What to do if experiencing signs of a miscarriage, such as vaginal bleeding or abdominal pain?

Management of Suspected Miscarriage

If experiencing signs of a miscarriage such as vaginal bleeding or abdominal pain, seek immediate medical evaluation as prompt diagnosis and appropriate management can significantly improve outcomes and reduce complications. 1

Initial Assessment and Diagnosis

• Ultrasound is the mainstay for diagnosing miscarriage, with transvaginal ultrasound (TVS) being the most accurate method 2
• Digital pelvic examination should be avoided until diagnoses such as placenta previa, low-lying placenta, and vasa previa have been excluded 1
• Transabdominal ultrasound should be performed as the initial imaging procedure to assess:
  • Fetal viability
  • Placental location and integrity
  • Presence of any clots suggesting placental separation 1
• If transabdominal ultrasound is inconclusive, transvaginal ultrasound should be performed to:
  • Better visualize the cervix from external to internal os
  • Assess cervical length
  • Evaluate the inferior placental margin 1
• For indeterminate ultrasound findings, β-hCG levels should be measured, with levels >2,000 mIU/mL without a visible gestational sac indicating higher risk of ectopic pregnancy 1

Management Options

1. Expectant Management

• Success rates of 66-91% depending on the type of miscarriage 3
• Appropriate for hemodynamically stable patients with minimal bleeding 3
• Complications include hemorrhage requiring blood transfusion in 1-2% of cases 3
• If expectant therapy fails, subsequent treatment with misoprostol or surgical management is indicated 3

2. Medical Management

• Misoprostol treatment (typically vaginal administration) has success rates of 81-95% 3
• Advantages include better planning capability compared to expectant management 3
• Vaginal administration is the most effective route with fewest side effects 3
• Side effects include nausea (more common than with surgical management), vomiting, and diarrhea 4
• Surgical evacuation is needed in 5-20% of cases following medical management 3

3. Surgical Management

• Indicated for patients with:
  • Infection
  • Marked and persistent bleeding
  • Hemodynamic instability
  • Pre-existing coagulopathy 3
• Suction curettage has a success rate of 97-98% 3
• Risks include anesthesia-related complications (0.2%), uterine perforation (0.1%), and need for repeat curettage (2-3%) 3

Special Considerations

For Rh-Negative Women

• Anti-D immunoglobulin (50 μg) should be administered in cases of threatened, incomplete, or complete abortion 1
• This prevents Rh sensitization which could affect future pregnancies 1

Psychological Support

• After a diagnosis of miscarriage, approximately half of women experience significant psychological effects that may last up to 12 months 2
• Appropriate supportive aftercare should be provided 5

When to Seek Emergency Care

• Heavy bleeding (soaking through a pad in less than an hour)
• Severe abdominal pain
• Fever or signs of infection
• Dizziness or fainting 1, 6

Follow-up Care

• Follow-up ultrasound and/or β-hCG measurements are necessary to confirm complete miscarriage, especially when managed expectantly or medically 2
• Complete miscarriage should not be diagnosed with TVS alone without serial biochemical confirmation (unless an intrauterine gestation sac has previously been visualized) 2
• After clinical assessment suggesting complete miscarriage, 45% of women will have retained tissue on ultrasound 2

Common Pitfalls to Avoid

• Diagnosing complete miscarriage without adequate confirmation can miss ectopic pregnancy in 6% of cases 2
• Inaccurate diagnosis of miscarriage can result in unintended termination of a wanted pregnancy 5
• Delaying treatment in cases of hemodynamic instability or signs of infection can lead to serious complications 3