Medical management of miscarriage with mifepristone, misoprostol, cyclizine and codeine

We are very sorry that you are having a miscarriage. The aim of this leaflet is to answer questions you may have about the medical management of your miscarriage. Medical management means taking tablets to help the miscarriage start. This leaflet explains:

• the benefits and risks of medical management

• what to expect during the process

• what to do if you have any concerns or worries.

The medications you will be given are mifepristone, misoprostol, cyclizine and codeine.

What is mifepristone?

Mifepristone works by blocking the hormone progesterone. Without progesterone, the lining of the uterus breaks down to prepare to pass the pregnancy.

There is a risk of significant bleeding and spontaneous miscarriage in the 48 hours after mifepristone has been taken.

What is misoprostol?

Misoprostol works by softening the cervix (the neck of the womb). This causes the womb (uterus) to contract and expel the pregnancy tissue.

Misoprostol has been used in the treatment for miscarriage for many years, but it is not licenced for this use. It is safe for us to use it for this purpose.

What is cyclizine?

Cyclizine is an anti-sickness medicine. It is an antihistamine that is used to help stop you feeling or being sick. It works by blocking a chemical called histamine in the brain, that can make you feel sick.

Common side effects can be drowsiness (feeling sleepy) and blurred vision. Do not drive, cycle, or operate machinery as cyclizine can affect your concentration and make you feel sleepy or dizzy.

What is codeine?

Codeine is an opioid-based painkiller. It can be used for short-term pain relief when simple painkillers, such as paracetamol and ibuprofen, do not work. Codeine works in the central nervous system and the brain, to block pain signals.

Common side effects can include:

• constipation (not be able to pass stools (poo))

• dizziness

• drowsiness

• headaches

• heart palpitations

• skin reactions, including rashes and itchy skin

• vertigo (feeling dizzy), and

• vomiting (being sick).

What are the benefits of medical management?

• You are more in control of your treatment.

• There is no need to stay in hospital.

• If successful, you avoid surgery.

• The risk of infection is low.

• Medical management is successful in approximately 8 in 10 cases.

What are the risks?

• Vaginal bleeding can be very heavy and you will pass clots, this can make you feel unwell. Make sure you have someone with you when taking medical management at home.

• The process of miscarriage can be very painful. Most women will have strong period-type cramping or early contraction like pains, which may increase as the pregnancy passes. You should be able to manage the pain with paracetamol and ibuprofen. We will also give you codeine to take, should you need to.

What are the side effects of using misoprostol?

• Chills are a common side effect of misoprostol, but this should not last long. If they last longer than 24 hours or you have a raised temperature that keeps stopping and starting, contact the Early Pregnancy Assessment Unit (EPAU). Or go to the Emergency Department if you feel unwell.

• Nausea and vomiting may occur, but should stop within four to six hours. 

• Diarrhoea (watery or loose stools) may occur, but should improve within 24 hours. 

• Skin rashes may occur, but should improve within a few hours.

Please tell your Early Pregnancy Assessment Unit (EPAU) if you have any other reactions.

What happens after taking misoprostol?

Pain and vaginal bleeding will usually occur within a couple of hours of taking misoprostol. The bleeding will be heavy with big clots, it is not unusual to soak four to six pads within the first hour.

Depending on the pregnancy gestation you may see a pregnancy sac. Nursing or medical staff should tell you what you may see and what to do with any pregnancy tissue you pass. Pregnancy gestation, is how long you have been pregnant for.

Once the pregnancy has passed, your pain should start to settle over 24 to 48 hours. Bleeding will become more like a heavier period-type loss. The bleeding will lessen over time and become brown after two weeks or so.

You will be called 48 hours (or the next working day) after taking misoprostol. This is to check its effectiveness and discuss any further follow-up you may need. 

General advice

• Wear sanitary pads not tampons to reduce the risk of infection.

• Do not swim, bathe for long periods, or have sex while you are still bleeding.

• Try to remain well. Eat a healthy diet, drink plenty of water, and rest for a few days. This does not mean strict bed rest.

• Do not have hot baths or showers, as they may make you feel faint.

When should I contact the EPAU or the Gynaecology Assessment Unit (GAU) after treatment?

• If your bleeding is very heavy, and does not appear to be easing after your pregnancy has passed.

• If you continue to bleed for more than two weeks, or you start passing large clots after the bleeding has settled.

• If you feel light-headed or dizzy. Go to the Emergency Department if you pass out (especially if you hit your head).

• If the medication you are using as pain relief is not working.

• If your pain is constant for more than 48 hours, or comes back after settling for a period of time.

• If you are showing signs of infection. This includes a bad smell from your vaginal loss, 'flu like symptoms, or a raised temperature.

Contact details

If you experience any of the above, please contact one of the following.

• EPAU, Queen Elizabeth the Queen Mother (QEQM) Hospital, Margate
  Telephone: 01843 234469

• GAU, Queen Elizabeth the Queen Mother (QEQM) Hospital, Margate
  Telephone: 01843 235009

• EPAU, William Harvey Hospital, Ashford
  Telephone: 01233 633331

• Women's Health Suite, William Harvey Hospital, Ashford
  Telephone: 01233 651987

Please go to your nearest Emergency Department for emergencies outside of EPAU and GAU working hours.