What is the management plan for a patient with a missed miscarriage and verified pregnancy with heart rate prior to dilation and curettage (D&C)?

Management of Missed Miscarriage with Prior Confirmed Fetal Cardiac Activity

For a missed miscarriage with previously documented fetal heart rate, offer the patient a choice between expectant management for up to 14 days, medical management with misoprostol, or surgical evacuation by dilation and curettage (D&C), with surgical management under ultrasound guidance showing the lowest complication rates. 1, 2, 3

Initial Assessment and Confirmation

Diagnostic verification:

• Confirm the diagnosis of missed miscarriage using transvaginal ultrasound showing crown-rump length ≥7 mm without cardiac activity 4
• Document that the embryo previously had documented cardiac activity, which confirms this is a true missed miscarriage rather than an anembryonic pregnancy 1
• Assess for signs of infection (fever, foul discharge, uterine tenderness) or hemodynamic instability (tachycardia, hypotension, orthostatic changes), which would exclude expectant or medical management 2, 5

Exclude high-risk scenarios:

• Rule out molar pregnancy by evaluating for markedly elevated β-hCG (>100,000 mIU/mL at this gestational age would be concerning) and characteristic ultrasound findings 6
• Confirm gestational age is <12 weeks, as management protocols differ for later losses 1
• Verify the miscarriage duration is <3 weeks old (crown-rump length should not be ≥3 weeks smaller than expected gestational age based on last menstrual period) 2

Management Options

Expectant Management (First-Line for Most Patients)

Success rates and timeline:

• Only 35% of missed miscarriages (with previously documented cardiac activity) will resolve spontaneously within 14 days, compared to 71% for incomplete miscarriages 2
• Extending expectant management beyond 2 weeks does not increase success rates and only delays definitive treatment 2, 5
• Overall, 80-90% of first-trimester losses will resolve within 2-6 weeks, though missed miscarriages have lower success rates than incomplete miscarriages 5

Protocol:

• Perform weekly transvaginal ultrasound examinations for 2 weeks to assess for complete passage of tissue 2
• After 2 weeks without complete resolution, advise surgical evacuation 2
• Emergency surgical evacuation rate is approximately 2.5% due to hemorrhage or infection 2

Contraindications to expectant management:

• Risk factors for hemorrhage (coagulopathy, anticoagulation therapy) 1
• Increased risk from effects of hemorrhage (severe anemia, cardiovascular disease) 1
• Patient preference against waiting 1

Medical Management with Misoprostol

Efficacy:

• Success rate of 92.4% for medical induction of missed abortion without need for surgical intervention 7
• Can be offered as an alternative to expectant management for women who prefer active intervention 1

Verification of completion:

• Both serial β-hCG measurements and ultrasound examination can verify complete abortion, though they should supplement clinical assessment 7
• β-hCG testing is as effective as ultrasound for confirming successful medical abortion but agreement between methods is moderate (Kappa 0.327) 7

Surgical Management (D&C)

Optimal technique:

• Office-based D&C under real-time ultrasound guidance has the lowest complication rate (0.87% retained products of conception), significantly lower than unguided D&C (2.6-4.9%) 3
• Use transabdominal ultrasound during the procedure followed immediately by transvaginal ultrasound to confirm complete evacuation 3
• No intraoperative complications (excessive bleeding, uterine perforation) were observed with ultrasound-guided technique 3

Indications for surgical management:

• Patient preference, especially if previous adverse experience with pregnancy loss 1
• Failed expectant or medical management 2
• Contraindications to expectant management 1, 5

Rh Status Management

Anti-D prophylaxis:

• Administer anti-D immunoglobulin if the patient is Rh-negative and the pregnancy is ≥12 weeks gestation with symptoms of bleeding 1
• For pregnancies <12 weeks, follow local protocols for anti-D administration in first-trimester pregnancy loss

Follow-Up and Monitoring

Post-treatment assessment:

• If expectant management chosen and symptoms persist beyond 14 days or worsen, refer back to early pregnancy unit for reassessment 1
• Changing a pad soaked with blood and clots more than once per hour indicates heavy bleeding requiring immediate referral 1
• Serial β-hCG measurements can supplement ultrasound findings but should not replace clinical assessment 7

Psychological Considerations

Counseling:

• Short-term psychological outcomes show no difference between expectant and surgical management 5
• Patient preference should guide management choice when medically appropriate 1, 5
• Discuss that missed miscarriage (with prior cardiac activity) has lower spontaneous resolution rates (35%) compared to incomplete miscarriage (71%) 2

Critical Pitfalls to Avoid

• Do not extend expectant management beyond 2 weeks, as this does not improve success rates and only delays definitive treatment 2
• Do not perform D&C without ultrasound guidance when available, as complication rates are significantly higher 3
• Do not discharge patients with heavy bleeding (>1 pad per hour) without immediate intervention 1
• Do not rely solely on β-hCG levels without clinical correlation and ultrasound findings 7