01Purpose and principlesWhat the treatment does and how it fits into care.
Treatment follows confirmation and shared decision-making. Explain expectant, medical and surgical options using the same outcomes: likelihood and timing of completion, pain, bleeding, need for unplanned intervention, anaesthesia, privacy, tissue handling and follow-up. A patient may prioritise avoiding surgery, finishing quickly, being at home, seeing or not seeing pregnancy tissue, preserving control after previous trauma or having immediate certainty. Respect the choice unless instability, infection or another contraindication makes it unsafe.
NICE uses expectant management for 7–14 days as first-line for confirmed miscarriage. Explore alternatives when haemorrhage risk is increased, such as later first trimester; when the consequences of bleeding are greater, such as coagulopathy or refusal of transfusion; when there is infection; or when previous stillbirth, miscarriage or haemorrhage makes waiting traumatic. Give realistic information: cramping and bleeding may be heavier than a period, tissue may be visible and emergency access must be available.
If pain and bleeding resolve within the expectant interval, provide a urine pregnancy test for three weeks after the miscarriage and review if positive. If bleeding and pain never start, persist or increase after 7–14 days, offer repeat ultrasound and revisit continued expectant, medical and surgical choices. Continued expectant care needs a further review at least 14 days after the first follow-up. Do not leave the patient to arrange all testing without a named service.
Medical treatment for missed miscarriage changed in 2023. Give mifepristone 200 mg orally, followed 48 hours later by misoprostol 800 micrograms vaginally, orally or sublingually unless the gestational sac has already passed. Mifepristone primes the uterus by antagonising progesterone; misoprostol causes cervical softening and uterine contractions. If bleeding has not started within 48 hours after misoprostol, contact the service for individualised care and proactively follow patients who may not be able to call.
For incomplete miscarriage, use misoprostol alone: a single 600 microgram vaginal, oral or sublingual dose. An 800 microgram dose may be used to align local protocols. NICE specifically says not to offer mifepristone for incomplete miscarriage because evidence supports combination treatment for missed, not incomplete, loss. State the regimen in discharge information so the patient and next clinician do not confuse the two pathways.
Provide analgesia and antiemetics before symptoms become severe. A practical plan may include paracetamol and, when medically suitable and permitted by the local protocol, an NSAID such as ibuprofen; stronger rescue analgesia may be required. Explain that misoprostol can cause chills, transient fever, nausea, vomiting and diarrhoea. Persistent fever, offensive discharge, increasing pain or feeling unwell is not simply a drug effect and requires infection assessment.
Surgical management is appropriate for haemodynamic instability, heavy ongoing bleeding, infected retained tissue, medical failure or patient preference. NICE offers, where clinically suitable, manual vacuum aspiration under local anaesthetic in an outpatient or clinic setting or uterine evacuation in theatre under general anaesthetic. Discuss cervical preparation, pain, uterine perforation, haemorrhage, infection, cervical trauma, intrauterine adhesions, incomplete evacuation and anaesthetic risk. Use ultrasound guidance according to local practice and clinical complexity.
In septic miscarriage, obtain cultures where this does not delay treatment, start broad-spectrum IV antibiotics covering aerobic and anaerobic genital-tract organisms under the local sepsis protocol and evacuate retained infected tissue once resuscitation and senior planning are underway. Antibiotics alone do not provide source control. Escalate organ dysfunction, lactate elevation, coagulopathy or shock through the maternal sepsis and critical-care pathway.
After medical care, supply a urine pregnancy test for three weeks. A positive result needs review to exclude retained pregnancy, molar pregnancy or ectopic pregnancy and decide further imaging or treatment. A negative test does not explain persistent heavy bleeding, pelvic pain or fever, which still requires assessment. After surgery, provide recovery and emergency advice and confirm any local testing or histology follow-up.
Apply current anti-D advice and discuss pregnancy remains sensitively. Through 11+6 weeks do not offer anti-D for miscarriage, including surgery. From 12+0 to 12+6 weeks, offer at least 250 IU to an RhD-negative patient having medical or surgical management. Explain choices for sensitive disposal, shared cremation or burial according to local arrangements and record preferences. Offer follow-up for results, emotional health, recurrent-loss eligibility and future conception or contraception.
Key points
- Confirm intrauterine miscarriage with safe ultrasound criteria before treatment; if location was never established, maintain PUL follow-up.
- NICE first-line for confirmed miscarriage is expectant management for 7–14 days, unless haemorrhage risk, prior traumatic experience, inability to tolerate bleeding or infection favours another option.
- For missed miscarriage, give mifepristone 200 mg orally, then 48 hours later misoprostol 800 micrograms vaginally, orally or sublingually unless the sac has passed.
- For incomplete miscarriage, give a single misoprostol 600 microgram dose vaginally, orally or sublingually; 800 micrograms is an acceptable protocol-alignment alternative, and do not add mifepristone.
- Offer pain relief and antiemetics with medical care and explain expected cramping, bleeding, diarrhoea, vomiting and the threshold for emergency help.
- If bleeding has not started within 48 hours after misoprostol for missed miscarriage, the patient should contact the responsible service for individualised follow-up.
- Where appropriate, offer surgical choice between outpatient manual vacuum aspiration under local anaesthetic and theatre management under general anaesthetic.
- After expectant or medical management, supply a urine pregnancy test for three weeks; a positive result or persistent symptoms needs review for retained, molar or ectopic pregnancy.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Confirmed uncomplicated miscarriage, stable physiology, manageable symptoms, emergency access and willingness to wait support the 7–14-day first-line pathway.
Retained nonviable pregnancy requires 200 mg oral mifepristone followed 48 hours later by 800 micrograms misoprostol unless the sac passes.
Partial tissue passage uses a single 600 microgram misoprostol dose, with 800 micrograms as an alternative; mifepristone is not added.
Haemodynamic compromise, uncontrolled bleeding, infected retained tissue or failed conservative treatment requires expedited evacuation and resuscitation.
A positive three-week pregnancy test or persistent pain, bleeding or fever suggests retained, ectopic, molar or infected tissue requiring review.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Diagnostic transvaginal ultrasoundFirst step - Why
- Confirm intrauterine miscarriage and assess whether tissue remains before treatment.
- Interpretation and limitations
- Use safe repeat criteria for uncertain viability. If prior intrauterine location is absent, an empty uterus remains PUL rather than complete miscarriage.
- 02
Full blood count - Why
- Assess anaemia, baseline haemoglobin and possible infection before treatment or during heavy bleeding.
- Interpretation and limitations
- Use with symptoms and observations; acute haemorrhage can initially show a normal value, while leukocytosis alone is nonspecific.
- 03
Blood group and RhD - Why
- Prepare for transfusion and determine 2026 anti-D eligibility.
- Interpretation and limitations
- No prophylaxis through 11+6 weeks; at 12+0 to 12+6 weeks offer at least 250 IU to RhD-negative patients having medical or surgical management.
- 04
Three-week urine pregnancy test - Why
- Screen for persistent trophoblast after expectant or medical miscarriage management.
- Interpretation and limitations
- A positive result prompts review for retained, molar or ectopic pregnancy; persistent symptoms require assessment even if the test is negative.
- 05
Sepsis investigations - Why
- Identify organ dysfunction and guide antimicrobial care without delaying source control.
- Interpretation and limitations
- Use blood cultures, lactate, renal and liver profile, coagulation and appropriate genital specimens; treatment begins from clinical sepsis, not culture confirmation.
04Treatment approachPreparation, options, escalation and aftercare.
01First-line expectant careWait safely for 7–14 daysFirst stepFirst lineA confirmed uncomplicated miscarriage is stable and the patient accepts expectant management.+
- 1Explain likely bleeding, pain, tissue passage, analgesia, remains options and exact emergency thresholds and provide written 24-hour contact information.
- 2Review at 7–14 days: if symptoms resolved, supply a three-week urine test; if they never began or persist, repeat ultrasound and discuss all three options again.
- 3EscalationIf continued expectant care is chosen, conduct another review at least 14 days after the first follow-up and escalate haemorrhage, infection or patient preference sooner.
02Medical first optionMatch medicines to miscarriage typeExpectant management is unacceptable or unsuccessful and home or unit medical care is safe.+
- 1For missed miscarriage give mifepristone 200 mg orally, then 48 hours later misoprostol 800 micrograms by an accepted route unless the sac passes.
- 2For incomplete miscarriage give misoprostol 600 micrograms once, or 800 micrograms for protocol alignment, without mifepristone; provide analgesia and antiemetics.
- 3Review if bleeding has not begun within 48 hours after misoprostol and provide a three-week urine test, earlier care for worsening symptoms and active follow-up where contact is difficult.
03Surgical first lineEvacuate for danger or preferenceFirst lineThere is haemorrhage, infection, conservative-treatment failure, contraindication or a clear preference for procedural completion.+
- 1Resuscitate haemorrhage or sepsis and give broad-spectrum IV antibiotics when infection is suspected, involving senior anaesthetic and gynaecology teams.
- 2Offer outpatient manual vacuum aspiration under local anaesthetic or theatre evacuation under general anaesthetic when clinically appropriate and explain comparative risks.
- 3Confirm completeness, send tissue according to histology policy, apply current anti-D rules and provide recovery, testing, remains and bereavement follow-up.
04Positive follow-up testFind persistent pregnancy tissueThe supplied urine pregnancy test remains positive three weeks after expectant or medical care.+
- 1Review pain, bleeding, fever and the original proof of pregnancy location and arrange quantitative hCG and transvaginal ultrasound as indicated.
- 2Exclude retained intrauterine tissue, ectopic pregnancy, ongoing pregnancy and gestational trophoblastic disease rather than repeating misoprostol blindly.
- 3Offer further expectant, medical, surgical or specialist trophoblastic care based on the established cause and the patient’s condition and preference.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Mifepristone plus misoprostol for missed miscarriage
Give mifepristone 200 mg orally once, followed 48 hours later by misoprostol 800 micrograms vaginally, orally or sublingually unless the gestational sac has already passed.Confirm intrauterine nonviable pregnancy, assess bleeding and infection risk, provide analgesia and antiemetics, and review if bleeding has not started within 48 hours after misoprostol.
Misoprostol for incomplete miscarriage
Give misoprostol 600 micrograms vaginally, orally or sublingually once; an 800 microgram single dose may be used to align missed and incomplete miscarriage protocols.Do not add mifepristone for incomplete miscarriage; explain bleeding, pain, gastrointestinal effects, infection signs and the need for a three-week pregnancy test.
Analgesia and antiemetic support
Give paracetamol 1 g orally up to four times daily when appropriate, with an eligible NSAID or prescribed stronger rescue analgesic and antiemetic according to the local miscarriage protocol.Check weight, liver disease, ulcer, renal, asthma and allergy risks, avoid exceeding paracetamol maximums and never allow analgesia to mask haemodynamic deterioration or sepsis.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Document bleeding, pain, temperature, haemodynamic symptoms and patient-defined completion throughout expectant and medical care, with a functioning emergency route.
- Actively confirm that bleeding started after missed-miscarriage misoprostol and contact patients at risk of not returning rather than waiting indefinitely.
- Supply and track the three-week pregnancy test and review every positive result or persistent symptom through imaging, hCG or histology as indicated.
- After surgery, review haemorrhage, infection, uterine or cervical injury, anaesthetic complications, histology and any ongoing pregnancy testing requirement.
- Offer emotional follow-up, assess sleep, intrusive memories, depression, anxiety and safety, and discuss recurrent-loss referral, conception timing or contraception only when wanted.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
First line still requires choice
NICE’s 7–14-day expectant default does not override haemorrhage risk, infection, trauma history or a patient who prefers medical or surgical completion.
Mifepristone belongs to missed loss
The 2023 combination update applies to retained missed miscarriage; incomplete miscarriage continues to use misoprostol alone.
No bleeding needs follow-up
Failure to start bleeding within 48 hours after misoprostol is an actionable sign, not a reason to repeat unsupervised doses.
Local anaesthetic surgery is a real choice
Manual vacuum aspiration can offer rapid completion without general anaesthesia when clinically suitable and acceptable.
A negative test does not cancel symptoms
Infection or another pelvic cause may persist after hCG clears, so ongoing bleeding, pain or fever still requires assessment.
08Common pitfallsFrequent interpretation and management errors.
- 01
Starting miscarriage treatment before safe confirmation of intrauterine nonviability or resolution of a PUL.
- 02
Calling expectant management first-line without discussing 7–14 days, bleeding, emergency access and alternatives.
- 03
Giving misoprostol alone for missed miscarriage or adding mifepristone to incomplete miscarriage contrary to the 2023 update.
- 04
Sending a patient home without analgesia, antiemetics, written emergency thresholds and a named follow-up service.
- 05
Failing to offer outpatient manual vacuum aspiration as an alternative to theatre general anaesthesia where appropriate.
- 06
Ignoring a positive three-week test or persistent symptoms after a negative test.