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Practice Uncertainties

What is the best method for managing early miscarriage?

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.l6438 (Published 20 January 2020) Cite this as: BMJ 2020;368:l6438
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Linked Opinion

Aftercare shouldn’t be an afterthought

Linked Opinion

Being more open might have helped me feel less isolated after a miscarriage
  1. Justin Chu, , sub-specialist trainee in reproductive medicine and national clinical coordinator (MifeMiso),1 2 Adam J Devall, senior clinical trial fellow and centre manager/team leader for miscarriage research2 3,
  2. Pollyanna Hardy, statistics lead4,
  3. Leanne Beeson, senior trial manager (MifeMiso)4,
  4. Arri Coomarasamy, professor of gynaecology and director of Tommy’s National Centre for Miscarriage Research3
  1. 1Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
  2. 2University of Birmingham, Institute of Metabolism and Systems Research, Birmingham, UK
  3. 3Tommy's Centre for Miscarriage Research, Birmingham, UK
  4. 4University of Birmingham, Birmingham Clinical Trials Unit, Birmingham, UK
  1. Correspondence to justinchu{at}doctors.org.uk

What you need to know

  • Guidelines from the National Institute for Health and Care Excellence recommend expectant management, ie, waiting for spontaneous miscarriage, for 7-14 days after early miscarriage is diagnosed if there are no complications

  • Medical management with misoprostol has comparable success rates to surgery but there is uncertainty about the appropriate dosing regimen, the route of administration, and the role of mifepristone

  • Evidence is limited on outcomes such as women’s preferences, satisfaction, and subsequent fertility

An early miscarriage is the loss of pregnancy at ≤13 weeks’ gestation.1 It is a major life event and can have a potentially devastating psychological impact on the woman in addition to the physical effects such as bleeding and pain.2 About one in four pregnancies, where a woman has missed a menstrual period and has a positive pregnancy test, ends in early miscarriage.3 Nearly 125 000 early miscarriages occur annually in the UK, accounting for 50 000 hospital admissions.4

Early miscarriage is usually diagnosed by pelvic ultrasound after a woman has experienced vaginal bleeding or abdominal pain. Women with a complete miscarriage, where expulsion of pregnancy tissue is complete, are managed conservatively without further intervention. Women with a missed or incomplete miscarriage (box 1) may require further intervention.

Box 1

Categories of early miscarriage

  • Missed miscarriage—pregnancy tissue is complete inside the uterus without fetal heart activity. The woman may have minimal symptoms

  • Incomplete miscarriage—ultrasound imaging shows that some but not all of the pregnancy tissue has passed.5 Women have usually had pain and bleeding

RETURN TO TEXT

Surgery under general anaesthesia used to be the standard treatment for miscarriage,6 but a wider choice of management options is now available (fig 1).3 Over the past two decades there has been a shift towards individualised care and shared decision making between clinician and patient. Up to 70% of women with miscarriage opted for …

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