Treatment for Foul Smell After Miscarriage
The first-line treatment for foul-smelling discharge after a miscarriage is oral metronidazole 500mg twice daily for 7 days, as this likely represents bacterial vaginosis or endometritis requiring antibiotic therapy. 1
Diagnosis of the Cause
When a woman presents with foul smell after a miscarriage, the most likely causes include:
- Bacterial vaginosis (BV): Characterized by a fishy odor, homogeneous white discharge, pH >4.5, and presence of clue cells on microscopy
- Retained products of conception: May cause a foul-smelling discharge due to infection of remaining tissue
- Endometritis: Infection of the endometrium following incomplete miscarriage
Diagnostic Approach
- Physical examination: Assess for fever, abdominal tenderness, and character of vaginal discharge
- Laboratory tests:
- Vaginal pH measurement (>4.5 suggests BV)
- Microscopic examination for clue cells
- Whiff test (fishy odor after adding 10% KOH)
- Complete blood count to assess for infection
Treatment Algorithm
First-line Treatment
- Metronidazole 500mg orally twice daily for 7 days 1
- Highly effective with a 95% cure rate for BV
- Addresses the most common cause of foul odor after miscarriage
For Suspected Retained Products of Conception
- Ultrasound evaluation to confirm presence of retained tissue
- If confirmed:
- Surgical evacuation may be necessary for significant retained tissue
- Misoprostol (vaginal or oral) can be considered as an alternative to surgery 2
Additional Measures
- Daily lukewarm baths (30 minutes) to help remove discharge and debris 3
- Mild antiseptic baths two to three times a week if recurrent infection is a concern:
- Chlorhexidine (dilution 5 parts in 1000–10,000)
- Octenidine 0.1%
- Polyhexanide 0.1% 3
Important Precautions
- Avoid alcohol during metronidazole treatment and for 24 hours afterward to prevent disulfiram-like reaction 1
- Abstain from sexual intercourse until treatment is completed and symptoms resolve 1
- Return for follow-up if symptoms persist or worsen after completing treatment
Special Considerations
For pregnant women who have experienced incomplete miscarriage and have foul odor:
- First trimester: clindamycin cream is preferred
- Second and third trimesters: metronidazole (oral or gel) or clindamycin cream 1
For women planning future pregnancies:
- Untreated infections after miscarriage can increase risk of subsequent pregnancy complications
- Current evidence suggests that conception immediately after a miscarriage is safe if infection has been adequately treated 4
Warning Signs Requiring Immediate Medical Attention
- High fever (>38°C/100.4°F)
- Severe abdominal pain
- Heavy bleeding
- Foul-smelling discharge that worsens despite treatment
- Signs of sepsis (rapid heart rate, confusion, extreme weakness)
Prompt and appropriate treatment of foul odor after miscarriage is essential to prevent complications such as pelvic inflammatory disease and future pregnancy complications.