Miscarriage / Early Pregnancy Loss

Clinical presentation
Management
Management modalities
Follow up

In both professional and direct care contexts, the recommended medical term for pregnancy loss < 20 weeks gestation is 'miscarriage'. The term ‘abortion’ should not be used. 

Clinical presentation and diagnosis 

1. Missed miscarriage: 

Confirmed ultrasound diagnosis of a miscarriage, with no POC passed and an intact gestational sac in the uterus. This includes ‘early fetal demise’ and ‘blighted ovum’. 

2. Incomplete miscarriage: 

Some POC have passed, but some POC remain in the uterus. There is usually a history of pregnancy symptoms followed by an episode of heavy bleeding with passage of clots with or without recognized POC. 

3. Complete miscarriage: 

Previous intrauterine pregnancy confirmed and all the POC have been passed. This is definitively confirmed by ultrasound examination and/or resolution of pain and vaginal bleeding. 

4. Septic miscarriage: 

Any type of miscarriage accompanied by evidence of intrauterine infection; urgent treatment using early goal directed therapy goals (early antibiotics, removal of infected foci etc.) is required. 

5. Recurrent miscarriage: 

Three or more consecutive miscarriages. These patients require specialist opinion and workup. 

Management:

1. Missed miscarriage 

In a pregnancy equivalent to 9+ weeks, pain and bleeding with passage of POC are likely to increase, surgery is recommended. 

Pregnancy equivalent to 7-9 weeks; medication, surgical or expectant management may be considered according to woman’s preference. 

Pregnancy size < 7 weeks may be difficult to find surgically with some risk of failed procedure; expectant or medication management generally preferable. 

2. Incomplete miscarriage 

• RPOCs < 15mm expectant management is generally preferable, because there is a high likelihood of spontaneous expulsion without intervention. 
• RPOCs > 15-20mm, medical or expectant management are reasonable options. Surgery should generally only be considered if there is a specific indication. 
• RPOCs > 35-50mm with increasing volumes of RPOC; administration of misoprostol to hasten passage of POCs should be encouraged and a speculum examination should be done prior to a surgical evacuation of the uterus. Admission should be considered to observe for a few hours or overnight until bleeding has settled. 

3. Complete miscarriage: 

Surgical and medical interventions to evacuate the uterus are contraindicated if this is a certain diagnosis. If there is any doubt as to the location of the pregnancy, serial HCG and gynae review may be needed to exclude ectopic pregnancy. 

Management modalities 

1. Expectant management 

Advantages: 

• Allows spontaneous passage of products of conception. 
• Avoids surgical and anaesthetic risks. 

Disadvantages: 

• Unpredictable time frame and results. 
• Expect ongoing pain and bleeding. 
• Potential for requiring an emergency suction and curettage. 

Indications 

Preferred treatment option if: 

• Incomplete miscarriage with POC diameter on US <15mm 

Can be considered if: 

• Incomplete miscarriage with larger diameter POCs, up to around 35mm diameter. 
• Missed miscarriage with sac size up to around 35mm (embryo size equivalent to < 9+0 weeks gestation) 

2. Medical management 

Advantages: 

• Allows women to avoid surgical and anaesthetic risks 

Disadvantages: 

• Unpredictable time frame and results. 
• Concerns with ongoing pain and bleeding. 
• Potential for requiring an emergency suction curettage (1%). 
• Potential side effects: Nausea, vomiting, diarrhoea (up to 40%). 

Indications: 

Suitable treatment option if: 

• Missed miscarriage with sac diameter on US <35mm (size equivalent to < 9+0 weeks gestation) 
• Incomplete miscarriage with POC's up to around 35mm diameter. 
• No contraindications to prostaglandins such as allergy, severe uncontrolled asthma. 
• Consider for larger size uterine contents only if the woman has a strong preference for this and a clear understanding of likely unpleasant pain and bleeding and potential haemorrhage risk. 

Treatment regimen: 

• Obtain informed consent (and make admission booking). 
• Misoprostol 800mcg PV followed by a repeat dose of 400mcg in 4 hours. 
• Admit to ward for observation for a total of 6 hours. 
• Prescribe analgesia and anti-emetics as needed. 
• If using medication management after 9 weeks gestation, consideration should be given to ultrasound examination after passage of POCs. 
• Anti-D as indicated. 

3. Surgical management (suction curettage) 

Advantages: 

• Allows planned procedure with predictable time frame. 
• Immediate relief from symptoms. 
• Less blood loss and shorter duration of bleeding than expectant/medical management. 

Disadvantages: 

• Risks of surgery-uterine perforation 
• Risks of anaesthesia 
• Some studies suggest increased infection risk. 

Indications: 

Recommended treatment option if: 

• Woman’s preference 
• Haemodynamically unstable 
• Evidence of infection (surgery under antibiotic cover) 
• Unacceptable bleeding 
•  ≥9+0 weeks gestation on us (sac>35mm, embryo >25mm) 

Treatment regimen: 

• Obtain written informed consent 
• If indicated, prescribe misoprostol (400mcg pv 3hours pre op) 
• Check results of infection tests; ensure follow-up/treatment occurs. 

Follow up: 

• Ensure contraception/future pregnancy plans discussed. 
• Allow access to bereavement counselling. 
• Prescribe analgesia to take home, such as paracetamol with codeine. 
• Review appointment if needed. 

References

1. Bourne T, Condous G. Handbook of Early Pregnancy Care. Informa Healthcare, 2006.

2. Neilson JP, Hickey M, Vazquez J. Medical treatment of early fetal death(less than 24 weeks).Cochrane Database of Systemic Reviews 2006, Issue 

3.Art. No.:CD002253.DOI:10.1002/14651858.CD002253.pub33. Royal College of Obstetricians and Gynaecologists. The Management of Early Pregnancy Loss. Guideline No. 25. London: RCOG; 2006.