Management

Patient and doctor need to accept that medical treatment has little to offer and work through the emotional problems a threatened miscarriage presents.

Diagnosis:

• pregnancy test, fetal heart sounds, fetal movements and ultrasound are all positive

Management:

• bed rest, sedation; there is no evidence that gonadotrophins are of any help in the treatment of threatened miscarriage, Rhesus prophylaxis if appropriate
• a systematic review concluded that progestogens are probably effective in the treatment of threatened miscarriage but may have little or no effect in the rate of preterm birth (1)
  • since then, the effects of first-trimester use of vaginal micronized progesterone have been evaluated in 2 large, high-quality, multicenter placebo-controlled trials, one targeting women with unexplained recurrent miscarriages (the PROMISE [PROgesterone in recurrent MIScarriagE] trial) and the other targeting women with early pregnancy bleeding (the PRISM [PRogesterone In Spontaneous Miscarriage] trial) (2)
    • a key finding, first observed in the PROMISE trial, and then replicated in the PRISM trial, was that treatment with vaginal micronized progesterone 400 mg twice daily was associated with increasing live birth rates according to the number of previous miscarriages
    • therefore, women with a history of miscarriage who present with bleeding in early pregnancy may benefit from the use of vaginal micronized progesterone 400 mg twice daily.

NICE state "..

• advise a woman with vaginal bleeding and a confirmed intrauterine pregnancy with a fetal heartbeat that:
  • if her bleeding gets worse, or persists beyond 14 days, she should return for further assessment
  • if the bleeding stops, she should start or continue routine antenatal care
• offer vaginal micronised progesterone 400 mg twice daily to women with an intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and have previously had a miscarriage
• if a fetal heartbeat is confirmed, continue progesterone until 16 completed weeks of pregnancy

Reference:

• 1) Wahabi HA et al. Progestogen for treating threatened miscarriage. Cochrane Database Syst Rev 2018 Aug 6;8(8):CD005943.
• 2) Coomarasamy A, Devall AJ, Brosens JJ, et al. Micronized vaginal progesterone to prevent miscarriage: a critical evaluation of randomized evidence. Am J Obstet Gynecol. 2020;223(2):167-176. doi:10.1016/j.ajog.2019.12.006
• 3) NICE (September 2023).Ectopic pregnancy and miscarriage: diagnosis and initial management