Completed Miscarriage – No Further Intervention Required
Your clinical picture—empty uterus on ultrasound, endometrial thickness of 8 mm, β-hCG of 6 mIU/mL 2.5 weeks after passing the sac, and now moderate bleeding 25–28 days later—is consistent with a completed miscarriage that is resolving spontaneously, and no surgical or medical intervention is indicated at this time. 1, 2
Why This Is a Completed Miscarriage
Empty uterus on ultrasound: The Society of Radiologists in Ultrasound 2025 consensus defines "completed early pregnancy loss" as an empty uterine cavity or no intracavitary tissue following expulsion of the gestational sac. 1
β-hCG of 6 mIU/mL: This level is essentially at the threshold of detection (<5 mIU/mL is considered non-pregnant), confirming that trophoblastic tissue has been cleared and the pregnancy has resolved. 2, 3
Endometrial thickness of 8 mm: This measurement is within the normal range for post-miscarriage endometrium and does not indicate retained products of conception (RPOC). The guideline threshold for concern is typically ≥14 mm with vascularity, which you do not meet. 1
Timeline: Three weeks (21 days) after passing the sac is sufficient time for β-hCG to decline to near-zero in a completed miscarriage. Research shows that β-hCG declines 60–84% by day 7 depending on the initial level, and by 2.5 weeks, levels should be undetectable or minimal. 4
The Moderate Bleeding at 25–28 Days Is Expected
Post-miscarriage menstruation: Ovulation typically resumes 2–4 weeks after a completed miscarriage, meaning the bleeding you are experiencing 25–28 days after passing the sac is likely your first menstrual period following the pregnancy loss. 2
Transient endometrial shedding: Even after a completed miscarriage, the endometrium may shed irregularly as hormonal levels normalize. An 8 mm lining is consistent with proliferative or early secretory endometrium that can bleed as estrogen and progesterone levels fluctuate. 1
Not retained products: The combination of an empty uterus, β-hCG of 6 mIU/mL, and absence of significant endometrial thickening (≥14 mm) or vascularity rules out RPOC. 1, 2
Why No Intervention Is Needed
Expectant management is appropriate: The American College of Obstetricians and Gynecologists supports expectant management for completed miscarriage when the uterus is empty, β-hCG is declining to undetectable levels, and the patient is hemodynamically stable. 2, 5
Surgical evacuation is not indicated: Dilation and curettage (D&C) or manual vacuum aspiration (MVA) is reserved for incomplete miscarriage with retained tissue, heavy bleeding causing hemodynamic instability, or signs of infection—none of which apply to your case. 2
Medical management (misoprostol) is not indicated: Misoprostol is used to expel retained products when the uterus is not empty or β-hCG is not declining appropriately. Your β-hCG of 6 mIU/mL confirms complete clearance. 2
What to Monitor and When to Seek Care
Expected resolution: The moderate bleeding should taper over 3–7 days, similar to a normal menstrual period. If bleeding becomes heavier than a normal period or persists beyond 7–10 days, contact your provider. 2
Signs of infection: Fever (≥38°C/100.4°F), foul-smelling discharge, severe pelvic pain, or uterine tenderness would indicate endometritis or retained infected tissue and require urgent evaluation with antibiotics and possible surgical evacuation. 2
Persistent or rising β-hCG: If you have ongoing symptoms or bleeding beyond 2 weeks, repeat β-hCG to confirm it has reached <5 mIU/mL. A plateau or rise would suggest retained trophoblastic tissue or, rarely, gestational trophoblastic neoplasia, but this is extremely unlikely given your current level of 6 mIU/mL. 2, 3
Heavy bleeding with hemodynamic instability: Soaking through more than 2 pads per hour for 2 consecutive hours, dizziness, syncope, or tachycardia requires immediate emergency evaluation for possible hemorrhage. 2
Contraception and Follow-Up
Ovulation resumes quickly: You can ovulate as early as 2–4 weeks after a completed miscarriage, so if you wish to avoid pregnancy, start contraception immediately. Combined hormonal contraceptives or implants can be initiated now without waiting for your next menses. 2
No routine follow-up ultrasound or β-hCG needed: Given your empty uterus, β-hCG of 6 mIU/mL, and stable clinical status, no further imaging or hormonal monitoring is required unless symptoms worsen. 2, 5
Rh immunoglobulin: If you are Rh-negative, you should have received 50 μg of anti-D immunoglobulin at the time of the miscarriage to prevent alloimmunization. If you did not receive it, contact your provider, though the window for administration is typically within 72 hours of the event. 2
Critical Pitfall to Avoid
- Do not confuse post-miscarriage menstruation with incomplete miscarriage: The presence of moderate bleeding 25–28 days after passing the sac, in the context of an empty uterus and β-hCG of 6 mIU/mL, is not a sign of retained products. Unnecessary surgical intervention (D&C) in this setting risks complications such as Asherman syndrome (intrauterine adhesions), infection, and uterine perforation. 2