have to do I MC at home and still had to have an ERPC two days later, but I hope that you won't as you've persevered so long without wanting surgical intervention. I'm 2 weeks on from ERPC now, almost all bleeding finished, just emotionally up and down and all over the place... Fingers crossed for you on Thursday xx

Erica were you told you had to have an ERPC or did you choose to have it to get the whole thing over and done with? If it's not all gone or I'm still testing +ve I don't know how long they'll give it before they recommend ERPC now. Given I feel I've been through the worst of it already, I'd rather avoid further intervention now. I hope having the physical side of things over with is helping you start to deal with the emotional side, which in some ways can take longer and be more complicated. I actually feel like experiencing the physical side has helped me come to terms with it.

Chat glad to hear you don't have any more medical hurdles to encounter and it sounds as though you are starting to recover. Give yourself good time though and don't rush to feel 'normal' before you're ready.

Bouncey I don't have any dc yet, so luckily (?!) childcare's not an issue for me. I'm a postgrad student and it's August so no demands to turn up to an office either and email dropped off dramatically too. I wish they'd given me some stronger painkillers to go away with though. Perhaps as they'd not officially confirmed mc they can't do that either as you're not supposed to take ibuprofen etc while pg (or drink loads of red wine, which I was doing too...)