Miscarriage
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
threatened miscarriage
analgesics plus counselling
Analgesics are imperative in the presence of pain and discomfort, and non-steroidal anti-inflammatory drugs are best avoided. Paracetamol is the analgesic of choice.
Counselling for the mothers (or couples) should be given. A patient information leaflet should also be provided. Pregnancies that continue require closer follow-up and targeted fetal surveillance. Many women who experience spontaneous vaginal bleeding in the first half of pregnancy have uneventful pregnancies thereafter.
Primary options
paracetamol: 500-1000 mg every 4-6 hours when required, maximum 4000 mg/day
progesterone
Additional treatment recommended for SOME patients in selected patient group
Vaginal progesterone may be recommended in some countries.
In the UK, the National Institute for Health and Care Excellence recommends offering vaginal micronised progesterone to women with an intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and have previously had a miscarriage.[69]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Nov 2021 [internet publication]. https://www.nice.org.uk/guidance/ng126
If a fetal heartbeat is confirmed, progesterone should be continued until 16 completed weeks of pregnancy.[69]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Nov 2021 [internet publication]. https://www.nice.org.uk/guidance/ng126
Clinical opinion on the utlity of progesterone and other progestogens for threatened miscarriage remains mixed, and is not currently recommended in US practice.[91]American College of Obstetricians and Gynecologists. Practice bulletin: early pregnancy loss. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss
Primary options
progesterone micronised: 400 mg intravaginally twice daily
anti-D immunoglobulin
Additional treatment recommended for SOME patients in selected patient group
In the US, the American College of Obstetricians and Gynecologists recommends that women who are rhesus negative and unsensitised should receive anti-D immunoglobulin within 72 hours of a potentially sensitising event in the first or second trimester. However, whether to administer anti-D immunoglobulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made. Because of the higher risk of alloimmunisation, rhesus-negative women who receive surgical management of their miscarriage should receive anti-D rhesus prophylaxis.[91]American College of Obstetricians and Gynecologists. Practice bulletin: early pregnancy loss. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss [121]Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 181: Prevention of Rh D alloimmunization. Obstet Gynecol. 2017 Aug;130(2):e57-70. https://journals.lww.com/greenjournal/FullText/2017/08000/Practice_Bulletin_No__181__Prevention_of_Rh_D.54.aspx http://www.ncbi.nlm.nih.gov/pubmed/28742673?tool=bestpractice.com
Advice in the UK differs, with the National Institute for Health and Care Excellence recommending that anti-D immunoglobulin is offered to all rhesus-negative women who have a surgical procedure to manage a miscarriage. It does not need to be offered to women who have received solely medical management, have a threatened or complete miscarriage, or a pregnancy of unknown location.[69]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Nov 2021 [internet publication]. https://www.nice.org.uk/guidance/ng126
Primary options
anti-D immunoglobulin: refer to consultant for guidance on dosage
More anti-D immunoglobulinDose differs between brands
inevitable/incomplete/missed miscarriage
manual evacuation
Remove the early pregnancy tissue digitally or with a sterile ovum or sponge-holding forceps.
analgesics plus counselling
Treatment recommended for ALL patients in selected patient group
Analgesics are imperative in the presence of pain and discomfort, and non-steroidal anti-inflammatory drugs are best avoided. Paracetamol is the analgesic of choice.
Counselling for the mothers (or couples) should be given. A patient information leaflet should also be provided. Prolonged psychological or psychiatric support may be needed in some patients. Some women experience guilt in addition to their grief. Loss of an early pregnancy can affect couples psychologically as significantly as a neonatal death. The extremely low chance of repeat miscarriage should be mentioned if any worry is expressed about the future. Depending on hospital or healthcare facility policy, the removed early pregnancy tissue may be sent for histopathology, after obtaining parental consent and offering counselling.
Primary options
paracetamol: 500-1000 mg every 4-6 hours when required, maximum 4000 mg/day
misoprostol
Additional treatment recommended for SOME patients in selected patient group
Patients with severe vaginal bleeding or those who continue to bleed after a manual evacuation should receive misoprostol, a prostaglandin analogue, even if early pregnancy tissue is removed from the upper vagina or cervical canal. This will aid complete emptying of the uterine cavity.[92]Kim C, Barnard S, Neilson JP, et al. Medical treatments for incomplete miscarriage. Cochrane Database Syst Rev. 2017 Jan 31;(1):CD007223. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007223.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/28138973?tool=bestpractice.com
Primary options
misoprostol: 800 micrograms intravaginally as a single dose; repeat once on day 3 if expulsion incomplete
More misoprostolOral tablets are used for intravaginal administration.
anti-D immunoglobulin
Additional treatment recommended for SOME patients in selected patient group
In the US, the American College of Obstetricians and Gynecologists recommends that women who are rhesus negative and unsensitised should receive anti-D immunoglobulin within 72 hours of a potentially sensitising event in the first or second trimester. However, whether to administer anti-D immunoglobulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made. Because of the higher risk of alloimmunisation, rhesus-negative women who receive surgical management of their miscarriage should receive anti-D rhesus prophylaxis.[91]American College of Obstetricians and Gynecologists. Practice bulletin: early pregnancy loss. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss [121]Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 181: Prevention of Rh D alloimmunization. Obstet Gynecol. 2017 Aug;130(2):e57-70. https://journals.lww.com/greenjournal/FullText/2017/08000/Practice_Bulletin_No__181__Prevention_of_Rh_D.54.aspx http://www.ncbi.nlm.nih.gov/pubmed/28742673?tool=bestpractice.com
Advice in the UK differs, with the National Institute for Health and Care Excellence recommending that anti-D immunoglobulin is offered to all rhesus-negative women who have a surgical procedure to manage a miscarriage. It does not need to be offered to women who have received solely medical management, have a threatened or complete miscarriage, or a pregnancy of unknown location.[69]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Nov 2021 [internet publication]. https://www.nice.org.uk/guidance/ng126
Primary options
anti-D immunoglobulin: refer to consultant for guidance on dosage
More anti-D immunoglobulinDose differs between brands
conservative management
A significant number of women prefer conservative (or expectant) management allowing early pregnancy tissue to be expelled spontaneously. It may be continued as long as the patient is willing and provided there are no signs of infection such as vaginal discharge, excessive bleeding, pyrexia, or abdominal pain.
Follow-up scans may be arranged at 2-weekly intervals, until a diagnosis of complete miscarriage is made.
Ultrasound is preferred for confirming early pregnancy loss. The American College of Obstetricians and Gynecologists recommends that surgical intervention is not required in asymptomatic women who have a thickened endometrial stripe after undergoing treatment for pregnancy loss.[91]American College of Obstetricians and Gynecologists. Practice bulletin: early pregnancy loss. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss
analgesics plus counselling
Treatment recommended for ALL patients in selected patient group
Analgesics are imperative in the presence of pain and discomfort, and non-steroidal anti-inflammatory drugs are best avoided. Paracetamol is the analgesic of choice.
Counselling for the mothers (or couples) should be given. A patient information leaflet should also be provided. Prolonged psychological or psychiatric support may be needed in some patients. Some women experience guilt in addition to their grief. Loss of an early pregnancy can affect couples as significantly as a neonatal death. The extremely low chance of repeat miscarriage should be mentioned if any worry is expressed about the future. Depending on hospital or healthcare facility policy, the removed early pregnancy tissue may be sent for histopathology, after obtaining parental consent and offering counselling.
Primary options
paracetamol: 500-1000 mg every 4-6 hours when required, maximum 4000 mg/day
anti-D immunoglobulin
Additional treatment recommended for SOME patients in selected patient group
In the US, the American College of Obstetricians and Gynecologists recommends that women who are rhesus negative and unsensitised should receive anti-D immunoglobulin within 72 hours of a potentially sensitising event in the first or second trimester. However, whether to administer anti-D immunoglobulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made. Because of the higher risk of alloimmunisation, rhesus-negative women who receive surgical management of their miscarriage should receive anti-D rhesus prophylaxis.[91]American College of Obstetricians and Gynecologists. Practice bulletin: early pregnancy loss. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss [121]Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 181: Prevention of Rh D alloimmunization. Obstet Gynecol. 2017 Aug;130(2):e57-70. https://journals.lww.com/greenjournal/FullText/2017/08000/Practice_Bulletin_No__181__Prevention_of_Rh_D.54.aspx http://www.ncbi.nlm.nih.gov/pubmed/28742673?tool=bestpractice.com
Advice in the UK differs, with the National Institute for Health and Care Excellence recommending that anti-D immunoglobulin is offered to all rhesus-negative women who have a surgical procedure to manage a miscarriage. It does not need to be offered to women who have received solely medical management, have a threatened or complete miscarriage, or a pregnancy of unknown location.[69]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Nov 2021 [internet publication]. https://www.nice.org.uk/guidance/ng126
Primary options
anti-D immunoglobulin: refer to consultant for guidance on dosage
More anti-D immunoglobulinDose differs between brands
medical evacuation with misoprostol
Drugs used to facilitate or to effect uterine evacuation may have a role where vaginal bleeding is reasonably mild.[106]Creinin MD, Harwood B, Guido RS, et al. Endometrial thickness after misoprostol use for early pregnancy failure. Int J Gynaecol Obstet. 2004 Jul;86(1):22-6. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15207665 http://www.ncbi.nlm.nih.gov/pubmed/15207665?tool=bestpractice.com [107]Trinder J, Brocklehurst P, Porter R, et al. Management of miscarriage: expectant, medical or surgical? Results of randomized controlled trial (miscarriage treatment (MIST) trial. BMJ. 2006 May 27;332(7552):1235-40. http://www.bmj.com/content/332/7552/1235.full http://www.ncbi.nlm.nih.gov/pubmed/16707509?tool=bestpractice.com [108]Ngoc NT, Blum J, Westheimer E, et al. Medical treatment of missed abortion using misoprostol. Int J Gynaecol Obstet. 2004 Nov;87(2):138-42. http://www.ncbi.nlm.nih.gov/pubmed/15491558?tool=bestpractice.com
The main drug therapy for non-surgical management of miscarriage is misoprostol, a prostaglandin analogue. The patient, however, needs to be informed that the surgical option may still be necessary if bleeding gets heavier or is persistent beyond a reasonable time. Vaginal bleeding after misoprostol therapy seems to be more prolonged and heavier, but seldom requires blood transfusion compared with after surgical evacuation.[101]Davis AR, Hendlish SK, Westhoff C, et al. Bleeding patterns after misoprostol vs surgical treatment of early pregnancy failure: results from a randomized trial. Am J Obstet Gynecol. 2007 Jan;196(1):31;e1-7. http://www.ncbi.nlm.nih.gov/pubmed/17240222?tool=bestpractice.com
Primary options
misoprostol: 800 micrograms intravaginally as a single dose; repeat once on day 3 if expulsion incomplete
More misoprostolOral tablets are used for intravaginal administration.
analgesics plus counselling
Treatment recommended for ALL patients in selected patient group
Analgesics are imperative in the presence of pain and discomfort, and non-steroidal anti-inflammatory drugs are best avoided. Paracetamol is the analgesic of choice.
Counselling for the mothers (or couples) should be given. A patient information leaflet should also be provided. Prolonged psychological or psychiatric support may be needed in some patients. Some women experience guilt in addition to their grief. Loss of an early pregnancy can affect couples as significantly as a neonatal death. The extremely low chance of repeat miscarriage should be mentioned if any worry is expressed about the future. Depending on hospital or healthcare facility policy, the removed early pregnancy tissue may be sent for histopathology, after obtaining parental consent and offering counselling.
Primary options
paracetamol: 500-1000 mg every 4-6 hours when required, maximum 4000 mg/day
anti-D immunoglobulin
Additional treatment recommended for SOME patients in selected patient group
In the US, the American College of Obstetricians and Gynecologists recommends that women who are rhesus negative and unsensitised should receive anti-D immunoglobulin within 72 hours of a potentially sensitising event in the first or second trimester. However, whether to administer anti-D immunoglobulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made. Because of the higher risk of alloimmunisation, rhesus-negative women who receive surgical management of their miscarriage should receive anti-D rhesus prophylaxis.[91]American College of Obstetricians and Gynecologists. Practice bulletin: early pregnancy loss. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss [121]Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 181: Prevention of Rh D alloimmunization. Obstet Gynecol. 2017 Aug;130(2):e57-70. https://journals.lww.com/greenjournal/FullText/2017/08000/Practice_Bulletin_No__181__Prevention_of_Rh_D.54.aspx http://www.ncbi.nlm.nih.gov/pubmed/28742673?tool=bestpractice.com
Advice in the UK differs, with the National Institute for Health and Care Excellence recommending that anti-D immunoglobulin is offered to all rhesus-negative women who have a surgical procedure to manage a miscarriage. It does not need to be offered to women who have received solely medical management, have a threatened or complete miscarriage, or a pregnancy of unknown location.[69]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Nov 2021 [internet publication]. https://www.nice.org.uk/guidance/ng126
Primary options
anti-D immunoglobulin: refer to consultant for guidance on dosage
More anti-D immunoglobulinDose differs between brands
suction evacuation of the uterus ± antibiotics
A flexible or rigid plastic cannula is connected to a controlled suction outlet. It is important to ascertain the axis of the uterus before inserting the cannula.
Because suction evacuation of the uterus is undertaken with some form of regional or parenteral/general anaesthetic, the risks of perforation are high. The most critical safeguards to this are to ascertain the cervico-uterine axis and to assess the approximate cervico-uterine cavity length.
The use of routine antibiotic prophylaxis in women with incomplete miscarriage and no signs of infection is controversial.[110]May W, Gülmezoglu AM, Ba-Thike K. Antibiotics for incomplete abortion. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD001779. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001779.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/17943756?tool=bestpractice.com
Women with incomplete miscarriage who have one or more features: a foul-smelling vaginal discharge, fever, chills, lower abdominal pain, or feeling unwell, may benefit from a preoperative course of antibiotics to be administered at least 1 hour before uterine evacuation.[111]Achilles SL, Reeves MF; Society of Family Planning. Prevention of infection after induced abortion: release date October 2010: SFP guideline 20102. Contraception. 2011 Apr;83(4):295-309. https://www.contraceptionjournal.org/article/S0010-7824(10)00644-X/fulltext http://www.ncbi.nlm.nih.gov/pubmed/21397086?tool=bestpractice.com Oral antibiotics may be prescribed for at least 3 days after surgery. In one study, administration of intravenous antibiotics preoperatively showed that oral antibiotics may not be necessary after 48 hours of clinical improvement.[112]Savaris RF, de Moraes GS, Cristovam RA, et al. Are antibiotics necessary after 48 hours of improvement in infected/septic abortions? A randomized controlled trial followed by a cohort study. Am J Obstet Gynecol. 2011 Apr;204(4):301.e1-5. https://www.ajog.org/article/S0002-9378(10)02271-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/21195382?tool=bestpractice.com
Antibiotics should be prescribed according to local guidelines.
Primary options
at increased risk of Chlamydia infection
doxycycline: 200 mg orally one hour preoperatively, followed by 100 mg orally twice daily for 10 days after surgery
OR
at increased risk of Chlamydia infection
azithromycin: 1g orally as a single dose one hour preoperatively
OR
not at increased risk of Chlamydia infection
amoxicillin/clavulanate: 1.2 g intravenously as a single dose preoperatively, followed by 250 mg orally every 8 hours for 3 days after surgery
More amoxicillin/clavulanateIntravenous dose consists of 1 g amoxicillin plus 0.2 g clavulanate. Oral dose refers to amoxicillin component only.
OR
not at increased risk of Chlamydia infection
metronidazole: 1 g rectally as a single dose preferably no later than 1 hour before uterine evacuation
analgesics plus counselling
Treatment recommended for ALL patients in selected patient group
Analgesics are imperative in the presence of pain and discomfort, and non-steroidal anti-inflammatory drugs are best avoided. Paracetamol is the analgesic of choice. Compared with women who underwent medical evacuation with misoprostol, women who underwent manual vacuum aspiration had higher pain scores, although they had fewer side effects.[124]Bique C, Ustá M, Debora B, et al. Comparison of misoprostol and manual vacuum aspiration for the treatment of incomplete abortion. Int J Gynaecol Obstet. 2007 Sep;98(3):222-6. http://www.ncbi.nlm.nih.gov/pubmed/17610879?tool=bestpractice.com
Counselling for the mothers (or couples) should be given. A patient information leaflet should also be provided. Prolonged psychological or psychiatric support may be needed in some patients. Some women experience guilt in addition to their grief. Loss of an early pregnancy can affect couples as significantly as a neonatal death. The extremely low chance of repeat miscarriage should be mentioned if any worry is expressed about the future. Depending on hospital or healthcare facility policy, the removed early pregnancy tissue may be sent for histopathology, after obtaining parental consent and offering counselling.
Primary options
paracetamol: 500-1000 mg every 4-6 hours when required, maximum 4000 mg/day
oxytocics
Additional treatment recommended for SOME patients in selected patient group
May be used to facilitate or to effect uterine evacuation in patients undergoing surgical evacuation and to reduce post-procedure bleeding.
Primary options
oxytocin: consult specialist for guidance on dose
and
ergometrine: consult specialist for guidance on dose
OR
misoprostol: consult specialist for guidance on dose
anti-D immunoglobulin
Additional treatment recommended for SOME patients in selected patient group
Women who are rhesus negative and unsensitised should receive anti-D immunoglobulin immediately after surgical management of miscarriage.[69]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Nov 2021 [internet publication]. https://www.nice.org.uk/guidance/ng126 [91]American College of Obstetricians and Gynecologists. Practice bulletin: early pregnancy loss. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss
Primary options
anti-D immunoglobulin: refer to consultant for guidance on dosage
More anti-D immunoglobulinDose differs between brands
medical evacuation with misoprostol
Drugs used to facilitate or to effect uterine evacuation may have a role where vaginal bleeding is reasonably mild.[106]Creinin MD, Harwood B, Guido RS, et al. Endometrial thickness after misoprostol use for early pregnancy failure. Int J Gynaecol Obstet. 2004 Jul;86(1):22-6. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15207665 http://www.ncbi.nlm.nih.gov/pubmed/15207665?tool=bestpractice.com [107]Trinder J, Brocklehurst P, Porter R, et al. Management of miscarriage: expectant, medical or surgical? Results of randomized controlled trial (miscarriage treatment (MIST) trial. BMJ. 2006 May 27;332(7552):1235-40. http://www.bmj.com/content/332/7552/1235.full http://www.ncbi.nlm.nih.gov/pubmed/16707509?tool=bestpractice.com [108]Ngoc NT, Blum J, Westheimer E, et al. Medical treatment of missed abortion using misoprostol. Int J Gynaecol Obstet. 2004 Nov;87(2):138-42. http://www.ncbi.nlm.nih.gov/pubmed/15491558?tool=bestpractice.com
The main drug therapy for non-surgical management of miscarriage is misoprostol, a prostaglandin analogue. The patient, however, needs to be informed that the surgical option may still be necessary if bleeding gets heavier or is persistent beyond a reasonable time.
Primary options
misoprostol: 800 micrograms intravaginally as a single dose; repeat once on day 3 if expulsion incomplete
More misoprostolOral tablets are used for intravaginal administration.
analgesics plus counselling
Treatment recommended for ALL patients in selected patient group
Analgesics are imperative in the presence of pain and discomfort, and non-steroidal anti-inflammatory drugs are best avoided. Paracetamol is the analgesic of choice.
Counselling for the mothers (or couples) should be given. A patient information leaflet should also be provided. Prolonged psychological or psychiatric support may be needed in some patients. Some women experience guilt in addition to their grief. Loss of an early pregnancy can affect couples as significantly as a neonatal death. The extremely low chance of repeat miscarriage should be mentioned if any worry is expressed about the future. Depending on hospital or healthcare facility policy, the removed early pregnancy tissue may be sent for histopathology, after obtaining parental consent and offering counselling.
Primary options
paracetamol: 500-1000 mg every 4-6 hours when required, maximum 4000 mg/day
anti-D immunoglobulin
Additional treatment recommended for SOME patients in selected patient group
In the US, the American College of Obstetricians and Gynecologists recommends that women who are rhesus negative and unsensitised should receive anti-D immunoglobulin within 72 hours of a potentially sensitising event in the first or second trimester. However, whether to administer anti-D immunoglobulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made. Because of the higher risk of alloimmunisation, rhesus-negative women who receive surgical management of their miscarriage should receive anti-D rhesus prophylaxis.[91]American College of Obstetricians and Gynecologists. Practice bulletin: early pregnancy loss. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss [121]Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 181: Prevention of Rh D alloimmunization. Obstet Gynecol. 2017 Aug;130(2):e57-70. https://journals.lww.com/greenjournal/FullText/2017/08000/Practice_Bulletin_No__181__Prevention_of_Rh_D.54.aspx http://www.ncbi.nlm.nih.gov/pubmed/28742673?tool=bestpractice.com
Advice in the UK differs, with the National Institute for Health and Care Excellence recommending that anti-D immunoglobulin is offered to all rhesus-negative women who have a surgical procedure to manage a miscarriage. It does not need to be offered to women who have received solely medical management, have a threatened or complete miscarriage, or a pregnancy of unknown location.[69]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Nov 2021 [internet publication]. https://www.nice.org.uk/guidance/ng126
Primary options
anti-D immunoglobulin: refer to consultant for guidance on dosage
More anti-D immunoglobulinDose differs between brands
conservative management
A significant number of women prefer conservative management allowing early pregnancy tissue to be expelled spontaneously. It may be continued as long as the patient is willing and provided there are no signs of infection such as vaginal discharge, heavy bleeding, pyrexia, or lower abdominal pain.
Follow-up scans may be arranged at 2-weekly intervals, until a diagnosis of complete miscarriage is made.
Ultrasound is preferred for confirming early pregnancy loss. The American College of Obstetricians and Gynecologists recommends that surgical intervention is not required in asymptomatic women who have a thickened endometrial stripe after undergoing treatment for pregnancy loss.[91]American College of Obstetricians and Gynecologists. Practice bulletin: early pregnancy loss. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss
analgesics plus counselling
Treatment recommended for ALL patients in selected patient group
Analgesics are imperative in the presence of pain and discomfort, and non-steroidal anti-inflammatory drugs are best avoided. Paracetamol is the analgesic of choice.
Counselling for the mothers (or couples) should be given. A patient information leaflet should also be provided. Prolonged psychological or psychiatric support may be needed in some patients. Some women experience guilt in addition to their grief. Loss of an early pregnancy can affect couples as significantly as a neonatal death. The extremely low chance of repeat miscarriage should be mentioned if any worry is expressed about the future. Depending on hospital or healthcare facility policy, the removed early pregnancy tissue may be sent for histopathology, after obtaining parental consent and offering counselling.
Primary options
paracetamol: 500-1000 mg every 4-6 hours when required, maximum 4000 mg/day
anti-D immunoglobulin
Additional treatment recommended for SOME patients in selected patient group
In the US, the American College of Obstetricians and Gynecologists recommends that women who are rhesus negative and unsensitised should receive anti-D immunoglobulin within 72 hours of a potentially sensitising event in the first or second trimester. However, whether to administer anti-D immunoglobulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made. Because of the higher risk of alloimmunisation, rhesus-negative women who receive surgical management of their miscarriage should receive anti-D rhesus prophylaxis.[91]American College of Obstetricians and Gynecologists. Practice bulletin: early pregnancy loss. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss [121]Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 181: Prevention of Rh D alloimmunization. Obstet Gynecol. 2017 Aug;130(2):e57-70. https://journals.lww.com/greenjournal/FullText/2017/08000/Practice_Bulletin_No__181__Prevention_of_Rh_D.54.aspx http://www.ncbi.nlm.nih.gov/pubmed/28742673?tool=bestpractice.com
Advice in the UK differs, with the National Institute for Health and Care Excellence recommending that anti-D immunoglobulin is offered to all rhesus-negative women who have a surgical procedure to manage a miscarriage. It does not need to be offered to women who have received solely medical management, have a threatened or complete miscarriage, or a pregnancy of unknown location.[69]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Nov 2021 [internet publication]. https://www.nice.org.uk/guidance/ng126
Primary options
anti-D immunoglobulin: refer to consultant for guidance on dosage
More anti-D immunoglobulinDose differs between brands
complete miscarriage
analgesics plus counselling
Analgesics are imperative in the presence of pain and discomfort, and non-steroidal anti-inflammatory drugs are best avoided. Paracetamol is the analgesic of choice.
Counselling for the mothers (or couples) should be given. A patient information leaflet should also be provided. Prolonged psychological or psychiatric support may be needed in some patients. Some women experience guilt in addition to their grief. Loss of an early pregnancy can affect couples as significantly as a neonatal death. The extremely low chance of repeat miscarriage should be mentioned if any worry is expressed about the future. Depending on hospital or healthcare facility policy, the removed early pregnancy tissue may be sent for histopathology, after obtaining parental consent and offering counselling.
Primary options
paracetamol: 500-1000 mg every 4-6 hours when required, maximum 4000 mg/day
anti-D immunoglobulin
Additional treatment recommended for SOME patients in selected patient group
In the US, the American College of Obstetricians and Gynecologists recommends that women who are rhesus negative and unsensitised should receive anti-D immunoglobulin within 72 hours of a potentially sensitising event in the first or second trimester. However, whether to administer anti-D immunoglobulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made. Because of the higher risk of alloimmunisation, rhesus-negative women who receive surgical management of their miscarriage should receive anti-D rhesus prophylaxis.[91]American College of Obstetricians and Gynecologists. Practice bulletin: early pregnancy loss. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss [121]Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 181: Prevention of Rh D alloimmunization. Obstet Gynecol. 2017 Aug;130(2):e57-70. https://journals.lww.com/greenjournal/FullText/2017/08000/Practice_Bulletin_No__181__Prevention_of_Rh_D.54.aspx http://www.ncbi.nlm.nih.gov/pubmed/28742673?tool=bestpractice.com
Advice in the UK differs, with the National Institute for Health and Care Excellence recommending that anti-D immunoglobulin is offered to all rhesus-negative women who have a surgical procedure to manage a miscarriage. It does not need to be offered to women who have received solely medical management, have a threatened or complete miscarriage, or a pregnancy of unknown location.[69]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Nov 2021 [internet publication]. https://www.nice.org.uk/guidance/ng126
Primary options
anti-D immunoglobulin: refer to consultant for guidance on dosage
More anti-D immunoglobulinDose varies between brands
recurrent miscarriage
treatment of underlying cause
Although 1 in 5 women with a history of recurrent miscarriage may have further pregnancy loss, the other proportion do well, even without any intervention. The European Society for Human Reproduction and Gynaecology has provided recommendations for the treatment of recurrent miscarriage.[115]European Society of Human Reproduction and Embryology. Guideline on the management of recurrent pregnancy loss. Nov 2017 [internet publication]. https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Recurrent-pregnancy-loss.aspx
No intervention is advised in women with unexplained miscarriage.[125]Duckitt K, Qureshi A. Recurrent miscarriage. BMJ Clin Evid. 2015 [internet publication].
Multivitamins and folic acid supplementation have no confirmed benefit and are not recommended as treatment; however, if patients ask about using supplements you should advise which ones are safe in pregnancy as some supplements are associated with possible harms. Cervical cerclage may benefit second-trimester recurrent miscarriages, possibly explained by cervical incompetence, insufficiency, or weakness.
Neither anticoagulants nor aspirin have been shown to help prevent early pregnancy loss in women with thrombophilias (excluding those with antiphospholipid syndrome).[91]American College of Obstetricians and Gynecologists. Practice bulletin: early pregnancy loss. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss [115]European Society of Human Reproduction and Embryology. Guideline on the management of recurrent pregnancy loss. Nov 2017 [internet publication]. https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Recurrent-pregnancy-loss.aspx [Evidence C]400731cb-8963-421a-b7ef-acb5b1a03984guidelineCWhat are the effects of anticoagulant therapy versus no treatment in women with recurrent pregnancy loss (RPL) and hereditary thrombophilia?[115]European Society of Human Reproduction and Embryology. Guideline on the management of recurrent pregnancy loss. Nov 2017 [internet publication]. https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Recurrent-pregnancy-loss.aspx
Patients with antiphospholipid syndrome or multiple inherited thrombophilias have been treated with low-dose aspirin that is started before conception. These patients may also require heparin therapy following a positive pregnancy test, until delivery. Addition of unfractionated heparin to aspirin is more effective at reducing pregnancy loss compared with the addition of low molecular weight heparin.
With regards to immunotherapy in the treatment of unexplained miscarriage, paternal cell immunisation, third-party donor leukocytes, trophoblast membranes, and intravenous immunoglobulin provide no significant beneficial effect over placebo in improving the live birth rate.[120]Wong LF, Porter TF, Scott JR. Immunotherapy for recurrent miscarriage. Cochrane Database Syst Rev. 2014 Oct 21;(10):CD000112.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000112.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/25331518?tool=bestpractice.com
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What are the effects of immunotherapy for pregnant women who have had recurrent miscarriage?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.2171/fullShow me the answer
There is conflicting evidence regarding treatment with metformin in some women with polycystic ovarian disease in relation to reducing miscarriage rates.[115]European Society of Human Reproduction and Embryology. Guideline on the management of recurrent pregnancy loss. Nov 2017 [internet publication]. https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Recurrent-pregnancy-loss.aspx
It should be remembered that clinical evaluation of potential treatments for recurrent miscarriage are best undertaken in the context of controlled clinical trials. If a physician offers empirical treatment, it should be made clear to the patient that this is a departure from optimum clinical practice.[3]Royal College of Obstetricians and Gynaecologists. The investigation and treatment of couples with recurrent miscarriage Green-top guideline no. 17. Apr 2011 [internet publication]. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg17
counselling
Treatment recommended for ALL patients in selected patient group
Counselling for the mothers (or couples) should be given. A patient information leaflet should also be provided. Prolonged psychological or psychiatric support may be needed in some patients. Some women experience guilt in addition to their grief.
Referral to a specialist unit is often appreciated, even if no successful pregnancy is eventually achieved.
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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