Miscarriage

Silent miscarriage or early fetal death

Incomplete miscarriage in the first trimester

Midtrimester miscarriage (from 13-22 weeks gestation)

Septic miscarriage

Trophoblastic neoplasia

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Both manual vacuum aspiration (MVA) and medical evacuation are equally effective for miscarriage. However, MVA is preferred in the follow settings:

• anaemia
• haemodynamic instability
• second trimester miscarriage

SILENT MISCARRIAGE OR EARLY FETAL DEATH

ICD-10 code: O02.1

GENERAL MEASURES

• Counselling.
• Evacuation of the uterus.

MEDICINE TREATMENT

Before MVA, to ripen the cervix:

• Misoprostol, PV, 400 mcg as a single dose.

Medical evacuation:

ICD-10 code: (O04.9)

• Misoprostol, oral/PV, 600 mcg as a single dose.
  • Repeat after 24 hours if necessary.

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INCOMPLETE MISCARRIAGE IN THE FIRST TRIMESTER

ICD-10 code: O03.3-4

GENERAL MEASURES

• Counselling.
• Evacuation of the uterus.

MEDICINE TREATMENT

Before MVA, to ripen the cervix (if needed):

• Misoprostol, oral/PV, 400 mcg as a single dose.

Medical evacuation:

ICD-10 code: (O04.9)

• Misoprostol, SL/PV/buccal, 800 mcg immediately as a single dose.
  • Repeat after 24 hours if necessary.

LoE: IIIb^xx 

Routine analgesia for vacuum aspiration:

• Morphine, IM, 0.1 mg/kg 30 minutes before aspiration procedure, to a maximum of 10 mg (Doctor prescribed).

Alternatively, consider paracervical block - see: TOP: Management of pregnancies up to the twelfth week of gestation (12 weeks and 0 days). 

LoE: IVb^xxi 

Oral analgesia as required for 48 hours:

• Paracetamol, oral, 500mg-1 g, 4–6 hourly as required (to a maximum of 4g in 24 hours).
  • Maximum dose: 15 mg/kg/dose.

AND

• Ibuprofen, oral, 400 mg 8 hourly with or after a meal, if needed.

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Note:
- Follow up after one week to ensure that bleeding has stopped, or sooner with worsening symptoms.
- Perform a pregnancy test three weeks after medical management.

LoE: IIIb^xxii

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MIDTRIMESTER MISCARRIAGE (from 13–22 weeks gestation)

ICD-10 code: O03.3-4/O03.9

GENERAL MEASURES

• Counselling.
• Evacuation of the uterus after the fetus has been expelled.

MEDICINE TREATMENT

If cervical dilatation needed:

• Misoprostol, PV/SL/buccal, 200 mcg every 4–6 hours until products of conception have been expelled.
  • Duration of treatment must not exceed 5 doses within 24 hours.

LoE:IIIb^xxiii

Previous Caesarian delivery:

• Misoprostol, PV/SL/buccal 100 mcg every 4–6 hours products of conception have been expelled.
  • Duration of treatment must not exceed 5 doses within 24 hours.

LoE:IIIb^xxiv

If cervical dilation is already present:

• Oxytocin, IV.
  • Dilute 20 units in 1 L sodium chloride 0.9%, i.e. 20 milliunits/mL solution, and infuse at 125 mL/hour.
  • Reduce rate if strong contractions are experienced.

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Note:
Check serum sodium if used for more than 24 hours because of the danger of dilutional hyponatraemia.

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For analgesia:

• Morphine, IV, to a maximum dose of 10 mg (See Prescribing Information for Specific Medicines, for individual dosing and monitoring response and toxicity).

If Rh-negative:

ICD-10 code: (O36.0)

• Anti-D immunoglobulin, IM, 100 mcg as a single dose.

REFERRAL

• Uterine abnormalities.
• Recurrent miscarriages (3 consecutive spontaneous miscarriages).
• Suspected cervical weakness: mid-trimester miscarriage(s) with minimal pain and bleeding.
• Diabetes mellitus.
• Parental genetic defects and SLE or other causes of autoimmune disease.

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SEPTIC MISCARRIAGE 

ICD-10 code: O03.0/O03.5 + (A41.9/N71.0/R57.2)

GENERAL MEASURES 

• Counselling.
• Urgent evacuation of uterus (under general anaesthesia and not an MVA) and surgical management of complications.

MEDICINE TREATMENT

• Oxytocin, IV.
  • Dilute 20 units in 1 L sodium chloride 0.9%, i.e. 20 milliunits/mL solution administered at a rate of 125 mL/hour.
  • Reduce infusion rate if strong contractions are experienced.

Antibiotic therapy 

• Amoxicillin/clavulanic acid, IV, 1.2 g, 8 hourly.

Change to oral treatment after clinical improvement:

• Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 7–10 days.

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Note:
The addition of metronidazole to amoxicillin/clavulanic acid is unnecessary as amoxicillin/clavulanic acid has adequate anaerobic cover.

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LoE:IVb

Severe penicillin allergy:

ICD-10 code: (Z88.0)

• Clindamycin, IV, 600 mg 8 hourly.

AND

• Gentamicin, IV, 6 mg/kg daily (see Prescribing Information for Specific Medicines for guidance on prescribing).

Change to oral treatment after improvement:

• Clindamycin, oral, 450 mg 8 hourly for 5 days.

AND

• Ciprofloxacin, oral, 500 mg 12 hourly for 5 days.

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Note:
The addition of metronidazole to clindamycin is unnecessary as clindamycin has adequate anaerobic cover.

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If patient has severe sepsis, consider urgent hysterectomy.

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REFERRAL

• Evidence of trauma.
• No response to treatment within 48 hours.

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TROPHOBLASTIC NEOPLASIA (‘HYDATIDIFORM MOLE’)

ICD-10 code: O01.0-1/O01.9

• Misoprostol is not indicated in this condition because of risk of dissemination.
• Send products of conception for histology.

REFERRAL

• All patients.

Click here for the pdf

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Standard Treatment Guidelines and Essential Medicines List for South Africa Adult Hospital _Chapter 5: Gynaecology; Version 1.0, 2020-4_June 2024