From the Guidelines
The protocol for spontaneous abortion (miscarriage) typically involves three main approaches: expectant, medical, or surgical intervention, with the choice of approach depending on the patient's preferences, medical history, and the stage of pregnancy. According to the most recent evidence 1, the standard protocol for medical management includes misoprostol 800 mcg vaginally as a single dose, which can be repeated after 24 hours if needed. Alternatively, mifepristone 200 mg orally followed 24-48 hours later by misoprostol 800 mcg vaginally may be more effective, especially for missed miscarriages.
Key Considerations
- Patients should expect cramping and bleeding, often heavier than a normal period, lasting 2-3 weeks.
- Pain can be managed with ibuprofen 600-800 mg every 6-8 hours and acetaminophen 650-1000 mg every 6 hours as needed.
- Follow-up should occur within 1-2 weeks to confirm complete passage using ultrasound or serial hCG measurements.
- Warning signs requiring immediate medical attention include soaking more than two pads per hour for over two hours, severe pain unrelieved by medication, fever over 100.4°F, or foul-smelling discharge.
Emotional Support
Emotional support is essential throughout this process, and patients should be offered resources for grief counseling as needed. The Society of Radiologists in Ultrasound consensus conference recommendations 1 emphasize the importance of using clear and sensitive language when discussing early pregnancy loss with patients.
Ultrasound Lexicon
The Society of Radiologists in Ultrasound has developed a lexicon for first-trimester ultrasound, which includes terms such as "concerning for early pregnancy loss," "diagnostic of early pregnancy loss," and "completed early pregnancy loss" 1. This lexicon can help healthcare providers communicate more effectively with patients and ensure that they receive appropriate care.
Recent Guidelines
Recent guidelines from the Society for Maternal-Fetal Medicine 1 emphasize the importance of individualized counseling and informed decision-making for patients experiencing previable and periviable preterm prelabor rupture of membranes. While these guidelines do not specifically address spontaneous abortion, they highlight the need for patient-centered care and careful consideration of the risks and benefits of different management approaches.
From the Research
Protocol for Spontaneous Abortion (Miscarriage)
The protocol for spontaneous abortion (miscarriage) involves several approaches, including expectant management, medical management, and surgical management.
- Expectant Management: This approach is encouraged for 7-14 days after diagnosis of miscarriage, as most women will miscarry spontaneously during this time and will need no further treatment 2.
- Medical Management: Medical treatment using misoprostol can be offered for incomplete miscarriage or missed miscarriage. A vaginal dose of 800 μg of misoprostol, possibly repeated 24 to 48 hours later, seems to offer the best efficiency/tolerance ratio 3.
- Surgical Management: Surgical uterine evacuation remains the most effective and quickest method of treatment for miscarriage, especially for missed miscarriage 3. However, it may be chosen by a woman if she has had a previous adverse or traumatic experience associated with pregnancy 2.
Comparison of Approaches
Studies have compared the effectiveness, safety, and acceptability of medical treatment with expectant care or surgery for incomplete miscarriage.
- Misoprostol vs. Expectant Care: There was no statistically significant difference in complete miscarriage or in the need for surgical evacuation between misoprostol treatment and expectant care 4, 5.
- Misoprostol vs. Surgical Evacuation: There was a slightly lower incidence of complete miscarriage with misoprostol, but with a success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol, but more unplanned procedures 4, 5.
Considerations and Recommendations
The choice of approach depends on the individual woman's circumstances, including the gestational age, amount of bleeding, and presence of risk factors for haemorrhage.
- Gestational Age: There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation 5.
- Risk Factors: Advancing maternal and paternal age, being underweight or overweight, smoking, and high alcohol consumption are known to be associated with increasing chance of miscarriage 2.
- Health Service Resources: The availability of health service resources to support all three approaches (expectant management, medical management, and surgical management) is essential for providing women with an informed choice 4, 5.