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1. Purpose
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To support the Women's clinicians in the management of women who have been diagnosed with a miscarriage (refer to CPG: Initial assessment and triage).
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2. Definition of Terms
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EPAS - Early Pregnancy Assessment Service. This service runs Monday - Friday mornings in the Well Women's Clinic.
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Early pregnancy - all gestations up to 16 completed weeks. (Note: Women with pregnancy of gestation >16 completed weeks should be referred to the obstetric unit.)
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POC - Products of Conception. (Avoid using the term "products of conception" with women and their families, as from their perspective they have lost their baby.)
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Miscarriage - The recommended medical term for pregnancy loss under 20 weeks is 'miscarriage'. The word 'miscarriage' should be used in clinical practice and its use should be strongly encouraged. Miscarriages should be classified as follows:
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 | - Complete miscarriage - the pregnancy is not viable, and all the tissue from the pregnancy has been passed.
| - Incomplete miscarriage - some POC have passed but some POC remain in the uterus.
| - Missed miscarriage - no fetal heart activity is seen, the gestational sac is intact, the cervix is closed and no POC have been passed.
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3. Clinical Presentation
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- Women who have a positive pregnancy test, and present with a history of amenorrhea and pelvic pain and/or abnormal bleeding in the first trimester may be experiencing a miscarriage.
- Ultrasound (trans-vaginal / abdominal) assists in distinguishing between complete, incomplete and missed miscarriage.
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| | | - No intrauterine gestational sac
- No ovarian / fallopian mass
- POC passed
- No evidence of POC in uterus
- Endometrial thickness <15mm in longitudinal section
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| - No intrauterine gestational sac
- No ovarian / fallopian mass
- POC passed
- More POC seen in uterus
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| - Intact intrauterine gestational sac
- Fetal pole seen
- No fetal heart beat
- CRL is >6mm
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| OR
| - Intact intrauterine gestational sac measuring >20mm
- Fetal pole not seen
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4. Selecting an Appropriate Management Method
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- Women should be offered expectant management or surgical management as follows:
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| | | | - If minimal bleeding and POC measure <15mm, offer expectant management.
| - If minimal bleeding and POC measure 15mm-50mm, offer expectant management or surgical management.
| - If heavy bleeding, or if POC measure >50mm, offer surgical management.
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| - If minimal bleeding and no symptoms, offer expectant or surgical management
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- When a choice of management options is available, women should be involved in choosing their preferred treatment.
- Provide information regarding the treatment options and advise women of the risks and benefits associated with each approach (as per information sheet).
- To inform decision-making, the following inclusion criteria should be referred to:
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| | | Expectant management is most suitable for women who:
| - Are haemodynamically stable, and
- Will be compliant with regular follow ups, and
- Are within easy access to the hospital, and
- Do not have any signs of infection in the uterine cavity, and
- Have no evidence of cardiovascular compromise, and
- Are willing to wait until the uterus spontaneously evacuates.
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| | Surgical Surgical management is most suitable for women who:
| - Are NOT haemodynamically stable, or
- Have heavy bleeding, or
- Are not willing to wait until the uterus evacuates spontaneously, or
- Have signs of infection in the uterine cavity, or
- Have suspected gestational trophoblastic disease.
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| Studies suggest that up to 10% of women who miscarry have unstable vital signs or infected tissue.
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- All plans for management and follow-up should be clearly recorded in the EPAS Record.
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4.1. Expectant Management
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Treatment schedule
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- Explain treatment to the woman (and partner)
- Provide written information and initial counselling as required.
- Collect pre-treatment bloods (i.e. ßhCG, group and hold, FBC) and administer Anti D to women who are Rhesus negative as per the Women's CPG.
- Provide contact numbers / appointments for support services (e.g. Social Work / Pastoral Care).
- Advise woman of the following:
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| - What to expect (in terms of pain, bleeding etc.)
- She may take simple analgesia for pain.
- To contact EPAS / ED after hours if concerns regarding pain, signs of infection or bleeding
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Follow up and monitoring
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- Consider rescanning in the EPAS in 1-2 weeks if required.
- Surgical intervention will be necessary if:
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| - Woman becomes symptomatic,
- Woman changes her mind, and wants to have surgical management,
- Tissue becomes infected.
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- On completion of treatment:
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| - Discharge woman to GP and complete discharge summary
- Discuss contraceptive options and institute / plan as appropriate
- Cancel pregnancy booking.
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4.2. Surgical Management
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Treatment schedule
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- Contact Operating Theatres to book a time and date for surgery.
- If there are complex issues, contact Gynaecology Registrar to arrange time and date for surgery.
- Explain treatment (including risks of surgery and anaesthetic) to the woman and partner, and provide written information.
- Explain contraceptive options including intrauterine contraceptive device (IUCD) and implanon which may be initiated with surgery.
- Obtain written informed consent.
- Determine ßhCG / FBC / Blood Group / antibody status, and administer Anti-D if Rhesus negative, as per the Women's CPG.
- Where clinically indicated, women should be screened for Chlamydia trachomatis by swab / urine).
- For missed miscarriages, consider oral or vaginal Misoprostol prior to surgical evacuation, based on individual circumstances.
- Antibiotic prophylaxis should be given based on individual clinical indications - there is insufficient evidence to recommend routine antibiotic prophylaxis prior to surgical uterine evacuation.
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- For women who are not haemodynamically stable:
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| - Consider cervical shock
- Remove any POC from cervix.
- Secure immediate IV access and treat appropriately.
- Send blood for FBC and cross match 4 units.
- Inform: Theatres; Anaesthetist; On-call Gynaecology Consultant.
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The urgency of the situation must be stressed to all concerned. Surgery should be performed even before blood and fluid losses have been replaced.
NB: Tissue obtained at the time of evacuation should be sent to histology to exclude ectopic pregnancy and gestational trophoblastic disease.
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On discharge after surgery
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- Complete discharge summary and inform GP.
- Provide contact numbers / appointments for support services (e.g. Social Work / Pastoral Care)
- Advise woman of the following:
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| - To see GP in 4-6 weeks for follow-up, or earlier if significant bleeding / pain
- What to expect (in terms of pain, bleeding etc.)
- She may take simple analgesia for pain.
- To avoid vaginal intercourse and tampon use until bleeding ceases
- To wait for one clear menstrual period, before trying to conceive another pregnancy
- Any type of contraception including placement of intrauterine devise may be started immediately.
- To contact EPAS / ED after hours if concerns regarding pain, signs of infection or bleeding
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5. Refer also to the following Women's resources:
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Clinical Practice Guidelines
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6. References
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The content of this CPG is based on:
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- Royal College of Obstetricians and Gynaecologists - RCOG (2006) Greentop Guideline number 25: The Management of Early Pregnancy Loss, http://www.rcog.org.uk/index.asp?PageID=515
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- The Association of Early Pregnancy Units - AEPU (2004) Organisational, Clinical and Supportive Guidelines, http://www.earlypregnancy.org.uk/guidelines.asp
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Additional information has been drawn from:
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- Goodhope Hospital NHS Trust: Guideline for the management of complete miscarriage
- Goodhope Hospital NHS Trust: Guideline for the management of incomplete miscarriage
- Goodhope Hospital NHS Trust: Guideline for the management of missed miscarriage
- Goodhope Hospital NHS Trust: Guideline for the medical management of failed pregnancy / retained products of conception (RPOC) in the first trimester
- Sheffield NHS Foundation Trust: Management of early pregnancy problems
- Cambridge University NHS Foundation Trust: Guidelines for the management of women presenting with bleeding and or pain in early pregnancy
- Cambridge University NHS Foundation Trust: Protocol for surgical management of miscarriage
- Cambridge University NHS Foundation Trust: Guideline for expectant management of miscarriage
- Gold Coast Health Services EPAC - Protocol for incomplete miscarriage
- Gold Coast Health Services EPAC - Protocol for missed miscarriage
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Evidence Table
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31 July 2007
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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