Miscarriage Management

NOTE: This document is not a substitute for medical advice. You should ask your doctor about the risks involved.

Medication can be an alternative to D&C for managing a missed or incomplete miscarriage when the woman prefers not to wait for miscarriage to begin naturally. This link provides information about Using Misoprostol for a Missed or Incomplete Miscarriage.

Below are some suggestions regarding miscarriage management from one of our members:

  • Don’t have a D&C for a miscarriage as it can cause further damage especially if you have had Asherman's Syndrome previously. Also, your endometrium may get thinner each time you have a D&C.
  • Misoprostol helps clear out most of the uterine contents. It is more painful than a D&C but worth it in the long run - unless you are not interested in preserving your fertility. NOTE: If you have had a previous Cesarean section or uterine perforation or severe AS, discuss with your ObGyn to see if misoprostol is safe for you (or you may need to take a lower dose than what I was given).
  • You should have estrogen therapy to prevent adhesions from forming. I'm not sure if this is 100% necessary but Asherman's specialists recommend it. Some women didn't use it because of adverse reactions to estrogen (blood clots etc.) and they did not develop adhesions.
  • You might have retained tissue and require a hysteroscopy (not a blind D&C!!) to remove it. In most cases if you have had a missed miscarriage you will need to either use misoprostol or, alternatively, wait to miscarry before hysteroscopy can be effective, otherwise there is just too much tissue and blood to work with.
  • Have a mid cycle scan to measure endometrial thickness after your first post-treatment period and always check that your uterine cavity is free of adhesions before you attempt to conceive again just in case. An in-office hysteroscopy is best but failing that, an HSG can be done.

There are also some implications that can be speculated:

  • It may take a few hours for the placenta to deliver when using misoprostol post Asherman's Syndrome if you are beyond the first trimester.
  • It is likely that if you have had Asherman's Syndrome in the past, you will have retained products after every future miscarriage. Hysteroscopic removal of tissue allows the doctor to view your uterus as he/she clears it. Note: Hysteroscopy itself can cause complications if undertaken by an unexperienced or unskilled doctor. Please see only a highly experienced specialist.
  • You should anticipate that you may have placenta accreta in a future pregnancy particularly if the placenta does not deliver when expected or you have had confirmed retained products of conception (RPOC). Obviously, any woman with past history of Asherman's Syndrome should be monitored throughout their pregnancy by a high-risk Obstetrician.

One members suggestions after her own experience:

  • Early pregnancy monitoring to ensure early fetal demise is caught and that tissue is not left to become fibrotic and cause infection and potential complications and more Asherman's.
  • You could wait 2 - 3 days from the fetal demise to see if your body will miscarry naturally or you can opt to go the medical management route immediately.
  • Take cyctotec/misoprostol strictly as directed, preferably as suppositories and not orally as not as effective and can make you sick.
  • Be aware how much blood is too much and what to expect, ask lots of questions and have your plan in place for anything that you feel is getting out of control.
  • Let your uterus settle for 2 - 3 days and then have your first scan by a skilled operator who knows how to look for RPOC.
  • If RPOC exist, then you can either go the course of another dose of Misoprostol/cytotec or you can discuss hysteroscopic removal.
  • Scan again 3 days later if you have taken another dose of Misoprostol. Your uterus needs time to calm in between doses and hence why the 3 day wait.
  • If RPOC are still present, then definite reason for hsyteroscopic removal of the RPOC. Antibiotics and hormones should be prescribed to aid healing.
  • Rest after this. Your body may take 1 to 2 more cycles to return to normal.
  • It may take 2 to 4 weeks to fully rid your body of any RPOC just due to your post AS status. Nothing is an exact science and especially when dealing with trauma. It is important to discuss the plan with your Dr/RE so that you are all on the same page and you go through the what if scenarios. Your most important thing if you want to get pregnant again is to protect your uterus, a D&C will not do this, especially a blind one.
  • Mostly Misoprostol is not traumatic and it is a good option. You need to understand it and you need to know that the same kind of things happen both with Misoprostol and with a natural miscarriage. It really depends on you and your body and the situation you are in. Misoprostol mimics a natural miscarriage and is a safe and very good option for all of us Post AS girls.
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