The incidence of clinically recognised miscarriage remains around 10–20 %, though post-implantation and biochemical pregnancy loss rates appear to be in the order of 30 %. The majority of miscarriages occur early, before 12 weeks of pregnancy. Second trimester pregnancy loss contributes to less than 4 % of pregnancy losses, and less than 5 % of miscarriages occur after identification of fetal heart activity. In the UK, miscarriage is defined as the loss of an intrauterine pregnancy before 24 completed weeks of gestation.

1. Saraswat L, Ashok PW, Mathur M. Medical management of miscarriage. Obstet Gynaecol. 2014;16:79–85.

2. Alberman E. Spontaneous abortions: epidemiology. In: Stabile I, Grudzinskas JG, Chard T, editors. Spontaneous abortion: diagnosis and treatment. London: Springer; 1992. p. 9–20.

Bleeding in early pregnancy is the most common reason for women to present to the gynaecology emergency department, and miscarriage alone accounts for 50,000 of inpatient admissions to hospitals in the UK annually

1. Saraswat L, Ashok PW, Mathur M. Medical management of miscarriage. Obstet Gynaecol. 2014;16:79–85.

2. Bradley E, Hamilton-Fairley D. Managing miscarriage in early pregnancy assessment units. Hosp Med. 1998;59:451–6.

Routes of misoprostol administration include oral, vaginal, sublingual, buccal or rectal. This medication is not administered in injectable form. There are many studies comparing the pharmacokinetics of misoprostol in various modes of administration.

Vaginal misoprostol is associated with slower absorption, lower peak plasma levels and slower clearance, similar to an extended-release preparation.

The rectal route of administration shows a similar pattern to vaginal administration but has a lower AUC, including a significantly lower maximum peak concentration. The sublingual route of administration has an AUC similar to that of vaginal administration but more rapid absorption (higher T_max) and higher peak levels (C_max) than either vaginal or oral administration.

The buccal route is another mode of administration—the drug is placed between the teeth and the cheek and absorbed through the buccal mucosa. The absorption rate (T_max) after the buccal administration is the same as after vaginal administration, but the serum drug levels attained are much lower with the AUC being half that of the vaginal route.

1. Khan RU, El-Refaey H, Sharma S, Sooranna D, Stafford M. Oral, rectal, and vaginal pharmacokinetics of misoprostol. Obstet Gynecol. 2004;103:866–70.

2. Danielsson KG, Marions L, Rodriguez A, Spur BW, Wong PY, Bygdeman M. Comparison between oral and vaginal administration of misoprostol on uterine contractility. Obstet Gynecol. 1999;93:275–80.

Diagnosis of miscarriage using just one ultrasound scan cannot be guaranteed to be 100 % accurate and there is a small chance that the diagnosis may be incorrect, particularly at very early gestational ages.

According to the NICE guideline, if the crown-rump length is 7.0 mm or more with a transvaginal ultrasound scan and there is no visible heartbeat, seek a second opinion on the viability of the pregnancy and/or perform a second scan a minimum of 7 days after the first before making a diagnosis.

If the mean gestational sac diameter is less than 25.0 mm with a transvaginal ultrasound scan and there is no visible fetal pole, perform a second scan a minimum of 7 days after the first before making a diagnosis. Further scans may be needed before a diagnosis can be made.

https://​www.​nice.​org.​uk/​guidance/​CG154/​chapter/​1-Recommendations#symptoms-and-signs-of-ectopic-pregnancy-and-initial-assessment-2

It is defined as bleeding without passage of tissue but with an open cervix. The patient may be managed by expectant, medical or surgical management. Surgical evacuation remains the treatment of choice if bleeding is excessive, vital signs are unstable or infected tissue is present in the uterine cavity (in which case surgery must be done under antibiotic cover). Fewer than 10 % of women who miscarry fall into these categories. Expectant management can be continued as long as the woman is willing and provided there are no signs of infection. For medical management, a variety of equally effective prostaglandin regimens have been described, including Gemeprost 0.5–1 mg, vaginal misoprostol and oral misoprostol. However, vaginal misoprostol is as effective as oral misoprostol, with a significant reduction in the incidence of diarrhoea. Success rates varied from 61 to 95 %, mild to moderate bleeding lasted 4–6 days, side effects were tolerable in 96 %, and satisfaction rates were 95 %.

Sagili H, Divers M. Modern management of miscarriage. Obstet Gynaecol. 2007;9:102–8.

The NICE guideline recommends offering systemic methotrexate as a first-line treatment to women who are able to return for follow-up and who have all of the following:

http://​www.​nice.​org.​uk/​guidance/​CG154/​chapter/​1-Recommendations#management-of-ectopic-pregnancy