Management of Miscarriage
Even though miscarriage is common, its diagnosis – especially after an ultrasound – is still unexpected and heartbreaking, especially if no bleeding was present.
An ultrasound should be the first-time couples get to see their baby and hear the heartbeat for the first time, and when this does not occur, it can be devastating. Even more distressing is the sudden choice that women are asked to make regarding their next steps.
When HCPs believe a miscarriage is imminent, women are generally offered three options: allow the miscarriage to occur naturally, take medication, or have a surgical procedure. These options depend on gestational age, as well as a woman's obstetric and overall medical history.
Women need to take their time, become informed of their options, understand the risks and benefits of each, and make the choice that suits them best – along with proper guidance from their HCP.
Note: If an HCP is unsure of the diagnosis after an ultrasound, this is known as an intrauterine pregnancy of uncertain viability.
Background
Current management of first trimester pregnancy loss includes more options for women than generations before, with some of these options allowing for more comfort and privacy. All options have excellent safety profiles, allowing women to choose what makes them most comfortable.
However, all options do carry certain risks. If women are aware of the risks and benefits of each option, and understand them completely prior to making a decision, they can feel more confident they made the right choice.
Researchers have highlighted that "diagnostic certainty and choosing the most appropriate treatment are essential to women's experiences".
Women make decisions differently. There are generally three different "models" of decision making and women should explore which they prefer:
Health care professional determines what to do (some women may prefer this route if the decision is too difficult)
Health care professional informs, provides risks and benefits, and the patient decides
Health care professional and patient collaborate on the decision
There are two categories of care: expectant management and active management.
Active management usually includes medical assistance, such as medication (misoprostol) or surgery (primarily dilation and curettage, commonly known as a D&C). Expectant management includes no formal medical intervention and allows the woman’s body to manage the miscarriage on its own.
Expectant Management
Expectant management involves allowing the miscarriage to happen naturally, which is associated with a lower risk of severe bleeding and infection. However, this process can be unpredictable, and could take anywhere from a few days to a few weeks.
If women wish to avoid medication or a surgical procedure and are prepared to wait a (possibly) lengthier time for the miscarriage to resolve, this option is reasonable, safe, and effective.
Some HCPs advise women to try this method first, at least for the first week or two, as most women will experience resolution within this time frame. The only time this method is not advised is if a woman has independent risk factors for severe bleeding or hemorrhage.
Women may experience cramping under expectant management and are usually advised to take acetaminophen (Tylenol®) for any discomfort. If women choose this method, and become concerned with the amount of bleeding they may be experiencing, or the bleeding is accompanied by pain or a fever, they need to call their HCP immediately.
Women who had severe bleeding in a prior miscarriage under expectant management, or who may have had a previous traumatic experience regarding pregnancy loss, may wish to resolve the miscarriage sooner with medical or surgical options.
Active Management – Medical
Medical management can resolve a miscarriage rather quickly, especially for women who want closure sooner (surgical provides this benefit as well). However, the biggest disadvantage to medical management is the potential for increased pain and/or bleeding.
Misoprostol and mifepristone are the most common medications used (they block progesterone), but the standard doses and routes of administration (orally or through the vagina) have not been definitively established; however, they are both considered safe and effective.
A study published in September 2021 concluded that women with early miscarriage can be reassured that fertility is similar after misoprostol treatment compared to expectant management (above) and that the medication option does not harm chances for a successful subsequent pregnancy.
Side effects of using either medication include the possibility of heavy bleeding that may last 3 to 4 days, followed by a week or more of spotting, as well as nausea, vomiting, and/or diarrhea. These gastrointestinal side effects occur more often when the medication is taken by mouth.
Active Management – Surgical
Surgical management of miscarriage has been the traditional first-line treatment for decades. It is very effective and minimizes bleeding. It also has a higher rate of completing the miscarriage as it immediately removes all tissue.
A surgical option may be positive for pregnant women who would like mental and physical closure in a short period and with less bleeding and a higher success rate. Further, the tissue can be examined to attempt to find a reason for the loss. However, a surgical procedure under local or general anesthesia may be emotionally difficult for some women.
Dilation and curettage (D&C) is the main surgical procedure utilized to remove tissue from the uterus. Additional options include electric vacuum aspiration (EVA), manual vacuum aspiration (MVA), or a combination of vacuum aspiration and D&C.
The dilation and curettage procedure is described in detail here.
MVA is performed while a woman is awake, with a flexible plastic curette, manually operated, and may or may not occur in an operating room. It has been showed to be safe and effective, but is not offered in many medical centers.
EVA is usually performed in an operating room with an electric suction device and a firm curette, and typically involves general, intravenous, or spinal anesthesia.
Although rare, the surgical option can pose a risk of infection, hemorrhage, cervical damage, uterine perforation, as well as complications associated with anesthesia. A D&C also increases the risk of adhesions (see box), which could cause complications in subsequent pregnancies (similar to a cesarean section). Additional risks include a hospital stay, higher costs, as well as potential loss of work.
Follow-up
Follow-up with an HCP is critical to confirm a miscarriage has resolved. Women are advised to take a pregnancy test after about two to three weeks to confirm they are no longer pregnant.
Although this can be very emotional for some women, it is important to confirm the miscarriage has completed, as complications may otherwise result. Unfortunately, especially with expectant management, a return to a zero HCG level may range from 7 to 60 days.
If subsequent testing is positive, women are advised to call their HCP to determine additional steps.
Action
Women need to take their time, become informed of their options, understand the risks and benefits of each, and make the choice that suits them best – along with proper guidance from their HCP.
Regardless of the method chosen, if women become concerned with the amount of bleeding they may be experiencing during recovery, or the bleeding is accompanied by pain or a fever, they need to call their HCP immediately.
Some women may find that counseling helps them through the emotional aspect of managing a miscarriage. HCPs are great resources who can recommend counselors and support groups.
Resources
Management of Early Pregnancy Loss (American College of Obstetricians and Gynecologists)
Asherman Syndrome Fact Sheet (American Society for Reproductive Medicine)