What is the treatment for a patient experiencing miscarriage?

Treatment for Miscarriage

For patients experiencing miscarriage, offer three evidence-based management options—surgical evacuation, medical management with misoprostol, or expectant management—with surgical evacuation (vacuum aspiration or dilation and evacuation) being the safest method with the lowest complication rates, though medical management is highly effective and acceptable for most first-trimester losses. 1, 2

Initial Diagnostic Evaluation

Before initiating treatment, confirm the diagnosis and type of miscarriage:

• Transvaginal ultrasound is the primary diagnostic method to confirm miscarriage type, assess for retained products of conception, and critically rule out ectopic pregnancy 1, 2
• Serial β-hCG measurements when diagnosis is uncertain—levels that fail to rise appropriately (should double every 48-72 hours in viable pregnancy) or decrease confirm pregnancy loss 3, 1
• Classify the miscarriage type: incomplete abortion (partial expulsion), complete abortion (complete expulsion), missed abortion/embryonic demise (fetal death without expulsion), or inevitable abortion (cervical dilation with bleeding) 1

Management Options by Safety and Efficacy

Surgical Evacuation (Preferred for Safety)

Surgical evacuation has the lowest complication rates and provides immediate resolution:

• Hemorrhage rate: 9.1% (versus 28.3% with medical management) 1, 2
• Infection rate: 1.3% (versus 23.9% with medical management) 1, 2
• Retained tissue requiring additional procedures: 1.3% (versus 17.4% with medical management) 1, 2
• Success rate: 97-98% for complete evacuation 4

Specific techniques:

• Manual vacuum aspiration or suction curettage is preferred for pregnancies under 12 weeks gestation 1, 4
• Dilation and evacuation (D&E) is the safest method for second-trimester losses 1, 2
• Performed as outpatient or day-case procedure 1

Risks to discuss:

• Anesthesia-related risk: 0.2% 4
• Uterine perforation: 0.1% 4
• Need for repeat curettage: 2-3% 4
• May be more psychologically traumatic for some patients compared to medical management 1

Medical Management with Misoprostol

Misoprostol 800 mcg vaginally is the most effective medical regimen with fewest side effects:

• Success rate: 81-95% for complete evacuation depending on miscarriage type 1, 4, 5
• Vaginal administration is more effective than oral or sublingual routes 1, 6
• Can be performed in outpatient or home settings before 9 weeks gestation 1

Enhanced regimen for embryonic demise:

• Mifepristone 200 mg orally followed by misoprostol 800 mcg vaginally/buccally is more effective than misoprostol alone, particularly for missed abortion and anembryonic pregnancy 1, 2

Expected side effects:

• Nausea: 2.5 times more common than surgery 1
• Vomiting: approximately 2 times more common than surgery 1
• Diarrhea: approximately 5 times more common than surgery 1

Complication rates:

• Hemorrhage requiring transfusion: 1-2% 4
• If medical management fails, proceed to surgical evacuation 1, 4

Expectant Management (Generally NOT Recommended)

Expectant management carries significantly higher maternal morbidity and should be avoided in most cases:

• Maternal morbidity rate: 60.2% (versus 33.0% with abortion care) 3, 1, 2
• Intraamniotic infection: 38.0% (versus 13.0% with abortion care) 3, 1, 2
• Postpartum hemorrhage: 23.1% (versus 11.0% with abortion care) 3, 1, 2
• Sepsis rate: 6.8% 7, 2
• Maternal death: 45 per 100,000 patients 7, 2

Outcomes with expectant management:

• Only 16% avoid maternal morbidity with fetal survival 3, 7, 2
• 37% experience maternal morbidity without fetal survival 3
• 23% have maternal morbidity with fetal survival 3
• 24% have no maternal morbidity and no fetal survival 3

Limited acceptable scenarios:

• May consider for incomplete abortion with minimal bleeding where success rates reach 66-91% 4, 8
• Never appropriate for missed abortion, heavy bleeding, or signs of infection 1, 2

Absolute Contraindications to Expectant Management

Proceed immediately to surgical evacuation if:

• Confirmed fetal demise (missed abortion) 1, 2
• Active heavy bleeding or hemorrhage 3, 1
• Clinical signs of infection (see below) 3, 1
• Hemodynamic instability 4
• Pre-existing coagulopathy 4

Critical Infection Recognition and Management

Do not wait for fever to diagnose infection—clinical deterioration can be rapid:

• Median time from membrane rupture to infection: 5 days 7, 2
• Median time from infection identification to death: 18 hours 7, 2

Signs of infection requiring immediate action:

• Maternal tachycardia 3, 1
• Purulent cervical discharge 3, 1
• Uterine tenderness 3, 1
• Fetal tachycardia (if fetus still viable) 3

If infection suspected:

• Initiate broad-spectrum antibiotics immediately 3, 1
• Proceed with urgent surgical evacuation without delay 3, 1
• Do not wait for fever, amniocentesis results, or other confirmatory tests 1

Essential Preventive Measures

Rh Immunoprophylaxis (Critical—Never Omit)

All Rh-negative women must receive anti-D immunoglobulin:

• Dose: 50 mcg (50 μg) for incomplete or complete abortion 3, 1, 2
• Rationale: 32% of spontaneous abortions present with fetomaternal hemorrhage 1, 7, 2
• Administer regardless of management method chosen 3, 1, 2

Antibiotic Prophylaxis

• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 2
• Risk of infection increases significantly after 18 hours of ruptured membranes 2

Common Pitfalls to Avoid

1. Misdiagnosis of ectopic pregnancy as incomplete abortion—always perform careful ultrasound evaluation with visualization of adnexa 3, 1, 2

2. Failing to administer Rh immunoglobulin to Rh-negative women—this is mandatory regardless of management approach 3, 1, 7, 2

3. Underestimating infection risk with expectant management, especially after membrane rupture—infection can progress to sepsis within hours 3, 7, 2

4. Multiple or aggressive curettage procedures—increases risk of Asherman syndrome (intrauterine adhesions) 1, 7, 2

5. Delaying definitive treatment when infection is suspected—do not wait for fever or laboratory confirmation 3, 1

Post-Management Care

Immediate post-procedure:

• Contraceptive counseling immediately—ovulation can resume within 2-4 weeks post-abortion 1, 2
• Combined hormonal contraceptives or implants can be initiated immediately without waiting for next menses 1, 2
• If starting contraception within 7 days of abortion, no backup contraception needed 1, 2

Follow-up monitoring:

• Clinical follow-up to confirm complete resolution 1, 2
• Monitor for signs of infection: fever, foul-smelling discharge, worsening pain 2, 4
• Psychological support as needed 8

Algorithm for Treatment Selection

Step 1: Assess for absolute contraindications to expectant/medical management

• Heavy bleeding → Surgical evacuation
• Signs of infection → Antibiotics + urgent surgical evacuation
• Hemodynamic instability → Surgical evacuation
• Coagulopathy → Surgical evacuation

Step 2: If no contraindications, offer patient choice based on:

• Surgical evacuation: Lowest complication rates (9.1% hemorrhage, 1.3% infection), immediate resolution, requires anesthesia 1, 2, 4
• Medical management: High success (81-95%), outpatient-based, more side effects (nausea, cramping), 5-20% require subsequent surgery 1, 4, 5
• Expectant management: Only for incomplete abortion with minimal bleeding; high morbidity (60%) makes this generally inadvisable 3, 1, 2

Step 3: Ensure Rh immunoprophylaxis for all Rh-negative women 3, 1, 2