Miscarriage

Description

General measures

Medicine treatment

Referral

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O02.1/O03.4/O03.9

DESCRIPTION

Bleeding from the genital tract < 22 weeks' gestation, which may or may not be associated with lower abdominal pain (LAP).

• Miscarriage is classified as follows

Cervix closed on digital examination	Cervix dilated on digital examination
- Threatened miscarriage:    - mild vaginal bleeding, usually no associated LAP    - foetus is still in the uterus	- Inevitable miscarriage:    - moderate vaginal bleeding with associated LAP    - foetus is still in the uterus
- Complete miscarriage:    - complete passage of all products of conception    - bleeding and pain have settled    - usually still requires referral for confirmation	- Incomplete miscarriage:    - vaginal bleeding often with clots    - partial expulsion of products of conception

• Miscarriage is considered to be safe or unsafe (septic) miscarriage:

Safe miscarriage	Unsafe (septic) miscarriage
- Normal vital signs: pulse, BP, temperature, respiratory rate, Hb - No clinical signs of infection, e.g. chills, malaise - Uterus < 12 weeks in size - No offensive products of conception - No purulent vaginal discharge	- History of interference - Abnormal vital signs: any of tachycardia, hypotension, pyrexia, tachypnoea, pallor - Persistent heavy bleeding - Clinical signs of infections, e.g. chills, malaise - Uterus palpable abdominally (≥ 12 weeks in size) - Offensive vaginal discharge/ products of conception

For perinatal mortality audit and statistics (DHIS or PPIP), all foetuses ≥ 500 g are included.

GENERAL MEASURES

• Monitor vital parameters, e.g. Hb, pulse, BP, temperature.
• Treat for shock if indicated.
• Counselling and support.
• There is no specific treatment for threatened miscarriages: reassure the patient that bleeding usually stops spontaneously. Advise to return if bleeding worsens or persists or abdominal pain develops.

MEDICINE TREATMENT

For inevitable/incomplete miscarriages:

• Oxytocin, IV, 20 units, diluted in 1000 mL sodium chloride 0.9% and infused at 125 mL/hour (avoid where threatened miscarriage is suspected).

For Rh-negative non-sensitised women from 13 to 22 weeks Anti-D immunoglobulin, IM, 50 mcg preferably within 72 hours but may be given up to 7 days following management of miscarriage

LoE:IVb¹

If unsafe (septic) miscarriage is suspected, also give before referral:

O03.0/O08.0 + (A41.9/R57.2)

• Ceftriaxone, IV, 1 g as a single dose

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CAUTION: USE OF CEFTRIAXONE
Do not administer calcium-containing fluids, e.g. Ringer’s Lactate, concurrently with ceftriaxone.

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AND

• Metronidazole, oral, 400 mg as a single dose.

REFERRAL

Urgent

• All patients with unsafe miscarriage
• Suspected ectopic pregnancy
• Previous miscarriage or previously diagnosed incompetent cervix

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Note:
For patients with safe miscarriage the need for referral is determined by skills and facilities at the primary health care level. A local referral policy should be in place. Ideally, midwife obstetric units and community health centres should be able to manage safe miscarriage using manual vacuum aspiration or medical management.

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See: Management of incomplete miscarriage in the 1st trimester, at primary health care level 

See: Antepartum haemorrhage

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2025-9_Version 1.0_26 March 2026

Chapter 6: Obstetrics and Gynaecology_6.2 Miscarriage