management

Last edited 03/2020 and last reviewed 09/2023

Women with a suspected miscarriage should ideally be assessed in an early pregnancy assessment unit (EPAU) with ultrasound equipment (including transvaginal probes) and laboratory facilities for rhesus antibody testing and selective serum human chorionic gonadotrophin (hCG) and progesterone estimation (1).

The following women should be referred to an EPAU:

• women in first trimester who have had a positive pregnancy test and
  • abdominal pain
  • vaginal bleeding
  • previous ectopic pregnancy
  • previous tubal surgery
  • two or more previous miscarriages
  • IUCD in-situ
• non-viable pregnancies (diagnosed during ante-natal booking clinic)
• post evacuation (medical/surgical) with persistent bleeding (2)

In the UK, 88% of women with miscarriages go through surgical evacuation of retained products due to risk complications (although excessive vaginal bleeding or infected products of conception within the uterine cavity are seen in less than 10% of women with a miscarriage) (3).

Management of a woman with miscarriage can be divided into:

• there are broadly three management options if a woman has been diagnosed with an early miscarriage (<= 13 weeks gestation):
  
  
  • 1.Expectant management - waiting for spontaneous miscarriage
  
  
  • uncertainty regarding the length of time that women should try expectant management
  • NICE recommends expectant management for 7-14 days once miscarriage is confirmed on ultrasound
  • however an exception to this strategy is in a women with excessive bleeding
  • emergency surgery may be required
  • the American College of Obstetricians and Gynaecologists (ACOG) suggests up to 8 weeks of expectant management to achieve approximately an 80% success rate (2)
  • medical or surgical management if expectant management is unsuccessful
    
    
  • 2.Medical management
  • NICE and ACOG guidance currently recommend an 800 μg dose of misoprostol given vaginally for missed miscarriage
  • if required then a repeat dose of 600 or 800 μg for incomplete miscarriage.
  • the PreFaiR trial (300 participants) found a higher likelihood of expulsion of the gestational sac when mifepristone (200 mg orally) was used before misoprostol
    administration (800 μg vaginally) compared with misoprostol alone
  • ACOG also advises the administration of 200 mg oral mifepristone, if available, 24 hours before misoprostol
    
    
  • Surgical management
  • an option if failure/contraindication to expectant management
  • has similar rates of complete miscarriage to both expectant and medical management
  • may lead to more prompt resolution of miscarriage compared with other approaches
  • complications (bleeding, infection, and uterine perforation) and need for further surgery are rare

Women undergoing medical or expectant management should have access to 24 hour telephone advice and emergency admission. Comparison of expectant, medical and surgical management has been carried out in various randomized trials and has found out that:

Tissue from the evacuated material should be obtained to carry out histological examinations to confirm pregnancy and to rule out ectopic pregnancy or unsuspected gestational trophoblastic disease (1).

Reference:

• 1. Royal College of Obstetricians and Gynaecologists (RCOG) 2006. The management of early pregnancy loss
• 2. Association of early pregnancy units (2007). AEPU Guidelines
• 3. Condous G et al. The conservative management of early pregnancy complications: a review of the literature. Ultrasound in Obstetrics and Gynaecology 2003;22(4):420-430
• 4. Chu J et al. What is the best method for managing early miscarriage?BMJ 2020;368:l6438.
• 5. ACOG Practice Bulletin No. 200 Summary: Early Pregnancy Loss. (2018). Obstet Gynecol 2018;132:1311-310.