Miscarriage Work-up Protocol
A comprehensive miscarriage work-up should include ultrasound evaluation, laboratory testing, and assessment for potential underlying causes to reduce risk of recurrence and improve future pregnancy outcomes. 1
Diagnostic Evaluation
Ultrasound Assessment
- Transvaginal ultrasound is the cornerstone of miscarriage diagnosis, using specific criteria to categorize early pregnancy loss (EPL) 1:
- Concerning for EPL: Embryonic crown-rump length (CRL) <7 mm with no cardiac activity, mean sac diameter (MSD) 16-24 mm with no embryo, or absence of embryo 7-13 days after visualized gestational sac 1
- Diagnostic of EPL: CRL ≥7 mm with no cardiac activity, MSD ≥25 mm with no embryo, or absence of embryo ≥14 days after visualization of gestational sac 1
- Special scenarios include embryonic/fetal demise (CRL ≥7 mm with no cardiac activity) and anembryonic pregnancy (gestational sac ≥25 mm without embryo) 1
Laboratory Testing
- Quantitative hCG measurements to confirm declining levels and eventual resolution 1
- Complete blood count with platelets to assess for anemia and thrombocytopenia 1
- Blood type and Rh status (administer Rho(D) immunoglobulin to Rh-negative women) 1
- Thyroid function tests to rule out thyroid dysfunction 1
- Liver and renal function tests 1
Evaluation for Recurrent Miscarriage
For women with two or more miscarriages, additional testing is recommended 2, 3:
Genetic Evaluation
- Parental karyotyping to identify chromosomal abnormalities (accounts for approximately 7% of recurrent miscarriages) 2
- Consider genetic testing of products of conception when available 2
Anatomical Assessment
- Hysterosalpingography, sonohysterography, or MRI to evaluate for uterine anomalies (10-15% of recurrent miscarriages) 2, 3
- Evaluation for uterine fibroids, polyps, or cervical insufficiency 3
Endocrine Evaluation
- Thyroid function tests (TSH, free T4) 2
- Evaluation for polycystic ovary syndrome 2
- Assessment for luteal phase defect and other hormonal abnormalities (accounts for approximately 15% of recurrent miscarriages) 2
Thrombophilia Screening
- Testing for antiphospholipid syndrome (lupus anticoagulant, anticardiolipin antibodies, anti-β2 glycoprotein-I) 2, 3
- Consider testing for inherited thrombophilias (Factor V Leiden, prothrombin gene mutation, protein C and S deficiencies, antithrombin deficiency) 2, 3
- Evaluation for sticky platelet syndrome and other platelet function disorders 2
Management Considerations
Immediate Management
- For incomplete miscarriage: options include expectant management, medical management (misoprostol), or surgical evacuation (suction dilation and curettage) 1
- Surgical evacuation is preferably performed under ultrasound guidance to reduce risk of uterine perforation 1
- Administer uterotonic agents during and after the procedure to reduce bleeding risk 1
Follow-up
- Serial hCG monitoring until levels return to non-pregnant state 1
- Ultrasound evaluation to confirm complete evacuation of products of conception 1
- Histopathologic examination of tissue to confirm intrauterine pregnancy and rule out gestational trophoblastic disease 1
Psychological Support
- Acknowledge the significant psychological impact of miscarriage, which may include anxiety, depression, and post-traumatic stress disorder 4
- Provide appropriate counseling and mental health resources 4, 5
- Inform women of their rights after pregnancy loss 5
Prevention Strategies for Recurrent Miscarriage
- For women with thrombophilia-related recurrent miscarriage: preconception low-dose aspirin (81 mg/day) followed by postconception low-dose heparin (5000 units every 12 hours) has shown success rates approaching 98% 2, 3
- Address modifiable risk factors: smoking cessation, alcohol avoidance, stress reduction, and maintaining healthy BMI 4
- Consider specialized preconception care for women with history of recurrent miscarriage 4