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Guidelines on management of
miscarriage
Family Health
Obstetrics and Gynaecology
Date of submission
March 2013
March 2016
Abstract
Key Words
Consultation Process
Target audience
This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The
interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If
in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review
date.
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Introduction
Miscarriageoccursin1020%ofclinicalpregnanciesandaccountsfor50000inpatientadmissionsto
Hospitals in the UK annually. The common clinical features include varying amounts of pain and
vaginal bleeding. At all times women should be supported in making informed choices about their
care and management. Adequate explanation supplemented with written information should be
giventoassistdecisionmaking.
Completemiscarriageisatermusedwhentheclinicalsignsandsymptomssuggestamiscarriageand
ultrasound scan confirms an endometrial thickness of less than 15 mm. There may be very little
pregnancytissuegivingbrightechoesoralargeamountofbloodshowingnoechogenicityatalland
thereforewomenshouldbeadvisedtoreportifbleedingcontinuedbeyond2weeks.
Incompletemiscarriageisatermusedwhentheclinicalsignsandsymptomssuggestamiscarriage
andultrasoundscanconfirmspresenceofproductsofconceptionwithevidenceofnonviability.
Missed miscarriage is a term used when there is no clinical feature of miscarriage however the
ultrasoundscanconfirmsabsenceofaviablepregnancy.
Women should be offered the choices of conservative, medical or surgical methods of miscarriage
management.Patientpreferenceisimportantandshouldbeacknowledgedasadeterminingfactorin
managementdecisions.
Conservative or expectant management involves passage of products of conception naturally and
thereforearescanshouldbearrangedin1014days.Thereisnodefinedtimelimitforthesuccessof
treatment,howeverotheroptionsbeconsideredifnoPOCsarepassedupto2weeksandwomans
condition reviewed. In the presence of infection, the treatment should be abandoned and surgical
managementbeconsidered.Aurinepregnancytestshouldbeadvised3weeksfollowingthepassage
ofproductstoestablishcompletionofprocess.Ifitisfoundtobepositive,anultrasoundscanshould
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be performed. (NICE guideline CG154). Conservative management requires robust counselling and
supportforthetreatmenttosucceed.
Medical management involves administration of drugs to assist passage of POCs naturally. Anti
progesterone oral tablet, Mifepristone and prostaglandin analogue, Misoprostol as a vaginal tablet
are commonly used to achieve this. Recent NICE guideline (CG154) recommends that missed
miscarriageandincompletemiscarriagebetreatedwithmisoprostolalone.Asingledoseof800mcg
of misoprostol intravaginally is recommended. This can be managed as an outpatient procedure.
Woman should be advised that if bleeding has not started 24 hours after treatment, she should
contact the early pregnancy assessment unit and care be individualised. This may include re
administrationofmisoprostolorasurgicalmanagement.Allwomenshouldbeofferedpainreliefand
antiemetics. They should be counselled about the length and extent of bleeding and the potential
sideeffects of treatment including pain, diarrhoea and vomiting. A urine pregnancy test should be
advised3weeksfollowingthepassageofproductstoestablishcompletionofprocess.Ifitisfoundto
bepositive,anultrasoundscanshouldbeperformed.(NICEguidelineCG154)
Surgical management includes completion of miscarriage using vacuum aspiration. It is the most
successful treatment option however requires anaesthesia and carries a small risk of uterine
perforation. The advantages of prostaglandin administration prior to surgical abortion are well
established,withsignificantreductionsindilatationforce,haemorrhageanduterine/cervicaltrauma.
Theguidelinesbelowdetailthemanagementoptionsofmiscarriagealongwiththepathwaytofollow.
Recent research suggests that given interobserver variability in ultrasound measurements and the
greater variation in early embryonic growth than has hitherto been assumed, a more conservative
approachtothediagnosisofearlypregnancylossiswarranted.AnMSDcutoffof25mmandaCRL
cutoffof7mmcouldbeintroducedtominimizetheriskofafalsepositivediagnosisofmiscarriage.
GuidelinesforExpectantManagementofMiscarriage
PATIENTCHOICE
Patientfullycounselled
Informationleaflet
Informnurseincharge
FBCandGroup+Save(ensureHb>10g%)
ArrangerepeatultrasoundscanandEPACappointmentin2weeks
AntiDimmunoglobulinifrhesusnegative
Ifthepatientisclinicallywellwithnosymptomsandsignssuggestiveofinfection,there
isnodefinedtimelimittoconcludethatthetreatmenthasfailed
GENERAL RULES
Ifthepatientplanstocontinuewithexpectantmanagementbeyond2weeksof
diagnosis,performanultrasoundscanandbloodtestforclottingandCRPevery
2weeks.
Offersurgicalmanagementifproductsofconceptionnotexpelledby2weeks
of diagnosis, as the success of the treatment progressively reduces with
duration.
Givebroadspectrumantibioticsifthereisanysuggestionofinfectionandplan
an ERPC. In women with pyrexia, IV antibiotics should be given for initial 24
hoursfollowedbyoralantibioticsfor5days.
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GuidelinesforSurgicalManagementofMiscarriage
PATIENTCHOICE
Patientfullycounselled
Informationleaflet
Informnurseincharge
Bookwiththeatrecoordinator
Obtainconsentforprocedureandproductsofconception
FBCandGroup+Save
PrescribethefollowingonDrugChart:
Misoprostol400mcgPVfor7.00AMondayofERPC
AntiDimmunoglobulinifrhesusnegative
Metronidazole1gPRintraoperative+Azithromycin1gPOpost
operative(statdose)
PatientdischargedhomewithadatetocometoC32
ERPC(minimum2theatreslots)inemergencytheatrestartingat8.00am
Patientdischargedhomewithin6hours
Checkresultsofhistopathologyassoonasavailable
EnsureAntiDisgiveninrhesusnegativewomenbeforedischarge(itcould
begivenupto72hoursfromthepresumedtimeofexposureoffoetalblood
tomaternalcirculationi.e.timeofERPC
GENERALRULES
Avoidmisoprotolifpreviouscaesareansection,myomectomyoruterineperforation.
Competentsurgeonshouldbeavailabletogotoemergencytheatrefor08.00hrs.
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GuidelinesforMedicalManagementofMiscarriage
PATIENTCHOICE
Patientfullycounselled
Informationleaflet
Informnurseincharge
Obtainconsentforprocedureandproductsofconception
FBCandG&S(ensureHbis>10g%)
Prescribethefollowingondrugchart:
SingledoseofMisoprostol800mcgpervaginum.
Azithromycin1gPO
AntiDImmunoglobulinifRhesusnegative
Analgesicsparacetamolandcodeinephosphate(avoidNSAIDs)
Antiemetics
Patientdischargedhomewithadatefortreatment
Patientcanbeeithermanagedonoutpatientorinpatientbasis.
Misoprostol800mcginsertedvaginallyby patientornurseincharge
NOPOCsorsomePOCs
Passedwithin24hours
POCspassedcompletelywithin24hours
RepeattreatmentwithMisoprostol800mcgP.V.in2448
hours(patientchoice,reducedsuccess)
ERPCpatientchoice
(Refertopathwayonsurgicalmanagement)
Advisewomantoperformurinepregnancytest3weeksfollowingpassageof
productsofconceptiontoconfirmcompletionoftreatment.
IfUPTpositiveorwomansymptomatic(pain,bleeding,pyrexia)performpelvic
ultrasoundscan
CONTRAINDICATIONS
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References
Blohm F, Hahlin M, Nielsen S, Milsom I. Fertility after a randomised trial of spontaneous abortion
managedbysurgicalevacuationorexpectanttreatment.Lancet1997;349:995.
De Jonge EJM et al. Randomised clinical trial of medical evacuation and surgical curettage for
incompletemiscarriage.BMJ1995;311:662.
ElRefaeyetal.Inductionofabortionwithmifepristone(RU486)and oralorvaginalmisoprostol. N
EnglJMed1995;332:9837.
HinshawHKS.Medicalmanagementofmiscarriage.InGrudzinkasTG,OBrienPMS,editors.Problems
inearlypregnancy:advancesindiagnosisandmanagement.London:RCOGpress,1997;28495.
NICE Guideline CG154, Ectopic pregnancy and miscarriage Diagnosis and initial management in
earlypregnancyofectopicpregnancyandmiscarriage.December2012.
Royal College of Obstetricians and Gynaecologists. Useof AntiD Immunoglobulin forRh Prophylaxis.
GuidelineNo.22.London:RCOG;2002.
RoyalcollegeofObstetricianandGynaecologist.Themanagementofearlypregnancyloss.Guideline
No.25,London:RCOG;2004.
TrinderJ,BrocklehurstP,PorterR,ReadM,VyasS,SmithL.Managementofmiscarriage:expectant,
medical,orsurgical?Resultsofrandomisedcontrolledtrial(miscarriagetreatment(MIST)trial).BMJ
2006;332(7552):123538
Abdallah Y, Daemen A, Kirk E, Pexsters A, Naji O, Stalder C, Gould D, Ahmed S, Guha S, Syed S,
Bottomley C, Timmerman D, Bourne T. Limitations of current definitions of miscarriage using mean
gestationalsacdiameterandcrownrumplengthmeasurements:amulticenterobservationalstudy.
UltrasoundObstetGynecol.2011Oct13.doi:10.1002/uog.10109.[Epubaheadofprint]
GuidelinesforManagementofMiscarriageinAntenatalclinic
Miscarriageconfirmedon
ultrasoundscan
Gestationalsacmorethan
orequalto25mm
CRLmorethanorequalto
7mm
NOfoetalheartorempty
sac
Evidenceofretained
productsofconception
Miscarriagenotconfirmedon
ultrasoundscan
Lessthan12weeks
Gestationalsaclessthan
25mm
CRLlessthan7mm
Foetalbradycardia
RefertoEPAU
Contactnumbers
EPAC:64873/64874
Seniornurse:70437
Consultantoncall:70436
Givewomaninformation
leafletonmiscarriages
Advisewomantokeep
handheldnoteswhen
visitingEPAC
Repeatultrasoundscanin714
days
Miscarriageconfirmed
GENERALRULES
Pleaseinformwomenthattheymaynotbeseenthesamedayand
thatitisnotessentialtobeseenthesamedayinEPAC.
Whenreferredasanemergency,theremightbeawaitbeforeseen
Whendoubtfulofthediagnosis,offeranotherscanand/orsecond
opinion
Miscarriageisgenerallymanagedin3waysandthereforewomen
have3treatmentoptions
1. Expectantmanagement:awaitspontaneousmiscarriage,success
approx7080%
2. Medicalmanagement:medicinesadministeredtohastennatural
processofmiscarriage,successapprox80%
3. Surgicalmanagement:ERPC,successapprox95%
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