Conservative (expectant) management

Expectant management allows spontaneous passage of retained products of conception without any interventions (1).

It can be offered to selected patients with a confirmed first trimester miscarriage (2).

Expectant management is particularly successful in incomplete miscarriage when compared to other types of miscarriages. According to a review based on multiple cohort studies, expectant management was successful within 2-6 weeks without increasing complications in:

• 80-90% of women with incomplete spontaneous miscarriage
• 65-75% of women with delayed miscarriage or an empty sac (3).

Patients undergoing expectant management should be ready to have surgical evacuation in case of failed conservative management.

NICE suggest with respect to expectant management of miscarriage (4)

• use expectant management for 7-14 days as the first-line management strategy for women with a confirmed diagnosis of miscarriage
  • explore management options other than expectant management if:
    • the woman is at increased risk of haemorrhage (for example, she is in the late first trimester) or
    • she has previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) or
    • she is at increased risk from the effects of haemorrhage (for example, if she has coagulopathies or is unable to have a blood transfusion) or
    • there is evidence of infection

Although evidence suggest that expectant management of miscarriage carries a lower risk of infection, a large randomized controlled trial failed to find a considerable difference in infection risks between expectant, medical, and surgical management of miscarriage (5)

• the rate of unplanned hospital admissions was higher in expectant management when compared to the other two methods (1).

To confirm whether a complete miscarriage has occurred, a follow up scan could be done at an interval of two weeks. Around 90% of the women miscarry in three weeks time but a small number of women may take up to 6-8 weeks (5).

Reference:

• 1. Trinder J et al. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). BMJ 2006;332:1235-1240
• 2. Royal College of Obstetricians and Gynaecologists (RCOG) 2006. The management of early pregnancy loss
• 3. Sagili H, Divers M. Modern management of miscarriage. The Obstetrician & Gynaecologist 2007;9:2:102-108
• 4. NICE (April 2019).Ectopic pregnancy and miscarriage
• 5. Association of early pregnancy units (2007). AEPU Guidelines