Management of Miscarriage

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Dr Judith Kundodyiwa MRCOG / Dr Funmi Odusoga MRCOG

Per Vagina bleeding (often associated with ‘period-like’ abdominal pain).
Detected on ultrasound scan after referral for vaginal bleeding or pain in early pregnancy
Diagnosis is by Transvaginal Ultrasound scan.

Threatened-Uterine bleeding without dilatation of cervix or passage of product of conception. The fetus is still viable and the uterus is expected size for dates. Around 25% will go on to miscarry
Inevitable – Heavy bleeding with cervical dilatation but without passage of product of conception. The fetus may still be alive but miscarriage will occur
Incomplete – Bleeding with cervicaldilatation and passage of some but not all products of conception
Complete – bleeding which diminishes with complete passage of products of conception. Pain and bleeding eases, cervix is closed
Missed – fetal death, bleeding or pain, the fetus or embryo has been dead for some weeks, but no tissue has been passed. Ultrasound reveals fetus that is smaller when compared to the estimated gestational age from last menstrual period.Patient may complain of ‘feeling less pregnant than before’.
Septic – Any miscarriage that becomes infected resulting in endometritis, parametritis or peritonitis in severe cases

If patient is not bleeding excessively, can go home.
If patient bleeding heavily:
- Do speculum examination.
- If Product of conception is visible in the cervical os, remove them using sponge holders and gauze.
- Send any Product of Conception for histology.
- Keep patient in hospital until bleeding settles.
- Consider need for IV access and check FBC.
- Get senior review if very heavy bleeding as may need to go to theatre.
Anti-D prophylaxis is only required if bleeding is repeated, heavy or associated with abdominal pain in pregnancies <12weeks.

Patient goes home for 1-2weeks to await events.
Patient returns to early pregnancy unit after 2weeks to discuss options if she has not passed the products spontaneously.

Check scan report to ensure that patient definitely has non-viable pregnancy.
Get written consent from patient. (Risks of the procedure include pain, infection, bleeding and retained products of conception). Consent for blood transfusion.
Prescribe mifepristone 200mg Per oral on day 0
48hours later, patient returns and has misoprostol 600micrograms (PV / PO). (follow your hospital’s protocol)
Prescribe analgesia and anti-emetics.
Patient should remain on the ward until she has passed the products.
She can have a further 1 or 2 doses of misoprostol 6hours apart as required.
Prescribe 1500IU Anti-D if Rh negative.
Patient may bleed for 3 weeks after medical management
Patient should do urine pregnancy test 3weeks after management and must return to the early pregnancy unit if this is positive

Avoids need for general anaesthetic.
Performed in Early pregnancy unit, by trained senior clinician
Local anaesthetic is injected into the cervix and product of conception are removed using suction aspiration.
Procedure takes less than 10minutes.
Requires written consent. (Risks include pain, infection, bleeding, uterine perforation, incomplete removal of products of conception). Consent for blood transfusion.
Prescribe 1500IU Anti-D if Rh negative.

Performed in theatre
Patient is given dose of misoprostol 600micrograms PV a few hours before the procedure to enable easy dilatation of cervix.
Involves general anaesthetic.
Procedure takes about 10minutes.
Requires written consent. (Risks include pain, infection, bleeding, uterine perforation, incomplete removal of products of conception). Consent for blood transfusion.
Prescribe 1500IU Anti-D if Rh negative.