Expectant Management of First Trimester Miscarriage (679)

Objectives

To provide safe management for women diagnosed with a non-continuing pregnancy who wish expectant management up to 12 weeks gestation.

Audience

This guideline is designed for use within the Early Pregnancy Assessment Services across GG&C.

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Diagnosis

Miscarriage in the first trimester, is made using ultrasound scan.  The recommended mode of imaging for diagnosis of first trimester miscarriage is transvaginal ultrasound.

Criteria for Diagnosis on Ultrasound

  • Confirm presence or absence of fetal heartbeat (FH).
  • If absent FH – look for fetal pole and measure crown rump length (CRL).
    • If CRL 7.0mm or more with absent FH – can confirm diagnosis of miscarriage with second opinion from an additional sonographer. If no other qualified staff available for second opinion arrange rescan in 7 days.
    • If CRL <7.0mm with absent FH – arrange rescan in minimum of 7 days.
  • If no fetal pole seen but gestational sac present – measure mean sac diameter (MSD).
    • If MSD 25.0mm or more with no fetal pole - can confirm diagnosis of miscarriage with second opinion from an additional sonographer. If no other qualified staff available for second opinion arrange rescan in 7 days.
    • If MSD <25.0mm with no fetal pole - arrange rescan in minimum of 7 days.
  • If transvaginal ultrasound scan not possible or patient declines transvaginal ultrasound – perform transabdominal ultrasound.
    • If FH absent but fetal pole seen – measure CRL and arrange rescan in minimum of 14 days.
    • If gestational sac seen with no fetal pole – measure MSD and arrange rescan in minimum of 14 days.
  • Ensure women who are awaiting repeat scan have EPAS contact details, information on what to expect if spontaneous miscarriage occurs while waiting and where and when to access help in an emergency.

Management

Current NICE guidance [1] 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 any of the following apply:

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

Arrange 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

Please see current local guidelines Anti-D Immunoglobulin Administration Following Potentially Sensitising Events and Routine Antenatal Anti-D Prophylaxis in RhD Negative Women (559) | Right Decisions

Antibiotic prophylaxis

Should not be given routinely and should only be given based on individual clinical indications.  Where infection is suspected, other management options should be considered for expedite evacuation of the uterus.

VTE prophylaxis

Please see current local guidelines

Support and follow up

  • Ensure appropriate patient information given – a written leaflet should be given where possible. Following confirmation of an early pregnancy loss: information for patients from the Early Pregnancy Assessment Service (EPAS) | Right Decisions
  • 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 provide a prescription as appropriate
  • 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 (Form 2).

Fetal Tissue - handling and disposal (up to and including 23+6 weeks gestation) (340) | Right Decisions

Form 2: Authorisation for burial or cremation following pregnancy loss up to 23 weeks and 6 days gestation | Right Decisions

Form 3: Pregnancy loss - authorisation for completion of Form 2 on behalf of the patient | Right Decisions

Editorial Information

Last reviewed: 25/03/2026

Next review date: 31/03/2031

Author(s): Dr Roslyn MacBride, ST7 trainee O&G, QEUH, Dr Claire Higgins, Consultant O&G, QEUH.

Version: 2

Approved By: Gynaecological Clinical Governance Group

Document Id: 679

References
  1. NICE. Ectopic pregnancy and miscarriage: diagnosis and initial management [CG154]. 2019.
  2. NICE pathway for medical management of incomplete or missed miscarriage. 2015.
  3. 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.