Clinical Topic A-Z Clinical Speciality

Miscarriage

Miscarriage
D000022Abortion, Spontaneous
PregnancyWomen's health
2013-07-01Last revised in July 2013

Miscarriage - Summary

Miscarriage is the spontaneous loss of a pregnancy before 24 weeks' gestation. Recurrent miscarriage is the spontaneous consecutive loss of three pregnancies before 24 weeks' gestation.

Most non-recurrent miscarriages are caused by abnormalities in the embryo (up to 95% of abnormal embryos miscarry).

Up to 50% of couples with recurrent miscarriage show no determinable cause.

Miscarriage should be suspected in women who are pregnant, or with symptoms of pregnancy (amenorrhoea, missed period, breast tenderness), presenting with vaginal bleeding in the first 24 weeks of pregnancy.

Bleeding is typically scanty, varying from a brownish discharge to bright red bleeding and may recur over several days.

Lower abdominal cramping pain or lower backache, when it occurs, usually develops after the onset of bleeding.

All women with vaginal bleeding who are (or could be) within the first 15 weeks of pregnancy should be asked about symptoms of an ectopic pregnancy, especially abdominal or pelvic pain.

All women who are haemodynamically unstable should be transferred immediately to hospital by ambulance.

All women who are haemodynamically stable should have a urine pregnancy test (if not already done) and if pregnancy is confirmed:

An ectopic pregnancy should be strongly suspected if there is any abdominal pain or tenderness and immediate admission should be arranged to an early pregnancy assessment unit (EPAU), or out-of-hours gynaecology service.

If there is NO abdominal pain and tenderness, a pelvic examination should be done to look for pelvic or cervical motion tenderness without palpating for adnexal masses. An ectopic pregnancy should be strongly suspected if there is any pelvic or cervical motion tenderness and immediate admission arranged to an early pregnancy assessment unit (EPAU), or out-of-hours gynaecology service.

If there is NO abdominal pain and tenderness, pelvic or cervical motion tenderness and they are more than 6 weeks pregnant (or of uncertain gestation) ectopic pregnancy is still possible, although less likely. Admission should be arranged to an early pregnancy assessment unit (EPAU) or out-of-hours gynaecology service, to determine the cause of symptoms, the urgency of which should depend on the clinical situation.

For women who are less than 6 weeks gestation who are bleeding but not in pain:

A referral to an EPAU should be made if bleeding continues after 6 weeks of gestation, or if they develop symptoms of ectopic pregnancy.

If bleeding settles before 6 weeks of gestation, a pregnancy test should be repeated after 7-10 days to determine if they have had a miscarriage.

Following miscarriage:

Arrangements for routine antenatal care should be cancelled if they have been started.

An opportunity should be given to ask any questions she may have about the causes and consequences of miscarriage.

Discuss how she is coping and offer information about where to access support and counselling where appropriate.

Be aware that grief, anxiety, and depression are common following miscarriage.

Have I got the right topic?

120months3060monthsFemale

This CKS topic is based on a guideline issued by the National Institute for Health and Care Excellence Ectopic pregnancy and miscarriage: Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. This CKS topic provides a practical, evidence-based scheme for the assessment and management of a woman presenting with symptoms and signs of a possible miscarriage. Brief information is also provided about management following referral to secondary care.

There are separate CKS topics on Amenorrhoea, Ectopic pregnancy, and Pelvic inflammatory disease.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in July 2013

July 2013 — revised. A literature search was conducted in June 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. Changes have been made regarding the assessment of a woman presenting with symptoms and signs of an early pregnancy complication and the recommended urgency of referral to secondary care for assessment and management. These changes reflect the guidance published by the National Institute for Health and Care Excellence Ectopic pregnancy and miscarriage: Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage.

Previous changes

October 2009 to February 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines published since 1 June 2013.

HTAs (Health Technology Assessments)

No new HTAs since 1 June 2013.

Economic appraisals

No new economic appraisals relevant to England since 1 June 2013.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analyses since 1 June 2013.

Primary evidence

No new randomized controlled trials published in the major journals since 1 June 2013.

New policies

No new national policies or guidelines since 1 June 2013.

New safety alerts

No new safety alerts since 1 June 2013.

Changes in product availability

No changes in product availability since 1 June 2013.

Goals and outcome measures

Goals

To determine the viability of the pregnancy

To manage the distress caused by miscarriage

To offer referral for the investigation and management of recurrent miscarriage

Background information

Definition

What is it?

Miscarriage is the spontaneous loss of a pregnancy before 24 weeks' gestation.

First trimester miscarriage is the spontaneous loss of a pregnancy before 13 weeks' gestation.

Complete miscarriage is when all the products of conception have been expelled from the uterus and bleeding has stopped.

Threatened miscarriage is diagnosed when typical symptoms of a miscarriage occur when the viability of the pregnancy is unknown.

Miscarriage is considered inevitable when cramping pelvic pain and bleeding is associated with a dilated cervix.

Missed (or delayed) miscarriage occurs when the pregnancy has failed but no bleeding has occurred and products of conception have not been expelled.

Recurrent miscarriage is the spontaneous consecutive loss of three pregnancies before 24 weeks' gestation.

[Porter et al, 2008; RCOG, 2009]

Causes

What causes it?

Most non-recurrent miscarriages are caused by abnormalities in the embryo. These include:

Chromosomal abnormalities.

Genetic abnormalities.

Defects in the development of the placenta or embryo.

Up to 95% of abnormal embryos miscarry.

No cause of recurrent miscarriage can be determined in about 50% of couples. When it can be determined, recurrent miscarriage may be caused by one or more of the following:

Genetic abnormalities in one or both parents.

Uterine abnormalities.

Immunological abnormalities in the woman.

Thrombophilic abnormalities in the woman.

Environmental factors.

[Rai and Regan, 2006; Porter et al, 2008]

Prevalence

How common is it?

Overall, 12% of recognized pregnancies end in miscarriage. A prospective study of 550 women 15–44 years of age with a recognized pregnancy, found that [Everett, 1997]:

21% had bleeding before the twentieth week of pregnancy.

12% had a miscarriage.

Many pregnancies end in miscarriage before pregnancy is recognized [Wilcox et al, 1988].

Pregnancy can be detected by serial human chorionic gonadotropin (hCG) measurement at a stage when the woman is unaware that she is pregnant.

Using this method of pregnancy detection, up to 30% of pregnancies were found to miscarry.

Most miscarriages occur before the woman recognizes that she is pregnant.

The risk of miscarriage increases with increasing maternal age, particularly when the woman is older than 30 years of age. Miscarriage occurs in [Porter et al, 2008]:

Approximately 10% of pregnancies in women younger than 30 years of age.

15–20% of pregnancies in women 35–39 years of age.

Over 50% of pregnancies in women older than 45 years of age.

The risk of miscarriage reduces with increasing gestational age, with up to 75% of miscarriages occurring before 12 weeks' gestation [Porter et al, 2008].

Recurrent miscarriage affects 1% of women [Porter et al, 2008].

Psychological complications

What are the psychological complications of miscarriage?

Grief, anxiety, or depression will be experienced by many women following pregnancy loss.

These reactions are common, but it is not possible to accurately quantify how common from the available evidence.

These reactions tend to be most intense in the 4–6 weeks after the miscarriage and are usually markedly improved within 6 months.

Grief following miscarriage is comparable in nature, intensity, and duration to grief reactions in people suffering other types of major loss.

The risk of more intense or longer lasting distress is likely to be increased if the woman:

Strongly desired the pregnancy.

Waited a long time to conceive.

Has experienced abortion or other pregnancy loss in the past.

Had a miscarriage later in the pregnancy.

Has little social support.

Has a history of difficulty coping with distressing situations.

[Brier, 1999; Brier, 2004; Brier, 2008]

When to suspect

When to suspect miscarriage

When to suspect miscarriage

When to suspect a miscarriage

Suspect miscarriage in women who are pregnant, or with symptoms of pregnancy (amenorrhoea, missed period, breast tenderness), presenting with vaginal bleeding in the first 24 weeks of pregnancy.

Bleeding is typically scanty, varying from a brownish discharge to bright red bleeding and may recur over several days.

Lower abdominal cramping pain or lower backache, when it occurs, usually develops after the onset of bleeding.

Ask all women with vaginal bleeding who are (or could be) within the first 15 weeks of pregnancy about symptoms of an ectopic pregnancy including:

Abdominal or pelvic pain.

Gastrointestinal symptoms.

Dizziness, fainting or syncope.

Shoulder tip pain.

Urinary symptoms.

Passage of tissue.

Rectal pressure or pain on defecation.

If any symptoms of miscarriage or ectopic pregnancy are present, confirm pregnancy with a pregnancy test (if not already done) and examine the woman for signs of an ectopic pregnancy. For further information see Managing suspected miscarriage.

Suspect a missed (or delayed) miscarriage in pregnant women who do not have bleeding or pain if they have resolving symptoms of pregnancy.

Basis for recommendation

Basis for recommendation

Suspecting a miscarriage or an ectopic pregnancy

The Guideline Development Group (GDG) from the National Institute for Health and Care Excellence (NICE) in the guideline Ectopic pregnancy and miscarriage recommend that health professionals should always consider the possibility of an ectopic pregnancy in women of reproductive age [National Collaborating Centre for Women's and Children's Health, 2012]. Miscarriage and ectopic pregnancy may present with amenorrhoea, vaginal bleeding and abdominal or pelvic pain. Evidence from 29 observational studies found that most women presented with:

Abdominal or pelvic pain (93%, 21 studies), Amenorrhoea (73%, 11 studies).

Vaginal bleeding (64%, 25 studies).

Suspecting a missed or delayed miscarriage

The information on the clinical features of a missed miscarriage comes from the textbook Danforth's Obstetrics and Gynaecology [Porter et al, 2008].

Differential diagnosis

What else might cause bleeding in early pregnancy?

Uterine bleeding in early pregnancy may also occur with:

Ectopic pregnancy (see the CKS topic on Ectopic pregnancy) — presents at 5–14 weeks of gestation (very rarely later that this) with any of the following:

Abdominal or pelvic pain.

Gastrointestinal symptoms.

Dizziness, fainting or syncope.

Shoulder tip pain.

Urinary symptoms.

Passage of tissue.

Rectal pressure or pain on defecation.

Molar pregnancy — commonly presents with bleeding in early pregnancy. Fetal heart sounds are absent. It is more likely if any of the following are present:

Bleeding is heavy and prolonged.

Symptoms of pregnancy are exaggerated.

The uterus is large for dates.

Vesicles are passed.

A viable intrauterine pregnancy.

Extrauterine causes of bleeding in early pregnancy include:

Urethral bleeding.

Cervical ectropion.

Cervical polyps.

Gynaecological cancers.

Causes of pregnancy-related abdominal pain include:

Ruptured ovarian cyst.

Adnexal torsion.

Pregnancy-related degeneration of a fibroid.

Causes of non-pregnancy-related abdominal pain include:

Pelvic inflammatory disease/cervicitis.

Ovarian torsion.

Appendicitis.

Urinary tract infection.

Renal colic.

Torsion of a fibroid.

Basis for recommendation

Basis for recommendation

Clinical features of miscarriage

The clinical features of the differential diagnoses of miscarriage are based on the those reported in a textbook: Danforth's Obstetrics and Gynaecology [Porter et al, 2008].

Clinical features of ectopic pregnancy

These recommendations are based on evidence (of moderate to low quality) from 29 studies (24 retrospective case series, four prospective observational studies, and one case control study) that was reviewed by the Guideline Development Group from the National Institute for Health and Care Excellence [National Collaborating Centre for Women's and Children's Health, 2012]. In these studies:

Most women with an ectopic pregnancy presented with:

Abdominal or pelvic pain (93%, 21 studies), amenorrhoea (73%, 11 studies).

Vaginal bleeding (64%, 25 studies).

Management

Management

Scenario: Managing suspected miscarriage : covers the management of first trimester threatened miscarriage or suspected missed miscarriage.

Scenario: Managing confirmed miscarriage : covers the management of women following confirmation of the diagnosis.

Scenario: Managing suspected miscarriage

Scenario: Managing suspected first trimester miscarriage

156months3060monthsFemale

Managing suspected miscarriage

How should I manage someone with a suspected first trimester miscarriage?

For women with bleeding or any other symptom suggestive of an early pregnancy complication:

Assess blood pressure and pulse.

For women who are not haemodynamically stable:

Arrange immediate ambulance transfer to hospital without undertaking a pelvic examination.

Resuscitate with intravenous fluids, if available.

For women who are haemodynamically stable arrange a urine pregnancy test (if not already done) and if pregnancy is confirmed:

Undertake an abdominal examination:

Strongly suspect ectopic pregnancy if there is any abdominal pain and tenderness and arrange immediate admission to an early pregnancy assessment unit (EPAU), or out-of-hours gynaecology service.

If there is NO abdominal pain and tenderness, undertake a pelvic examination for pelvic or cervical motion tenderness without palpating for adnexal masses (which risks rupturing an ectopic pregnancy if present).

Strongly suspect ectopic pregnancy if there is any pelvic or cervical motion tenderness and arrange immediate admission to an early pregnancy assessment unit (EPAU) or out-of-hours gynaecology service.

If there is NO abdominal pain and tenderness, pelvic or cervical motion tenderness and they are more than 6 weeks pregnant (or of uncertain gestation) ectopic pregnancy is still possible, although less likely.

Arrange admission to an early pregnancy assessment unit (EPAU) or out-of-hours gynaecology service, to determine the cause of symptoms, the urgency of which should depend on the clinical situation.

For women who are less than 6 weeks gestation who are bleeding but not in pain:

The National Institute for Health and Care Excellence (NICE) recommends:

Referring to an EPAU only if bleeding continues after 6 weeks of gestation, or they develop symptoms of an ectopic pregnancy.

If bleeding settles before 6 weeks of gestation, repeat a pregnancy test after 7-10 days to determine if they have had a miscarriage.

Arrange follow up to manage any changes in the clinical situation appropriately.

CKS recognises that the uncertainty caused by bleeding in early pregnancy can be very distressing and referral to an EPAU may be seen as a way of managing this uncertainty. However, before referring a woman who is less than 6 weeks pregnant with a suspected miscarriage consider the following:

The criteria recommended by the Royal College of Obstetricians and Gynaecologists for diagnosing miscarriage in early pregnancy were changed in 2011 in response to evidence that the previous criteria could lead to misdiagnosis. The changes mean that for most pregnancies of less than 6 weeks, miscarriage cannot be diagnosed with certainty.

NICE recommend that before referring a women to an EPAU she should be informed of the limitations of ultrasound in making a diagnosis. When a diagnosis cannot be made, investigations may need to be repeated after an interval of at least 7 days. In some cases further scans will be needed before a diagnosis can be made with any certainty.

For women with light bleeding in early pregnancy, the risk of miscarriage is not significantly different compared to women who are not bleeding.

For women with a suspected missed (or delayed) miscarriage

Refer all women with resolving symptoms of pregnancy especially if the uterus is small for dates or the heartbeat is undetectable when it would be expected to be heard.

Symptoms suggestive of an early pregnancy complication

Symptoms suggestive of an early pregnancy complication

Symptoms suggestive of an early pregnancy complication include:

Abdominal or pelvic pain.

Vaginal bleeding with or without clots.

Dizziness, fainting, or syncope.

Shoulder tip pain.

Passage of tissue.

Rectal pressure or pain on defecation.

[National Collaborating Centre for Women's and Children's Health, 2012]

Basis for recommendation

Basis for recommendation

Immediate admission to hospital for women who are haemodynamically unstable

The Guideline Development Group (GDG) of the National Institute for Health and Care Excellence (NICE) in the guideline Ectopic pregnancy and miscarriage recommends immediate admission to hospital for women who are haemodynamically unstable based on accepted good clinical practice [National Collaborating Centre for Women's and Children's Health, 2012].

Arranging a pregnancy test for women who are haemodynamically stable

This recommendation is based on the expert opinion of the GDG of NICE who agreed that clinicians should consider doing a pregnancy test in women of reproductive age who present with non-specific symptoms. They advise continuing to assess the woman for an ectopic pregnancy or miscarriage only if the pregnancy test is positive [National Collaborating Centre for Women's and Children's Health, 2012].

All the CKS expert reviewers were of the opinion that if a urinary pregnancy test is negative, then an ectopic pregnancy is virtually ruled out. Several pointed out the rare possibility of a false-negative pregnancy test result and advised a repeat urine pregnancy test or serum human chorionic gonadotropin (hCG) measurement as a possibility. It was emphasized that the result needed to be considered with the clinical findings, and if discordant an urgent assessment should be arranged.

Advise not to examine for an adnexal mass

This recommendation is based on the expert opinion of the GDG of NICE that palpation may increase the risk of an ectopic pregnancy rupturing [National Collaborating Centre for Women's and Children's Health, 2012].

Immediate referral for women who are haemodynamically stable with signs that are strongly suggestive of ectopic pregnancy

The GDG of NICE in the guideline Ectopic pregnancy and miscarriage recommends immediate referral for women who are haemodynamically stable but with features that are strongly suggestive of ectopic pregnancy based on accepted good clinical practice [National Collaborating Centre for Women's and Children's Health, 2012].

Features that are strongly suggestive of ectopic pregnancy are based on moderate and low quality evidence from 29 studies (24 retrospective case series, four prospective observational studies, and one case control study) reviewed by the GDG of NICE that showed that [National Collaborating Centre for Women's and Children's Health, 2012]:

Most women with an ectopic pregnancy had at least one of the following:

Pelvic tenderness (91%, one study); adnexal tenderness (82%, seven studies); abdominal tenderness (78%, 11 studies).

Other important but less common signs:

In 40–75% of women included cervical motion tenderness (eight studies); rebound tenderness or peritoneal signs (nine studies).

In 20–40% of women included abdominal distension (two studies, low quality); an enlarged uterus (six studies); an adnexal mass (nine studies); tachycardia or hypotension (five studies, low quality).

In less than 20% of women included a palpable pelvic mass (two studies); collapsed or in shock (eight studies), or orthostatic hypotension (three studies).

Referral of women who are more than 6 weeks pregnant, who have symptoms of an early pregnancy complication but no signs strongly suggestive of an ectopic pregnancy

These recommendations are based on moderate and low quality evidence from 29 studies (see above) that found that although most women with an ectopic pregnancy have abdominal pain and tenderness or pelvic or cervical motion tenderness, some women do not. Therefore, although the risk of ectopic pregnancy in these women is low, and miscarriage more likely, further investigations are required to establish the diagnosis with certainty [National Collaborating Centre for Women's and Children's Health, 2012].

Expectant management for women who are less than 6 weeks pregnant with bleeding but no pain

The recommendations for women who are less than 6 weeks pregnant are based on evidence reviewed by the GDG of NICE that demonstrates that [National Collaborating Centre for Women's and Children's Health, 2012]:

An ultrasound scan will not be able to give useful information about viability at a gestation of less than 6 weeks.

Many women have spotting in early pregnancy that resolves without needing intervention.

Checking a pregnancy test will determine if the pregnancy has miscarried.

Managing women with a missed (or delayed) miscarriage

CKS recommend referral to an EPAU to determine the viability of a pregnancy when there is any doubt, to inform further management, and minimize distress.

Diagnosis in secondary care

How is a diagnosis made in secondary care?

Ultrasonography (usually a trans-vaginal ultrasound scan) is used to assess the location and viability of the pregnancy.

If the location of the pregnancy cannot be established, other investigations may include:

Serum beta-human chorionic gonadotropin (hCG).

Repeated trans-vaginal ultrasound scans.

Laparoscopy.

If the viability of an intrauterine pregnancy cannot be established because the fetus is of insufficient size for a heartbeat to be visualized, measurements are made and the scan repeated after a minimum of 7 days. A non-viable pregnancy is strongly suggested by a lack of growth and the continuing absence of a detectable heartbeat.

Basis for recommendation

Basis for recommendation

Information on establishing a diagnosis in secondary care has been taken from the guideline Ectopic pregnancy and miscarriage: diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage, published by the National Institute for Health and Care Excellence [National Collaborating Centre for Women's and Children's Health, 2012].

Scenario: Managing confirmed miscarriage

Scenario: Managing confirmed first trimester miscarriage

156months3060monthsFemale

Follow up for the woman

What follow up should I offer a woman following a miscarriage?

Ensure that arrangements for routine antenatal care are cancelled if they have been started.

Discuss any questions she has about her miscarriage. The following leaflets are available from the miscarriage association about:

The causes of miscarriage:

Why me? (pdf)

Blighted ovum (pdf)

Future fertility, and risk of miscarriage.

Pregnancy loss and infertility (pdf)

Discuss how the woman is coping and offer information about where to access support and counselling where appropriate.

Be aware that:

Grief, anxiety, and depression are common following miscarriage.

Grief following miscarriage is comparable in nature, intensity, and duration to grief reactions in people suffering other types of major loss.

Distress is commonly at its worst up to 6 weeks after a miscarriage.

The following leaflet produced by the miscarriage association may be helpful:

Your feelings after miscarriage (pdf)

Ensure that all non-sensitized rhesus-negative women who have had a surgical procedure to manage miscarriage have received anti-D immunoglobulin.

Be aware that anti-D immunoglobulin should no longer be given to women who have had:

Medical management for a miscarriage.

A threatened miscarriage.

A complete miscarriage.

Additional patient information about miscarriage and its management is available from:

The Royal College of Obstetricians and Gynaecologists, in their leaflet Early miscarriage: information for you (pdf).

The Miscarriage Association's website. Patient information leaflets include:

Your miscarriage (pdf) , which provides general information about miscarriage and what to expect following a miscarriage.

Management of miscarriage (pdf)

Men and miscarriage (pdf)

Miscarriage and the workplace (pdf)

Someone you know (pdf)

Talking to children about miscarriage (pdf)

Basis for recommendation

Basis for recommendation

Cancelling further antenatal appointments

CKS recommend cancelling antenatal care arrangements to avoid unnecessary distress for the woman.

Offering a follow up appointment

This recommendation is based on the expert opinion of the Guideline Development Group (GDG) of the National Institute for Health and Care Excellence (NICE) in the guideline Ectopic pregnancy and miscarriage [National Collaborating Centre for Women's and Children's Health, 2012], and evidence from a Cochrane review.

The GDG of NICE reviewed the quantitative and qualitative evidence from eight studies which varied from very low to high quality. The GDG concluded that most women do not experience significant anxiety and depression following miscarriage and that counselling support therefore had little impact [National Collaborating Centre for Women's and Children's Health, 2012]. The GDG emphasised that formal counselling is very different to emotional and psychological support.

The GDG found the qualitative data from these trials (moderate to low quality) to be the most helpful at informing practice. Women described their experience of care and commented on what support they would have liked. Based on this descriptive data, the GDG have recommended that all women should be offered a follow up appointment. The GDG made the following comments which also reflected their own experience:

They believed that offering the appointment would have a beneficial effect even for those women who chose not to accept it. For some women a follow up appointment is valuable but others do not want or need an appointment.

Many women appreciate the opportunity to discuss possible reasons for the miscarriage and discuss planning for the future.

Only a minority of women would attend the follow up appointment.

Some women might feel the need for a follow up appointment at a later date.

A Cochrane systematic review (search date December 2011) also concluded that women should be able to choose what support they wanted after a miscarriage [Murphy et al, 2012]. This review investigated whether follow up with counselling affects the psychological well-being of women following miscarriage. The review included six randomized controlled trials (1001 women). All of the trials compared counselling with no counselling. The evidence was insufficient to demonstrate the superiority of either no intervention or counselling.

Being aware of possible psychological distress

This information is based on evidence on the prevalence and severity of psychological distress following miscarriage [Brier, 1999; Brier, 2004; Brier, 2008].

Ensuring that anti-D immunoglobulin has been given where appropriate

These recommendations are based on the expert opinion of the GDG of NICE in Ectopic pregnancy and miscarriage [National Collaborating Centre for Women's and Children's Health, 2012].

The GDG of NICE consider there to be an increased risk of mixing of maternal and fetal blood, and subsequent sensitization during surgical treatment of miscarriage, and therefore recommend that non-sensitized rhesus-negative women receive anti-D rhesus prophylaxis.

The GDG of NICE considered the risk of significant fetal and maternal blood mixing during a spontaneous miscarriage or following treatment with misoprostol to be low and therefore do not recommend anti-D rhesus prophylaxis.

Provision of easily accessible information

This recommendation is based on the expert opinion of the GDG of NICE who felt that it was important that women should be able to access information easily [National Collaborating Centre for Women's and Children's Health, 2012].

Advice about sex and contraception

What advice should I give about sex and contraception following miscarriage?

Advise avoidance of sexual intercourse until miscarriage symptoms have completely settled.

Explain that menstruation can be expected to resume within 4–8 weeks of the miscarriage, and ovulation will occur before this.

For women who wish to become pregnant:

Advise that they can do so as soon as they feel psychologically and physically ready. A patient information leaflet to support this advice is available from the Miscarriage Association, titled Thinking about another pregnancy

Offer pre-conception advice. For further information, see the CKS topic on Pre-conception - advice and management.

For women who do not wish to become pregnant, advise the use of contraception immediately after the miscarriage.

For further information on the use of combined hormonal contraception (pill, patch or vaginal ring), see the CKS topic on Contraception - combined hormonal methods.

For further information on the use of progestogen-only contraception (pill, implant or injectable), see the CKS topic on Contraception - progestogen-only methods.

Basis for recommendation

Basis for recommendation

These recommendations are based on expert opinion in the patient information leaflet Early miscarriage: information for you published by the Royal College of Obstetricians and Gynaecologists [RCOG, 2008].

Recurrent miscarriage

How should I manage a woman with recurrent miscarriage?

Offer referral to investigate the cause of recurrent miscarriage for all women who have had:

Three or more miscarriages before 10 weeks gestation.

One or more morphologically normal fetal losses occurring after 10 weeks gestation.

Advise that it may not be possible to determine the cause of recurrent miscarriage. However, women in whom no cause is found may be reassured that the prognosis for a future successful pregnancy is 75%.

Following referral, the woman is likely to be offered:

Assessment for antiphospholipid antibodies and possibly other immunological abnormalities. If antiphospholipid antibodies are found, treatment with aspirin plus heparin will be considered in future pregnancies.

Investigations for genetic abnormalities in both partners.

Investigations for fetal genetic abnormalities (if fetal tissue is available).

Pelvic ultrasound scan to detect uterine abnormalities (such as fibroids).

The following patient information leaflets produced by the Miscarriage Association may be helpful:

Investigations following recurrent miscarriage (pdf)

Antiphospholipid syndrome and pregnancy loss (pdf)

Basis for recommendation

Basis for recommendation

When to refer

These recommendations are based on the expert opinion of the guideline committee of the Royal College of Obstetricians and Gynaecologists (RCOG) in their guideline The investigation and treatment of couples with recurrent first-trimester and second-trimester miscarriage [RCOG, 2011].

Informing a woman with recurrent unexplained miscarriage about prognosis

This information is based on evidence from two high-quality cohort studies reviewed by the guideline committee of the RCOG in their guideline The investigation and treatment of couples with recurrent first-trimester and second-trimester miscarriage [RCOG, 2011].

Secondary care investigations and management

This information is taken from the RCOG guideline The investigation and treatment of couples with recurrent first-trimester and second-trimester miscarriage [RCOG, 2011].

Providing easily accessible information

This recommendation is based on the expert opinion of the Guideline Development Group (GDG) of the National Institute for Health and Care Excellence in their guideline Ectopic pregnancy and miscarriage who felt that it was important that women should be able to access information easily [National Collaborating Centre for Women's and Children's Health, 2012].

Information on secondary care management

Information on secondary care management for a woman with an incomplete or a missed miscarriage?

If the woman has an incomplete miscarriage or a missed miscarriage:

Expectant management is offered first line if the woman has a confirmed diagnosis of incomplete or missed miscarriage.

Expectant management lasts for 7–14 days and all women are given information about what to expect, advice on analgesia and how to get help in an emergency. Other management options such as medical uterine evacuation or surgical treatment are explored if the woman:

Is at increased risk of haemorrhage (such as her pregnancy is in the late first trimester) or

Has had a previous adverse and/or traumatic experience associated with pregnancy (such as stillbirth, miscarriage or antepartum haemorrhage) or

Is at increased risk from the effects of haemorrhage (such as she had a coagulopathy or is unable to have a blood transfusion) or

Has an infection.

If the bleeding and pain settle (suggesting complete miscarriage) the woman is advised to take a urine pregnancy test after 3 weeks and to return to the hospital if it is positive.

If the bleeding and pain persist or are increasing (suggesting incomplete miscarriage), or if bleeding and pain has not started (suggesting a missed miscarriage), a repeat scan is done and expectant, medical and surgical options are discussed. Woman who choose to continue expectant management are reviewed 14 days or more later.

Medical management is offered if expectant management is not clinically appropriate or a woman has ongoing symptoms after 14 days of expectant management.

Vaginal or oral misoprostol is used for the treatment of missed or incomplete miscarriage to stimulate uterine expulsion of the products of conception. Women are advised about what to expect and potential adverse effects of treatment.

Medical uterine evacuation avoids the risks of surgery and allows the woman to feel more in control.

Women are advised to do a pregnancy test after 3 weeks and return if it is positive.

Surgical intervention may be required if products of conception are retained despite medical treatment or offered if the woman has ongoing symptoms after 14 days of expectant management.

Women with a missed or incomplete miscarriage are offered a choice of:

Manual vacuum aspiration under local anaesthetic.

Surgical management under a general anaesthetic.

Surgery has the advantage of rapid resolution of symptoms.

Basis for recommendation

Basis for recommendation

Information on the secondary care management of miscarriage has been taken from the guideline Ectopic pregnancy and miscarriage published by the National Institute for Health and Care Excellence [National Collaborating Centre for Women's and Children's Health, 2012].

Evidence

Evidence

Supporting evidence

Evidence for when to suspect miscarriage in primary care has been summarized within the Basis For Recommendations.

Evidence on the recommended secondary care management of women with a confirmed miscarriage has not been reviewed. This is available in the guideline Ectopic pregnancy and miscarriage published by the National Institute for Health and Care Excellence [National Collaborating Centre for Women's and Children's Health, 2012].

Search strategy

Scope of search

A full literature search was not requested/required as this CKS topic is primarily based on the National Institute for Health and Care Excellence (NICE) guideline Ectopic pregnancy and miscarriage: Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage [National Collaborating Centre for Women's and Children's Health, 2012].

Search dates

February 2012 - June 2013

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.

exp Abortion, Spontaneous/, pregnancy ADJ loss.tw., miscarr$.tw., spontaneous ADJ abortion.tw.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

Royal College of Physicians

Royal College of General Practitioners

Royal College of Nursing

NICE Evidence

Health Protection Agency

World Health Organization

National Guidelines Clearinghouse

Guidelines International Network

TRIP database

GAIN

NHS Scotland National Patient Pathways

New Zealand Guidelines Group

Agency for Healthcare Research and Quality

Institute for Clinical Systems Improvement

National Health and Medical Research Council (Australia)

Royal Australian College of General Practitioners

British Columbia Medical Association

Canadian Medical Association

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Singapore Ministry of Health

National Resource for Infection Control

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Driver and Vehicle Licensing Agency

NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Drug & Therapeutics Bulletin

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Patient experiences

Healthtalkonline

BMJ - Patient Journeys

Patient.co.uk - Patient Support Groups

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

References

Brier, N. (1999) Understanding and managing the emotional reactions to a miscarriage. Obstetrics & Gynaecology 93(1), 151-155. [Abstract]

Brier, N. (2004) Anxiety after miscarriage: A review of the empirical literature and implications for clinical practice. Birth 31(2), 138-142. [Abstract]

Brier, N. (2008) Grief following miscarriage: a comprehensive review of the literature. Journal of Women's Health 17(3), 451-464. [Abstract]

Everett, C. (1997) Incidence and outcome of bleeding before the 20th week of pregnancy: prospective study from general practice. British Medical Journal 315(7099), 32-35. [Abstract] [Free Full-text]

Murphy, F.A., Lipp, A. and Powles, D.L. (2012) Follow-up for improving psychological well being for women after a miscarriage (Cochrane Review). The Cochrane Library. Issue 3. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]

National Collaborating Centre for Women's and Children's Health (2012) Ectopic pregnancy and miscarriage. Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage (full NICE guideline). Clinical guideline 154National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]

Porter, T.F., Branch, D.W. and Scott, J.R. (2008) Early pregnancy loss. In: Gibbs, R.S., Karlan, B.Y., Haney, A.F. and Nygaard, I. (Eds.) Danforth's Obstetrics and Gynecology. 10th edn. Philadelphia: Lippincott Williams & Wilkins. 60-70.

Rai, R. and Regan, L. (2006) Recurrent miscarriage. Lancet 368(9535), 601-611. [Abstract]

RCOG (2008b) Early miscarriage: information for you. Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk [Free Full-text]

RCOG (2009b) Medical terms explained. Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk [Free Full-text]

RCOG (2011b) The investigation and treatment of couples with recurrent first-trimester and second-trimester miscarriage. . Guideline No. 17. Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk [Free Full-text]

Wilcox, A.J., Weinberg, C.R., O'Connor, J.F. et al. (1988) Incidence of early loss of pregnancy. New England Journal of Medicine 319(4), 189-194. [Abstract]