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Miscarriage Management

Miscarriage affects 1 in 5 pregnancies. Management options are expectant, medical, or surgical — patient choice is central. Anti-D is offered from 12+0 weeks to rhesus-negative women with miscarriage or threatened miscarriage with heavy bleeding…

NICE NG126 Ectopic Pregnancy & Miscarriage

The pathway

1 · Confirm diagnosis

Transvaginal USS: empty sac (blighted ovum), no FH when CRL ≥7mm (missed miscarriage), open os with products (inevitable/incomplete). Repeat USS 7–14 days if uncertain.

2 · Threatened miscarriage

Bleeding + closed os + viable IUP on USS. Expectant management. Reassure. 50% will progress to miscarriage. Rescan in 2 weeks.

3 · Expectant management

Appropriate for most women with missed or incomplete miscarriage. Up to 80% success rate in 2 weeks. Follow-up USS to confirm completion. Return if heavy bleeding >2 pads/hr, fever, or persistent symptoms.

4 · Medical management

Mifepristone 200mg PO then misoprostol 800 micrograms vaginally 24–48h later (or misoprostol alone for incomplete miscarriage)
Effective in 80–90%

5 · Surgical management (ERPC)

Manual vacuum aspiration (outpatient) or surgical evacuation under GA. Indicated if:

Haemodynamic instability
Septic miscarriage
Patient preference
Failed medical management

6 · Anti-D & emotional support

Do NOT offer anti-D up to and including 11+6 weeks (NG126, June 2026). At 12+0–12+6: offer at least 250 IU IM for medical or surgical management, and consider it for threatened miscarriage with heavy or recurrent bleeding. Beyond 12+6, follow local obstetric guidance. Refer to early pregnancy counselling and miscarriage charities.

Drugs

Drug	Dose	Route	Notes
Misoprostol	800 micrograms	Vaginal/sublingual	Can be given at home for missed miscarriage. Follow-up scan in 2 weeks.
Mifepristone	200mg	PO	Sensitises uterus. Given 24–48h before misoprostol.
Anti-D immunoglobulin	At least 250 IU at 12+0–12+6	IM	Rh-negative only, and not below 12+0 weeks (NG126, June 2026). Give within 72h.
Metronidazole	400mg BD	PO	Prophylaxis with surgical evacuation. For septic miscarriage: IV co-amoxiclav + metronidazole.

When to escalate

Haemodynamic instability — IV access, fluid resuscitation, emergency ERPC,Septic miscarriage — IV co-amoxiclav + metronidazole, urgent ERPC, HDU,Failed medical management after 2 weeks — surgical management,Recurrent miscarriage (≥3) — referral to recurrent miscarriage clinic for investigation

Reference: NICE NG126 Ectopic Pregnancy & Miscarriage 2019 / RCOG GTG 25

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