Miscarriage Diagnosis and Management

Diagnostic Evaluation

The American College of Radiology recommends transvaginal ultrasound as the cornerstone of miscarriage diagnosis, using specific criteria to categorize early pregnancy loss (EPL), including embryonic crown-rump length and mean sac diameter 1, 2
Concerning for EPL: Embryonic crown-rump length (CRL) <7 mm with no cardiac activity, mean sac diameter (MSD) 16-24 mm with no embryo, or absence of embryo 7-13 days after visualized gestational sac 2
Diagnostic of EPL: CRL ≥7 mm with no cardiac activity, MSD ≥25 mm with no embryo, or absence of embryo ≥14 days after visualization of gestational sac 1, 2
Quantitative hCG measurements are used to confirm declining levels and eventual resolution 3
Complete blood count with platelets is recommended to assess for anemia and thrombocytopenia 3, 4
Blood type and Rh status should be assessed, with Rho(D) immunoglobulin administered to Rh-negative women 3
Thyroid function tests are recommended to rule out thyroid dysfunction 3
Liver and renal function tests are also recommended 4, 5

The American College of Obstetricians and Gynecologists recommends options for incomplete miscarriage, including expectant management, medical management (misoprostol), or surgical evacuation (suction dilation and curettage) 3
Surgical evacuation is preferably performed under ultrasound guidance to reduce risk of uterine perforation 3
Uterotonic agents should be administered during and after the procedure to reduce bleeding risk 3
Serial hCG monitoring is recommended until levels return to non-pregnant state 3
Ultrasound evaluation should be used to confirm complete evacuation of products of conception 1, 2
Histopathologic examination of tissue is recommended to confirm intrauterine pregnancy and rule out gestational trophoblastic disease 3

Patients retain the right to change their management decision and switch to medical or surgical options at any time, according to the American College of Obstetricians and Gynecologists 6

The Society of Radiologists in Ultrasound recommends that embryonic crown-rump length (CRL) <7 mm with no cardiac activity, mean sac diameter (MSD) 16-24 mm with no embryo, and absent embryo 7-13 days after visualized gestational sac with no yolk sac are concerning for early pregnancy loss (EPL) 7, 8
The Society of Radiologists in Ultrasound also recommends that CRL ≥7 mm with no cardiac activity, MSD ≥25 mm with no embryo, and absent embryo ≥14 days after visualization of gestational sac are diagnostic of EPL 7, 8

The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines state that any surgical procedure during pregnancy carries VTE risk and may warrant thromboprophylaxis for 10 days 9
Multiple international guidelines consider surgical procedures as VTE risk factors requiring assessment, and women with prior VTE history or multiple risk factors require individualized VTE risk stratification before surgical management 9, 10, 11, 12