Miscarriage (Types and Management)

1. Clinical Overview

Summary

Miscarriage is the spontaneous loss of pregnancy before viability, defined as before 24 weeks gestation in the UK (before 20 weeks in some countries). It affects 10-20% of clinically recognised pregnancies and is the most common complication of early pregnancy. The vast majority (80%) occur in the first trimester. Women presenting with vaginal bleeding in early pregnancy require careful assessment to determine the type of miscarriage, exclude ectopic pregnancy, and provide appropriate management. Classification into threatened, inevitable, incomplete, complete, missed, or septic miscarriage guides subsequent management decisions. Modern management emphasizes patient choice between expectant, medical, and surgical options, with equivalent outcomes demonstrated for most clinical scenarios. [1,2]

Key Facts

• Definition: Loss of pregnancy before 24 weeks gestation (UK) or before 20 weeks (USA).
• Incidence: 10-20% of clinically recognised pregnancies; higher if biochemical pregnancies included. [3]
• Recurrence: Single miscarriage = 20% risk next pregnancy; 3 consecutive = 30-40% risk.
• Timing: 80% occur in first trimester (less than 12 weeks).
• Cause: 50-60% are due to chromosomal abnormalities (primarily trisomies).
• Terminology: "Miscarriage" is the preferred patient-facing term; "spontaneous abortion" is clinical/ICD terminology.

Clinical Pearls

Rule Out Ectopic First: Before diagnosing any type of intrauterine miscarriage, you must determine pregnancy location. An "incomplete miscarriage" diagnosis is dangerous if the pregnancy is actually ectopic.

Cervical Shock: Products of conception impacted in the cervical os cause vagal stimulation → bradycardia, hypotension, pallor. Treatment is IMMEDIATE removal of products from the os with sponge forceps.

Empty Uterus = Not Reassurance: An empty uterus on ultrasound with a positive pregnancy test may be: complete miscarriage, ectopic pregnancy, or very early intrauterine pregnancy. Serial β-hCG and follow-up scan are essential.

Anti-D Immunoglobulin: Give to all Rh-negative women with threatened, inevitable, incomplete, or missed miscarriage greater than 12 weeks, or any surgical/medical management.

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2. Epidemiology

Incidence and Demographics

• Overall Miscarriage Rate: 10-20% of clinically recognised pregnancies (pregnancy test positive + ultrasound confirmation).
• Including Biochemical Losses: 30-50% of all conceptions (pregnancy test positive before clinical confirmation).
• Gestational Age Distribution:
  • Less than 6 weeks: 50% of all miscarriages.
  • 6-12 weeks: 30% of all miscarriages (80% total first trimester).
  • 12-20 weeks: 15% of all miscarriages.
  • 20-24 weeks: 5% of all miscarriages.
• Age-Related Risk (exponential increase with maternal age):
  • Age 20-24: 9%
  • Age 25-29: 10%
  • Age 30-34: 12%
  • Age 35-39: 18%
  • Age 40-44: 34%
  • Age 45+: 53% [4]
  • Mechanism: Increasing oocyte aneuploidy with maternal age.
• Recurrent Miscarriage: Affects 1-2% of couples (3+ consecutive losses).
• Geographic Variation: Rates similar across high-income countries; higher reported rates in low-income settings (may reflect under-ascertainment of early losses).

Risk Factors

Causes by Frequency

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3. Pathophysiology

Step 1: Normal Early Pregnancy Development

• Implantation: Blastocyst implants 6-7 days post-conception.
• Trophoblast Development: Produces β-hCG detected by 10 days.
• Gestational Sac: Visible on scan from 4-5 weeks.
• Yolk Sac: Visible from 5 weeks.
• Fetal Pole and Heartbeat: Visible from 6 weeks.

Step 2: Mechanisms of Pregnancy Loss

Chromosomal Abnormalities (Most Common)

• Account for 50-60% of first-trimester miscarriages. [17]
• Random errors in meiosis (maternal or paternal), increasing with maternal age.
• Specific abnormalities:
  • Autosomal trisomy (52%): Trisomy 16 most common (100% lethal); trisomies 21, 18, 13 may survive to term.
  • Monosomy X (19%): 45,X (Turner syndrome); 99% abort spontaneously.
  • Triploidy (16%): 69 chromosomes (69,XXY or 69,XXX); often presents as partial molar pregnancy.
  • Tetraploidy (6%): 92 chromosomes; always lethal.
  • Structural abnormalities (7%): Translocations, deletions.
• Timing: Chromosomal abnormalities more common in earlier losses (less than 10 weeks).
• Recurrence risk: Sporadic chromosomal abnormalities (95%) have low recurrence; parental balanced translocation (5%) has 25-50% recurrence.

Abnormal Placentation

• Shallow trophoblast invasion.
• Inadequate spiral artery remodelling.
• Leads to later losses and recurrent miscarriage.

Immunological Factors

• Antiphospholipid syndrome (APS): Most important treatable cause of recurrent miscarriage.
  • Antibodies (lupus anticoagulant, anti-cardiolipin, anti-β2-glycoprotein I) cause thrombosis in placental vessels.
  • Accounts for 5-15% of recurrent miscarriages.
  • Treatment: Low-dose aspirin 75mg OD + LMWH (enoxaparin 40mg SC OD) from positive pregnancy test reduces miscarriage from 60% to 20%. [31]
• Natural killer (NK) cells: Controversial; no proven treatment despite commercial testing.
• HLA compatibility: Historical theory (excessive sharing of HLA alleles); no evidence for "paternal cell immunization."

Uterine Factors

• Septate uterus: Poor vascularisation of septum.
• Fibroids: Submucous fibroids distort cavity.
• Asherman's syndrome: Intrauterine adhesions.

Step 3: Clinical Progression

1. Fetal/Embryonic Demise: Developmental arrest or genetic abnormality.
2. Hormonal Decline: β-hCG and progesterone begin falling.
3. Uterine Response: Contractions, decidual breakdown.
4. Bleeding and Expulsion: Products of conception expelled.
5. Cervical Changes: Os opens during expulsion (inevitable/incomplete).

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4. Classification of Miscarriage Types

Critical: Excluding Ectopic Pregnancy

Before classifying any miscarriage type, ectopic pregnancy MUST be excluded.

Ectopic vs Intrauterine Miscarriage - Differentiation

β-hCG Discriminatory Zone

• β-hCG greater than 1500 IU/L: Intrauterine gestational sac should be visible on TVUS.
• If β-hCG greater than 1500 IU/L with empty uterus → high suspicion of ectopic. [9]
• β-hCG doubling time:
  • Viable intrauterine pregnancy: Doubles every 48 hours (66% rise minimum).
  • Ectopic: Suboptimal rise (less than 66% in 48 hours).
  • Failing intrauterine pregnancy: Falling or plateau. [10]

β-hCG Kinetics and Clinical Interpretation

Normal Early Pregnancy hCG Pattern [9,32]

• Initial rise: Detectable 10-11 days post-conception (25-50 IU/L).
• Doubling time:
  • hCG less than 1200 IU/L: Doubles every 31-72 hours (median 48 hours).
  • hCG 1200-6000 IU/L: Slower doubling (72-96 hours acceptable).
  • hCG greater than 6000 IU/L: Doubling time increases; less reliable marker.
• Peak: 50,000-100,000 IU/L at 10-12 weeks, then plateau/decline.
• Minimum rise: 53% increase in 48 hours (99% specificity for viability). [9]

Failing Pregnancy hCG Pattern [32,33]

• Decline rate: hCG falls by minimum 21-35% over 48 hours in failing pregnancies.
• Slow decline: Suggests possible ectopic or persistent trophoblast.
• Plateau: hCG change less than ±15% over 48 hours → ectopic until proven otherwise.
• Time to zero: Complete miscarriage typically reaches undetectable (less than 5 IU/L) by 4-6 weeks.
• Persistent elevation: hCG not declining appropriately → investigate for:
  • Ectopic pregnancy.
  • Retained products of conception.
  • Gestational trophoblastic disease (rare).

Clinical Application: The Two-Test Rule [33]

• Single hCG value has limited diagnostic utility.
• Always obtain serial values 48 hours apart for pregnancy of unknown location.
• Combine hCG trend with ultrasound findings for accurate diagnosis.

hCG Pitfalls

• Heterophilic antibodies: False-positive elevations (rare).
• Phantom hCG: Persistent low-level hCG (less than 100 IU/L) in menopausal women.
• Multiple gestation: Higher baseline, more variable doubling time.
• Pituitary hCG: Low-level production in postmenopausal women (less than 20 IU/L).

Pregnancy of Unknown Location (PUL)

• Definition: Positive pregnancy test with no visible intrauterine or extrauterine pregnancy on scan.
• Incidence: 8-31% of women scanned in early pregnancy units. [11]
• Differential:
  • Very early intrauterine pregnancy (too early to see).
  • Complete miscarriage.
  • Ectopic pregnancy.
• Management: Serial β-hCG every 48 hours + repeat TVUS in 7-14 days.
• Risk stratification:
  • β-hCG rising appropriately → likely viable intrauterine.
  • β-hCG falling → likely complete miscarriage.
  • β-hCG plateau/slow rise → likely ectopic.

When to Suspect Ectopic

1. Risk factors: Previous ectopic, PID, tubal surgery, IVF, IUCD.
2. Unilateral pain.
3. β-hCG greater than 1500 IU/L with empty uterus.
4. Adnexal mass on scan.
5. Free fluid in pelvis.
6. Suboptimal β-hCG rise.

Clinical Pearl: An "incomplete miscarriage" with products in the cervix can mimic ectopic pain. Always correlate β-hCG trends with ultrasound findings.

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5. Classification of Miscarriage Types

Types of Miscarriage - Summary Table

Detailed Descriptions

Threatened Miscarriage

• Definition: Bleeding with viable intrauterine pregnancy.
• Presentation: Light vaginal bleeding, minimal pain, closed cervix.
• Ultrasound: Viable fetus (cardiac activity present).
• Prognosis:
  • 50-75% continue to full-term delivery if heartbeat seen. [5]
  • Risk of loss higher with maternal age greater than 35, heavy bleeding, or subchorionic haematoma.
  • CA125 greater than 35 U/mL associated with increased miscarriage risk (sensitivity 89%, specificity 91%). [12]
• Management:
  • Reassurance that bed rest does not improve outcomes.
  • Progesterone 400mg PV twice daily reduces miscarriage in women with previous losses (PRISM trial: 75% vs 70% live births). [8,13]
  • No progesterone benefit in women without previous miscarriages.
  • Follow-up scan in 1-2 weeks.
  • Safety-netting for worsening symptoms.

Inevitable Miscarriage

• Definition: Cervix is open, miscarriage will occur.
• Presentation: Heavy bleeding, significant cramping, os open.
• Ultrasound: Products in lower segment or cervix.
• Management: Cannot be prevented; expedite with medical or surgical management.

Incomplete Miscarriage

• Definition: Some products expelled, some retained.
• Presentation: Heavy bleeding, cramping, os may be open or closed.
• Ultrasound: Heterogeneous tissue greater than 15mm in endometrial cavity (retained products of conception - RPOC).
  • Cut-off 15 mm: Sensitivity 72%, specificity 91% for need for intervention. [14]
  • Measurement: Anteroposterior diameter on sagittal view.
• β-hCG: May remain elevated or plateau.
• Risk: Continued bleeding, infection, Asherman's syndrome if untreated.
• Management:
  • Medical (first-line): Misoprostol 800μg PV or sublingual. Success 80-90% at 7 days. [6,15]
  • Surgical: Manual vacuum aspiration (MVA) or suction evacuation. Success greater than 99%.
  • Expectant: Less effective for incomplete (50-60%) than complete miscarriage.

Complete Miscarriage

• Definition: All products of conception expelled.
• Presentation: Bleeding settling, pain resolved, os closed.
• Ultrasound: Empty uterus or endometrial thickness less than 15mm.
• β-hCG: Declining.
• Management: Confirm completeness, emotional support, contraception.

Missed Miscarriage (Early Fetal Demise/Anembryonic Pregnancy)

• Definition: Non-viable pregnancy with retained products, no active bleeding.
• Types:
  • Early Fetal Demise: Embryo present but no cardiac activity.
  • Anembryonic Pregnancy (Blighted Ovum): Gestational sac without embryo development.
• Presentation: Often asymptomatic; discovered on routine scan. May report loss of pregnancy symptoms.
• Ultrasound Criteria (NICE NG126):
  • CRL greater than or equal to 7mm with no heartbeat (definitive).
  • Mean sac diameter (MSD) greater than or equal to 25mm with no embryo visible (definitive).
  • Caution: Use conservative criteria to avoid false-positive diagnosis. If uncertain, repeat scan in 7-14 days.
  • Second sonographer opinion recommended for borderline cases. [1,16]
• Pathophysiology:
  • 60-80% due to chromosomal abnormalities, primarily trisomies. [17]
  • Embryonic demise may occur days-weeks before diagnosis.
• Management:
  • Expectant (first-line if stable):
    • 25-50% complete expulsion by 2 weeks.
    • 80-90% by 8 weeks. [6,18]
    • Lower success if gestation greater than 9 weeks or MSD greater than 40mm.
  • Medical: Misoprostol 800μg PV (can repeat after 24-48h). Vaginal route preferred over oral (81% vs 71% efficacy). [15,19]
  • Surgical: MVA or suction evacuation if patient preference, failed medical/expectant, or clinical urgency.

Septic Miscarriage

• Definition: Miscarriage complicated by ascending uterine infection.
• Incidence: 1-2% of spontaneous miscarriages; higher with unsafe abortion or retained products. [20]
• Risk Factors:
  • Retained products (incomplete miscarriage).
  • Unsafe termination of pregnancy.
  • Instrumentation.
  • Prolonged rupture of membranes.
  • Pre-existing bacterial vaginosis or STIs.
• Presentation:
  • Fever (greater than 38°C), tachycardia, rigors.
  • Offensive, purulent vaginal discharge.
  • Lower abdominal pain and uterine tenderness.
  • May progress to septic shock, DIC, or pelvic abscess.
• Organisms: Polymicrobial; E. coli, anaerobes (Bacteroides), Group A Streptococcus, Staphylococcus aureus. [21]
• Investigations:
  • Blood cultures, high vaginal swab, endocervical swab.
  • FBC (leukocytosis), CRP, lactate.
  • Coagulation screen if DIC suspected.
• Management (URGENT):
  1. Resuscitation: IV fluids, oxygen, sepsis six bundle.
  2. IV Broad-Spectrum Antibiotics (start immediately, do NOT delay for evacuation):
     • Co-amoxiclav 1.2g IV TDS + Metronidazole 500mg IV TDS, OR
     • Clindamycin 900mg IV TDS + Gentamicin 5-7mg/kg IV OD.
     • Add gentamicin if severe sepsis/septic shock.
  3. URGENT Surgical Evacuation: Within 6 hours of diagnosis. Remove source of infection.
  4. ICU: If septic shock or multi-organ dysfunction.
• Complications: Septic shock, DIC, pelvic abscess, Asherman's syndrome, infertility, maternal death (rare in high-income countries).
• Prognosis: Excellent with prompt treatment. Delay increases mortality risk.

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6. Clinical Presentation

History Taking

Gynaecological History

• Last menstrual period (LMP) and cycle regularity.
• Pregnancy confirmation (test, scan).
• Any previous scans (booking or dating).

Current Symptoms

• Bleeding: Onset, duration, amount (pads/tampons per day), clots, tissue.
• Pain: Location, severity, cramping vs constant.
• Dizziness, palpitations (hypovolaemia).
• Fever, rigors, discharge (sepsis).

Risk Factors for Ectopic

• Previous ectopic, PID, tubal surgery, IVF, IUCD in situ.
• MUST exclude ectopic before diagnosing miscarriage.

Symptoms by Frequency

Red Flags - "The Don't Miss" Signs

1. Cervical shock: Products in os with bradycardia, hypotension → remove products immediately.
2. Heavy bleeding with haemodynamic instability → fluid resuscitation, urgent surgical.
3. Fever, offensive discharge, tachycardia → septic miscarriage; antibiotics + surgery.
4. Severe unilateral pain → ectopic until proven otherwise.
5. Shoulder tip pain → haemoperitoneum from ruptured ectopic.

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7. Clinical Examination

General Assessment

• Vital signs: Pulse, BP (assess for shock).
• Pallor, distress level.
• Temperature (fever suggests infection).

Abdominal Examination

• Tenderness (usually suprapubic).
• Uterine size (may be smaller than dates in missed miscarriage).
• Peritonism (suggests ectopic with bleeding).

Speculum Examination

Purpose

• Visualise cervix and os.
• Identify source of bleeding.
• Remove products from os if causing cervical shock.

Findings

Bimanual Examination

• Cervical motion tenderness (think ectopic).
• Uterine size.
• Adnexal mass (ectopic, corpus luteum cyst).

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8. Investigations

First-Line Investigations

Urine Pregnancy Test

• Confirms pregnancy.
• Negative test with reported positive = ?complete miscarriage, ?false positive previously.

Serum β-hCG

• Quantitative level.
• Serial measurements (48 hours apart) if diagnosis unclear.
• Viable pregnancy: β-hCG rises by greater than 66% in 48 hours.
• Failing pregnancy: Suboptimal rise or falling values.
• Ectopic: Plateau or slow rise.

Transvaginal Ultrasound (TVUS)

• Gold standard for assessing early pregnancy location and viability.
• Advantages over transabdominal:
  • Higher resolution (7.5 MHz vs 3.5 MHz).
  • Earlier visualization (1 week earlier).
  • Less dependent on maternal BMI or bladder filling.
• Normal early pregnancy milestones:
  • Gestational sac: Visible from 4.5-5 weeks (β-hCG 1000-2000 IU/L).
  • Yolk sac: Visible from 5.5 weeks (MSD 10mm).
  • Fetal pole: Visible from 6 weeks (MSD 18mm).
  • Fetal heartbeat: Visible from 6 weeks (CRL 2-4mm).
• Measurement technique:
  • Mean sac diameter (MSD): Average of three orthogonal diameters.
  • Crown-rump length (CRL): Greatest length of embryo excluding yolk sac.
• Pitfalls:
  • Retroverted uterus: May delay visualization; repeat scan in 7-14 days.
  • Ectopic mimics intrauterine: Pseudogestational sac (decidual reaction) vs true gestational sac (double ring sign).
  • Interobserver variability: Second opinion for borderline cases recommended.

Advanced Ultrasound Features for Miscarriage Diagnosis [16,34]

Secondary Signs of Failed Pregnancy

• Yolk sac abnormalities:
  • Enlarged yolk sac (greater than 7mm): 80% positive predictive value for pregnancy failure. [34]
  • Irregular or calcified yolk sac.
  • Absent yolk sac when MSD greater than 10mm.
• Subchorionic haematoma:
  • Present in 20-40% of threatened miscarriages.
  • Large haematoma (greater than 50% sac circumference) increases miscarriage risk 2-fold.
  • Location: Retroplacental worse prognosis than marginal.
• Abnormal sac shape: Irregular contour, deflated appearance.
• Low gestational sac position: Implantation near internal os.
• Slow or absent fetal heart rate:
  • Less than 100 bpm at 5-7 weeks: High risk of loss (predictive value 80%). [34]
  • Normal: 110-170 bpm by 7 weeks.

Retained Products of Conception (RPOC) - Diagnostic Criteria [14,35]

• Endometrial thickness:
  • Greater than 15mm with heterogeneous echogenicity: Sensitivity 72%, specificity 91%. [14]
  • Measurement: Anteroposterior diameter on sagittal view, double-layer thickness.
• Vascularity on Doppler:
  • Increased vascularity within endometrium suggests active trophoblastic tissue.
  • Resistance index less than 0.5 → increased likelihood of RPOC.
• 3D power Doppler: Improved detection of vascular RPOC vs blood clot.
• Pitfall: Blood clot can mimic RPOC; correlation with clinical picture and hCG trend essential.

Inter-Observer Reliability and Quality Assurance [16,36]

• Measurement variability:
  • CRL: ±3-5 days variation between observers.
  • MSD: ±2-3mm variation.
• Quality standards:
  • Use strict criteria (CRL ≥7mm, MSD ≥25mm) to minimize false-positive miscarriage diagnosis. [16]
  • Two independent measurements by different operators for borderline cases.
  • Allow minimum 7-14 days between scans before confirming non-viability.
• Medicolegal considerations: Misdiagnosis of viable pregnancy as non-viable has resulted in litigation; conservative approach essential. [16,36]

Ultrasound Criteria (NICE NG126)

Confirming Non-Viable Pregnancy (Definitive)

If Uncertain

• CRL less than 7mm with no heartbeat → repeat scan in minimum 7 days.
• MSD less than 25mm with no embryo → repeat scan in minimum 14 days.

Pregnancy of Unknown Location (PUL)

• Positive pregnancy test but no intrauterine or extrauterine pregnancy on scan.
• Serial β-hCG and repeat scan essential.
• May be: very early intrauterine pregnancy, complete miscarriage, or ectopic.

Blood Tests

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9. Management

Management Algorithm

          SUSPECTED MISCARRIAGE
          (Bleeding ± Pain in Early Pregnancy)
                      ↓
┌─────────────────────────────────────────┐
│        EXCLUDE ECTOPIC FIRST            │
│  - Risk factors?                        │
│  - TVUS + β-hCG                         │
└─────────────────────────────────────────┘
                      ↓
              TVUS FINDINGS
                      ↓
    ┌─────────────────┼─────────────────┐
    ↓                 ↓                 ↓
VIABLE IUP     NON-VIABLE IUP     UNCERTAIN
    ↓                 ↓                 ↓
Threatened       Discuss        Repeat scan
Miscarriage      Options        in 7-14 days
    ↓                 ↓
Reassure     ┌───────┴───────┐
Follow-up    ↓               ↓
          INCOMPLETE/    MISSED
          INEVITABLE    MISCARRIAGE
              ↓               ↓
         OPTIONS:        OPTIONS:
    ┌────────┼────────┐  ┌────────┼────────┐
    ↓        ↓        ↓  ↓        ↓        ↓
Expectant Medical Surgical Expectant Medical Surgical

Management Options

1. Expectant Management ("Watchful Waiting")

• Principle: Allow natural expulsion of products without intervention.
• Suitable For:
  • Haemodynamically stable women.
  • No signs of infection.
  • Patient preference for conservative approach.
  • Incomplete or missed miscarriage.
• Success Rate:
  • Incomplete miscarriage: 50-80% complete by 7-14 days. [6,18]
  • Missed miscarriage: 25-50% by 2 weeks; 80-90% by 8 weeks. [18]
  • Lower success if gestational age greater than 9 weeks or large RPOC.
• Duration:
  • 7-14 days for incomplete miscarriage.
  • Up to 2-4 weeks for missed miscarriage (patient choice).
• Follow-Up:
  • Urine pregnancy test in 3 weeks (should be negative).
  • If positive at 3 weeks, arrange scan to exclude RPOC or ectopic.
  • Safety-netting: Return if heavy bleeding (greater than 1 pad/hour), severe pain, fever, offensive discharge.
• When to Intervene:
  • Heavy bleeding requiring transfusion.
  • Signs of infection.
  • Patient request for intervention.
  • Failed expectant management at 2-4 weeks.
• Advantages: Avoids anaesthesia and surgery, perceived as more "natural."
• Disadvantages: Unpredictable timing, risk of prolonged bleeding, small risk of infection or incomplete evacuation requiring intervention.

2. Medical Management

• Drug: Misoprostol (prostaglandin E1 analogue).
• Mechanism: Induces uterine contractions, cervical ripening, and expulsion of products.
• Indications: Incomplete or missed miscarriage (first trimester).
• Regimens:
  • Vaginal: 800μg PV (can self-administer or clinic insertion).
  • Sublingual: 800μg SL (alternative if vaginal route declined).
  • Buccal: 800μg (held between cheek and gum for 30 minutes).
  • Oral: Less effective (71% vs 81% for vaginal). [19]
• Dosing:
  • Single dose initially.
  • Repeat dose after 24-48 hours if no response (tissue passage, continued bleeding).
  • Maximum 2-3 doses.
• Success Rate:
  • 80-90% complete evacuation by 7 days (incomplete miscarriage). [6,15]
  • 70-80% for missed miscarriage.
  • Lower success if gestation greater than 9 weeks or large RPOC.
• Time to Expulsion: Usually within 24-48 hours of first dose. Peak bleeding and cramping 2-6 hours post-dose.
• Side Effects:
  • Very common (greater than 50%): Cramping pain, bleeding (can be heavy with clots), nausea.
  • Common (10-50%): Diarrhoea, vomiting, fever/chills, headache.
  • Rare (less than 1%): Severe haemorrhage requiring transfusion or surgical intervention.
• Contraindications:
  • Known or suspected ectopic pregnancy.
  • IUD in situ (remove before misoprostol).
  • Haemodynamic instability.
  • Bleeding disorder or anticoagulation.
  • Chronic adrenal failure (prostaglandin effect on adrenal function).
• Analgesia:
  • Pre-emptive: Ibuprofen 400mg TDS or naproxen 500mg BD.
  • Moderate pain: Codeine 30-60mg PRN or tramadol 50-100mg PRN.
  • Severe pain: May indicate incomplete evacuation or infection; reassess.
• Antiemetic: Metoclopramide 10mg TDS or ondansetron 4-8mg PRN.
• Follow-Up:
  • Urine pregnancy test in 3 weeks (should be negative).
  • Low-sensitivity UPT preferred (25 IU/L threshold) to avoid false positives from residual hCG.
  • If positive or ongoing symptoms, arrange scan to assess for RPOC.
• Failure Rate: 10-20%. Defined as continued bleeding, RPOC greater than 15mm on scan, or persistent symptoms requiring surgical evacuation.
• Advantages: Avoids surgery and anaesthesia, can be done at home, faster than expectant.
• Disadvantages: Cramping and bleeding (often unpredictable timing), small risk of failed treatment requiring surgery.

3. Surgical Management

• Techniques:
  • Manual Vacuum Aspiration (MVA): Handheld vacuum device; under local anaesthesia (paracervical block); outpatient.
  • Electric Vacuum Aspiration (EVA): Electric suction; under general or spinal anaesthesia; day-case or outpatient.
  • Suction Curettage: Formerly "ERPC" (evacuation of retained products of conception), now "surgical management of miscarriage (SMM)."
• Indications:
  • Absolute:
    • Heavy bleeding with haemodynamic instability.
    • Septic miscarriage (urgent).
    • Failed medical or expectant management with symptomatic RPOC.
  • Relative:
    • Patient choice (immediate resolution).
    • Anxiety about prolonged process.
    • Incomplete miscarriage with large RPOC (greater than 25mm).
    • Medical contraindications to misoprostol.
• Procedure:
  1. Cervical priming (if cervix closed): Misoprostol 400μg PV 3 hours pre-procedure.
  2. Anaesthesia: Local (paracervical block for MVA) or general/spinal (for EVA).
  3. Cervical dilation: Hegar dilators to 6-8mm.
  4. Aspiration: Suction catheter inserted, products evacuated.
  5. Confirm complete evacuation: Gritty sensation, minimal aspirate.
• Success Rate: greater than 99% complete evacuation. [6,22]
• Complications:
  • Common (1-5%):
    • Retained products (2-5%): May require repeat procedure.
    • Infection (1-2%): Endometritis; treat with antibiotics.
  • Uncommon (0.1-1%):
    • Uterine perforation (0.5-1%): Higher risk if retroverted uterus, nulliparous, surgeon inexperience. [23]
    • Cervical trauma (0.5%): Laceration during dilation.
    • Haemorrhage (0.5%): May require uterotonics or transfusion.
  • Rare (less than 0.1%):
    • Asherman's syndrome (intrauterine adhesions): 1-2% after single procedure; higher after multiple. [24]
    • Anaesthesia complications.
• Post-Operative Care:
  • Analgesia: Ibuprofen 400mg TDS, paracetamol 1g QDS.
  • Expect light bleeding for 7-14 days.
  • Avoid tampons, sexual intercourse, swimming for 2 weeks (infection risk).
  • Urine pregnancy test in 3 weeks.
  • Return if heavy bleeding, fever, severe pain, offensive discharge.
• Advantages: Immediate resolution, predictable, highest success rate, allows histological examination of products.
• Disadvantages: Requires anaesthesia (if GA), small surgical risks, perceived as invasive.
• MVA vs EVA:
  • MVA: Outpatient, local anaesthetic, cheaper, lower complication rate, equivalent efficacy. [25]
  • EVA: May be preferred for larger gestations (greater than 12 weeks) or patient anxiety about being awake.

Management by Type

Comparative Effectiveness: MIST Trial (2006) [6]

Landmark study comparing expectant vs medical vs surgical management for miscarriage (N=1,200).

Key Findings:

• All three options are safe and effective.
• No difference in infection rates, future fertility, or psychological outcomes.
• Surgical has fastest resolution but invasive.
• Medical intermediate success and timing.
• Expectant longest time but avoids intervention.
• Patient choice should drive management in stable women.

Patient Selection Criteria for Management Options [37,38]

Optimal Candidates for Expectant Management

• Best suited for:
  • Complete miscarriage (os closed, minimal bleeding).
  • Incomplete miscarriage with minimal RPOC (less than 15mm).
  • Missed miscarriage less than 9 weeks gestation.
  • Patient preference for natural process.
  • Low anxiety, good social support.
• Predictors of success [37]:
  • Gestational age less than 9 weeks: 80% success.
  • Gestational age 9-13 weeks: 50% success.
  • MSD less than 40 mm: Higher success rate.
  • Lower initial hCG (less than 10,000 IU/L): Better outcomes.
  • Open cervical os on examination: Increased expulsion rate.
• Contraindications:
  • Haemodynamic instability.
  • Heavy ongoing bleeding (soaking greater than 1 pad/hour).
  • Signs of infection.
  • Patient anxiety or preference for rapid resolution.
  • Limited access to emergency care.

Optimal Candidates for Medical Management

• Best suited for:
  • Incomplete miscarriage with RPOC 15-30mm.
  • Missed miscarriage less than 12 weeks.
  • Patient desires faster resolution than expectant but wants to avoid surgery.
  • Failed expectant management.
• Predictors of success [15,19]:
  • Incomplete miscarriage: 85-90% success (better than missed).
  • Missed miscarriage less than 9 weeks: 80% success.
  • Missed miscarriage 9-12 weeks: 65% success.
  • Open cervical os: Higher success rate.
  • Vaginal route superior to oral (81% vs 71%). [19]
• Enhanced protocols [15,38]:
  • Mifepristone 200mg PO 24 hours before misoprostol increases success rate (83% vs 67%).
  • Repeat misoprostol dose after 24-48 hours if no response.
  • Buccal or sublingual routes if vaginal declined.
• Contraindications:
  • Suspected ectopic pregnancy.
  • Haemodynamic instability.
  • Severe anaemia (Hb less than 80 g/L).
  • Bleeding disorder or anticoagulation (relative).
  • IUD in situ (remove first).
  • Chronic adrenal failure.
  • Unable to access emergency care within 1 hour.

Optimal Candidates for Surgical Management

• Best suited for:
  • Patient preference for immediate, definitive resolution.
  • Failed medical or expectant management.
  • Heavy bleeding (haemodynamically stable but concerning).
  • Large RPOC (greater than 30mm).
  • Missed miscarriage greater than 12 weeks.
  • Concurrent indication for hysteroscopy (e.g., suspected uterine anomaly).
  • High patient anxiety about prolonged process.
  • Limited access to follow-up or emergency care.
• Mandatory indications:
  • Haemodynamic instability.
  • Septic miscarriage.
  • Cervical shock.
• Predictors of success: Greater than 99% complete evacuation in all scenarios. [22]
• MVA vs EVA selection [25,39]:
  • MVA (manual vacuum aspiration):
    • First trimester (less than 12 weeks).
    • Local anaesthetic acceptable to patient.
    • Outpatient or clinic setting.
    • Lower cost, equivalent efficacy to EVA.
    • Lower complication rate (less uterine trauma).
  • EVA (electric vacuum aspiration):
    • Greater than 12 weeks gestation.
    • Patient preference for general anaesthesia.
    • Complex cases (e.g., large RPOC, previous uterine surgery).
    • Operating theatre setting.

Shared Decision-Making Framework [40]

1. Present all three options with success rates specific to patient scenario.
2. Discuss timelines:
   • Expectant: Days to weeks (unpredictable).
   • Medical: Usually within 24-48 hours.
   • Surgical: Same-day resolution.
3. Address patient values and preferences:
   • Desire for control vs medical intervention.
   • Tolerance for uncertainty and waiting.
   • Previous experiences with miscarriage.
   • Cultural or religious considerations.
4. Provide realistic expectations for bleeding, pain, and side effects.
5. Safety-net for all options: Clear instructions on when to seek help.
6. Flexibility: Can escalate from expectant → medical → surgical if first choice unsuccessful.

Anti-D Immunoglobulin

Indications for Rhesus-negative women:

Timing: Within 72 hours of event (but can give up to 10 days if delay).

Rationale: Prevent Rhesus sensitization and haemolytic disease of the newborn in future pregnancies. Feto-maternal haemorrhage can occur even in early miscarriage, especially with intervention.

Antibody screen: Check maternal blood group and antibody status. If already sensitized (anti-D positive), anti-D immunoglobulin is not required but document sensitization for future pregnancies. [26]

Special Scenarios

Cervical Shock

• Definition: Vagal response to products of conception impacted in cervical os.
• Presentation: Bradycardia (less than 60 bpm), hypotension (less than 90/60 mmHg), pallor, diaphoresis, syncope.
• Mechanism: Cervical distension → vagal stimulation → parasympathetic overdrive.
• Emergency Management:
  1. Immediate removal of products from os: Use sponge forceps or ring forceps to grasp and remove tissue from cervical os.
  2. Place patient supine, elevate legs.
  3. IV access: Crystalloid bolus 500mL if hypotensive.
  4. Atropine 0.5-1mg IV if severe bradycardia persists after removal.
  5. Monitor vital signs: Usually rapid resolution after product removal.
• Prognosis: Excellent if promptly treated. Removal of products from os typically results in immediate symptom resolution.

Recurrent Bleeding After Treatment

• Differential:
  • Retained products of conception (RPOC).
  • Ectopic pregnancy (especially if β-hCG not falling appropriately).
  • Gestational trophoblastic disease (molar pregnancy).
  • Arteriovenous malformation (rare).
  • Endometrial pathology (polyp, fibroid).
• Investigations:
  • Quantitative β-hCG (should fall to undetectable by 4-6 weeks post-miscarriage).
  • TVUS: Look for RPOC (heterogeneous tissue greater than 15mm), vascularity.
  • FBC, coagulation if heavy bleeding.
• Management:
  • If RPOC confirmed: Repeat medical or surgical management.
  • If β-hCG plateau/rising: Exclude ectopic or gestational trophoblastic disease.

Histological Examination

• Indications:
  • Surgical evacuation: Products routinely sent for histology.
  • Suspected molar pregnancy (β-hCG disproportionately high, "snowstorm" on scan).
  • Recurrent miscarriage (third or more consecutive loss).
  • Late miscarriage (greater than 12 weeks): May identify structural abnormalities.
• Findings:
  • Confirm products of conception (chorionic villi).
  • Identify molar pregnancy (complete or partial mole).
  • Occasionally identify infection.
• Note: Absence of chorionic villi raises suspicion of ectopic pregnancy.

Emotional Support

• Acknowledge loss; allow grieving.
• Offer written information.
• Provide contact for support services (e.g., Miscarriage Association).
• Offer follow-up appointment (1-2 weeks).
• Discuss when safe to try again (usually next cycle if ready).

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10. Complications

Immediate Complications

Surgical Complications

Psychological Complications

• Grief and Loss: Normal; most resolve spontaneously within 3-6 months.
• Anxiety in Future Pregnancies: 30-50% experience heightened anxiety in subsequent pregnancies. [27]
• Depression: 10-15% meet criteria for clinical depression at 6 months post-miscarriage. [28]
• PTSD symptoms: 15-25% report intrusive thoughts, avoidance, hyperarousal. [28]
• Complicated Grief: Prolonged, intense grief interfering with function; may need specialist psychological support.
• Risk Factors for Psychological Morbidity:
  • Previous mental health history.
  • Lack of social support.
  • Late miscarriage (greater than 12 weeks).
  • Wanted pregnancy.
  • History of infertility or recurrent loss.
• Support:
  • Acknowledge loss; validate emotions.
  • Provide written information.
  • Offer follow-up appointment (1-2 weeks).
  • Refer to support organizations: Miscarriage Association, Tommy's, Sands.
  • Screen for depression/anxiety at follow-up.
  • Consider formal psychological referral if symptoms persist greater than 6 weeks.

Detailed Psychological and Emotional Impact [27,28,41,42,43]

Acute Grief Response (First 2-4 Weeks)

• Psychological reactions:
  • Shock, disbelief, numbness (especially if asymptomatic missed miscarriage).
  • Sadness, crying, emptiness.
  • Anger (at self, partner, healthcare system, fate).
  • Guilt ("What did I do wrong?").
  • Anxiety about future fertility.
• Physical manifestations:
  • Sleep disturbance (insomnia or hypersomnia).
  • Appetite changes.
  • Fatigue, low energy.
  • Psychosomatic symptoms (headaches, chest tightness).
• Cognitive changes:
  • Difficulty concentrating.
  • Preoccupation with loss.
  • Rumination on possible causes.
• Normal grief trajectory: Intensity peaks at 2-4 weeks, gradual improvement over 3-6 months. [28]

Prolonged Grief and Complicated Bereavement (10-20% of Cases) [41,42]

• Definition: Intense grief persisting beyond 6 months and interfering with daily function.
• Features:
  • Persistent yearning for the pregnancy.
  • Inability to accept the loss.
  • Social withdrawal, isolation.
  • Loss of interest in previously enjoyed activities.
  • Severe functional impairment (work, relationships).
• Risk factors:
  • Late miscarriage (greater than 12 weeks): Higher emotional investment. [42]
  • Planned, highly desired pregnancy.
  • History of infertility or previous losses.
  • Limited social support or partner discord.
  • Pre-existing mental health conditions.
  • Concurrent life stressors.
  • Traumatic circumstances (e.g., emergency surgery, ICU admission).

Depression Following Miscarriage [28,43]

• Incidence:
  • 1 month post-miscarriage: 20-30% screen positive for depression.
  • 3 months: 15-20%.
  • 6 months: 10-15%.
  • Majority resolve spontaneously; 5% develop persistent major depression.
• Screening: Use validated tools at follow-up (PHQ-9, Edinburgh Postnatal Depression Scale).
• Symptoms:
  • Low mood most of the day, nearly every day.
  • Loss of interest or pleasure.
  • Worthlessness, excessive guilt.
  • Fatigue, sleep disturbance.
  • Difficulty concentrating.
  • Suicidal ideation (rare but assess).
• Management:
  • Mild: Watchful waiting, supportive counselling, self-help resources.
  • Moderate: Consider CBT (cognitive behavioural therapy) or brief psychological intervention.
  • Severe: Antidepressants (if not trying to conceive immediately) + specialist referral.
  • SSRI choice if needed: Sertraline or citalopram (lower teratogenic risk if conception occurs).

Anxiety and PTSD [27,28,44]

• Pregnancy-specific anxiety in subsequent pregnancy:
  • 30-50% report heightened anxiety when conceive again. [27]
  • Fear of repeat loss, hypervigilance to symptoms.
  • Reluctance to bond or announce pregnancy until later gestation.
  • Frequent reassurance-seeking (scans, tests).
• Post-traumatic stress symptoms (15-25%): [44]
  • Re-experiencing: Intrusive memories, flashbacks, nightmares.
  • Avoidance: Avoiding pregnancy discussions, babies, healthcare settings.
  • Hyperarousal: Irritability, hypervigilance, exaggerated startle.
  • Negative cognitions: Self-blame, distorted beliefs about cause.
• Triggers:
  • Due date of lost pregnancy.
  • Seeing pregnant women or babies.
  • Medical settings (hospitals, clinics).
  • Anniversary of miscarriage.
• Management:
  • Trauma-focused CBT.
  • EMDR (eye movement desensitization and reprocessing).
  • Medication if severe (SSRIs effective for PTSD).

Impact on Partners and Relationships [41,45]

• Partner grief often minimized: Male partners report feeling "invisible" in grief process. [45]
• Different grieving styles: Can lead to relationship strain if not addressed.
  • Women: More likely to seek support, express emotions openly.
  • Men: May focus on "being strong," practical tasks, return to work quickly.
• Sexual relationship:
  • Temporary loss of libido common (both partners).
  • Anxiety about future conception.
  • Timing pressure if trying again quickly.
• Relationship outcomes:
  • 20% report relationship strengthened (shared experience).
  • 15% report significant relationship strain.
  • Communication and mutual support protective.
• Couple counselling: Consider if communication breakdown or partner discord.

Evidence-Based Psychological Interventions [42,43,46]

Early Intervention (Within 4 Weeks)

• Supportive counselling:
  • Normalize grief response.
  • Provide accurate information (dispel guilt, myths about causation).
  • Validate both partners' experiences.
• Written information: Evidence-based leaflets (avoid overwhelming detail initially).
• Peer support: Miscarriage Association, online forums (caution re: quality of information).
• Follow-up contact: Phone call or appointment 1-2 weeks post-miscarriage.

Moderate Intervention (4-12 Weeks)

• Screening: PHQ-9, GAD-7 at follow-up appointments.
• Brief psychological therapy: 4-6 sessions CBT or counselling if persistent symptoms. [43,46]
• Mindfulness-based interventions: Emerging evidence for reducing anxiety. [46]
• Support groups: Facilitated group therapy (8-10 sessions) shows benefit in RCTs. [43]

Intensive Intervention (Greater than 12 Weeks or Severe)

• Specialist mental health referral:
  • Major depression (PHQ-9 greater than 15).
  • Suicidal ideation.
  • PTSD symptoms interfering with function.
  • Complicated grief.
• Pharmacotherapy: Antidepressants if clinically indicated.
• Long-term therapy: Trauma-focused CBT, EMDR, or psychodynamic therapy.

Support in Subsequent Pregnancy ("Pregnancy After Loss") [27,44]

• Early reassurance scans:
  • Evidence shows reduces anxiety without harm. [44]
  • Offer scan at 6-7 weeks (heartbeat detection).
  • Repeat scan at 9-10 weeks.
• Dedicated clinic: "Rainbow clinic" or "pregnancy after loss" clinic.
  • Continuity of care with same clinician.
  • Easy access to scans and support.
  • Acknowledges previous loss, validates anxiety.
• Partner involvement: Encourage partners to attend appointments.
• Graduated emotional investment: Reassure that caution in bonding is normal protective mechanism.
• Professional support: Access to specialist midwife or counsellor.

Organizational and Clinical Practice Recommendations [40,42]

• Sensitive communication:
  • Use "miscarriage" (preferred by patients) over "abortion."
  • Acknowledge the pregnancy and loss (not just "tissue").
  • Avoid minimizing language ("It wasn't a real baby yet," "You can try again").
• Timely follow-up: Offer appointment within 1-2 weeks of diagnosis.
• Provide choice and control: Involve women in management decisions.
• Privacy: Separate early pregnancy units from antenatal clinics where possible.
• Remember tissue handling: Offer sensitive disposal options or keepsakes if desired (photos, scan images).
• Certification: Offer certificate of remembrance (some hospitals provide).
• Workplace support: Provide documentation for sick leave, time off.
• Cultural sensitivity: Consider religious and cultural practices around pregnancy loss.

Red Flags for Urgent Psychological Referral

• Suicidal ideation or self-harm.
• Severe depression (unable to function, self-care).
• Psychotic symptoms.
• Risk to others.
• Complicated grief with severe functional impairment.
• Pre-existing severe mental illness requiring crisis input.

Quality Improvement and Clinical Audit Standards [1,40,47]

Service Quality Indicators

Audit Standards: Surgical Management [1,47]

• Surgical evacuation for incomplete/missed miscarriage: Greater than 99% complete evacuation rate.
• Uterine perforation rate: Less than 1% (target less than 0.5%).
• Infection rate: Less than 3% (target less than 2%).
• Asherman's syndrome (after single procedure): Less than 2%.
• All products sent for histology: Greater than 95%.
• Consultant review for complications: 100%.

Audit Standards: Medical Management [1,38]

• Success rate (incomplete miscarriage, first dose): Greater than 70%.
• Success rate (incomplete miscarriage, with repeat dose): Greater than 85%.
• Admission rate for bleeding: Less than 5%.
• Emergency surgical evacuation rate: Less than 5%.
• Patient satisfaction with information provided: Greater than 80%.

Early Pregnancy Unit (EPU) Standards [1,40]

• Access: Open-access EPU for women with bleeding/pain in early pregnancy.
• Staffing: Dedicated sonographers trained in early pregnancy scanning.
• Multidisciplinary: Access to gynaecology, psychology, and specialist nurses.
• Privacy: Separate waiting area from antenatal clinics.
• Efficiency: Scan, results, and management plan within same visit (one-stop clinic).
• Safety-netting: Written and verbal instructions on when to seek help.
• Follow-up pathways: Clear protocols for PUL, expectant management monitoring.

Key Performance Metrics to Monitor

1. Time from presentation to scan (target: less than 48 hours).
2. Misdiagnosis rate of viable pregnancy as non-viable (target: 0%).
3. Percentage of eligible women given all three management choices.
4. Completion rate of expectant/medical management vs surgical escalation.
5. Patient-reported experience measures (satisfaction surveys).
6. Complication rates (infection, haemorrhage, perforation).
7. Psychological screening completion rate.
8. Return visit rate for failed treatment or complications.

National Guidelines and Quality Standards [1]

• NICE NG126 (2019): Ectopic pregnancy and miscarriage diagnosis and management.
• RCOG Green-top Guideline No. 17: Recurrent miscarriage investigation.
• RCOG Green-top Guideline No. 25: Management of early pregnancy loss.
• Care Quality Commission (CQC) standards for maternity early pregnancy services.

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11. Prognosis and Outcomes

Prognosis After Single Miscarriage

• Risk of next pregnancy miscarriage: 20% (same as baseline).
• 85% of women will have successful subsequent pregnancy.
• No investigations or treatment needed after single miscarriage.

Prognosis After Recurrent Miscarriage (3+)

• Overall subsequent live birth rate: 60-75%.
• With antiphospholipid syndrome (treated): 70-80% success.
• Unexplained recurrent miscarriage: 75% success with supportive care only.

Time to Next Pregnancy

• Historical Advice: WHO previously recommended 6-month wait (no evidence base).
• Current Evidence:
  • Conception within 3 months of miscarriage has better outcomes than waiting longer. [7,29]
  • Love et al. (2010): 30,937 women; conception within 6 months had:
    • Lower risk of subsequent miscarriage (RR 0.82).
    • Lower risk of ectopic pregnancy.
    • No increase in adverse outcomes.
  • Potential mechanisms: Healthier endometrium, higher fertility window, psychological readiness.
• Physical Readiness: Can conceive as soon as first menstrual cycle (usually 4-6 weeks post-miscarriage).
• Psychological Readiness: More important than arbitrary time interval. Try when emotionally ready.
• Recommendation: No evidence to delay conception. Try when physically and emotionally ready. [7,29]

Follow-Up Recommendations

Recurrent Miscarriage Investigation (3+ Consecutive Losses)

Definition: Three or more consecutive pregnancy losses before 24 weeks.

Investigations (RCOG/ESHRE Guidelines) [30]

NOT Routinely Recommended:

• Natural killer cell testing (no proven treatment).
• Progesterone levels (not predictive).
• Infectious disease screening (unless history suggests).

Unexplained Recurrent Miscarriage

• Frequency: 50% of recurrent miscarriage cases remain unexplained after full investigation.
• Prognosis: 60-75% subsequent live birth with supportive care alone. [30]
• Management:
  • Early pregnancy reassurance scans (6-7 weeks, then 9-10 weeks).
  • Dedicated early pregnancy clinic with consistent care.
  • Psychological support.
  • Progesterone 400mg PV BD (if history of threatened miscarriage in previous pregnancies).
  • No evidence for: Immunotherapy, steroids, immunoglobulins, aspirin alone (without APS).

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12. Evidence and Guidelines

Key Guidelines

Landmark Studies

1. MIST Trial (2006) [6]

• Question: Expectant vs medical vs surgical for incomplete/missed miscarriage?
• N: 1,200 women.
• Result: All three effective; no difference in infection or subsequent fertility.
• Impact: Established patient choice as central to management.
• PMID: 16627509.

2. Quenby et al. (2021) [8]

• Question: Does progesterone prevent miscarriage in threatened miscarriage?
• N: PRISM trial, 4,153 women.
• Result: Vaginal progesterone reduced miscarriage in women with previous losses; no benefit in those without.
• Impact: Progesterone offered to women with threatened miscarriage and history of loss.
• PMID: 33164751.

3. Love et al. (2010) [7]

• Question: Optimal interpregnancy interval after miscarriage?
• N: 30,937 women.
• Result: Conception within 6 months had lowest risk of subsequent miscarriage.
• Impact: No evidence to delay conception.
• PMID: 20688838.

4. PROMISE Trial (2015)

• Question: Does progesterone prevent recurrent miscarriage?
• N: 826 women with recurrent miscarriage.
• Result: No overall benefit (but subgroup may benefit).
• Impact: Progesterone not routine for recurrent miscarriage.
• PMID: 26586795.

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13. Clinical Vignettes and Exam Scenarios

Vignette 1: Threatened Miscarriage

Presentation: 28-year-old woman, 8 weeks pregnant, presents with light vaginal bleeding for 24 hours. No pain. This is her second pregnancy; she has one previous miscarriage at 6 weeks.

Examination: Obs stable. Abdomen soft, non-tender. Speculum: Small amount of blood in vault, os closed.

Investigations: TVUS shows viable intrauterine pregnancy, CRL 14mm, heartbeat 160 bpm. β-hCG 45,000 IU/L.

Diagnosis: Threatened miscarriage.

Management:

1. Reassure that 60-70% chance of ongoing pregnancy.
2. Offer progesterone 400mg PV BD (PRISM trial evidence: reduces miscarriage in women with previous loss and current bleeding).
3. Advise to avoid strenuous activity (though no proven benefit).
4. Follow-up scan in 2 weeks.
5. Safety-netting: Return if heavy bleeding, severe pain, or dizziness.
6. No anti-D required (less than 12 weeks, no intervention).

Key Learning: Progesterone effective in threatened miscarriage with history of previous loss.

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Vignette 2: Missed Miscarriage

Presentation: 32-year-old woman attends routine 12-week dating scan. Asymptomatic. No bleeding or pain. Reports loss of pregnancy symptoms (nausea, breast tenderness) over past week.

Examination: Obs stable. Abdomen soft. Uterus size smaller than dates.

Investigations: TVUS shows gestational sac 28mm with no embryo visible (anembryonic pregnancy). No cardiac activity. Confirmed by second sonographer.

Diagnosis: Missed miscarriage (anembryonic pregnancy, "blighted ovum").

Management Options (discuss all three):

1. Expectant: Wait up to 2-4 weeks for natural expulsion. Success ~50% by 2 weeks. Urine pregnancy test in 3 weeks.
2. Medical: Misoprostol 800μg PV (can repeat after 24-48h). Success ~75% by 7 days. Cramping, bleeding expected.
3. Surgical: MVA or EVA. Success greater than 99%. Immediate resolution.

Patient Choice: After discussion, patient opts for medical management. Prescribe:

• Misoprostol 800μg PV (self-administer at home).
• Ibuprofen 400mg TDS + codeine 30mg PRN.
• Metoclopramide 10mg TDS PRN.
• Follow-up UPT in 3 weeks.

Rhesus Status: Patient is Rh-negative. Give anti-D 250 IU IM (medical management at any gestation requires anti-D).

Key Learning: Shared decision-making central; all three options equally safe. Anti-D required for medical/surgical management.

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Vignette 3: Cervical Shock

Presentation: 35-year-old woman, 10 weeks pregnant, presents to ED with heavy vaginal bleeding and severe cramping for 2 hours. Now feeling faint and clammy.

Examination: Pale, diaphoretic. Pulse 48 bpm, BP 85/50 mmHg. Abdomen tender suprapubically. Speculum: Large clot with tissue visible in cervical os.

Diagnosis: Incomplete miscarriage with cervical shock.

Emergency Management:

1. IMMEDIATE removal of products from os using sponge forceps.
2. IV access, crystalloid bolus 500mL.
3. Atropine 0.5mg IV if bradycardia persists after removal.
4. Monitor vital signs (expect rapid recovery).
5. Arrange surgical evacuation once stabilized.

Post-Intervention: Pulse 72 bpm, BP 110/70 mmHg within 5 minutes of removing products. Patient feels better.

Key Learning: Cervical shock is vagal response to products in os. Treatment is immediate removal. Do not delay for investigations.

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Vignette 4: Septic Miscarriage

Presentation: 24-year-old woman presents with 3 days of heavy bleeding and cramping. Now has fever, rigors, and offensive discharge. Reports she "passed some tissue" 2 days ago.

Examination: Temp 38.9°C, pulse 118 bpm, BP 95/60 mmHg. Abdomen tender. Speculum: Offensive, purulent discharge. Bimanual: Uterus tender, os open.

Investigations:

• FBC: WCC 18.2, Hb 95 (was 130 baseline).
• CRP 245.
• Blood cultures, HVS.
• TVUS: Heterogeneous tissue 22mm in cavity (RPOC).

Diagnosis: Septic miscarriage (incomplete miscarriage with ascending infection).

Management (URGENT):

1. Sepsis six: IV access, bloods, cultures, lactate, fluids, oxygen.
2. IV antibiotics (start immediately, do NOT wait for surgery):
   • Co-amoxiclav 1.2g IV TDS + Metronidazole 500mg IV TDS, OR
   • Clindamycin 900mg IV TDS + Gentamicin 5-7mg/kg IV OD.
3. URGENT surgical evacuation within 6 hours (source control).
4. IV fluids, monitor for septic shock.
5. Anti-D if Rh-negative.

Post-Operative: Patient improves with antibiotics and evacuation. Cultures grow E. coli and Bacteroides fragilis.

Key Learning: Septic miscarriage is life-threatening. Start antibiotics immediately. Surgical evacuation urgent but do NOT delay antibiotics.

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Vignette 5: Pregnancy of Unknown Location (PUL)

Presentation: 26-year-old woman, 5 weeks by LMP, presents with light vaginal bleeding. Positive home pregnancy test.

Examination: Obs stable. Abdomen soft. No peritonism.

Investigations: TVUS shows empty uterus, no adnexal mass, no free fluid. β-hCG 800 IU/L (below discriminatory zone).

Diagnosis: Pregnancy of Unknown Location (PUL).

Differential:

1. Very early viable intrauterine pregnancy (too early to see on scan).
2. Complete miscarriage (products fully expelled).
3. Ectopic pregnancy (not yet visible).

Management:

1. Serial β-hCG every 48 hours:
   • If β-hCG rises greater than 66% → likely viable intrauterine pregnancy. Repeat TVUS when β-hCG greater than 1500 IU/L.
   • If β-hCG falls → likely complete miscarriage. Follow to zero.
   • If β-hCG plateau or slow rise (less than 66%) → likely ectopic. Consider laparoscopy or methotrexate.
2. Safety-netting: Return immediately if severe pain, shoulder tip pain, collapse (ruptured ectopic).
3. Repeat TVUS in 7-14 days.

Follow-Up: β-hCG 48 hours later is 450 IU/L (falling). Likely complete miscarriage. Follow β-hCG to zero.

Key Learning: PUL is common. Do NOT assume it's a miscarriage until ectopic excluded. Serial β-hCG is key.

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Vignette 6: Recurrent Miscarriage

Presentation: 33-year-old woman referred to recurrent miscarriage clinic. Three consecutive first-trimester miscarriages (7, 9, and 6 weeks). No live births.

History: Non-smoker, BMI 24, no medical history. Regular cycles. Partner has fathered two children in previous relationship.

Investigations:

• Antiphospholipid antibodies: Lupus anticoagulant positive (confirmed on repeat 12 weeks later).
• Anti-cardiolipin IgG: Positive.
• Parental karyotype: Normal.
• Pelvic USS: Normal uterus.
• Thyroid function: TSH 2.1, normal.

Diagnosis: Antiphospholipid syndrome (APS)-associated recurrent miscarriage.

Management:

1. Pre-conception: Aspirin 75mg OD (start now).
2. Once pregnant:
   • Continue aspirin 75mg OD.
   • Add LMWH (enoxaparin 40mg SC OD) from positive pregnancy test.
   • Early reassurance scans (6-7 weeks, then 9-10 weeks).
3. Evidence: Aspirin + LMWH reduces miscarriage from 60% to 20% in APS. [31]
4. Continue LMWH throughout pregnancy (thromboprophylaxis).

Outcome: Patient conceives 3 months later. Aspirin + LMWH started. Successful pregnancy delivered at 38 weeks.

Key Learning: APS is most important treatable cause of recurrent miscarriage. Treatment is aspirin + LMWH.

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What is a Miscarriage?

A miscarriage is the loss of a pregnancy before 24 weeks. Most happen in the first 12 weeks. Miscarriages are very common - about 1 in 5 confirmed pregnancies ends in miscarriage.

Why Does Miscarriage Happen?

• Most miscarriages (over half) happen because of chromosome problems in the developing baby that happened by chance.
• It is NOT caused by anything you did - exercise, work, sex, or stress do not cause miscarriage.
• Sometimes the cause is not known.

What Are the Warning Signs?

• Vaginal bleeding (spotting to heavy).
• Cramping or pain in your lower tummy or back.
• Passing tissue or clots.
• Pregnancy symptoms (nausea, breast tenderness) reducing suddenly.

What Happens Next?

If you have bleeding in early pregnancy, you may be offered:

• Ultrasound scan: To check if the pregnancy is healthy.
• Blood tests: To check pregnancy hormone levels.
• Follow-up scan: Sometimes a second scan is needed a week later to be certain.

How is Miscarriage Managed?

There are three options, and you can usually choose:

Expectant (Wait and Watch)

• Let your body pass the pregnancy naturally.
• Can take 1-4 weeks.
• You'll have a pregnancy test in 3 weeks to confirm it's complete.

Medical (Tablets)

• A tablet called misoprostol helps your body pass the pregnancy.
• Usually works within a few days.
• Causes cramping and bleeding.

Surgical

• A small procedure to remove the pregnancy tissue.
• Done under local or general anaesthetic.
• Quick and effective.

What About Future Pregnancies?

• Most women who have a miscarriage go on to have a healthy pregnancy next time.
• You can try again when you feel ready - there's no need to wait.
• If you have three miscarriages in a row, you may be referred for specialist tests.

When to Seek Urgent Help

• Very heavy bleeding (soaking more than 1 pad per hour).
• Severe pain.
• Fever or feeling very unwell.
• Dizziness or fainting.
• Shoulder tip pain (could indicate ectopic pregnancy).

Support

• The Miscarriage Association: miscarriageassociation.org.uk
• Tommy's: tommys.org
• Sands (if late miscarriage): sands.org.uk

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14. References

Primary Sources

1. NICE Guideline NG126. Ectopic pregnancy and miscarriage: diagnosis and initial management. 2019. https://www.nice.org.uk/guidance/ng126.
2. ACOG Practice Bulletin No. 200. Early Pregnancy Loss. Obstet Gynecol. 2018;132:e197-e207. PMID: 30157093.
3. Wilcox AJ, et al. Incidence of early loss of pregnancy. N Engl J Med. 1988;319:189-194. PMID: 3393170.
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