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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Expectant, medical and surgical miscarriage care

Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Haemorrhage or sepsis changes the plan

Shock, uncontrolled bleeding, syncope, severe escalating pain, fever, offensive discharge, uterine tenderness or systemic illness requires urgent resuscitation, antibiotics and surgical source control rather than routine expectant or home medical care.

Action: Use ABCDE, IV access, FBC, coagulation, renal profile, lactate, cultures and crossmatch as indicated, start broad-spectrum IV antibiotics for sepsis and involve senior gynaecology for urgent evacuation.

Synopsis

Offer confirmed miscarriage treatment in a clear sequence, using NICE first-line expectant care, exact medical regimens, surgical choices, emergency thresholds and completion follow-up.

  • 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.

Key red flags

Soaking pads rapidly with dizziness, collapse, tachycardia, hypotension or pallor indicates clinically important haemorrhage and requires emergency care.

Fever, rigors, offensive discharge, uterine tenderness or feeling acutely unwell suggests infected retained tissue and needs urgent antibiotics and evacuation assessment.

Unilateral pain, shoulder-tip pain or persistent positive testing when location was never confirmed requires ectopic assessment rather than further miscarriage medication.

A positive urine pregnancy test three weeks after treatment may represent retained, molar or ectopic pregnancy and requires review, not automatic reassurance.

Investigation priorities

01
Diagnostic transvaginal ultrasoundFirst step

Confirm intrauterine miscarriage and assess whether tissue remains before treatment.

Management branches

First-line expectant careWait safely for 7–14 days

A confirmed uncomplicated miscarriage is stable and the patient accepts expectant management.

  1. Explain likely bleeding, pain, tissue passage, analgesia, remains options and exact emergency thresholds and provide written 24-hour contact information.
  2. Review 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.
  3. If 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.
Surgical first lineEvacuate for danger or preference

There is haemorrhage, infection, conservative-treatment failure, contraindication or a clear preference for procedural completion.

  1. Resuscitate haemorrhage or sepsis and give broad-spectrum IV antibiotics when infection is suspected, involving senior anaesthetic and gynaecology teams.
  2. Offer outpatient manual vacuum aspiration under local anaesthetic or theatre evacuation under general anaesthetic when clinically appropriate and explain comparative risks.
  3. Confirm completeness, send tissue according to histology policy, apply current anti-D rules and provide recovery, testing, remains and bereavement follow-up.

Key medicines

Mifepristone plus misoprostol for missed miscarriageGive 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 miscarriageGive 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.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG126 miscarriage managementExpectant sequence, exact medicines, surgery and follow-up.
  • NICE NG126 anti-D prophylaxisJune 2026 prophylaxis recommendations.
  • NHS miscarriage treatmentPatient-facing expectant, medical and surgical care.
  • NHS miscarriage recoveryPhysical recovery and emotional support.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom