What is the management plan for a woman experiencing a miscarriage?

From the Guidelines

The management plan for a woman experiencing a miscarriage should prioritize minimizing the risk of venous thromboembolism (VTE) and ensuring proper emotional and medical support, with options including expectant management, medical management with misoprostol, or surgical evacuation, depending on the type of miscarriage and patient preference. When considering the management of miscarriage, it's crucial to assess the risk of VTE, as pregnancy itself increases this risk due to hypercoagulability, stasis, and vascular injury 1. The risk of VTE in early pregnancy loss, including miscarriage, is a significant concern, with studies indicating an increased risk, particularly in the postpartum period 1. Given the potential for VTE, low molecular weight heparin (LMWH) is recommended for thromboprophylaxis in high-risk cases, with the duration of treatment varying based on the individual's risk factors and the method of miscarriage management. For example, in cases of surgical management of miscarriage, LMWH may be administered until the patient is mobile or for a specified period post-procedure, depending on the assessed risk 1. In terms of specific management options:

• Expectant management may be suitable for women with a complete miscarriage or those who prefer to avoid medical or surgical intervention.
• Medical management with misoprostol 800mcg vaginally, either as a single dose or repeated after 24 hours, is an effective option for incomplete or missed miscarriages.
• Surgical evacuation via vacuum aspiration or dilation and curettage is recommended for cases of heavy bleeding, infection, or patient preference, and may also reduce the risk of VTE compared to expectant or medical management. Pain management is crucial and should include NSAIDs like ibuprofen 600-800mg every 6-8 hours, with opioids considered for severe pain. Emotional support and follow-up care are essential to monitor for complications and provide psychological support during this period. Rh-negative women should receive Rh immunoglobulin (RhoGAM) as appropriate, based on gestational age. Patients should be advised to seek immediate medical attention for signs of complications, such as heavy bleeding, severe pain, fever, or foul-smelling discharge. Ultimately, the management plan should be individualized, taking into account the woman's preferences, medical history, and risk factors for VTE, to minimize morbidity, mortality, and improve quality of life 1.

From the Research

Management Plan for Miscarriage

The management plan for a woman experiencing a miscarriage involves several options, including expectant, medical, and surgical treatment.

• Expectant treatment allows the body to expel the pregnancy tissue naturally, with success rates ranging from 66-91% depending on the type of miscarriage 2.
• Medical treatment involves the use of misoprostol, which can be administered vaginally or orally, with a success rate of 81-95% 2.
• Surgical treatment, also known as curettage, is a more invasive option that involves the removal of pregnancy tissue from the uterus, with a success rate of 97-98% 2.

Factors Influencing Treatment Choice

The choice of treatment depends on various factors, including the type of miscarriage, the presence of infection or bleeding, and the woman's personal preferences.

• Women with incomplete or delayed miscarriage may be offered expectant, medical, or surgical treatment, with detailed counseling to help them make an informed decision 3.
• The type of miscarriage can influence the relative success rates of each treatment option, with expectant treatment being more effective for certain types of miscarriage 3.
• The woman's preference should play a dominant role in decision-making, as there is no clear superiority of one approach over the other 4.

Risks and Complications

Each treatment option carries its own risks and complications, including:

• Expectant treatment: risk of incomplete miscarriage, need for unplanned surgical treatment, and bleeding 4.
• Medical treatment: risk of side effects, such as nausea and diarrhea, and the need for multiple doses of misoprostol 2.
• Surgical treatment: risk of infection, cervical trauma, uterine perforation, and hemorrhage 2, 4.

Psychological and Emotional Support

Miscarriage can have significant psychological and emotional consequences, including anxiety, depression, and post-traumatic stress disorder.

• Effective screening instruments and treatment options for mental health consequences of miscarriage should be available 5.
• Women should receive care in preconception and obstetric clinics specializing in patients at high risk, with a focus on providing emotional support and counseling 5.