Guidelines

Threatened Miscarriage – Management

Management depends on whether the patient has a history of previous miscarriage or not.
 

No Previous Miscarriage

Offer expectant management:

• If bleeding gets worse / persists >14 days → return for further assessment
• If bleeding stops → start or continue routine antenatal care

Previously Had a Miscarriage

Offer vaginal micronised progesterone 400mg BD until 16 weeks of gestation.

Other Miscarriage Types – Management

1st line: expectant management for 7-14 days

Indications for other 1st line options:

• Expectant management is not acceptable to the patient → offer medical management
• Patient is at increased risk of haemorrhage (e.g. late first trimester)
• Patient is at increased risk from the effects of haemorrhage (e.g. coagulopathies, unable to have a blood transfusion)
• Features of infection
• Presence of previous adverse and/or traumatic experience associated with pregnancy (e.g. stillbirth, miscarriage, antepartum haemorrhage)

Expectant Management

If pain and bleeding resolve after 7-14 days:

• This suggests that the miscarriage has been completed
• Provide the patient a urine pregnancy test to carry out at home 3 weeks after the miscarriage
• Advise the patient to return if the pregnancy test is +ve

If the pain and bleeding have not started OR are persisting and/or increasing:

• Offer a repeat scan

Medical Management

All women:

• Analgesics and antiemetics as needed
• See below for the choice of drug
• Home urinary pregnancy test to be carried out 3 weeks after medical management 
  • Return to clinic if the pregnancy test is +ve or still bleeding heavily or have other symptoms

 
Missed Miscarriage

Offer:

• Oral mifepristone 200mg, AND
• 48 hours later → oral / sublingual / vaginal misoprostol 800mcg (unless the gestational sac has already been passed)

If the bleeding did not start within 48 hours after misoprostol → contact their doctor.

Incomplete Miscarriage

Offer a single dose of oral / sublingual / vaginal misoprostol 600 mcg

Do not offer mifepristone for incomplete miscarriage.

Surgical Management

Offer the women a choice of:

• Manual vacuum aspiration under local anaesthetic in outpatient setting, OR
• Surgical management under general anaesthetic in theatre

Offer anti-D immunoglobulin prophylaxis (250 IU / 50 mcg) to all Rh-ve women who have a surgical procedure for miscarriage.

References

Original Guideline