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Emergency Gynaecology SSU_S.

Deb

Guidelines on Management of miscarriage

Title of Guideline (must include the word Guideline (not


protocol, policy, procedure etc)

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Guidelines on management of
miscarriage

Contact Name and Job Title (author)

Dr. Shilpa Deb


Consultant Obstetrician and Gynaecologist

Directorate & Speciality

Family Health
Obstetrics and Gynaecology

Date of submission

March 2013

Date on which guideline must be reviewed (this should be one to


three years)

March 2016

Explicit definition of patient group to which it applies (e.g.


inclusion and exclusion criteria, diagnosis)

Patients with an early pregnancy of 12 weeks

Abstract

This guideline is aimed at management of


women with an early pregnancy when the
location of pregnancy is not known.

Key Words

Ultrasound, early pregnancy, intra-uterine,


ectopic, hCG

Statement of the evidence base of the guideline has the


guideline been peer reviewed by colleagues?

Literature review, evidence ranging from 1 to 5.


Peer-reviewed by the risk management group

Consultation Process

Risk Management Group


Consultant Gynaecologists
Ward Sisters
Gynaecology Nurse Specialists
Practice Development Matron

Target audience

All the medical, nursing and admin staff involved


with emergency gynaecology

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The
interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If
in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review
date.

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Guidelines on Management of miscarriage

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Introduction
Miscarriageoccursin1020%ofclinicalpregnanciesandaccountsfor50000inpatientadmissionsto
Hospitals in the UK annually. The common clinical features include varying amounts of pain and
vaginal bleeding. At all times women should be supported in making informed choices about their
care and management. Adequate explanation supplemented with written information should be
giventoassistdecisionmaking.
Completemiscarriageisatermusedwhentheclinicalsignsandsymptomssuggestamiscarriageand
ultrasound scan confirms an endometrial thickness of less than 15 mm. There may be very little
pregnancytissuegivingbrightechoesoralargeamountofbloodshowingnoechogenicityatalland
thereforewomenshouldbeadvisedtoreportifbleedingcontinuedbeyond2weeks.
Incompletemiscarriageisatermusedwhentheclinicalsignsandsymptomssuggestamiscarriage
andultrasoundscanconfirmspresenceofproductsofconceptionwithevidenceofnonviability.
Missed miscarriage is a term used when there is no clinical feature of miscarriage however the
ultrasoundscanconfirmsabsenceofaviablepregnancy.
Women should be offered the choices of conservative, medical or surgical methods of miscarriage
management.Patientpreferenceisimportantandshouldbeacknowledgedasadeterminingfactorin
managementdecisions.
Conservative or expectant management involves passage of products of conception naturally and
thereforearescanshouldbearrangedin1014days.Thereisnodefinedtimelimitforthesuccessof
treatment,howeverotheroptionsbeconsideredifnoPOCsarepassedupto2weeksandwomans
condition reviewed. In the presence of infection, the treatment should be abandoned and surgical
managementbeconsidered.Aurinepregnancytestshouldbeadvised3weeksfollowingthepassage
ofproductstoestablishcompletionofprocess.Ifitisfoundtobepositive,anultrasoundscanshould

Emergency Gynaecology SSU_S.Deb

Guidelines on Management of miscarriage

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be performed. (NICE guideline CG154). Conservative management requires robust counselling and
supportforthetreatmenttosucceed.
Medical management involves administration of drugs to assist passage of POCs naturally. Anti
progesterone oral tablet, Mifepristone and prostaglandin analogue, Misoprostol as a vaginal tablet
are commonly used to achieve this. Recent NICE guideline (CG154) recommends that missed
miscarriageandincompletemiscarriagebetreatedwithmisoprostolalone.Asingledoseof800mcg
of misoprostol intravaginally is recommended. This can be managed as an outpatient procedure.
Woman should be advised that if bleeding has not started 24 hours after treatment, she should
contact the early pregnancy assessment unit and care be individualised. This may include re
administrationofmisoprostolorasurgicalmanagement.Allwomenshouldbeofferedpainreliefand
antiemetics. They should be counselled about the length and extent of bleeding and the potential
sideeffects of treatment including pain, diarrhoea and vomiting. A urine pregnancy test should be
advised3weeksfollowingthepassageofproductstoestablishcompletionofprocess.Ifitisfoundto
bepositive,anultrasoundscanshouldbeperformed.(NICEguidelineCG154)
Surgical management includes completion of miscarriage using vacuum aspiration. It is the most
successful treatment option however requires anaesthesia and carries a small risk of uterine
perforation. The advantages of prostaglandin administration prior to surgical abortion are well
established,withsignificantreductionsindilatationforce,haemorrhageanduterine/cervicaltrauma.
Theguidelinesbelowdetailthemanagementoptionsofmiscarriagealongwiththepathwaytofollow.
Recent research suggests that given interobserver variability in ultrasound measurements and the
greater variation in early embryonic growth than has hitherto been assumed, a more conservative
approachtothediagnosisofearlypregnancylossiswarranted.AnMSDcutoffof25mmandaCRL
cutoffof7mmcouldbeintroducedtominimizetheriskofafalsepositivediagnosisofmiscarriage.

Emergency Gynaecology SSU_S.Deb

Guidelines on Management of miscarriage

GuidelinesforExpectantManagementofMiscarriage

PATIENTCHOICE

Patientfullycounselled

Informationleaflet

Informnurseincharge

FBCandGroup+Save(ensureHb>10g%)

ArrangerepeatultrasoundscanandEPACappointmentin2weeks

AntiDimmunoglobulinifrhesusnegative

Ifthepatientisclinicallywellwithnosymptomsandsignssuggestiveofinfection,there
isnodefinedtimelimittoconcludethatthetreatmenthasfailed

GENERAL RULES

Ifthepatientplanstocontinuewithexpectantmanagementbeyond2weeksof
diagnosis,performanultrasoundscanandbloodtestforclottingandCRPevery
2weeks.

Offersurgicalmanagementifproductsofconceptionnotexpelledby2weeks
of diagnosis, as the success of the treatment progressively reduces with
duration.

Givebroadspectrumantibioticsifthereisanysuggestionofinfectionandplan
an ERPC. In women with pyrexia, IV antibiotics should be given for initial 24
hoursfollowedbyoralantibioticsfor5days.

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Emergency Gynaecology SSU_S.Deb

Guidelines on Management of miscarriage

GuidelinesforSurgicalManagementofMiscarriage
PATIENTCHOICE

Patientfullycounselled

Informationleaflet

Informnurseincharge

Bookwiththeatrecoordinator

Obtainconsentforprocedureandproductsofconception

FBCandGroup+Save

PrescribethefollowingonDrugChart:

Misoprostol400mcgPVfor7.00AMondayofERPC

AntiDimmunoglobulinifrhesusnegative
Metronidazole1gPRintraoperative+Azithromycin1gPOpost
operative(statdose)

PatientdischargedhomewithadatetocometoC32

ERPC(minimum2theatreslots)inemergencytheatrestartingat8.00am

Patientdischargedhomewithin6hours

Checkresultsofhistopathologyassoonasavailable

EnsureAntiDisgiveninrhesusnegativewomenbeforedischarge(itcould
begivenupto72hoursfromthepresumedtimeofexposureoffoetalblood
tomaternalcirculationi.e.timeofERPC

GENERALRULES

Avoidmisoprotolifpreviouscaesareansection,myomectomyoruterineperforation.

Competentsurgeonshouldbeavailabletogotoemergencytheatrefor08.00hrs.

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Emergency Gynaecology SSU_S.Deb

Guidelines on Management of miscarriage

GuidelinesforMedicalManagementofMiscarriage
PATIENTCHOICE

Patientfullycounselled
Informationleaflet
Informnurseincharge
Obtainconsentforprocedureandproductsofconception
FBCandG&S(ensureHbis>10g%)
Prescribethefollowingondrugchart:
SingledoseofMisoprostol800mcgpervaginum.
Azithromycin1gPO
AntiDImmunoglobulinifRhesusnegative
Analgesicsparacetamolandcodeinephosphate(avoidNSAIDs)
Antiemetics
Patientdischargedhomewithadatefortreatment
Patientcanbeeithermanagedonoutpatientorinpatientbasis.
Misoprostol800mcginsertedvaginallyby patientornurseincharge

NOPOCsorsomePOCs
Passedwithin24hours

POCspassedcompletelywithin24hours

RepeattreatmentwithMisoprostol800mcgP.V.in2448
hours(patientchoice,reducedsuccess)

ERPCpatientchoice
(Refertopathwayonsurgicalmanagement)
Advisewomantoperformurinepregnancytest3weeksfollowingpassageof
productsofconceptiontoconfirmcompletionoftreatment.
IfUPTpositiveorwomansymptomatic(pain,bleeding,pyrexia)performpelvic
ultrasoundscan
CONTRAINDICATIONS

HB < 10g%, previous C/S, myomectomy, uterine perforation, cardiac anomaly,


Jehovahs witness, bleeding disorders, anticoagulation therapy, steroid treatment,
Renaldisease,severeasthma,adrenalinsufficiency,andliverdisease

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Guidelines on Management of miscarriage

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References

Blohm F, Hahlin M, Nielsen S, Milsom I. Fertility after a randomised trial of spontaneous abortion
managedbysurgicalevacuationorexpectanttreatment.Lancet1997;349:995.

Chipchase J, James D. Randomised trial of expectant versus surgical management of spontaneous


miscarriage.BrJObstetGynaecol1997;104:8401.

De Jonge EJM et al. Randomised clinical trial of medical evacuation and surgical curettage for
incompletemiscarriage.BMJ1995;311:662.

ElRefaeyetal.Inductionofabortionwithmifepristone(RU486)and oralorvaginalmisoprostol. N
EnglJMed1995;332:9837.

Elson J,Tailor R, Hillaby K, Dew T, Jurkovic D. Expectant management of miscarriage prediction of


outcomeusingultrasoundandnovelbiochemicalmarkers.HumReprod2005;20:23303.

HinshawHKS.Medicalmanagementofmiscarriage.InGrudzinkasTG,OBrienPMS,editors.Problems
inearlypregnancy:advancesindiagnosisandmanagement.London:RCOGpress,1997;28495.

Jurkovic D. Modern management of miscarriage: is there a place for nonsurgical treatment?


UltrasoundObstetGynecol1998;11:1613.

Nielsen S, Hahlin M, PlatzChristensen J. Randomized trial comparing expectant with medical


managementforfirsttrimestermiscarriages.BrJObstetGynaecol1999;106:8047.

Nielsen S, Hahlin M. Expectant management of firsttrimester spontaneous abortion.Lancet


1995;345:846.

NICE Guideline CG154, Ectopic pregnancy and miscarriage Diagnosis and initial management in
earlypregnancyofectopicpregnancyandmiscarriage.December2012.

Royal College of Obstetricians and Gynaecologists. Useof AntiD Immunoglobulin forRh Prophylaxis.
GuidelineNo.22.London:RCOG;2002.

RoyalcollegeofObstetricianandGynaecologist.Themanagementofearlypregnancyloss.Guideline
No.25,London:RCOG;2004.

TrinderJ,BrocklehurstP,PorterR,ReadM,VyasS,SmithL.Managementofmiscarriage:expectant,
medical,orsurgical?Resultsofrandomisedcontrolledtrial(miscarriagetreatment(MIST)trial).BMJ
2006;332(7552):123538

Abdallah Y, Daemen A, Kirk E, Pexsters A, Naji O, Stalder C, Gould D, Ahmed S, Guha S, Syed S,
Bottomley C, Timmerman D, Bourne T. Limitations of current definitions of miscarriage using mean
gestationalsacdiameterandcrownrumplengthmeasurements:amulticenterobservationalstudy.
UltrasoundObstetGynecol.2011Oct13.doi:10.1002/uog.10109.[Epubaheadofprint]

Emergency Gynaecology SSU_S.Deb

Guidelines on Management of miscarriage

GuidelinesforManagementofMiscarriageinAntenatalclinic

Miscarriageconfirmedon
ultrasoundscan

Gestationalsacmorethan
orequalto25mm
CRLmorethanorequalto
7mm
NOfoetalheartorempty
sac
Evidenceofretained
productsofconception

Miscarriagenotconfirmedon
ultrasoundscan

Lessthan12weeks
Gestationalsaclessthan
25mm
CRLlessthan7mm
Foetalbradycardia

RefertoEPAU

Contactnumbers

EPAC:64873/64874
Seniornurse:70437
Consultantoncall:70436

Givewomaninformation
leafletonmiscarriages

Advisewomantokeep
handheldnoteswhen
visitingEPAC

Repeatultrasoundscanin714
days

Miscarriageconfirmed

GENERALRULES

Pleaseinformwomenthattheymaynotbeseenthesamedayand
thatitisnotessentialtobeseenthesamedayinEPAC.
Whenreferredasanemergency,theremightbeawaitbeforeseen
Whendoubtfulofthediagnosis,offeranotherscanand/orsecond
opinion
Miscarriageisgenerallymanagedin3waysandthereforewomen
have3treatmentoptions
1. Expectantmanagement:awaitspontaneousmiscarriage,success
approx7080%
2. Medicalmanagement:medicinesadministeredtohastennatural
processofmiscarriage,successapprox80%
3. Surgicalmanagement:ERPC,successapprox95%

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