Page 1 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements. Next Review: March 2023 NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library. 1. MANAGEMENT OF THREATENED MISCARRIAGE – where a patient presents with pain and /or bleeding with a known viable intrauterine pregnancy under 16/40 gestation but the cervical os remains closed, she will be offered scan to check for the viability of the pregnancy as soon as practical / possible in keeping with the current COVID crisis. a. If an ultrasound scan confirms an intrauterine viable fetus (with a heartbeat) then the patient can be reassured and advised that if her bleeding gets worse she should ring for advice. If the patient’s bleeding stops, she can resume routine antenatal care 1 . b. Advise the patient to book with the community midwife and a discharge letter should be written for the patient and GP c. If bleeding occurs over 12 weeks of gestation or occurs on more than one occasion at 11+/40weeks, Anti-D prophylaxis needs to be considered, please refer to the Trust guideline. * Miscarriage UHL Gynaecology Guideline Trust Reference C30/2013 1. Introduction and Who Guideline applies to The aim of this guideline is to advise practitioners of the benefits and risks of all of the methods of managing women with missed/ incomplete/threatened miscarriage to give them the facts needed to assist in their decision-making. Related UHL Documents: ➢ Gynaecology: Management of Pregnancy of Unknown Location and Ectopic Pregnancy ➢ Imaging Reporting Guidelines in Gynaecology ➢ Imaging Referral Guidelines in Gynaecology ➢ Anti D immunoglobulin UHL Obstetric Guideline ➢ Sensitive Disposal of Fetal Remains Background / Introduction There are three management options for Miscarriage. 1. Expectant or Conservative 2. Medical Evacuation of Retained Products of Conception (MERPC) 3. Surgical Evacuation of Retained products of Conception (SERPC) or Manual vacuum aspiration (MVA) 2. Guideline Standards and Procedures
Miscarriage UHL Gynaecology Guideline
Oct 11, 2022
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Guidelines for prophylaxis against thromboembolic disease following caesarean sectionPage 1 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
1. MANAGEMENT OF THREATENED MISCARRIAGE – where a patient presents with
pain and /or bleeding with a known viable intrauterine pregnancy under 16/40 gestation but the
cervical os remains closed, she will be offered scan to check for the viability of the pregnancy
as soon as practical / possible in keeping with the current COVID crisis.
a. If an ultrasound scan confirms an intrauterine viable fetus (with a heartbeat) then the
patient can be reassured and advised that if her bleeding gets worse she should ring for
advice. If the patient’s bleeding stops, she can resume routine antenatal care1.
b. Advise the patient to book with the community midwife and a discharge letter should
be written for the patient and GP
c. If bleeding occurs over 12 weeks of gestation or occurs on more than one occasion at
11+/40weeks, Anti-D prophylaxis needs to be considered, please refer to the Trust
guideline. *
1. Introduction and Who Guideline applies to
The aim of this guideline is to advise practitioners of the benefits and risks of all of the methods of managing women with missed/ incomplete/threatened miscarriage to give them the facts needed to assist in their decision-making.
Related UHL Documents:
Gynaecology: Management of Pregnancy of Unknown Location and Ectopic Pregnancy
Imaging Reporting Guidelines in Gynaecology Imaging Referral Guidelines in Gynaecology Anti D immunoglobulin UHL Obstetric Guideline Sensitive Disposal of Fetal Remains
Background / Introduction
There are three management options for Miscarriage. 1. Expectant or Conservative 2. Medical Evacuation of Retained Products of Conception (MERPC) 3. Surgical Evacuation of Retained products of Conception (SERPC) or Manual
vacuum aspiration (MVA)
2. Guideline Standards and Procedures
Page 2 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
3. MANAGEMENT OF MISSED MISCARRIAGE – where a woman presents with no or minimal
symptoms and is found to have a missed miscarriage under 16/40 gestation, expectant
management is recommended for the first 7-14 days unless there is increased risk of
bleeding/infection/previous bad experience. Following this she may be offered further medical or
surgical management depending on clinical circumstances and woman’s choice.
4. MANAGEMENT OF RPOC / INCOMPLETE MISCARRIAGE – where a woman presents
with continued bleeding after 3 weeks of miscarriage or heavy bleeding +/- continued pain,
incomplete miscarriage and or endometritis may be suspected. Clinical assessment and stabilisation
will include
b. Assessment of the amount of bleeding and pain
c. Urine pregnancy test
d. USS where diagnosis is uncertain, along with serial serum hCG levels if ectopic pregnancy has
not been excluded
e. If attending in person: Speculum examination and removal of any products of conception, if
unwell consider IV fluids, 2 x G&S, FBC, clotting screen, lactate, CRP and blood cultures if
infection suspected
Expectant / Medical / Surgical ERPC or MVA (manual vacuum aspiration)
2. MANAGEMENT OF INEVITABLE MISCARRIAGE – where a woman presents with pain and
/or bleeding under 16/40 gestation and the cervical os is open, assess and inform sensitively that she
will miscarry / is miscarrying the pregnancy. Where products of conception are seen at the cervix they
should be removed gently with sponge holding forceps. Further management should be individualised
and the need for Anti-D assessed. Products of conception are disposed following local policy on
sensitive disposal of fetal remains.
IF TISSUES ARE SEEN IN THE CERVICAL OS, REMOVAL WITH SPONGE HOLDING
FORCEPS IF SAFE. If left, the woman may go into cervical shock, become bradycardic and
hypotensive or even have a cardiac arrest.
Where a woman is actively miscarrying and bleeding consider 2x G&S, FBC, Clotting screen,
Sickle cell screen (if reqd); IV access and IV fluid resuscitation; it may be appropriate to give
Ergometrine, Syntometrine or Misoprostol or even perform an emergency surgical
ERPC/MVA. Medical support should be urgently sought from a Registrar or above.
Page 3 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
5. EXPECTANT MANAGEMENT OF INCOMPLETE/MISSED MISCARRIAGE
Expectant management -involves passage of products of conception naturally.
Success rate is 79 to 96% following an incomplete miscarriage, 62% after a missed miscarriage after
2weeks and 81% after 4 weeks.
Criteria
• No evidence of infection
• No pre-existing conditions that increase her risk of bleeding. e.g. coagulopathies or Jehovah’s
witness
• Woman’s choice after full information provision of other options
Instructions
• Inform woman that she would experience pain and bleeding during the expectant management
period of 7-14 days
• Give information leaflet
• Advise woman to contact GAU/EPAU if there is excessive pain or bleeding
Follow up
• If pain and bleeding have not started within 7-14 days but she wishes to continue expectant management arrange further follow up (by telephone or in person) in 2 weeks.
• If pain and bleeding resolve during 7-14 days of expectant management, advise woman to
take a home urine pregnancy test after 3 weeks from miscarriage and call EPAU with the
result. If pregnancy test (PT) is negative, bleeding is settled and woman is feeling well,
she can be discharged.
• Review in EPAU for rescan ONLY if PT remains positive or clinically indicated
(persistent pain or bleeding).
• If there is continued presence of products of conception offer medical or surgical management.
• If any evidence of infection, plan surgical procedure after giving broad spectrum antibiotics.
• Offer medical or surgical treatment if there is no response in maximum 4 weeks of expectant
management.
Page 4 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
6. OUTPATIENT MANAGEMENT FOR INCOMPLETE MISCARRIAGE WITH AP
DIAMETER 20-50MM INTRAUTERINE TISSUE
NHS Consent form 1
FBC, G&S if bleeding moderate to heavy and concerned about Hb
Dose
• Single buccal/sublingual or vaginal dose of Misoprostol 800 microgram if haemodynamically stable and not in too much pain and/or not bleeding too heavily.
• Medication either self-administered at home or if in the hospital can be observed for an
hour and sent home and advise for a competent adult to stay with her.
Instructions
• Inform woman what to expect when she goes home i.e. about pain and bleeding
• Discuss side effects of misoprostol: nausea, vomiting, diarrhoea and rise in temperature
• Inform/prescribe pain relief and antiemetic to take home
• Provide leaflets, open access to GAU/EPAU
Follow up
• GAU/EPAU staff to ring woman after a week of treatment to assess if miscarriage
completed or not; if not, arrange follow up with ultrasound scan in 7-10 days from taking
medical treatment.
• If miscarriage completed, woman should take a home urine pregnancy test 3 weeks after
miscarriage and call EPAU with the result. If pregnancy test (PT) is negative, bleeding settled and woman is feeling well, she can be discharged.
• Review in EPAU for rescan ONLY if PT remains positive or clinically indicated
(prolonged bleeding /pain).
• Advise that next period may be heavier than usual.
Page 5 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
7. OUTPATIENT MANAGEMENT FOR MISSED MISCARRIAGE FOR
PREGNANCY ≤ 10 WEEKS GESTATION BY ULTRASOUND SCAN
Criteria
• Gestational age 10+0weeks or less by ultrasound scan (Mean sac diameter is ≤45mm or CRL is ≤32mm)
• Not more than one previous caesarean section
• Haemodynamically stable and not anaemic
• No suggestion of molar pregnancy on scan
• No co-morbidities of cardiac dysfunction, bleeding disorders, Jehovah’s witness or anticoagulation therapy
• No contraindication to misoprostol (severe asthma, inherited porphyria and adrenal failure) or mifepristone if prescribed.
• Discuss with a Consultant as treatment needs to be individualised taking into
consideration age, demographics and ability of the woman to cope at home.
NHS Consent form 1
• Single buccal/sublingual or vaginal dose of Misoprostol 800 microgram followed
by misoprostol 400 microgram by the same route of administration (buccal/sublingual or vaginal).
• Medication either self-administered at home or if in the hospital can be observed for
an hour and sent home and advise for a competent adult to stay with her.
Instructions
• Inform woman what to expect: length and extent of bleeding and pain
• Discuss side effects of misoprostol: nausea, vomiting, diarrhoea and rise in temperature
• Inform/prescribe pain relief and antiemetic to take home
• Provide leaflets, open access to GAU / EPAU
• If excessive bleeding or pain, patient should contact GAU
• If bleeding does not start within 24h, patient should contact GAU/EPAU for individualised care. Recommended options would include a further dose
of Misoprostol 800 microgram or consideration of SERPC/MVA or repeated complete
cycle preceded by Mifepristone PO 200mg
Follow up
Woman should take a home urine pregnancy test 3 weeks after miscarriage and call EPAU
with the result. If pregnancy test (PT) is negative, bleeding settled and woman is feeling well,
she can be discharged.
Review in EPAU for rescan ONLY if PT remains positive or clinically indicated
(prolonged bleeding /pain).
Advise that next period may be heavier than usual.
Page 6 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
8. SURGICAL MANAGEMENT
Surgical ERPC under GA or Manual Vacuum Aspiration under local anaesthetic in an
outpatient setting to prevent exposure to GA (especially with COVID crisis)
Criteria SERPC
• Less than 12+6 weeks size fetus or sac on scan.
• Clinically unstable- heavy bleeding, tachycardia or hypotension. Start resuscitation and
proceed for urgent surgical management as appropriate.
• Evidence of infection– procedure must be covered with antibiotics 12-24 hrs preoperatively
unless too unstable/septic. Consider USS guided SERPC.
• Suggestion of molar pregnancy on ultrasound scan- avoid use of oxytocics if possible
• Pre-existing conditions that increase her risk of bleeding. e.g. coagulopathies or cannot have
blood transfusion.
Consent
• NHS Consent form 1 and sensitive disposal of fetal remains form.
Procedure
• Cervical preparation: Misoprostol 400 micrograms PV/buccal/sublingual if not contraindicated-
administered an hour prior to the procedure (Not required for urgent ERPC) The patient should be
warned that if the procedure is delayed for any reason, the pregnancy tissue may begin to pass and
therefore an inadvertent medical treatment may ensue.
Follow up
• Anti-D as per Rhesus status.
Criteria MVA
• Management of retained products of conception (50 mm or below) and missed miscarriage (up
to 10+0 weeks gestation).
• Failed medical or surgical management of miscarriage up to 10 weeks gestation.
Contraindications to MVA
• Allergy to local anaesthetic drugs or contraindication to the use of misoprostol
• Haemorrhagic disorders (prolonged bleeding time) and those on anticoagulants
• Anaemia (Haematocrit <30; Hb <100g/L)
• Panic attacks, excessive anxiety
Sepsis
• Postnatal retained products of conception
Page 7 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
9. Anti D Immunoglobulin
situations:
• Surgical management of miscarriage.
• For threatened miscarriage under 12 weeks gestation when bleeding is heavy or associated
with pain.
• Recurrent bleeding episodes (2 bleeds a week apart) in any woman (even if gestational age is
<12 weeks) undergoing miscarriage/medical management
Anti-D not required for cases of:
• Expectant management of miscarriage or ectopic pregnancy (under 12 weeks gestation) (NICE
2013).
• Medical management of miscarriage or ectopic pregnancy (under 12 weeks gestation) (NICE
2013).
• Complete miscarriage under 12 weeks of gestation with no intervention.
Discharge documentation should clearly state whether or not anti-D was required/given.
Page 8 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
Definition of Missed / Delayed Miscarriage: A transvaginal ultrasound scan diagnosis of absence of fetal heart pulsations where
the Crown-Rump Length (CRL) is ≥7mm or in the absence of a fetal pole (FP), where the Mean Sac Diameter (MSD) is ≥25mm. Ideally this should be confirmed with second opinion.
Where CRL is <7mm or MSD is <25mm, a repeat scan should be done and the interval between scans must not be less than 7-10 days. This repeat scan showing no growth from previous scan and no fetal heart pulsations can confirm diagnosis of missed miscarriage. Deviation from this interval must be discussed with the consultant
miscarriage. Deviation from this interval must be discussed with the consultant
Transvaginal scan First scan:
Not yet 7-10 days
Yes, since it’s a second repeat scan to confirm miscarriage. If viable pregnancy, 2nd opinion not required.
CRL ≥7mm and no fetal heart pulsations or MSD (no FP) ≥25mm in absence of fetal pole
Need a second opinion to confirm viability and document findings AND/OR offer repeat scan if woman requesting
7-10 days
Yes, always
Offer treatment: Rescan Second opinion at rescan
If no fetal heart noted, measure CRL and document followed by repeat scan
Not yet 14 days Yes, if it’s a second repeat scan to confirm miscarriage. If viable pregnancy, 2nd opinion not required.
If no fetal pole seen, measure gestational sac diameter and document followed by repeat scan
Not yet 14 days Yes, if it’s a second repeat scan to confirm miscarriage. If viable pregnancy, 2nd opinion not required.
Women must always be offered a further scan at the specified intervals to confirm the absence of fetal heart at all gestations/CRL measurements but this is to be
encouraged before commencing any treatment for missed miscarriage.
If scan done in private sector reports missed miscarriage, repeat Trust scan should be performed and diagnosis confirmed before offering treatment.
Page 9 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
Differential Diagnosis of Prolonged or excessive bleeding after miscarriage:
• Incomplete Miscarriage Retained Products of Conception (RPOC) refers to fetal or placental tissue which remains in the uterus following either pregnancy loss or termination. The presence of RPOC defines incomplete miscarriage.
• Endometritis - with or without concurrent RPOC. If a woman was clinically unstable (tachycadic/hypotensive/pyrexial) she needs admission and intravenous/intramuscular antibiotic therapy, IV Fluids +/- blood products supportive therapy and urgent senior assessment. She may also require SERPC with consideration for USS guidance.The timing of surgery will be decided by the Senior Registrar or Consultant on-call, ideally after 12-24h IV Abx unless the degree of sepsis precludes this.
• Gestational trophoblastic disease – may follow any pregnancy. Consider symptoms of metastatic GTD (e.g. abnormal bleeding, chest: haemoptysis, Dry cough, SOB / chest pain, vaginal mass, focal neurological symptoms). A negative urinary pregnancy test and serum hCG effectively excludes GTD.
• AV Malformation – very rare, diagnosed on USS. Refer to interventional radiology for MRI and consideration of embolization.
• Heterotopic pregnancy – to be considered if history of clomifene for ovulation
induction and /or assisted conception treatment
Page 10 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
Ultrasound Diagnosis of Incomplete Miscarriage
Endometrial thickness OR AP diameter 20mm - The patient will most likely be
successfully managed conservatively4,10.
Any “RPOC” < 20mm are unlikely to be clinically significant but take symptoms into account
Diagnosed as “Complete miscarriage” ¹only if previous USS showed IUP or Products of conception have been seen. Advise to report if bleeding persists longer than 3/52, is very heavy or pt. unwell. GP follow up if well. A pregnancy test should be performed in 3/52 and call EPAU with result If no previous scan showing IUP or no definite POC passed and sent for histology – exclude ectopic…
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
1. MANAGEMENT OF THREATENED MISCARRIAGE – where a patient presents with
pain and /or bleeding with a known viable intrauterine pregnancy under 16/40 gestation but the
cervical os remains closed, she will be offered scan to check for the viability of the pregnancy
as soon as practical / possible in keeping with the current COVID crisis.
a. If an ultrasound scan confirms an intrauterine viable fetus (with a heartbeat) then the
patient can be reassured and advised that if her bleeding gets worse she should ring for
advice. If the patient’s bleeding stops, she can resume routine antenatal care1.
b. Advise the patient to book with the community midwife and a discharge letter should
be written for the patient and GP
c. If bleeding occurs over 12 weeks of gestation or occurs on more than one occasion at
11+/40weeks, Anti-D prophylaxis needs to be considered, please refer to the Trust
guideline. *
1. Introduction and Who Guideline applies to
The aim of this guideline is to advise practitioners of the benefits and risks of all of the methods of managing women with missed/ incomplete/threatened miscarriage to give them the facts needed to assist in their decision-making.
Related UHL Documents:
Gynaecology: Management of Pregnancy of Unknown Location and Ectopic Pregnancy
Imaging Reporting Guidelines in Gynaecology Imaging Referral Guidelines in Gynaecology Anti D immunoglobulin UHL Obstetric Guideline Sensitive Disposal of Fetal Remains
Background / Introduction
There are three management options for Miscarriage. 1. Expectant or Conservative 2. Medical Evacuation of Retained Products of Conception (MERPC) 3. Surgical Evacuation of Retained products of Conception (SERPC) or Manual
vacuum aspiration (MVA)
2. Guideline Standards and Procedures
Page 2 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
3. MANAGEMENT OF MISSED MISCARRIAGE – where a woman presents with no or minimal
symptoms and is found to have a missed miscarriage under 16/40 gestation, expectant
management is recommended for the first 7-14 days unless there is increased risk of
bleeding/infection/previous bad experience. Following this she may be offered further medical or
surgical management depending on clinical circumstances and woman’s choice.
4. MANAGEMENT OF RPOC / INCOMPLETE MISCARRIAGE – where a woman presents
with continued bleeding after 3 weeks of miscarriage or heavy bleeding +/- continued pain,
incomplete miscarriage and or endometritis may be suspected. Clinical assessment and stabilisation
will include
b. Assessment of the amount of bleeding and pain
c. Urine pregnancy test
d. USS where diagnosis is uncertain, along with serial serum hCG levels if ectopic pregnancy has
not been excluded
e. If attending in person: Speculum examination and removal of any products of conception, if
unwell consider IV fluids, 2 x G&S, FBC, clotting screen, lactate, CRP and blood cultures if
infection suspected
Expectant / Medical / Surgical ERPC or MVA (manual vacuum aspiration)
2. MANAGEMENT OF INEVITABLE MISCARRIAGE – where a woman presents with pain and
/or bleeding under 16/40 gestation and the cervical os is open, assess and inform sensitively that she
will miscarry / is miscarrying the pregnancy. Where products of conception are seen at the cervix they
should be removed gently with sponge holding forceps. Further management should be individualised
and the need for Anti-D assessed. Products of conception are disposed following local policy on
sensitive disposal of fetal remains.
IF TISSUES ARE SEEN IN THE CERVICAL OS, REMOVAL WITH SPONGE HOLDING
FORCEPS IF SAFE. If left, the woman may go into cervical shock, become bradycardic and
hypotensive or even have a cardiac arrest.
Where a woman is actively miscarrying and bleeding consider 2x G&S, FBC, Clotting screen,
Sickle cell screen (if reqd); IV access and IV fluid resuscitation; it may be appropriate to give
Ergometrine, Syntometrine or Misoprostol or even perform an emergency surgical
ERPC/MVA. Medical support should be urgently sought from a Registrar or above.
Page 3 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
5. EXPECTANT MANAGEMENT OF INCOMPLETE/MISSED MISCARRIAGE
Expectant management -involves passage of products of conception naturally.
Success rate is 79 to 96% following an incomplete miscarriage, 62% after a missed miscarriage after
2weeks and 81% after 4 weeks.
Criteria
• No evidence of infection
• No pre-existing conditions that increase her risk of bleeding. e.g. coagulopathies or Jehovah’s
witness
• Woman’s choice after full information provision of other options
Instructions
• Inform woman that she would experience pain and bleeding during the expectant management
period of 7-14 days
• Give information leaflet
• Advise woman to contact GAU/EPAU if there is excessive pain or bleeding
Follow up
• If pain and bleeding have not started within 7-14 days but she wishes to continue expectant management arrange further follow up (by telephone or in person) in 2 weeks.
• If pain and bleeding resolve during 7-14 days of expectant management, advise woman to
take a home urine pregnancy test after 3 weeks from miscarriage and call EPAU with the
result. If pregnancy test (PT) is negative, bleeding is settled and woman is feeling well,
she can be discharged.
• Review in EPAU for rescan ONLY if PT remains positive or clinically indicated
(persistent pain or bleeding).
• If there is continued presence of products of conception offer medical or surgical management.
• If any evidence of infection, plan surgical procedure after giving broad spectrum antibiotics.
• Offer medical or surgical treatment if there is no response in maximum 4 weeks of expectant
management.
Page 4 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
6. OUTPATIENT MANAGEMENT FOR INCOMPLETE MISCARRIAGE WITH AP
DIAMETER 20-50MM INTRAUTERINE TISSUE
NHS Consent form 1
FBC, G&S if bleeding moderate to heavy and concerned about Hb
Dose
• Single buccal/sublingual or vaginal dose of Misoprostol 800 microgram if haemodynamically stable and not in too much pain and/or not bleeding too heavily.
• Medication either self-administered at home or if in the hospital can be observed for an
hour and sent home and advise for a competent adult to stay with her.
Instructions
• Inform woman what to expect when she goes home i.e. about pain and bleeding
• Discuss side effects of misoprostol: nausea, vomiting, diarrhoea and rise in temperature
• Inform/prescribe pain relief and antiemetic to take home
• Provide leaflets, open access to GAU/EPAU
Follow up
• GAU/EPAU staff to ring woman after a week of treatment to assess if miscarriage
completed or not; if not, arrange follow up with ultrasound scan in 7-10 days from taking
medical treatment.
• If miscarriage completed, woman should take a home urine pregnancy test 3 weeks after
miscarriage and call EPAU with the result. If pregnancy test (PT) is negative, bleeding settled and woman is feeling well, she can be discharged.
• Review in EPAU for rescan ONLY if PT remains positive or clinically indicated
(prolonged bleeding /pain).
• Advise that next period may be heavier than usual.
Page 5 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
7. OUTPATIENT MANAGEMENT FOR MISSED MISCARRIAGE FOR
PREGNANCY ≤ 10 WEEKS GESTATION BY ULTRASOUND SCAN
Criteria
• Gestational age 10+0weeks or less by ultrasound scan (Mean sac diameter is ≤45mm or CRL is ≤32mm)
• Not more than one previous caesarean section
• Haemodynamically stable and not anaemic
• No suggestion of molar pregnancy on scan
• No co-morbidities of cardiac dysfunction, bleeding disorders, Jehovah’s witness or anticoagulation therapy
• No contraindication to misoprostol (severe asthma, inherited porphyria and adrenal failure) or mifepristone if prescribed.
• Discuss with a Consultant as treatment needs to be individualised taking into
consideration age, demographics and ability of the woman to cope at home.
NHS Consent form 1
• Single buccal/sublingual or vaginal dose of Misoprostol 800 microgram followed
by misoprostol 400 microgram by the same route of administration (buccal/sublingual or vaginal).
• Medication either self-administered at home or if in the hospital can be observed for
an hour and sent home and advise for a competent adult to stay with her.
Instructions
• Inform woman what to expect: length and extent of bleeding and pain
• Discuss side effects of misoprostol: nausea, vomiting, diarrhoea and rise in temperature
• Inform/prescribe pain relief and antiemetic to take home
• Provide leaflets, open access to GAU / EPAU
• If excessive bleeding or pain, patient should contact GAU
• If bleeding does not start within 24h, patient should contact GAU/EPAU for individualised care. Recommended options would include a further dose
of Misoprostol 800 microgram or consideration of SERPC/MVA or repeated complete
cycle preceded by Mifepristone PO 200mg
Follow up
Woman should take a home urine pregnancy test 3 weeks after miscarriage and call EPAU
with the result. If pregnancy test (PT) is negative, bleeding settled and woman is feeling well,
she can be discharged.
Review in EPAU for rescan ONLY if PT remains positive or clinically indicated
(prolonged bleeding /pain).
Advise that next period may be heavier than usual.
Page 6 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
8. SURGICAL MANAGEMENT
Surgical ERPC under GA or Manual Vacuum Aspiration under local anaesthetic in an
outpatient setting to prevent exposure to GA (especially with COVID crisis)
Criteria SERPC
• Less than 12+6 weeks size fetus or sac on scan.
• Clinically unstable- heavy bleeding, tachycardia or hypotension. Start resuscitation and
proceed for urgent surgical management as appropriate.
• Evidence of infection– procedure must be covered with antibiotics 12-24 hrs preoperatively
unless too unstable/septic. Consider USS guided SERPC.
• Suggestion of molar pregnancy on ultrasound scan- avoid use of oxytocics if possible
• Pre-existing conditions that increase her risk of bleeding. e.g. coagulopathies or cannot have
blood transfusion.
Consent
• NHS Consent form 1 and sensitive disposal of fetal remains form.
Procedure
• Cervical preparation: Misoprostol 400 micrograms PV/buccal/sublingual if not contraindicated-
administered an hour prior to the procedure (Not required for urgent ERPC) The patient should be
warned that if the procedure is delayed for any reason, the pregnancy tissue may begin to pass and
therefore an inadvertent medical treatment may ensue.
Follow up
• Anti-D as per Rhesus status.
Criteria MVA
• Management of retained products of conception (50 mm or below) and missed miscarriage (up
to 10+0 weeks gestation).
• Failed medical or surgical management of miscarriage up to 10 weeks gestation.
Contraindications to MVA
• Allergy to local anaesthetic drugs or contraindication to the use of misoprostol
• Haemorrhagic disorders (prolonged bleeding time) and those on anticoagulants
• Anaemia (Haematocrit <30; Hb <100g/L)
• Panic attacks, excessive anxiety
Sepsis
• Postnatal retained products of conception
Page 7 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
9. Anti D Immunoglobulin
situations:
• Surgical management of miscarriage.
• For threatened miscarriage under 12 weeks gestation when bleeding is heavy or associated
with pain.
• Recurrent bleeding episodes (2 bleeds a week apart) in any woman (even if gestational age is
<12 weeks) undergoing miscarriage/medical management
Anti-D not required for cases of:
• Expectant management of miscarriage or ectopic pregnancy (under 12 weeks gestation) (NICE
2013).
• Medical management of miscarriage or ectopic pregnancy (under 12 weeks gestation) (NICE
2013).
• Complete miscarriage under 12 weeks of gestation with no intervention.
Discharge documentation should clearly state whether or not anti-D was required/given.
Page 8 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
Definition of Missed / Delayed Miscarriage: A transvaginal ultrasound scan diagnosis of absence of fetal heart pulsations where
the Crown-Rump Length (CRL) is ≥7mm or in the absence of a fetal pole (FP), where the Mean Sac Diameter (MSD) is ≥25mm. Ideally this should be confirmed with second opinion.
Where CRL is <7mm or MSD is <25mm, a repeat scan should be done and the interval between scans must not be less than 7-10 days. This repeat scan showing no growth from previous scan and no fetal heart pulsations can confirm diagnosis of missed miscarriage. Deviation from this interval must be discussed with the consultant
miscarriage. Deviation from this interval must be discussed with the consultant
Transvaginal scan First scan:
Not yet 7-10 days
Yes, since it’s a second repeat scan to confirm miscarriage. If viable pregnancy, 2nd opinion not required.
CRL ≥7mm and no fetal heart pulsations or MSD (no FP) ≥25mm in absence of fetal pole
Need a second opinion to confirm viability and document findings AND/OR offer repeat scan if woman requesting
7-10 days
Yes, always
Offer treatment: Rescan Second opinion at rescan
If no fetal heart noted, measure CRL and document followed by repeat scan
Not yet 14 days Yes, if it’s a second repeat scan to confirm miscarriage. If viable pregnancy, 2nd opinion not required.
If no fetal pole seen, measure gestational sac diameter and document followed by repeat scan
Not yet 14 days Yes, if it’s a second repeat scan to confirm miscarriage. If viable pregnancy, 2nd opinion not required.
Women must always be offered a further scan at the specified intervals to confirm the absence of fetal heart at all gestations/CRL measurements but this is to be
encouraged before commencing any treatment for missed miscarriage.
If scan done in private sector reports missed miscarriage, repeat Trust scan should be performed and diagnosis confirmed before offering treatment.
Page 9 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
Differential Diagnosis of Prolonged or excessive bleeding after miscarriage:
• Incomplete Miscarriage Retained Products of Conception (RPOC) refers to fetal or placental tissue which remains in the uterus following either pregnancy loss or termination. The presence of RPOC defines incomplete miscarriage.
• Endometritis - with or without concurrent RPOC. If a woman was clinically unstable (tachycadic/hypotensive/pyrexial) she needs admission and intravenous/intramuscular antibiotic therapy, IV Fluids +/- blood products supportive therapy and urgent senior assessment. She may also require SERPC with consideration for USS guidance.The timing of surgery will be decided by the Senior Registrar or Consultant on-call, ideally after 12-24h IV Abx unless the degree of sepsis precludes this.
• Gestational trophoblastic disease – may follow any pregnancy. Consider symptoms of metastatic GTD (e.g. abnormal bleeding, chest: haemoptysis, Dry cough, SOB / chest pain, vaginal mass, focal neurological symptoms). A negative urinary pregnancy test and serum hCG effectively excludes GTD.
• AV Malformation – very rare, diagnosed on USS. Refer to interventional radiology for MRI and consideration of embolization.
• Heterotopic pregnancy – to be considered if history of clomifene for ovulation
induction and /or assisted conception treatment
Page 10 of 18 Title: Miscarriage UHL Gynaecology Guideline -(including COVID 19 plan) Trust Ref No: C30/2013 Authors: Dr Victoria Timlin and Miss Olivia Barney – updated by Neelam Potdar, Olivia Barney and Raji Aravindan Approved by: Gynaecology Guidelines and Governance Group 6 Months Review Date Extension Approved by Director of CLA as Document Remains Fit for Purpose & Legislative Requirements.
Next Review: March 2023
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.
Ultrasound Diagnosis of Incomplete Miscarriage
Endometrial thickness OR AP diameter 20mm - The patient will most likely be
successfully managed conservatively4,10.
Any “RPOC” < 20mm are unlikely to be clinically significant but take symptoms into account
Diagnosed as “Complete miscarriage” ¹only if previous USS showed IUP or Products of conception have been seen. Advise to report if bleeding persists longer than 3/52, is very heavy or pt. unwell. GP follow up if well. A pregnancy test should be performed in 3/52 and call EPAU with result If no previous scan showing IUP or no definite POC passed and sent for histology – exclude ectopic…
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