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    Miscarriage – Treatment

    Obstetrics and Gynecology

    Last Reviewed on Oct 05, 2023
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    Context

    • Early Pregnancy Loss (EPL): Intrauterine pregnancy (IUP) loss < 20 weeks Gestational Age (GA).
    • 80% occur in first 12 weeks GA.
    • 15-25% of all pregnancies.

    Recommended Treatment

    Overall treatment principles:

    • Hemodynamic stabilization.
    • Prevent alloimmunization if Rh negative.
    • Guidance and pain control.
    • If nonviable – expectant, medical, or surgical management usually OB/GYN input.

    A) Initial ED treatment (threatened, inevitable, incomplete, missed, and completed miscarriages):

    1. Treat complications:
    • Infection (endometritis and/or septic abortion) occurs in 2-3% of cases, irrespective of treatment.
    • Hemorrhage
    • Retained Products of Conception
    • OB/GYN consult, admission, fluid resuscitation, antibiotics
    1. Prevent Rh alloimmunization:
    • For Rh Negative patients, administer:
      • If < 12 weeks GA:
      • 50-120 mcg anti-D immunoglobulin within 72 hours (expectant, medical or surgical management).
      • 300 mcg dose is acceptable.
      • If >12 weeks GA: dose = 300 mcg IM.
    1. Symptom management:
    • Naproxen 500 mg q12h or Ibuprofen 800 mg q8h
    • Acetaminophen 1000 mg q6h
    • Heating pads
    • Consider antiemetics, especially if receiving medical management with misoprostol
    1. Address psychological concerns:
    • Acknowledge distress and grief
    • Reassure that they are not at fault
    • Reassure that they are not at increased risk of future miscarriages. Fewer than 5% of women will experience two miscarriages, and only 1% experience three or more.

    B) Treatment by Miscarriage Category:

    Incomplete, inevitable or missed miscarriage:

    • Consider OB/GYN consult to discuss surgical, medical, and expectant options.
    • The MIST trial found no difference in rates of infection between all three options, but an increased rate of unplanned admissions and surgical management with expectant and medical management.
    • If available F/U with OB/GYN for monitoring of miscarriage completion through expectant, medical, or surgical management often best.

    Created by Ella Barrett-Chan, MSI UBC 2023

    Threatened Miscarriage:

    • Viability confirmed: Return care to main OB provider.
    • Viability uncertain: see PECS Miscarriage – Diagnosis.
    • Provide anticipatory guidance on possibility of future miscarriage.

    Completed Miscarriage:

    • F/U with primary OB provider (or Early Pregnancy Assessment Clinic if in the Lower Mainland) to ensure resolution of bleeding (< 72 hours).

    C) Discharge planning:

    • Discharge Instructions: Return to ED if: significant increase in bleeding, pain, lightheadedness or fainting, fever, foul-smelling discharge.
    •  F/U with main OB provider within 72 hours.

    Counselling:

    Lower Mainland Resources for follow up:

    Criteria For Safe Discharge Home

    1. Bleeding controlled and hemodynamically stable.
    2. No infection – septic miscarriage (no fever, uterine tenderness, leukocytosis, foul-smelling discharge).
    3. Follow up arranged.
    4. Discharge counselling and instructions completed.

    Criteria For Hospital Admission

    Requiring urgent surgical management:

    1. Heavy bleeding and/or hemodynamic instability.
    2. Septic miscarriage.

    Criteria For Close Observation And/or Consult

    OB/GYN consult if:

    • Hemodynamic instability.
    • Septic miscarriage.
    • Incomplete, inevitable, or missed miscarriage for discussion of expectant vs. medical vs. surgical management and arrangement of timely follow up.
    • Unclear diagnosis of complete vs. incomplete miscarriage.

    Criteria For Transfer To Another Facility

    Indications: Anticipating surgical management not available at current facility.

    Quality Of Evidence?

    Justification

    Comparison of expectant vs. medical vs. surgical management.

    Moderate-High

    All women with 1st trimester miscarriage who are Rh negative should receive Rho-gam5. Based on expert opinion and extrapolation.

    Low

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