Management of Miscarriage Being Passed
The recommended first-line management for incomplete abortion (miscarriage being passed) is medical treatment with misoprostol 800 μg administered vaginally as a single dose, which has approximately 90% effectiveness in achieving complete evacuation without surgical intervention. 1
Diagnosis Confirmation
- Perform sterile speculum examination to:
- Visualize fluid pooling in vagina
- Assess amount of bleeding
- Check for tissue passage
- Obtain transvaginal ultrasound to:
- Confirm absence of cardiac activity
- Assess gestational age
- Evaluate for retained products of conception (heterogeneous material within endometrial cavity, often with internal vascularity)
- Consider laboratory tests:
- Serial βhCG when diagnosis is uncertain
- Complete blood count to assess for anemia
- Blood type and Rh status
Management Options
1. Medical Management (First-Line)
- Medication regimen: Misoprostol 800 μg vaginally as a single dose 1
- Advantages:
- High success rate (~90%)
- Avoids surgical risks
- Can be administered in outpatient setting
- Vaginal route has fewer gastrointestinal side effects than oral administration 1
- Follow-up: Transvaginal ultrasound in 7-14 days to confirm complete evacuation 1
- Side effects to warn patient about:
- Cramping and pain (can be managed with NSAIDs)
- Bleeding (typically heavier than normal menses)
- Nausea, vomiting, diarrhea (less common with vaginal administration)
2. Surgical Management
- Indications:
- Heavy bleeding
- Signs of infection
- Patient preference
- Failed medical management 1
- Procedure: Vacuum aspiration or dilation and curettage (D&C)
- Advantages:
- Higher success rate (93.6%)
- Quicker resolution
- Lower risk of prolonged bleeding 1
- Risks:
- Anesthesia complications
- Uterine perforation
- Cervical trauma
- Intrauterine adhesions (Asherman syndrome)
3. Expectant Management
- Approach: Monitoring without intervention
- Success rate: Lower than medical or surgical management
- Disadvantages:
- Unpredictable time until spontaneous evacuation
- Higher risk of incomplete evacuation requiring subsequent intervention
- Higher risk of infection and hemorrhage 1
- Follow-up: More frequent monitoring required
Prevention of Rh Sensitization
- Administer anti-D immunoglobulin (50 μg) to all Rh-negative patients 1
- This is standard practice for all types of abortion, including spontaneous miscarriage
Patient Instructions and Warning Signs
Instruct patients to seek immediate medical attention if they experience:
- Heavy bleeding (soaking through >2 pads per hour for >2 hours)
- Severe abdominal pain not relieved by analgesics
- Fever >100.4°F (38°C)
- Foul-smelling vaginal discharge
- Dizziness or syncope
Follow-up Care
- Schedule follow-up visit in 7-14 days with transvaginal ultrasound 1
- If incomplete evacuation is found:
- Consider second dose of misoprostol
- Consider surgical evacuation if medical management fails
- Provide emotional support and counseling resources
- Discuss contraception options if desired
Common Pitfalls to Avoid
- Misdiagnosing viable pregnancy as miscarriage: Always confirm absence of cardiac activity before initiating treatment
- Inadequate pain management: Provide appropriate analgesics (NSAIDs) for cramping
- Forgetting Rh prophylaxis: Always check Rh status and administer anti-D immunoglobulin to Rh-negative patients
- Insufficient follow-up: Ensure complete evacuation with follow-up ultrasound
- Neglecting emotional impact: Acknowledge psychological effects of miscarriage and offer support resources
Medical management with misoprostol is highly effective, safe, and acceptable to most patients, making it the preferred first-line treatment for incomplete miscarriage when there are no contraindications.