Management

Referral Criteria

Refer immediately to the Early Pregnancy Assessment Service if any of the following 2 scenarios:

• +ve Pregnancy test AND abdo-pelvic pain / tenderness OR cervical motion tenderness (high risk of ectopic pregnancy)
• Per vaginal bleeding AND pain OR >6 weeks gestation OR uncertain gestation (possible ectopic pregnancy or miscarriage)

NICE explicitly states to use expectant management if ALL the following apply (likely very early miscarriage or implantation bleeding in viable pregnancy):

• Pregnancy <6 weeks
• Bleeding but NO PAIN
• No risk factors (e.g. previous ectopic pregnancy)

Expectant management involves: 1) safety netting – return if bleeding continues or pain develops, 2) repeat urine pregnancy test after 7-10 days, and to return if +ve

Viable Pregnancy (i.e. Threatened Miscarriage)

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.

Non-Viable Pregnancy (i.e. ALL Other Miscarriage Types)

1st line: expectant management for 7-14 days

Indications for other 1st line options (i.e. medical or surgical management):

• 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 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