Miscarriage
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). These include:
Chromosomal abnormalities.
Genetic abnormalities.
Defects in the development of the placenta or embryo.
Up to 50% of couples with recurrent miscarriage show no determinable cause. Determinable causes include:
Genetic abnormalities in one or both parents.
Uterine abnormalities.
Immunological or thrombophilic abnormalities in the woman.
Environmental factors.
Miscarriage occurs in about 12% of recognized pregnancies, although many pregnancies end in miscarriage before the pregnancy is recognized. The risk of miscarriage increases with maternal age, particularly in women older than 30 years of age.
Grief, anxiety, or depression will be experience by many women following miscarriage — this is normally most intense in the first 4–6 weeks following miscarriage.
Threatened miscarriage presents with vaginal bleeding in the first 24 weeks of pregnancy. The woman may also present once the miscarriage is complete and symptoms and signs are resolving, or with a missed miscarriage, which is often found incidentally during routine ultrasound assessment.
Uterine bleeding in early pregnancy may also occur with ectopic pregnancy (which must be excluded), molar pregnancy, or a viable intrauterine pregnancy.
Women with suspected miscarriage and severe pain or bleeding and shock should be urgently admitted to hospital.
Women with threatened or suspected complete miscarriage should be seen at an early pregnancy assessment unit for confirmation of diagnosis by ultrasonography.
Have I got the right topic?
This CKS topic covers the management of first trimester miscarriage in primary care. Information is also provided about the management that might be offered following referral to secondary care.
This CKS topics does not cover diagnosis of the cause of bleeding or pain in early pregnancy.
There is a separate CKS topic on Ectopic pregnancy.
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
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
Guidelines published since the last revision of this topic:
NICE (2012) Ectopic pregnancy and miscarriage. Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage (NICE guideline). National Institute for Health and Clinical Excellence. www.nice.org.uk [Free Full-text]
HTAs (Health Technology Assessments)
No new HTAs since 1 October 2009.
Economic appraisals
No new economic appraisals relevant to England since 1 October 2009.
Systematic reviews and meta-analyses
Systematic reviews published since the last revision of this topic:
Bonde, J.P., Jorgensen, K.T., Bonzini, M., and Palmer, K.T. (2012) Miscarriage and occupational activity: a systematic review and meta-analysis regarding shift work, working hours, lifting, standing, and physical workload. Scandinavian Journal of Work, Environment and Health epub ahead of print. [Abstract]
Devaseelan, P., Fogarty, P.P., and Regan, L. (2010) Human chorionic gonadotrophin for threatened miscarriage (Cochrane Review). The Cochrane Library. Issue 5. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Li, L., Dou, L., Leung, P.C., and Wang, C.C. (2012) Chinese herbal medicines for threatened miscarriage (Cochrane Review). The Cochrane Library. Issue 5. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Li, L., Dou, L.X., Neilson, J.P., et al. (2012) Adverse outcomes of Chinese medicines used for threatened miscarriage: a systematic review and meta-analysis. Human Reproduction Update 18(5), 504-524. [Abstract]
Morley, L.C., Simpson, N., and Tang, T. (2013) Human chorionic gonadotrophin (hCG) for preventing miscarriage (Cochrane Review). The Cochrane Library. Issue 1. John Wiley & Sons, Ltd. www.thecochranelibrary.com [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]
Neilson, J.P., Gyte, G.M.L., Hickey, M., et al. (2010) Medical treatments for incomplete miscarriage (less than 24 weeks) (Cochrane Review). The Cochrane Library. Issue 1. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Primary evidence
Randomized controlled trials published in the major journals since the last revision of this topic:
Kaandorp, S.P., Goddjin, M., van der Post, J.A., et al. (2010) Aspirin plus heparin or asprin alone in women with recurrent miscarriage. New England Journal of Medicine 362(17), 1586-1596. [Abstract] [Free Full-text]
Observational studies published since the last revision of this topic:
Love, E.R., Bhattacharya, S., Smith, N.C. and Bhattacharya, S. (2010) Effect of interpregnancy interval on outcomes of pregnancy after miscarriage: retrospective analysis of hospital episode statistics in Scotland. BMJ 341, c3967. [Abstract] [Free Full-text]
New policies
No new national policies or guidelines since 1 October 2009.
New safety alerts
No new safety alerts since 1 October 2009.
Changes in product availability
No changes in product availability since 1 October 2009.
Goals and outcome measures
Goals
To determine the viability of the pregnancy
To manage confirmed miscarriage in the way preferred by the woman, when possible
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.
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.
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 beta-human chorionic gonadotropin (beta-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.
Presentation
Presentation of miscarriage
Clinical features of miscarriage
What are the clinical features of miscarriage?
Ectopic pregnancy must be excluded before diagnosing miscarriage in women presenting with pain or bleeding in the first 14 weeks of pregnancy. A separate CKS topic is planned to cover the diagnosis of the cause of bleeding or pain in early pregnancy.
Threatened miscarriage presents 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.
Tenderness of the abdomen or pelvis may be present on examination, and if present, ectopic pregnancy must be excluded.
The cervical os is closed.
Inevitable miscarriage presents with the same symptoms as threatened miscarriage, although generally the symptoms are more severe. On examination, the internal cervical os is open or products of conception are found.
A completed miscarriage presents with resolving symptoms and signs of a miscarriage.
A missed (or delayed) miscarriage:
May present with resolving symptoms of pregnancy in women with no pain or bleeding. The fetal heartbeat is undetectable and the uterus may be small for dates.
May be found incidentally during a routine ultrasound assessment of pregnancy.
Basis for recommendation
Basis for recommendation
The clinical features of miscarriage are based on those reported by experts in textbooks [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); the woman has a closed cervical os, and any of the following:
Cardiovascular shock.
An episode of fainting.
Shoulder tip pain on lying down.
Any abdominal pain.
Abdominal tenderness on examination.
Cervical excitation or adnexal tenderness.
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/cervititis.
Ovarian torsion.
Appendicitis.
Urinary tract infection.
Renal colic.
Torsion of a fibroid.
Basis for recommendation
Basis for recommendation
The clinical features of the differential diagnoses of miscarriage are based on the those reported in a textbook [Porter et al, 2008].
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. It includes the management of an inevitable first trimester miscarriage diagnosed on clinical grounds.
Scenario: Managing suspected miscarriage
Scenario: Managing suspected first trimester miscarriage
Managing suspected miscarriage
How should I manage someone with a suspected first trimester miscarriage?
For women with severe pain or bleeding, or who are shocked — arrange immediate ambulance transfer to hospital.
For women with a threatened or suspected complete miscarriage — arrange for the woman to be seen at an early pregnancy assessment unit for confirmation of the diagnosis. Advise the woman to seek medical advice if symptoms deteriorate while awaiting assessment.
Approximately 50% of women with a threatened miscarriage will miscarry.
Approximately 75% of women will miscarry if they have any of the following features:
Bleeding that is increasing.
Bleeding that is heavier than a normal menstrual period.
Bleeding with clots.
A history of continued pregnancy-associated vomiting associated with bleeding in early pregnancy decreases the risk of miscarriage to approximately 30%.
For women with a suspected missed (delayed) miscarriage — arrange for the woman to be seen at an early pregnancy assessment unit.
Basis for recommendation
Basis for recommendation
Women with severe pain or bleeding or who are shocked
Immediate admission to hospital is accepted as good clinical practice.
Assessment of pregnancy viability
The assessment of women with a suspected miscarriage in an early pregnancy assessment unit is recommended by experts to ensure an accurate diagnosis [RCOG, 2006]. This is based on evidence on the limitations of clinical features to distinguish a viable pregnancy from a miscarriage.
In a prospective study of 739 women with bleeding in the first 24 weeks of pregnancy, the clinical features were recorded for each woman and a trans-vaginal ultrasound scan was undertaken to establish a definite diagnosis [Chung et al, 1999].
The clinical features associated with an inevitable miscarriage were the only features that could reliably distinguish miscarriage from a viable pregnancy.
Bleeding that was increasing, bleeding that was heavier than a normal menstrual period, and bleeding with clots were associated with a 75% miscarriage risk.
A history of continued pregnancy-associated vomiting was associated with a decreased miscarriage risk of 30%.
Diagnosis in secondary care
How is a diagnosis made in secondary care?
Following referral to an early pregnancy assessment unit, ultrasonography (usually a trans-vaginal ultrasound scan) is used to assess the location and viability of the pregnancy.
If this can not clearly establish the location and viability of the pregnancy, other investigations may include:
Serum beta-human chorionic gonadotropin (hCG).
Serum progesterone.
Repeated trans-vaginal ultrasound scans.
Basis for recommendation
Basis for recommendation
This information is based on guidelines from the Royal College of Obstetricians and Gynaecologists for the assessment of women with bleeding in early pregnancy [RCOG, 2006].
Scenario : Managing confirmed miscarriage
Scenario : Managing confirmed first trimester miscarriage
Managing inevitable miscarriage
How can inevitable first trimester miscarriage be managed in primary care?
For women with an inevitable miscarriage who are hemodynamically stable, explain that:
Miscarriage may be complete or incomplete, and this can only be reliably determined by an ultrasound examination.
If miscarriage is complete, symptoms should resolve without any intervention.
If miscarriage is incomplete, the management options include:
Admission for surgical evacuation of retained products of conception. This has the advantage that symptoms resolve rapidly but has the disadvantage of risks associated with an operation.
Admission for medical treatment with prostaglandin analogues to stimulate uterine expulsion of the retained products of conception. This has the advantage of avoiding the risks of an operation. There is a risk of increased pain and bleeding, persistent symptoms following treatment, and of treatment failure requiring surgical evacuation.
Conservative management at home to allow resolution without other interventions. This has the advantage of avoiding hospitalization and the risks of an operation. Explain that the symptoms may take several weeks to resolve and sometimes surgical intervention is required for failed conservative management.
For women who prefer surgical or medical intervention for an incomplete miscarriage, arrange for them to be seen at an early pregnancy assessment unit to determine the completeness of the miscarriage.
For women with an inevitable miscarriage who wish to be managed at home:
Advise that complete resolution of symptoms may take several weeks.
Advise the woman to seek medical advice if:
Symptoms become unacceptable.
Symptoms of infection develop (fever, general malaise, smelly vaginal discharge).
Arrange follow up to assess the woman's psychological well-being. For further information, see Psychological support.
Consider the need for anti-D immunoglobulin. For further information, see When to give anti-D immunoglobulin.
Basis for recommendation
Basis for recommendation
Inevitable miscarriage
The reliability of the clinical assessment to make a diagnosis of inevitable miscarriage is based on evidence from a prospective study of 739 women with bleeding in the first 24 weeks of pregnancy [Chung et al, 1999].
The clinical features associated with bleeding in pregnancy were recorded for each woman and a trans-vaginal ultrasound scan was undertaken to establish a definite diagnosis.
An open internal cervical os and products of conception seen on examination were the only features that could reliably distinguish miscarriage from a viable pregnancy.
Conservative management is recommended by experts as an effective and acceptable management option for women with a confirmed miscarriage based on evidence for its efficacy and safety [RCOG, 2006].
Psychological support
What psychological support can I offer a woman following a miscarriage?
Ensure that arrangements for routine antenatal care are cancelled if they have been started.
Ensure that all women are offered a follow-up appointment. At follow up:
Assess the woman's psychological well-being and offer counselling if 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 4–6 weeks after a miscarriage and may last 6–12 months.
Give the woman an opportunity to discuss any questions she has about her miscarriage.
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. In addition they provide patient information leaflets including:
We are sorry you have had a miscarriage (pdf), which provides general information about miscarriage and what to expect following a miscarriage.
Antiphospholipid syndrome and pregnancy loss (pdf)
Investigations following recurrent miscarriage (pdf)
Management of Miscarriage: surgical, medical, natural (pdf)
Miscarriage and the workplace (pdf)
Pregnancy loss — how you might feel (pdf)
Pregnancy loss and infertility (pdf)
Preparing for another pregnancy (pdf)
Someone you know — a leaflet for family and friends (pdf)
Talking to children about pregnancy loss (pdf)
Why did it happen to us? (pdf)
Basis for recommendation
Basis for recommendation
Assessing and supporting the psychological well-being of women following miscarriage is widely recommended by experts [RCOG, 2006] based on evidence on the prevalence and severity of psychological distress following miscarriage [Brier, 1999; Brier, 2004; Brier, 2008].
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, but may take several cycles to re-establish a regular pattern.
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 Preparing for another pregnancy (pdf).
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 advice published by the Royal College of Obstetricians and Gynaecologists [RCOG, 2008].
When to give anti-D immunoglobulin
When should I give anti-D immunoglobulin following a miscarriage?
Non-sensitized rhesus-negative women should receive anti-D immunoglobulin if:
A miscarriage or threatened miscarriage occurs after at least 12 weeks of pregnancy.
Miscarriage is managed by surgical or medical evacuation of the uterus at any gestation.
A threatened miscarriage is associated with heavy or recurrent bleeding or pain before 12 weeks of pregnancy.
Anti-D immunoglobulin is normally given in secondary care.
Basis for recommendation
Basis for recommendation
These recommendations are based on guidelines from the Royal College of Obstetricians and Gynaecologists to reduce the risk of maternal sensitization [RCOG, 2006].
Recurrent miscarriage
How should I manage a woman with recurrent miscarriage?
Offer referral to all women who have had three or more miscarriages for investigation of the cause.
Advise that it may not be possible to determine the cause of recurrent miscarriage.
Following referral, the woman is likely to be offered:
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).
Assessment for antiphospholipid antibodies and possibly other immunological abnormalities.
A patient information leaflet produced by the Miscarriage Association is available on Investigations following recurrent miscarriage (pdf).
Basis for recommendation
Basis for recommendation
These recommendations are based on guidelines from the Royal College of Obstetricians and Gynaecologists on investigating and treating couples with recurrent miscarriage [RCOG, 2003].
Secondary care management
What secondary care management may be offered for a confirmed first trimester miscarriage?
The choice of management for a confirmed first trimester miscarriage is largely based on the woman's preference, unless there are clinical indications for surgical intervention.
Surgical uterine evacuation using suction curettage — should be offered to all women. It is clinically indicated for managing miscarriage associated with persistent excessive bleeding, haemodynamic instability, infected retained products of conception, and suspected trophoblastic disease.
It has the advantage of rapid resolution of symptoms.
Approximately 2% of women experience a serious complication of surgery, which may include:
Uterine perforation.
Cervical tears.
Intra-abdominal trauma.
Intrauterine adhesions and haemorrhage.
Medical uterine evacuation using prostaglandin analogues to stimulate uterine expulsion of the products of conception. This should be offered to all women unless there is a clinical indication for surgical evacuation.
It has the advantage of avoiding the risks of an operation and allows the woman to feel more in control.
There is a risk of increased pain and bleeding following treatment, and symptoms may persist for several weeks.
Surgical intervention may be required if products of conception are retained despite medical treatment. The success of medical treatment is largely dependant on the type of miscarriage being treated. Medical treatment for incomplete miscarriage is most likely to be successful; the success rate decreases when treating a missed miscarriage.
Conservative management allows natural resolution of the miscarriage without any intervention. It should be offered to all women unless there is a clinical indication for surgical evacuation.
It has the advantage of avoiding hospitalization and the risks of an operation.
Symptoms may take several weeks to resolve. Some women require surgical evacuation for failed conservative management.
Basis for recommendation
Basis for recommendation
This information is based on the treatment options recommended by the Royal College of Obstetricians and Gynaecologists [RCOG, 2006].
Evidence
Evidence
Supporting evidence
CKS has reviewed the evidence on the accuracy of clinical features to predict pregnancy outcomes in women with a suspected miscarriage, and the conservative management of women with an inevitable miscarriage.
Evidence on the recommended secondary care management of women with a confirmed miscarriage has not been reviewed. This is available from the Royal College of Obstetricians and Gynaecologists in the guidance Management of early pregnancy loss [RCOG, 2006].
Estimating miscarriage risk
Evidence on estimating miscarriage risk in women with bleeding in early pregnancy
A prospective observational study found that approximately 50% of women with bleeding in early pregnancy had a miscarriage. This risk was increased by finding a uterus that was small for dates, bleeding that was increasing, bleeding that was heavier than a normal menstrual period, and bleeding associated with clots. The miscarriage risk was reduced in women with both bleeding in early pregnancy and continuing pregnancy-associated vomiting.
Study: Threatened abortion: prediction of viability based on signs and symptoms [Chung et al, 1999].
Methods
This prospective observational study examined the association between clinical features and miscarriage risk in 739 women presenting with bleeding in early pregnancy.
The clinical features associated with bleeding in early pregnancy were recorded for each woman and a trans-vaginal ultrasound scan was undertaken to establish a definite diagnosis.
The clinical features predictive of miscarriage were identified by logistic regression analysis.
Results
The overall risk of miscarriage for women with bleeding in early pregnancy was approximately 50%.
This miscarriage risk was statistically significantly increased in women with:
Bleeding that was heavier than a normal menstrual period (miscarriage risk 75%).
Bleeding of increasing severity (miscarriage risk 80%).
Bleeding associated with passage of clots (miscarriage risk 80%).
Uterine size that was small for dates.
An open cervical os on examination (miscarriage risk 100%).
Products of conception seen on examination (miscarriage risk 100%).
The miscarriage risk was statistically significantly reduced in women with bleeding in early pregnancy if:
Bleeding was lighter than a normal menstrual period (miscarriage risk 40%).
Bleeding was reducing in severity (miscarriage risk 40%).
Bleeding was not associated with passage of clots (miscarriage risk 40%).
There was ongoing pregnancy-associated vomiting (miscarriage risk 30%).
Conservative management
Evidence on conservative management of confirmed miscarriage
Evidence from a systematic review of randomized control trials (RCTs) compared the effectiveness of surgical, medical, and conservative management of confirmed miscarriage [Graziosi et al, 2004]. A subsequent RCT examined the risk of harm for each management [Trinder et al, 2006]. These trials found that successful and rapid resolution of miscarriage was most effectively managed surgically, less effectively managed medically, and least effectively managed conservatively. However, the risk of harm was highest for surgery, lower for medical management, and lowest for conservative management.
Study: Management of early pregnancy loss [Graziosi et al, 2004].
Methods
This systematic review identified thirteen RCTs examining the effectiveness of surgical, medical, and conservative management of first trimester miscarriage.
The outcomes included complete evacuation, complications, duration of bleeding, pain, adverse effects, and the woman's satisfaction with the procedure.
Results
Surgical management compared with medical management was reported by five studies.
Overall, surgical management achieved complete evacuation in approximately 97% of women compared with 70% of women who had medical management.
Nearly all failures of medical management occurred in women treated for missed miscarriage.
Medical management compared with conservative management was reported by five studies.
Overall, medical management achieved complete evacuation in approximately 80% of women compared with 40% of women managed conservatively.
Conservative management achieved complete evacuation in approximately 40% of women.
Nearly all failures of medical and conservative management occurred in women treated for a missed miscarriage.
Conservative management compared with surgical management was reported by three studies.
Overall, conservative management achieved complete evacuation in approximately 70% of women compared with 97.6% of women who had surgical management.
All failures of conservative management occurred in women with a missed miscarriage.
Study: Management of miscarriage: expectant, medical, or surgical? Results of a randomized controlled trial [Trinder et al, 2006].
Methods
This RCT randomized 1200 women with confirmed miscarriage to surgical, medical, or conservative management [Trinder et al, 2006].
The incidence of confirmed infection within the first 14 days following the miscarriage, and the use of an antibiotic for presumed infection, was recorded for each group.
Results
The incidence of confirmed infection was not statistically significantly different between groups. The incidence of confirmed infection:
For the surgically managed group, was 3%.
For the medically managed group, was 2%.
For the conservatively managed group, was 3%.
The incidence of presumed infection treated by antibiotics was significantly lower in the conservatively managed group compared with the surgically managed group. There was no statistically significant difference in the incidence of presumed infection between the medically and surgically managed groups. The incidence of presumed infection:
For the surgically managed group, was 8.5%.
For the medically managed group, was 7.8%.
For the conservatively managed group, was 4%.
The cessation of bleeding after randomization was significantly earlier in the surgical group compared with the medically and conservatively managed groups. There was no statistically significant difference between the groups in:
The time to return to normal activities.
The duration of sick leave.
Anxiety or depression scores.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of miscarriage with additional searches for evidence in the following areas:
First trimester miscarriage
Primary and Secondary care management
Management of recurrent miscarriage
Management following miscarriage
Search dates
January 1999 – October 2009
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.
Abortion, Spontaneous/, pregnancy loss.tw., miscarriage.tw.
recurrent miscarriage.tw., cause$.tw.
bleeding in pregnancy.tw.
subchorionic hemorrhage.tw., subchorionic hematoma.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 Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
National Guidelines Clearinghouse
British Columbia Medical Association
Institute for Clinical Systems Improvement
Guidelines International Network
National Library of Guidelines
National Health and Medical Research Council (Australia)
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Sources of systematic reviews and meta-analyses
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
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
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
DynaMed
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
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)
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]
Chung, T.K.H., Sahota, F.D.S., Lau, T.K. et al. (1999) Threatened abortion: prediction of viability based on signs and symptoms. Australia and New Zealand Journal of Obstetrics and Gynecology 39(4), 443-447. [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]
Graziosi, G.C., Mol, B.W., Ankum, W.M. and Bruinse, H.W. (2004) Management of early pregnancy loss. International Journal of Gynaecology and Obstetrics 86(3), 337-346. [Abstract]
Porter, T.F., Branch, D.W. and Scott, J.R. (2008)
Rai, R. and Regan, L. (2006) Recurrent miscarriage. Lancet 368(9535), 601-611. [Abstract]
RCOG (2003) The investigation and treatment of couples with recurrent miscarriage. .Guideline No. 17.Royal College of Obstetricians and Gynaecologists.www.rcog.org.uk [Free Full-text]
RCOG (2006) The management of early pregnancy loss. ..Royal College of Obstetrics and Gynaecologists.www.rcog.org.uk [Free Full-text]
RCOG (2008) Early miscarriage: information for you. ..Royal College of Obstetricians and Gynaecologists.www.rcog.org.uk [Free Full-text]
RCOG (2009) Medical terms explained. ..Royal College of Obstetricians and Gynaecologists.www.rcog.org.uk [Free Full-text]
Trinder, J., Brockelhurst, P., Porter, R. et al. (2006) Management of miscarriage: expectant, medical, or surgical? results of randomised controlled trial (miscarriage treatment (MIST) trial). British Medical Journal 332(7552), 1235-1240. [Abstract] [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]