What is the management for a patient who had a miscarriage?

Management of Miscarriage

Immediate Management Decision

For a patient who has had a miscarriage, offer a choice between surgical evacuation, medical management with misoprostol, or expectant management, with surgical evacuation (suction aspiration or dilation and curettage) being the most effective and having the lowest complication rates. 1, 2

Three Management Options

Surgical Evacuation (Preferred Method)

Surgical evacuation is the safest and most effective option with the highest success rates and lowest complication rates. 1

• Success rate: 97-98% for complete evacuation 1, 3
• Hemorrhage rate: only 9.1% (compared to 28.3% with medical management) 1, 2
• Infection rate: only 1.3% (compared to 23.9% with medical management) 1, 2
• Retained tissue requiring additional procedures: only 1.3% (compared to 17.4% with medical management) 1, 2
• Suction aspiration is preferred over sharp curettage as it has lower risk of uterine perforation and Asherman syndrome 1, 4
• Provides immediate resolution and certainty of complete evacuation 1
• Associated risks include anesthesia-related complications (0.2%), uterine perforation (0.1%), and need for repeat curettage (2-3%) 1, 3

Medical Management with Misoprostol

Medical management is highly effective and acceptable for most first-trimester losses, though it has higher complication rates than surgery. 1

• Success rate: 81-95% for complete termination 1, 3, 5
• Vaginal administration of misoprostol (800 mcg) is the most effective route with fewest side effects 1, 4
• Hemorrhage rate: 28.3% (significantly higher than surgical) 1, 2
• Infection rate: 23.9% (significantly higher than surgical) 1, 2
• Retained tissue rate: 17.4% requiring subsequent intervention 1, 2
• Curettage is needed in 5-20% of cases after failed medical management 1, 3
• Common side effects include nausea (2.5 times more common than surgery), vomiting (nearly 2 times more common), and diarrhea (nearly 5 times more common) 5
• Offers better planning capability than expectant management 1, 3

Expectant Management (Least Recommended)

Expectant management has significantly higher maternal morbidity and should be strongly discouraged unless specifically requested by the patient. 1, 2

• Success rate: only 66-91% depending on type of miscarriage 3
• Maternal morbidity rate: 60.2% (compared to 33.0% with active management) 1, 2
• Only 16% of women avoid maternal morbidity while achieving resolution 1
• Major risks include intraamniotic infection (38.0%), postpartum hemorrhage (23.1%), sepsis (6.8%), and maternal death (45 per 100,000) 1
• Hemorrhage requiring blood transfusion occurs in 1-2% of cases 3
• If expectant therapy fails, subsequent treatment with misoprostol or curettage is required 1, 3

Essential Diagnostic Evaluation Before Treatment

• Transvaginal ultrasound is the primary diagnostic method to confirm miscarriage type, assess for retained products of conception, and rule out ectopic pregnancy 1, 2
• Serial β-hCG measurements when diagnosis is uncertain (levels fail to rise appropriately or decrease) 1, 2
• Baseline laboratory studies including complete blood count, type and crossmatch, and coagulation panel 1

Critical Preventive Measures (Do Not Miss These)

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
• This is a critical step that cannot be omitted 1, 2

Infection Prevention

• Risk of infection increases significantly after 18 hours of ruptured membranes 1, 2
• Prophylactic antibiotics should be re-dosed if blood loss exceeds 1,500 mL 1

Absolute Indications for Immediate Surgical Evacuation

Proceed directly to surgical evacuation without offering other options when: 3, 4

• Active infection or septic abortion is present 3, 4
• Marked and persistent bleeding occurs 3, 4
• Hemodynamic instability is present 3, 4
• Pre-existing coagulopathy exists 3, 4

Type of Miscarriage Influences Success Rates

• Incomplete miscarriage: Expectant management is more effective (higher success rates) 3, 5
• Missed abortion (missed miscarriage): Surgical and medical methods are significantly more beneficial than expectant management 1, 5
• Missed abortion has higher risk of complications if left untreated: infection, hemorrhage, sepsis 1

Post-Management Care

• Contraceptive counseling to prevent unintended pregnancy 1
• Clinical follow-up to confirm complete resolution 1
• Monitor for signs of infection: fever, foul-smelling discharge, worsening pain 1
• Psychological support as needed, as women who feel in control of decision-making have improved psychological outcomes 6

Common Pitfalls to Avoid

• Misdiagnosis of ectopic pregnancy as incomplete abortion - always perform careful ultrasound evaluation to rule out ectopic pregnancy 1
• Failing to administer Rh immunoglobulin to Rh-negative women - this is mandatory 1, 2
• Underestimating infection risk with expectant management, especially after membrane rupture beyond 18 hours 1, 2
• Multiple or aggressive curettage procedures increase Asherman syndrome risk - use suction aspiration when possible 1, 2
• Confusing enhanced myometrial vascularity (EMV) with endometritis - EMV is a normal finding after miscarriage and does not indicate infection; endometritis requires fever, uterine tenderness, and foul discharge 1

Patient Satisfaction

• Women's satisfaction is similar between misoprostol and surgery (no significant difference) 5
• Patient preference should guide treatment choice when no contraindications exist, but patients must be counseled on the significantly higher complication rates with expectant management 1, 3, 4