Three weeks after a miscarriage I am still passing red, dark‑red and pink tissue when I urinate; serum β‑human chorionic gonadotropin (β‑hCG) is 6 IU/L, endometrial thickness is 8 mm and home pregnancy test is negative – what is the appropriate next management?

Your Symptoms Are Consistent with Normal Post-Miscarriage Healing

With an hCG of 6 IU/L, an 8 mm endometrial lining, and a negative pregnancy test three weeks after miscarriage, your ongoing spotting and tissue passage represent normal uterine healing rather than retained products of conception, and you can continue expectant management with close monitoring for warning signs. 1

Why Your Current Findings Are Reassuring

Normal endometrial healing after miscarriage:

• An endometrial thickness of 8 mm is well below the threshold that raises concern for retained products of conception (RPOC), which typically requires thickness ≥20–25 mm to be considered suspicious 1
• Endometrial thickness up to 20–25 mm in the early post-miscarriage period is considered nonspecific and does not by itself indicate RPOC 1
• The shedding of residual endometrial tissue at approximately 8 mm thickness is a normal component of uterine healing after miscarriage 1

Your hCG pattern confirms resolution:

• An hCG level of 6 IU/L with a negative home pregnancy test indicates near-complete clearance of trophoblastic tissue 1, 2
• Serial quantitative β-hCG measurements should demonstrate progressive decline to undetectable levels following complete miscarriage, which your case demonstrates 1
• Most standard urine pregnancy tests become negative within 2 weeks after miscarriage, and your negative test at 3 weeks is consistent with normal resolution 2

What the Bleeding and Tissue Represent

Sources of ongoing spotting:

• Intermittent bleeding arises from the placental implantation site as it remodels and heals after tissue expulsion 1
• Ongoing uterine involution involves gradual breakdown and expulsion of the endometrial lining, which can produce spotting for several weeks 1
• The red, dark red, and pink tissue you're seeing when urinating represents normal sloughing of the healing endometrial lining, not retained pregnancy tissue 1

Ultrasound Findings That Would Indicate RPOC (Which You Don't Have)

You would need these specific findings to diagnose RPOC:

• An echogenic endometrial mass with Doppler-detected vascularity (blood flow within the tissue) 1
• Focal endometrial thickening accompanied by blood flow on Doppler imaging 1
• A discrete, identifiable mass rather than diffuse, uniform thickening 1

Your 8 mm uniform lining does not meet any of these criteria 1

When to Seek Immediate Evaluation

Return for urgent assessment if you develop:

• Heavy vaginal bleeding (soaking more than one pad per hour for ≥2 consecutive hours) 1
• Fever ≥38°C (100.4°F) or foul-smelling vaginal discharge suggesting infection 1
• Hemodynamic instability such as dizziness, syncope, or orthostatic symptoms 1
• Severe or worsening abdominal pain 1

Red Flags for Gestational Trophoblastic Disease (Extremely Unlikely in Your Case)

These hCG patterns would require immediate evaluation:

• Plateau of quantitative serum hCG over 3–4 consecutive weekly measurements 1
• Rising hCG >10% across three values within 2 weeks 1
• Persistence of detectable hCG for ≥6 months after pregnancy loss 1

Your declining hCG to 6 IU/L excludes these concerns 1

When Dilation and Curettage Would Be Indicated (Not Your Situation)

Surgery should be reserved for:

• Heavy bleeding requiring transfusion 1
• Confirmed vascular RPOC on Doppler ultrasound 1
• Persistent or rising hCG levels 1

None of these apply to your case 1

Recommended Follow-Up Plan

Continue expectant management with:

• No further intervention needed if bleeding remains light to moderate 1, 3
• Expect spotting to gradually decrease over the next 2–4 weeks as the endometrial lining completes healing 1
• One repeat hCG measurement in 1–2 weeks to confirm continued decline toward zero can provide additional reassurance, though it is not mandatory given your current level of 6 IU/L 1

Common pitfall to avoid:

• Do not diagnose retained products of conception solely on endometrial thickness <20 mm; an 8 mm stripe is normal after miscarriage and does not warrant intervention 1

Why Your Case Does Not Require Surgery

Research evidence demonstrates that expectant management is safe and effective for post-miscarriage care when clinical parameters are reassuring 4, 3. In studies comparing medical treatment, expectant care, and surgical evacuation, expectant management showed high success rates with minimal complications when patients were appropriately selected 3. Your declining hCG, thin endometrial lining, and absence of heavy bleeding or fever make you an ideal candidate for continued expectant management 1, 3.