Medical management

For women with a confirmed first trimester miscarriage, medical management could be offered. Patients should be informed regarding bleeding for up to three weeks after medical evacuation (1).

Depending on the clinical situation and the patient's choice, medical management can be carried out on an outpatient basis (1).

Increase in pain and bleeding has been documented as negative factors when considering medical management (1).

NICE have issued guidance with respect to medical management of miscarriage (3):

• mifepristone must not be offered as a treatment for missed or incomplete miscarriage
• offer vaginal misoprostol for the medical treatment of missed or incomplete miscarriage. Oral administration is an acceptable alternative if this is the woman's preference
  • if a missed miscarriage, use a single dose of 800 micrograms of misoprostol
    • advise the woman that if bleeding has not started 24 hours after treatment, she should contact her healthcare professional to determine ongoing individualised care
  • if an incomplete miscarriage, use a single dose of 600 micrograms of misoprostol. (800 micrograms can be used as an alternative to allow alignment of treatment protocols for both missed and incomplete miscarriage)
• offer all women receiving medical management of miscarriage pain relief and anti-emetics as needed
• advise women to take a urine pregnancy test 3 weeks after medical management of miscarriage unless they experience worsening symptoms, in which case advise them to return to the healthcare professional responsible for providing their medical management
• advise women with a positive urine pregnancy test after 3 weeks to return for a review by a healthcare professional to ensure that there is no molar or ectopic pregnancy

Some stated contraindications for medical management include (1,2):

• absolute
  • adrenal insufficiency
  • long term glucocorticoid therapy
  • haemoglobinopathies or anticoagulant therapy
  • anaemia (haemoglobin < 10 g/dl)
  • porphyria
  • mitral stenosis
  • glaucoma
  • NSAID's ingestion in previous 48 hours
• relative
  • hypertension
  • severe asthma (2)

Reference:

• 1. Royal College of Obstetricians and Gynaecologists (RCOG) 2006. The management of early pregnancy loss
• 2. Association of early pregnancy units (2007). AEPU Guidelines
• 3. NICE (April 2019).Ectopic pregnancy and miscarriage