early miscarriage

Last edited 03/2020 and last reviewed 11/2020

An early miscarriage is the loss of pregnancy at <= 13 weeks' gestation

Epidemiology:

• about one in four pregnancies, where a woman has missed a menstrual period and has a positive pregnancy test, ends in early miscarriage
• nearly 125 000 early miscarriages occur annually in the UK, accounting for 50 000 hospital admissions

Summary:

• miscarriages affect roughly one in every four pregnancies
(1)

• most women will have a healthy pregnancy after a miscarriage
  
  
• there are broadly three management options if a woman has been diagnosed with a miscarriage:


• 1.Expectant management - waiting for spontaneous miscarriage
• uncertainty regarding the length of time that women should try expectant management
• NICE recommends expectant management for 7-14 days once miscarriage is confirmed on ultrasound
• however an exception to this strategy is in a women with excessive bleeding
• emergency surgery may be required
• the American College of Obstetricians and Gynaecologists (ACOG) suggests up to 8 weeks of expectant management to achieve approximately an 80% success rate (2)
• medical or surgical management if expectant management is unsuccessful
  
  
• 2.Medical management
• NICE and ACOG guidance currently recommend an 800 μg dose of misoprostol given vaginally for missed miscarriage
• if required then a repeat dose of 600 or 800 μg for incomplete miscarriage.
• the PreFaiR trial (300 participants) found a higher likelihood of expulsion of the gestational sac when mifepristone (200 mg orally) was used before misoprostol
  administration (800 μg vaginally) compared with misoprostol alone
• ACOG also advises the administration of 200 mg oral mifepristone, if available, 24 hours before misoprostol
  
  
• Surgical management
• an option if failure/contraindication to expectant management
• has similar rates of complete miscarriage to both expectant and medical management
• may lead to more prompt resolution of miscarriage compared with other approaches
• complications (bleeding, infection, and uterine perforation) and need for further surgery are rare

Reference:

• Chu J et al. What is the best method for managing early miscarriage?BMJ 2020;368:l6438
• ACOG Practice Bulletin No. 200 Summary: Early Pregnancy Loss. (2018). Obstet Gynecol 2018;132:1311-310