AKT · Obstetrics & gynaecology/Early pregnancy

Miscarriage and intrauterine death

Pregnancy loss before 24 weeks (IUD after 24w)

Overview

Loss of a pregnancy before 24 weeks (miscarriage); intrauterine/stillbirth from 24 weeks. Types: threatened, inevitable, incomplete, complete, missed. Managed expectantly, medically or surgically.

Recognise

Vaginal bleeding ± crampy suprapubic pain in early pregnancy
Threatened: bleeding, os CLOSED, viable; Inevitable: os OPEN
Missed: no symptoms, no fetal heartbeat on USS; Incomplete: retained products

Red flags

Heavy bleeding/haemodynamic compromise, signs of sepsis (septic miscarriage)

Differentials & how to tell them apart

Ectopic pregnancymust exclude — empty uterus with positive βhCG, adnexal mass

Gestational trophoblastic diseasevery high hCG, "snowstorm" USS, hyperemesis

Cervical/local cause of bleedingspeculum exam

Investigations

Transvaginal USS (fetal pole + heartbeat / crown-rump length; mean sac diameter). Serial βhCG for pregnancy of unknown location. Exclude ectopic.

Management

Expectant management (first-line) — medical/surgical if needed

1Confirmed miscarriage: expectant management is first-line (up to 7–14 days) if stable.Gate: Offer medical/surgical management instead if: increased bleeding/infection risk, previous adverse pregnancy event, or the woman prefers not to wait
2Medical: misoprostol (vaginal/oral) ± mifepristone. Surgical: manual vacuum aspiration or ERPC.
3Anti-D for rhesus-negative women having surgical management; offer support and follow-up.

Misoprostol (± mifepristone) — medical management

Anti-D immunoglobulin — rhesus-negative women having surgical management (and per guidance)

Key points

Always exclude ectopic and molar pregnancy. Recurrent miscarriage (≥3) warrants investigation (antiphospholipid syndrome, parental karyotype, uterine anomaly).

Monitor & prognosis

Completion (bleeding/scan/βhCG); psychological support.

Most go on to successful future pregnancies.

Source: NICE NG126; CKS Miscarriage