Medical Management

After the pages of all of the different management options is a discussion of the pros and cons of each method and the factors that play into choosing each. While you should always discuss this decision with your doctor, you should also be informed of your options.

In this section we describe medical management for two different types of pregnancy: intrauterine (within the uterus, the normal location for an implanted embryo) and ectopic (when the baby has implanted somewhere outside of the uterus, typically the fallopian tube).

Intrauterine pregnancy

**Please note that this option is NOT allowed by the Catholic Church if the baby is still alive, and should only be used when the baby has died (such as in a missed miscarriage). It is also not an option if the baby is still alive but is not going to survive due to biological defects (such as when a partial molar pregnancy has been detected but the baby still has a heartbeat).**

When you choose medical management, your doctor or midwife will give you medications to help your uterus contract and expel its contents.  The most commonly used medication is misoprostol, which causes intense cramping of your uterus. Your doctor or midwife will also usually give you a medication for pain. Misoprostol often causes diarrhea and may cause some nausea. Let your doctor or midwife know if you aren’t able to keep the medicine down. You will usually have to take two doses of medication about 6 hours apart. Medical management of miscarriage is generally effective within 24-48 hours. You can expect less bleeding than with a natural miscarriage, but should still be prepared for strong labor-like pain.

Misoprostol can also be given vaginally and, less commonly, rectally. If using vaginally insert the pills as far up in the vagina as possible and lie down immediately afterward. It is a good idea to plan to do this at bedtime. You may also want to take pain medication at the same time. Try to stay horizontal so the pills stay in the right place so they can work. This dose may also have to be repeated. Some women notice less nausea and vomiting with the vaginal method.

If you are past the first trimester, expect to be admitted into the hospital for administration of the misoprostol. Otherwise, you will safely be able to do this at home. The management for the miscarriage once it starts is the same as found on the Expectant Management page.

Ectopic pregnancy

Your doctor or midwife will probably offer you several different ways to manage your miscarriage. An ectopic pregnancy is a pregnancy that is “out of place” (the literal meaning of the term). Most non-medical people refer to this as a “tubal pregnancy.” Ectopic pregnancies most commonly occur in the fallopian tubes, but they may also occur in the cervix, the cornua (area of the uterus where the tube enters), ovary, or the abdomen. Ectopic pregnancies are serious and are a significant cause of maternal death in the first trimester.

Your doctor or midwife may suspect an ectopic pregnancy because of your symptoms or because she doesn’t see anything in your uterus on an ultrasound. If your pregnancy hormone (beta HCG) level is above 1500, it should be possible to see a pregnancy in the uterus. Your doctor may also order a progesterone level to help evaluate the pregnancy. A progesterone level of less than 5 indicates an abnormal pregnancy and you may need progesterone support; a level greater than 25 indicates a normal pregnancy. Most women, however, have levels between 5 and 25. Your doctor or midwife may have you return in 48 hours for a repeat check of your pregnancy hormone level. In a normal pregnancy, the HCG level should increase by two thirds in 48 hours. A hormone level that does not go up as much indicates an abnormal pregnancy. If no sac was seen in the uterus, this implies an ectopic pregnancy.

Expectant management of an ectopic pregnancy is similar to that of a missed abortion or blighted ovum. Your doctor or midwife may have you return in 48 hours for a repeat check of your pregnancy hormone level or may have you wait until the next week. You will be given strict instructions on symptoms that should lead you to call your doctor. DO NOT IGNORE THESE SYMPTOMS. A ruptured ectopic pregnancy is a true medical emergency. If your hormone levels are decreasing and you are not having symptoms, your health care provider will continue weekly checks of your pregnancy hormone level until it reaches zero.

There are typically three different approaches to treating an ectopic pregnancy: medication (discussed in the following paragraphs) and two different types of surgery (discussed in the Ectopic Pregnancy section of Surgical Management). Before diving into their discussion, we want to clearly state that while we consulted with the National Catholic Bioethics Center on this topic, the debate about these approaches is still ongoing, and there really is no explicit Church teaching on any of these methods. The information provided here with regards to Church teaching is simply based on the collected ideas of theologians who have spoken on the subject and so therefore is still open to interpretation. If you would like further reading, please see Directives 45 and 47 of the USCCB’s Ethical and Religious Directives for Catholic Health Care Services (5th ed., 2009). While the reading may be helpful, much is still open to debate regarding what specific actions are considered to be direct abortions.

The only medical treatment option we are aware of is medication (methotrexate). This is often a shot given to end the pregnancy and produce bleeding similar to a regular early miscarriage; please see more information in the following paragraphs. However, Catholic theologians disagree as to whether or not this is licit under Church teaching. Some claim that the medication technically targets the fast-growing cells of the placenta and not the baby, so it is acceptable. Others claim that while it targets the placenta, it also targets the fast-growing cells of the baby itself, causing a direct abortion and therefore going against Church teaching. Still others claim that until the baby is viable, the placenta itself is a vital organ of the baby, and therefore targeting the placenta is also a direct abortion and therefore not acceptable. In other words, it’s an ongoing debate and as parents you will have to consult with your doctor and inform your conscience to the best of your ability to make the decision whether or not to use methotrexate as treatment for an ectopic pregnancy.

Methotrexate is a drug that prevents genes from being copied and prevents proteins from being made. It causes the placental tissues to die. Before you get methotrexate, your doctor will check to make sure that your liver and kidneys are functioning properly. Methotrexate is given as an injection into the muscle (usually the buttocks). You will have your pregnancy hormone level checked on the day you get the shot, the third day after the shot, and the sixth day after the shot. It is normal for the level to go up between days 1 and 4. Your doctor or midwife will look for the level to drop by 15% between days 4 and 7. If the hormone level does not drop enough, you and your midwife will need to discuss whether you should get another shot or whether you should have surgery. If it does drop enough, you will continue to have your pregnancy hormone level checked each week until it is negative.

Methotrexate has many side effects, including diarrhea, nausea and vomiting, and abdominal pain. There are some rare cases in which methotrexate causes the bone marrow to temporarily stop making blood cells. This only lasts for a short time and is reversible.