Expectant Management of First Trimester Miscarriage (679)

Objectives

This guideline is designed for use within the Early Pregnancy Assessment Services across GGC. The objective is to provide safe management for women diagnosed with a non-continuing pregnancy who wish expectant management up to 12 weeks gestation.

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Management (as per NICE)

Current NICE guidance [1,2] advises use of expectant management for 7–14 days as the first-line management strategy for women with a confirmed diagnosis of miscarriage. Explore management options other than expectant management if:

expectant management is not acceptable or
the woman is at increased risk of haemorrhage (for example, she is in the late first trimester) or
she has previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) or
she is at increased risk from the effects of haemorrhage (for example, if she has coagulopathies or is unable to have a blood transfusion) or
there is evidence of infection.

Explain what expectant management involves and that most women will need no further treatment (successful for 70-80% patients). Give all women oral and written information about what to expect throughout the process, advice on pain relief and where and when to get help in an emergency. Also provide women with oral and written information about further treatment options – medical or surgical (MVA or under GA). Written consent is not mandatory.

Give an appointment for 2-3 weeks’ time and offer a repeat scan. The patient should then be reviewed at 2-weekly intervals if she continues to opt for conservative management. Consider checking FBC/CRP. If ongoing bleeding and/or positive pregnancy test, the patient needs review and USS. Discuss alternative management options of miscarriage.

Exclusion criteria

Women who are/have:

Haemodynamically unstable
Hb <100g/l
Twin or higher order pregnancy
Specific haematological disorder (consider on individual basis) or would refuse blood products (e.g. Jehovah’s Witness)
Women must live or be able to stay locally so as to be able to access emergency admission if required and be able to attend within 1 hour.

Additional Management

Anti-D – not required for cases of complete miscarriage under 12+0 weeks gestation where there has been no formal intervention to evacuate the uterus. Anti-D IM required in non-sensitised Rh negative mothers if >12 weeks or if associated with heavy bleeding3 (dose as per current local guideline).
Antibiotic prophylaxis should not be given routinely and should only be given based on individual clinical indications.
Ensure appropriate patient information given – written leaflet given where possible.
If there are any concerns, or at the patient’s request, appropriate review should be arranged.
Ensure women understand the expected size of fetus and placenta to be passed.
Ensure the patient has analgesia at home or can prescribe analgesia such as Co-codamol if none available.
Inform all relevant primary care professionals of pregnancy outcome and management. Cancel any antenatal clinic appointments or scans.
Discuss histopathological examination and disposal of pregnancy products in line with trust policy. If tissue is passed at home, this can be appropriately disposed of at the time or can be brought in to hospital for pathology/genetics if the patient wishes. If POC are passed in hospital, signed agreement for sensitive disposal by the hospital is required (SD7 form).

Patient counselling and follow-up support is particularly important for women who adopt an expectant approach. They should be aware that complete resolution may take several weeks. Women and their families should be fully informed regarding the likely course of events, and given information on how to access the appropriate services in an emergency situation.

Appendix 1 SD7 form

SD7 form

Last reviewed: 01/04/2019

Next review date: 01/04/2024

Author(s): Ruth Jewell.

Approved By: Gynaecological Clinical Governance Group

Document Id: 679

References

NICE. Ectopic pregnancy and miscarriage: diagnosis and initial management [CG154]. 2019.
NICE pathway for medical management of incomplete or missed miscarriage. 2015.
Qureshi H et al. British Committee for Standards in Haematology (BCSH) guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn. Transfusion Medicine. 2014; 24(1): pp8-20.