What is the recommended management for a [AGE]-year-old female with a confirmed miscarriage, presenting with vaginal pressure, stomach pains, and a history of heavy vaginal bleeding, hyperprolactinemia, and possible pituitary adenoma, who is experiencing persistent symptoms after an emergency room visit?

Management of Confirmed Miscarriage with Persistent Symptoms

This patient requires pain management with NSAIDs or opioids if needed, close monitoring for retained products of conception, and urgent follow-up within 24-48 hours to assess for complications given her persistent symptoms and history of heavy bleeding. 1

Immediate Pain Management

Prescribe adequate analgesia for her ongoing abdominal pain and cramping. Options include:

• NSAIDs (ibuprofen 600-800mg every 6-8 hours) as first-line therapy for post-miscarriage pain 1
• Acetaminophen with codeine or hydrocodone for moderate to severe pain not controlled by NSAIDs alone 1
• Avoid aspirin due to antiplatelet effects that could worsen bleeding 1

The patient's current pain (described as "stomach pains" and "pressure in vaginal area") warrants prescription-strength analgesia, particularly given she required 30 pad changes over 3 days during the acute bleeding phase. 1

Assessment for Retained Products of Conception

Her persistent vaginal pressure and sensation of "still miscarrying" raise concern for retained products of conception (RPOC), which occurs in a significant proportion of miscarriages and can lead to infection or hemorrhage. 2

Key warning signs she should monitor:

• Heavy bleeding requiring pad changes more frequently than every hour 1
• Fever >100.4°F, which suggests endometritis 2
• Worsening abdominal pain despite analgesia 1
• Foul-smelling vaginal discharge 2

Mandatory Follow-Up Plan

Schedule follow-up within 24-48 hours (not weeks) given her persistent symptoms. 1, 3 This is critical because:

• The ER confirmed miscarriage but did not provide clear follow-up instructions
• She has ongoing symptoms suggesting incomplete evacuation
• Her history of 5 prior miscarriages places her at higher risk for complications 1

At follow-up, she needs:

• Pelvic ultrasound to evaluate for RPOC if symptoms persist or worsen 2
• Repeat quantitative β-hCG to ensure appropriate decline (should drop by at least 50% every 48 hours post-miscarriage) 1
• Physical examination including speculum exam to assess cervical os closure and bleeding source 1

Critical Pitfall to Avoid

Do not assume the miscarriage is "complete" based solely on ER evaluation and negative pregnancy test. 1 A negative urine pregnancy test does not exclude RPOC, as β-hCG levels may have dropped below detection threshold while tissue remains. Persistent symptoms warrant imaging. 2

Rh Status Consideration

If she is Rh-negative and has not received RhoGAM, administer 50 μg anti-D immunoglobulin immediately (within 72 hours of bleeding onset is ideal, but can be given up to 28 days). 2 This prevents alloimmunization that could affect future pregnancies—particularly critical given her desire for future fertility and history of 5 prior miscarriages. 2

Addressing the Pituitary Adenoma

While not immediately life-threatening, her untreated hyperprolactinemia and possible pituitary adenoma require urgent outpatient follow-up after the acute miscarriage management is complete. 4, 5 Prolactinomas are a common cause of recurrent pregnancy loss and infertility. 5, 6 However, this should not delay her acute miscarriage care. 1

Request the MRI records from the outside facility showing the "frontal lobe mass" to determine if this is actually a pituitary adenoma (which would be in the sella turcica, not frontal lobe). 5

Specific Discharge Instructions

Instruct her to return immediately for:

• Soaking through more than 1 pad per hour for 2 consecutive hours 1
• Fever ≥100.4°F 2
• Severe abdominal pain not relieved by prescribed medications 1
• Dizziness, lightheadedness, or syncope (signs of hemorrhage) 1, 3
• Passage of large tissue or clots 7