Medical Care for Miscarriage
For miscarriage management, offer patients a choice between expectant, medical (misoprostol), or surgical evacuation (dilation and evacuation/aspiration), with surgical methods having the lowest complication rates but medical management being highly effective and acceptable for most first-trimester losses. 1, 2
Management Options
Surgical Evacuation (Preferred for Lowest Complication Rates)
- Dilation and evacuation (D&E) or manual vacuum aspiration (AMEU) is the safest method with hemorrhage rates of only 9.1%, infection rates of 1.3%, and retained tissue requiring additional procedures in only 1.3% of cases 1, 2
- Preferred for pregnancies under 12 weeks gestation 1
- Provides immediate resolution and certainty of complete evacuation 2
- Key caveat: May be more psychologically traumatic for some patients compared to medical management 2
Medical Management with Misoprostol
- Effective in 77-93% of cases depending on regimen, type of miscarriage, and waiting period 3, 4, 5, 6
- Recommended dosing: 400 mcg misoprostol vaginally is as effective as 800 mcg with fewer side effects (less fever/rigors) and higher patient satisfaction 4
- Alternative regimen: 800 mcg vaginally initially, followed by 400 mcg orally twice, 3 hours apart the next day, achieves 77.3% success 6
- Higher complication rates than surgery: hemorrhage 28.3%, infection 23.9%, retained tissue 17.4% 2
- Advantages: Avoids surgery, can be done at home, 93.3% of women prefer home treatment over hospital 6
- Expected course: Bleeding lasts average 6.4 days, mostly mild to moderate; 51% require oral analgesia, 4% require intramuscular opiates 5
Expectant Management
- Waiting for spontaneous resolution without intervention 1
- Significantly higher maternal morbidity (60.2%) compared to active management (33.0%) 2, 7
- Only 16% of women avoid maternal morbidity while achieving fetal survival with expectant management 7
- Major risks: intraamniotic infection (38.0%), postpartum hemorrhage (23.1%), sepsis (6.8%), and maternal death (45 per 100,000) 7
- Median time from membrane rupture to infection is 5 days, but clinical deterioration can be rapid (median 18 hours to death once infection identified) 7
Essential Diagnostic Evaluation
- Transvaginal ultrasound is the primary diagnostic method to confirm miscarriage type, assess for retained products, and rule out ectopic pregnancy 1, 2
- Serial β-hCG measurements when diagnosis uncertain (levels fail to rise appropriately or decrease) 1, 2
- Baseline hemoglobin to assess for anemia from bleeding 1
Critical Preventive Measures
Rh Immunoglobulin Administration
- All Rh-negative women must receive anti-D immunoglobulin to prevent alloimmunization 1, 2
- Recommended dose: 50 mcg for incomplete or complete abortion 1
- Rationale: 32% of spontaneous abortions present with fetomaternal hemorrhage 1, 7
Infection Prevention
- Risk increases significantly after 18 hours of ruptured membranes 2
- Prophylactic antibiotics should be re-dosed if blood loss exceeds 1,500 mL 8
Specific Management by Miscarriage Type
Incomplete Miscarriage
- Medical management with 400 mcg oral misoprostol achieves 77.7% success for retained products 15-50 mm 5
- 92.4% avoid surgery when allowing for repeat misoprostol or conservative management 5
Missed Abortion (Retained Fetal Demise)
- Higher risk of complications if left untreated: infection, hemorrhage, sepsis 7
- Medical management with misoprostol 77-81% effective 6, 9
- Expectant management strongly discouraged due to 60% maternal morbidity rate 7
Complete Miscarriage
- May only require observation if bleeding minimal and ultrasound confirms empty uterus 1
- Follow-up to confirm resolution and rule out complications 1
Common Pitfalls to Avoid
- Misdiagnosis of ectopic pregnancy as incomplete abortion - always perform careful ultrasound evaluation 1
- Failing to administer Rh immunoglobulin to Rh-negative women 1, 2
- Underestimating infection risk with expectant management, especially after membrane rupture 2, 7
- Multiple or aggressive curettage procedures increase Asherman syndrome risk 1, 2, 7