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10.1576/toag.9.2.102.27311 www.rcog.org.uk/togonline

The Obstetrician & Gynaecologist

Review Modern management

of miscarriage
Authors Haritha Sagili / Mike Divers

Key content:
Miscarriage has traditionally been treated by surgical evacuation, on the
assumption that any retained tissue increases the risk of infection and
haemorrhage.
Over the last decade, effective non-surgical alternatives have been advocated to
minimise unnecessary surgical intervention while maintaining low rates of
morbidity and mortality.
Improved access to early pregnancy assessment units and greater awareness among
women has led to increasing demand for more conservative management of
miscarriage.

Learning objectives:
To learn about the use of appropriate miscarriage terminology.
To learn about the advantages and disadvantages of expectant, medical and
surgical management.
To understand that womens choice is paramount in planning treatment.

Ethical issues:
Guidance on the sensitive disposal of fetal remains is essential.
Keywords early pregnancy assessment units / expectant management / medical
management / miscarriage / surgical evacuation
Please cite this article as: Sagili H, Divers M. Modern management of miscarriage. The Obstetrician & Gynaecologist 2007;9:102108.

Author details
Haritha Sagili MD MRCOG DFFP
Senior House Officer Obstetrics and
Gynaecology
Department of Obstetrics and Gynaecology
Nobles Hospital
Isle of Man, IM4 4RJ, UK
Email: harithas@hotmail.com
(corresponding author)

102

Mike Divers FRCOG

Consultant Obstetrician and Gynaecologist
Department of Obstetrics and Gynaecology
Nobles Hospital
Isle of Man, IM4 4RJ, UK

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Introduction
Miscarriage accounts for approximately 50 000
inpatient admissions in the United Kingdom
annually (Department of Health statistics, 2005).1 It
is common, occurring in 1520% of all pregnancies,
and can have both medical and psychological
consequences. While maternal death is rare after
miscarriage, particularly in the first trimester, on
which this review focuses, it has featured in
previous Confidential Enquiries into Maternal
Deaths in the UK, particularly after surgical
procedures in association with sepsis. Ectopic
pregnancy, recurrent miscarriage, gestational
trophoblastic disease and pregnancy of unknown
location are not discussed.

requirement would be a unit open 5 mornings

only. Staffing varies between units but the
multidisciplinary team should ideally include
doctors, nurses, midwives, ultrasonographers and
support staff. Clear and consistent verbal and
written information should be available. Direct
access to an appointment system should be
available to all women and practitioners in the
primary care setting (including general
practitioners, nurses, midwives and health
visitors), as well as other hospital departments (for
example, accident and emergency departments,
wards). The AEPU recommends using clinical
guidelines to standardise management of early
pregnancy problems, record keeping and data
collection.

Early pregnancy
assessment units

Speculum examination

The benefits of an early pregnancy assessment unit

service were first described by Bigrigg and Read in
1991.2 Thorough assessment can occur in the
presence of a supportive multidisciplinary team,
with a confirmed diagnosis made at the first visit in
most cases. The admission time was reduced for
women requiring evacuation of the uterus from
3 days (range 1.55.0) to 1 day and from 1.5 days
(range 0.53.0) to 2 hours in those requiring no
treatment. Women were no longer separated from
their families for long periods and the reduced use
of inpatient beds produced significant economic
benefits for the National Health Service.
According to the Association of Early Pregnancy
Units (AEPU) 2004 guidelines,3 an effective unit
should be located in a dedicated area with goodquality ultrasound equipment, easy access to
laboratory facilities (for rhesus grouping, sensitive
urine pregnancy testing and -hCG assay with
results within 24 hours) and gynaecological
procedures. The National Chlamydia Screening
Programme recommends opportunistic screening
for all women under 25 years of age attending early
pregnancy assessment units.4 Although the gold
standard would be to have a unit open 7 days a
week, from 8 am to 5 pm, the minimum

A prospective study published in 2004 of 236

women with early pregnancy bleeding found that,
after speculum examination, 3 (1.3%) women had
a change of management plan but only 10 (4.2%)
women had a change of diagnosis, suggesting that it
contributes to a minority of management
decisions.5 The need for speculum examination
should be assessed on a case-by-case basis,
depending on whether the findings on bimanual
examination are conclusive.

The role of ultrasound

The use of transvaginal ultrasound has
revolutionised the management of early pregnancy
problems. Along with the development of highly
sensitive urinary -hCG assays, early pregnancy
ultrasound has resulted in women presenting
earlier but with the knock-on effect of an increase
in the number of inconclusive scans and the
requirement for repeat assessments. Knowledge of
the typical ultrasound appearances of normal early
pregnancy development and a good understanding
of its pitfalls are essential for the diagnosis and
management of early pregnancy problems.
It is vital to describe clinical and ultrasound
findings in early pregnancy using appropriate
terminology (Table 1):3,68 the word miscarriage

Recommended term

Previous term

Ultrasound appearance

Clinical presentation

Threatened miscarriage

Threatened abortion

Vaginal bleeding  abdominal pain;

closed cervix

Complete miscarriage

Complete abortion

Intrauterine gestation sac

Fetal pole with cardiac activity seen
Endometrial thickness 15 mm
No evidence of retained products
of conception
Heterogenous tissues  sac
distorting midline endometrial echo
Any endometrial thickness
Fetal pole > 6 mm with no fetal heart
activity. Gestation sac diameter
 20 mm with no fetal pole or yolk sac

Incomplete miscarriage

Incomplete abortion

Missed miscarriage
Delayed miscarriage
Silent miscarriage
Early fetal demise
(These reflect different stages
in the same process)
Inevitable miscarriage

Missed abortion
Anembryonic pregnancy
Blighted ovum

Miscarriage with infection

(sepsis)

(These reflect different stages in

the same process)
Inevitable abortion
Septic abortion

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Table 1

Clinical correlates of ultrasound

appearances.3,68

Cessation of vaginal bleeding and

abdominal pain; closed cervix
Passage of some pregnancy-related
tissue  bleeding and/or abdominal
pain; open cervix
Minimal vaginal bleeding or pain; loss of
pregnancy symptoms; closed cervix

Bleeding without passage of tissue but

with an open cervix
Vaginal discharge, bleeding, fever,
abdominal pain

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should replace abortion in clinical practice. The

use of the term indeterminate in relation to location
or viability is confusing and should be replaced by
the terms pregnancy of unknown location
(positive pregnancy test but no signs of intra- or
extrauterine pregnancy or retained products of
conception) and pregnancy of uncertain viability
(intrauterine sac 20 mm mean diameter with no
obvious yolk sac or fetus, or fetal echo 6 mm
crown-rump length with no obvious fetal heart
activity). In these circumstances a repeat scan at a
minimum interval of 1 week is necessary.9
No single ultrasound measurement of the different
anatomical features in the first trimester has been
shown to have a high predictive value for
determining early pregnancy outcome. Similarly,
Doppler studies and 3D ultrasound have failed to
predict those pregnancies that will subsequently
end in miscarriage and are, therefore, unlikely to
have a clinical role.10,11

Treatment
See Figure 1.3,4,6

Viable intrauterine pregnancy

(threatened miscarriage)
Ninety percent of women in whom fetal heart
activity is detected at 8 weeks will not miscarry. The
therapeutic value of progesterone in preventing or
treating threatened miscarriage has not yet been
established.12 There is also insufficient evidence to
support the use of uterine muscle relaxant drugs13
or a policy of bed rest.14 A small study published in
200515 showed no evidence of a difference in the
outcome of threatened miscarriage when treated
with hCG in the first trimester.

Non-viable pregnancy
The term non-viable pregnancy includes
incomplete, silent, delayed and missed miscarriage
and early fetal demise.
Expectant management
Up to 70% of women will choose expectant
management if given the choice.16 A review by
Butler17 showed that expectant management is
successful within 26 weeks without increasing
complications in 8090% of women with
incomplete spontaneous miscarriage and 6575%
of women with delayed miscarriage or an empty
sac. Womens experiences with expectant
management revealed a mean worst pain of 5.9 on
an 11-point scale.18 The satisfaction rates were
92.9% with family physician care and 84.6% with
hospital care. Bleeding varied, but was often very
heavy. The median daily levels of bleeding and pain
were highest during the first 8 days from the start of
bleeding and decreased thereafter in the 188
women managed expectantly.19
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The Obstetrician & Gynaecologist

Expectant management can be continued as long as

the woman is willing and provided there are no
signs of infection. The duration can sometimes be
as long as 68 weeks; this is reflected in the higher
success rates with prolonged follow-up. An
increasing bleeding pattern at inclusion19 and
ultrasound findings such as blood flow within
intervillous spaces7 can be used to predict the
likelihood of successful expectant management.
Biochemical markers (including serum hCG,
progesterone, inhibin A and inhibin pro-alpha C
RI) also show significant differences in those
pregnancies that resolve spontaneously
(P  0.05).20 Other ultrasound parameters such as
endometrial thickness and the presence or absence
of a gestational sac did not add any further
information to the likely outcome.7
Medical management
Incomplete miscarriage
A variety of equally effective prostaglandin
regimens have been described, including gemeprost
0.51 mg, vaginal misoprostol 800 g3 and oral
misoprostol 400 g.21 Single and repeated doses of
oral misoprostol 600 g (with the dose repeated
after 4 hours to a total of 1 200 g) have been
shown to be equally effective, although with a lower
incidence of diarrhoea in the single dose group.22
However, vaginal misoprostol is as effective as oral
misoprostol, with a significant reduction in the
incidence of diarrhoea.23 Success rates varied from
6195%, mildmoderate bleeding lasted 46 days,
side effects were tolerable in 96% and satisfaction
rates were 95%.2123 Misoprostol has the advantage
of being cheap and not requiring refrigeration,
although it is not licensed for use in the
management of miscarriage.
Silent, delayed, missed miscarriage or
early fetal demise
A confusing number of alternative regimens have
been described using prostaglandin alone (oral,
sublingual or vaginal misoprostol, 400, 600 or
800 g in single or repeated doses), or the antiprogestogen mifepristone (200, 400 or 600 mg
orally) followed 3648 hours later by either
misoprostol or gemeprost (0.51mg vaginally).
Mifepristone 200 mg, in combination with oral
misoprostol, was equally effective and better
tolerated than mifepristone 600 mg.24 Sublingual
misoprostol 400 g appears to be a safe, effective
alternative to the oral or vaginal routes.25 Success
rates with mifepristone and misoprostol varied
from 7084%, the median induction to miscarriage
interval was 8 hours, overall the satisfaction rate was
91% and bleeding stopped, on average, by 8 days.24,25
Since progesterone levels are low in non-viable
pregnancy, in contrast to medical termination of
pregnancy, mifepristone can be avoided and
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Figure 1

Algorithm for management of miscarriage3,4,6

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Table 2

Comparison of management
regimes6,16,17,21,23,24,26,28,36,3840,42

1. Success rates (%)

Incomplete miscarriage
Early fetal demise/
delayed/silent/missed miscarriage
2.
3.
4.
5.
6.

Net societal cost per woman ()

Risk of infection (%)
Unplanned surgical curettage (%)
Intrauterine adhesions (%)
Long-term conception rates and pregnancy outcomes

The Obstetrician & Gynaecologist

Expectant

Medical

Surgical

8091
2576

6195 (prostaglandin)
4093 (prostaglandin)
7084 (mifepristone 
prostaglandin)
1410.40
23
1036
0
No differences between different treatment modalities

95100
95100
95100

1086.20
23
1044
0

prostaglandins only administered. Misoprostol by

the vaginal route may be preferable, as the mean
time to expulsion is longer by the oral route and the
incidence of diarrhoea and fatigue higher with
sublingual regimens.26,27 Single-dose vaginal
misoprostol 800 g was more effective than 400 g
(55.4% versus 40.2%, P  0.05) and more effective
in delayed miscarriage compared with cases where
there was an empty sac (50.3% versus 40.2%,
P  0.05), which may require larger or repeat doses
as they seem to respond less readily to medical
treatment.28 One trial29 showed that an additional
1-week course of sublingual misoprostol did not
improve either the success rate or the duration of
bleeding, but increased the incidence of diarrhoea.
Women receiving misoprostol experienced more
pain and required more analgesia compared with a
placebo.30 Higher success rates (85%) using 800 g
vaginal misoprostol were reported in one study,
which demonstrated that bleeding for at least
2 weeks after vaginal misoprostol is common,
although heavy bleeding is usually limited to a few
days after treatment.31 Factors that seem to predict
success include active bleeding, nulliparity32 and
higher dosages of misoprostol.28
Surgical evacuation
Surgical evacuation remains the treatment of choice if
endometrial thickness is 50 mm, bleeding is
excessive, vital signs are unstable or infected tissue is
present in the uterine cavity (in which case surgery
must be done under antibiotic cover). Fewer than
10% of women who miscarry fall into these
categories.33 Certain women will still prefer to
undergo surgical evacuation and their choice should
be acknowledged. Rare surgical risks are: uterine
perforation (1%), cervical tears, intra-abdominal
trauma (0.1%), intrauterine adhesions, haemorrhage,
infection and anaesthetic complications.
The Cochrane review34 on surgical procedures to
evacuate incomplete miscarriage included two
trials showing that vacuum aspiration is safe, quick
to perform, has significantly decreased blood loss
and is less painful than sharp curettage. Serious
complications, such as uterine perforation, and
other morbidity were rare. Analgesia and sedation
should be provided as necessary for the procedure.
In all women in whom surgery is being considered,
the need for cervical priming should be assessed.
While women with Chlamydia trachomatis,
Neisseria gonorrhoea or bacterial vaginosis in the
106

1585.30
23
25
7.7

lower genital tract at the time of induced abortion

are at increased risk of subsequent pelvic
inflammatory disease,35 there is insufficient data to
recommend routine antibiotic prophylaxis before
surgical uterine evacuation for miscarriage.
Screening for infection, including C. trachomatis,
should be considered in all women. Antibiotic
prophylaxis should be given based on individual
clinical indications.6 An appropriate regimen
would be 1 g rectal metronidazole at the time of
surgery followed by 100 mg oral doxycycline twice
daily for 7 days.35

Comparison of different
methods of management
There are few robust randomised controlled studies
with sufficient numbers of women to enable true
comparison between expectant, medical and
surgical management for incomplete miscarriage
and early fetal demise (Table 2). The MIST trial36
revealed significantly more unplanned admissions
and unplanned surgical curettage procedures after
expectant management and medical management
than after surgical management, although the risk
of infection was low (23%), regardless of
treatment modality. A recent meta-analysis37 to
quantify the relative benefits and risks of different
management options for first-trimester
miscarriage reported that surgical treatment had
the best success rate, followed by medical and
expectant treatment, although many studies were
of poor methodological quality.
The 2006 Cochrane review38 identified five trials
comparing expectant with surgical management.
Expectant care led to a higher risk of incomplete
miscarriage, bleeding and need for surgical
evacuation of the uterus, while surgery resulted in a
significantly greater risk of infection (relative risk
0.29, CI 0.090.87, P  0.03). However, there was
no strong medical argument for either approach
and the individual womans preference was
considered the major concern.
Filmy intrauterine adhesions are present in 7.7% of
women examined hysteroscopically following
surgical evacuation but not in those managed
conservatively or medically. Long-term conception
rates and pregnancy outcomes are no different
following medical or surgical evacuation for
miscarriage, the median time to pregnancy being
8 months in both groups.39,40
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Cost analysis
Conflicting results have been reported on the cost
effectiveness of different treatment strategies.4143
Analysis of pooled data from 29 reports found
misoprostol the least costly alternative ($1 000 [US
dollars] per woman), followed by expectant care
($1 172) and surgical evacuation ($2 007).41
Misoprostol and expectant care groups were shown
to be less costly than the surgical evacuation group
100% and 88% of the time, while the misoprostol
group was less costly than the expectant group
100% of the time.
In an economic evaluation of the MIST trial,42
expectant management was shown to be cheaper
(net societal cost per woman estimated at
1 086.20) than both medical (1 410.40) and
surgical management (1 585.30). Overall, it was
the most cost effective.
In a study by Rocconi et al,43 expectant
management ($915 [US dollars] cost per cure) was,
similarly, more cost effective than both medical
($1 149) and conventional surgical management
($2 333), although manual vacuum aspiration, a
technique little used in the UK, was the most cost
effective ($793).

Womens perspective about

different choices
A survey44 of women attending a family planning
clinic found a strong preference for expectant
treatment in the event of a miscarriage, although
physician recommendation would influence their
decision. From a clinical viewpoint, the role of free
choice is supported by the fact that health-related
quality of life over time is best when women with
miscarriage choose their own treatment.45 With no
single best way to treat miscarriage to suit all
individuals, the largest qualitative study of womens
views on expectant, medical and surgical treatment
concluded that informed choice was paramount.
When surgical evacuation became necessary,
women in the medical group resented having a
second procedure, although a subsequent
operation for failed expectant treatment was not
perceived by women in the wait and see group in
such a negative way.46

Disposal of products of
conception
Guidance from the Royal College of Obstetricians
and Gynaecologists6 on early pregnancy loss
recommends that tissue obtained at the time of a
miscarriage should be submitted for histological
examination to exclude trophoblastic disease and
ectopic pregnancy. Each hospital trust should have
a clear system and protocol for the sensitive
disposal of fetal remains.3 A Scottish study47 to
determine the extent to which health professionals
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have adopted these recommendations found that

only 71% of records contained evidence of
histological examination of tissue. Around 50% of
women reported involvement with decisions about
tissue disposal, although documentation was found
in only 29% of records. It was concluded that the
national guidance on these issues was contentious,
implementation variable and that wide
consultation with stakeholders was needed prior to
publication of any revised guidance.

Conclusion
Modern treatment of miscarriage should provide a
rapid, sympathetic diagnosis and adequate
counselling. All women with early pregnancy
problems should preferably have prompt access to a
dedicated early pregnancy assessment unit that
provides efficient management, counselling and
access to appropriate information. At all times
women should be supported in making informed
choices about their care and management: Given
the lack of clear superiority of either approach, the
womans preference should play a dominant role in
decision making. Expectant and medical
management of first-trimester miscarriage possess
significant economic advantages over traditional
surgical management.48
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2007 Royal College of Obstetricians and Gynaecologists