Management of miscarriage

Miscarriage is very common, with an incidence of 1 in 5-6 pregnancies. It can present with vaginal bleeding and passage of the pregnancy tissues. If all the pregnancy tissues are completely passed, it is called ‘complete miscarriage’ or ‘complete abortion’. If some tissues are left behind in the uterus, it is called ‘incomplete miscarriage (or abortion)’. Miscarriage can also be asymptomatic, which is called ‘silent miscarriage (or abortion)’. Silent miscarriage is diagnosed on ultrasound in several ways:

• the fertilised egg has implanted in the uterus but fails to develop into an embryo. Only an empty gestational sac can be seen and this is termed ‘blighted ovum’;
• an embryo is seen within the gestational sac but there is no heart beat

1. Does complete miscarriage need evacuation?
Complete miscarriage, which can be diagnosed accurately on transvaginal ultrasound nowadays does not require evacuation procedure.

2. Options of evacuation of uterus
There are 3 treatment options in the case of incomplete miscarriage or silent miscarriage:

• Expectant management

1. (i) Observational studies have shown that 80% will have spontaneous complete miscarriage if waiting for another 8 weeks;
2. (ii) More likely to happen for those who have already experienced bleeding and uterus cramps;
3. (iii) The timing of spontaneous passage of tissue is not predictable and will usually be preceded by vaginal bleeding and abdominal pain. Hence, this option may not appeal to a lot of women

• Surgical evacuation

1. (i) A simple short operation (~5 min) usually performed under general anaesthesia;
2. (ii) Used to be the standard option for miscarriage in the past;
3. (iii) A good option for those with significant bleeding and suspected infection;
4. (iv) Also a good choice for frequent travelers, those with very tight schedule and those who do not like the other options;
5. (v) Risks of surgery include infection, bleeding, uterine perforation and damage to the lining of the uterus but are very uncommon

• Medical evacuation

1. (i) Use of misoprostol induces uterine contractions and expulsion of the tissues;
2. (ii) It can be given by mouth, placed under the tongue or given vaginally;
3. (iii) High success rate: >85%;
4. (iv) Some may experience intense uterine cramps or significant bleeding. Most find the pain and bleeding tolerable;
5. (v) Follow-up is required to ensure complete removal of the pregnancy tissues;

3. Does the treatment method affect the outcome of future pregnancies?
No. All treatment options do not affect the chance of future pregnancies or their success rates.