Clinical Guidelines for Treating a Patient
Experiencing Miscarriage
Written by Marie A. Walter, MS, RN, C-EFM, CPLC and
Rana Limbo, PhD, RN, CPLC, FAAN
Part of the It’s Never Too Early™ Initiative
Definition of a Miscarriage
For the purposes of these clinical guidelines, we will follow the definition provided
by The American College of Obstetricians and Gynecologists (ACOG) in the 2015
Practice Bulletin that describes miscarriage as “a non-viable, intrauterine
pregnancy with either an empty gestational sac or a gestational sac containing an
embryo or fetus without fetal heart activity within the first 12 6/7 weeks of
gestation.” Ectopic pregnancy and complete molar pregnancy are both early
pregnancy losses but will not be covered in the discussion.
We will be defining miscarriage in the following terms:
• Anembryonic or Blighted Ovum: fertilization occurs; gestational sac
develops. Although the woman is pregnant, no embryo is seen.
• Chemical Pregnancy: fertilization occurs; pregnancy ends before five or six
weeks’ gestation; there is no gestational sac seen on ultrasound.
• Partial Molar Pregnancy: fertilization occurs; mole contains both abnormal
cells and an embryo or fetus which eventually is overtaken by the abnormal
cells. Due to the presence of an embryo, this is defined as a miscarriage.
• Embryonic or Fetal demise: fertilization occurs; cardiac activity, which was
initially present, ceases, or a demonstrable embryo is not visible on
ultrasound.
Additionally, miscarriage can be understood based on when it occurs.
• Spontaneous or Inevitable Miscarriage: the miscarriage happens on its own,
without medical intervention. This spontaneous action can be deemed
complete or incomplete. Complete miscarriage refers to total expulsion of
all products of conception from the uterus, whereas incomplete means that
some tissue or placenta remains. As it is imperative that the uterus be
emptied to prevent sepsis, medical intervention is necessary.
• Missed Miscarriage: a demise has occurred; the actual process of expelling
the products of conception has not begun.
• Threatened Miscarriage: bleeding or other signs of distress may be present,
but are unconfirmed. About half of all threatened miscarriages will progress
to a complete miscarriage.
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Causes of a Miscarriage
A definite cause of the miscarriage may not be found. Genetic testing of products
of conception can be offered as part of miscarriage evaluation to determine
whether a chromosomal abnormality was present. Even if an abnormality is
found, it is not necessarily likely to occur again. Most chromosomal abnormalities
arise de novo rather than being inherited from a parent with a balanced
translocation. Furthermore, some genetic abnormalities are not easily detected
by conventional analysis because they are caused by point mutations, microdeletions, or duplications.
Potential causes of miscarriage are listed below.
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Aging ovum
Irregular ovulation
Luteal phase defects
Prior miscarriage
Maternal social factors; cigarette smoking, alcohol and illicit drug use
Maternal caffeine use – dose related
Uterine anomalies, both acquired and congenital, such as; Muellarian
defects, adhesions from curettage or septum removal, and scarring from
prior myomectomy, fibroid removal, or classical cesarean delivery
Maternal infections such as; rubella, toxoplasmosis, HSV, cytomegalovirus,
parvovirus, listeria, and Zika
Endocrinopathies such as, thyroid dysfunction, and polycystic ovary
syndrome (PCOS)
Maternal Diabetes, especially if not well-controlled
Thrombophilias such as; Factor V Leiden deficiency and methylene
tetrahydrofolate reductase (MTHFR)
Maternal immune disorders such as; lupus erythematosus and
antiphospholipid antibody syndrome (APS)
Embryonic/fetal chromosomal abnormality. Causative factor in 50% of all
miscarriages
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When Is a Miscarriage a Medical Crisis?
Miscarriage typically does not rise to the level of a medical emergency. Bleeding,
cramping, fever and chills, nausea, vomiting, or diarrhea are all common
symptoms. Still, there is cause to consider the risk of hemorrhage, anemia, high
fever, and other symptoms suggesting endometritis or extreme distress.
Cognitively and/or emotionally women may feel that they are in the midst of an
emergency; therefore, treatment that focuses on both the physical and emotional
presentation ought to be addressed.
The following symptoms warrant emergency care:
• Bleeding enough to soak through one heavy duty menstrual pad per hour
for 2 consecutive hours
• Fever of 100.4 degrees F (38 degrees C) for more than 4 consecutive hours
• Bad smelling discharge
• Pain considered intolerable by the patient despite use of OTC medications
such as Acetaminophen.
• Blood clots the size of a plum
Assess Before Treating
The symptoms of miscarriage such as vaginal bleeding and utrerine cramping, are
also common in a normal pregnancy (ACOG, 2015). Bleeding or spotting can occur
at any time during a pregnancy. Still, when a women notices bleeding or
experiences uterine cramping, she is likely to feel some measure of concern, even
alarm. To distinguish between early pregnancy complications and early pregnancy
loss, healthcare providers must conduct a thorough assessment. The approach
should be person-, family-, and culture-centered (Lor, Crooks, & Tluczek, 2016).
The evaluation must be inclusive of clinical assessments as well as the use of
active listening, information sharing, ample time for processing any bad news,
and decision-making.
As noted by Limbo, Glasser, and Sundaram (2014), “being sure” is central to a
woman’s ability to navigate through a miscarriage. She needs to be sure that her
pregnancy has ended and be sure that she has chosen the treatment option that
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is right for her. Thus, before any treatment options are contemplated, a thorough
and accurate assessment to confirm the diagnosis is critical for the patient.
Assessment components are listed below:
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Thorough medical history
Physical examination, including a pelvic exam
Vital signs
Transvaginal ultrasound
Laboratory: Serum β-hCG evaluation(s) Blood type and Rh, Hemoglobin/
Hematocrit, White Count
Treatment Options for Miscarriage
There are three options for treating miscarriage: expectant management, medical
management, and surgical treatment. Each of these options is considered safe
and has comparable risk factors for infection and hemorrhage. In the presence of
maternal hemodynamic instability and/or uncontrolled, heavy bleeding, suction
dilation and curettage (D&C) remains the standard of care; however, if there is
time to consider alternate therapies, it is vital that patients be included in
decision making (Walter & Alvarado, 2017).
Expectant management
This approach allows the body to respond naturally to its own process of expelling
the products of conception from the uterus. Bleeding and cramping occur as the
cervical os dilates. A follow-up appointment with both serial β-hCG evaluations
and ultrasound may be useful to confirm that the uterus is empty. Heavy or
prolonged bleeding and/or intense or prolonged cramping may indicate that the
miscarriage is incomplete and surgical treatment is necessary. The
unpredictability of expectant management is what leads some women to choose
another option.
Medical management
Misoprostol is a prostaglandin E1 analogue. It is typically administered
intravaginally due to higher bioavailability. Oral or buccal administration is
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acceptable but often leads to more bothersome side effects such as nausea and
vomiting. The miscarriage typically begins within 2 to 6 hours of administration.
Patient perception of pain and therefore need for analgesics may be higher.
Zhang et al. (2005) reported that up to 71% of women had complete expulsion of
POC with just one dose of Misoprostol. That rose to 84% with a second dose. A
D&C was needed in up to 16%. A perceived advantage of medical management is
that it is less invasive than surgery and yet expedites the miscarriage process.
Surgical treatment
Surgical options can be performed at a hospital or clinic utilizing manual vacuum
or curettage. Surgical options are predictable and fast, they reduce bleeding, and
they may lead to perceived better pain control by the woman. Of those women
undergoing D&C, 90% had complete clearing of uterine contents by day 15, and
97% by day 30. A repeat D&C was needed only 3% of the time (Zhang et al., 2005).
The major disadvantage of relying on surgery is its invasiveness and risks
associated with anesthesia if used.
Preparing the Patient
All three treatment options come with the possibility that the woman will
miscarry randomly prior to any intervention. That is, the woman may miscarry
before administration of misoprostol, prior to the surgical procedure, or
unexpectedly. Rather than leaving the patient unprepared for this possibility,
providing comfort items for use at home is strongly recommended.
These items can be placed in a nondescript bag with instructions on their use.
Also included should be a bereavement folder with appropriate materials, the
after-hours contact information and any other additional information that may be
helpful should the patient begin to hemorrhage or otherwise feel the need for
emergency care.
The comfort items listed on the follow page are shown in Figure 1.
• Potty hat to monitor blood loss and to safely capture the miscarriage, baby,
or products of conception (POC)
• Heavy duty menstrual pads
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• Disposable under pads with fluid resistant backing to protect bed/furniture
from absorbing blood and fluid
• Disposable gloves
• A small plastic container to place the POC in for safe keeping.
• A muslin bag or other appropriate bag for the patient to transport the POC
to the hospital or clinic
Figure 1
Physiological Impact on Patients
Miscarriage can be compared to the actual birthing process. As with labor at
term, the amount and duration of pain, bleeding, cramping, nausea, and other
symptoms experienced during a miscarriage will vary. Those providing care for
the woman experiencing a miscarriage need to be aware that women will often
experience fear, shock, uncertainty, and loss of control in the face of a
miscarriage. This can be heightened by the intense physical symptoms they feel.
• Consider antibiotic prophylaxis.
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• Assess hemoglobin level if continued heavy bleeding or other signs of
anemia.
• Assess for clinical signs of endometritis: high fever, heavy bleeding, or
increasing pelvic pain.
Patients need to know that vaginal bleeding or spotting may continue for several
weeks after a miscarriage. Breast tenderness, engorgement, or lactation can also
occur. Menstrual cycles typically begin within 4 to 8 weeks. Sexual activity can
resume when bleeding has stopped and the patient feels physically and
emotionally ready. A return to normal levels of physical activity usually takes 3 to
4 weeks.
If a woman knows that she will have a miscarriage, she rarely thinks about the
possibility of hemorrhage. Excessive bleeding is not a common complication, but
it is a type of traumatic birthing experience. Hemorrhage may cause fear for one’s
life, a lack of understanding about how to manage the heavy bleeding,
uncertainty about when to go to the emergency department or outpatient clinic,
and an overwhelming fear that it might happen again when considering a next
pregnancy. In the study by Limbo, Glasser, and Sundaram (2014), one woman
who initially signed the research consent form ultimately opted out before the
interview because she was too afraid to talk about her hemorrhage in the
required data-gathering interview.
Hormonal changes may lead to mood swings, shifts in sleeping and eating
patterns, difficulty concentrating or focusing, and adjustments in your overall
level of energy. Postpartum depression can also be experienced post-miscarriage.
Postpartum Depression
The DSM-V diagnosis of depression during the postpartum period refers to
peripartum onset. It is important to recognize that the patient may present in a
fragile emotional state. According to the Centers for Disease Control and
Prevention (2017), 1 in 9 women experiences postpartum depression. While it is
well understood that the postpartum period can be a challenging time for any
woman, postpartum depression (PPD) also affects women who miscarry.
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While multiple factors can contribute to postpartum depression, hormonal
changes and sleep deprivation are thought to be two major factors. Certainly, the
ending of a pregnancy itself can induce a grief reaction much like that felt after
the death of a loved one, that is, shock and disbelief, pangs of grief, confusion,
guilt, and somatic symptoms (Thieleman & Cacciatore, 2013). Still, postpartum
depression is more than a grief reaction as it is marked by extreme emotions and
an inability to care for oneself and one’s family. Counseling/psychotherapy and/or
anti-depressant medication are preferred methods of treatment. Left unabated,
postpartum depression can last for months or years and impact future
pregnancies.
It is important to alert the patient to the possibility of PPD and offer guidelines on
how to recognize symptoms and seek professional help. Symptoms include the
following:
• Feeling numb, invisible, disconnected, or empty
• Life feels meaningless or irrelevant
• Dramatic changes in the ability to concentrate, eat, sleep, and/or perform
routine tasks
• Feeling worthless or hopeless
• Having disturbing and/or intrusive thoughts
• Thinking about harming yourself or others
Communicating With the Patient
Emotional and/or behavioral reactions by patients are commonplace. Being in
pain or feeling fearful, in shock, or numb creates a less than ideal situation for
important discussions.
It is important to speak slowly, distinctly, and with a warm and compassionate
voice. Rely on active listening to ensure that you are hearing not only the words
of the patient, but the meaning and intentions of the communication. Pause
frequently to verify what the patient understood you to say and to determine if
they want information repeated. Ask the patient to repeat back instructions.
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Critical information should be provided in writing, and the materials should be
reviewed with the patient so that they can easily locate needed information.
The following tips can help guide your interactions and, if necessary, help in the
delivery of “bad news”:
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Make eye contact and speak clearly and distinctly.
Actively listen to the patient.
Determine the patient’s understanding of what is occurring.
Anticipate that the patient may have an emotional response to her current
state.
Correct any misunderstandings, myths, or misconceptions.
Use language that matches that of the patient when referring to the
pregnancy.
Take into consideration the patient’s language abilities, culture, and level of
education.
Give a gentle warning before imparting bad news (e.g., I have some
important news to share…).
Allow for silence after delivering bad news so that the patient has time to
absorb the information. Resist the urge to fill the quiet with information
the patient/family will be unable to attend to.
Be empathetic.
Summarize the current situation, strategize options, and support the
patient’s decision-making.
Use empathy to reflect on the patient’s emotional state.
o “You seem afraid, is that right?”
Legitimize the patient’s experience through validation.
o “Yes. You made the right choice to be seen because of the cramping
and bleeding you are having. ”
Appreciate the efforts the patient makes to communicate effectively.
o “Thank you for telling me that you are concerned about the amount
of blood you have already lost.”
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• Support the patient’s feelings and thoughts.
o “It’s okay with me that you are crying. I’m here to help you.”
• Use active listening to fully comprehend and understand the patient.
o “I gather that it hurts when I push on your abdomen here.”
Respectful Disposition
Far too often a patient who allowed the hospital to manage the disposition of
remains may call asking, “Where is my baby?” Women who make the decision to
leave the disposition of the remains up to the hospital can change perspectives.
Months or years later they may question what occurred during the miscarriage
and want to know and understand what happened to the remains. Requiring a
process for respectful disposition is a key strategy in providing sensitive care for
the patient experiencing a miscarriage.
This heartrending situation is one of the major reasons why policies and
procedures for respectful fetal disposition are necessary. Patient records should
accurately and thoroughly record the miscarriage, including how fetal remains
were managed. If the hospital was given responsibility, all pertinent data
regarding date, method, and location of disposition needs to be logged. All
remains should be tagged with the name of the patient so that identification is
possible.
Guidelines for Respectful Treatment of Fetal Remains
• Provide the patient oral and written information regarding the facility’s
policies and procedures for handling fetal remains.
• Place no demands on the patient to make decisions within a prescribed
timeframe; allow them time to process the experience.
• If possible, provide the patient and family the opportunity to see, touch,
name, and be witness to the baby.
• Separate remains from medical waste, individually preserve them, and
store them for final disposition by the patient or the facility.
• Bury intact remains (individually bundled) in a single casket (co-casketing).
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• Bury remains at a site deemed appropriate for burial by state and/or local
law.
• Cremate or incinerate the remains only if other options do not exist or are
overly burdensome. Remains are separated from other medical waste and
are sent to a facility licensed to dispose of fetal remains.
• With facility disposition, consider hosting a Memorial or Remembrance
Ceremony for interment of remains.
• With private disposition, compassionately and caringly present the remains
to the patient.
Memorial Services
Memorial services are seen as a way of helping a family say goodbye. These
services aren’t necessarily considered a religious ritual; instead, they are
considered a spiritual commemorative event that is welcoming and inclusive.
While a particular organization may be affiliated with a specific sect or religion, all
those in attendance may not share the same beliefs. With that in mind the service
designed by a specific organization or person may avoid works with religious
connotations and choose more humanistic works and images. Experience
suggests that there may be one or more participants at the service who had a
pregnancy loss in the past and may not have been afforded an opportunity for a
formal recognition or chance to say goodbye. These individuals can also be
allowed to remember their babies during the observance.
Photographs of the memorial service are encouraged so that they can be shared
with participants as a further extension of memory making. Photographs can also
be made available to those women and their families that were unable to attend
the observance.
Families with surviving children may wish to include them. The officiant can say,
“Children are present here today as significant family members: siblings of the
baby who died. Please welcome them and think of ways in which they embody
the sounds of the service today.”
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Music, either live or recorded, can help set a calming atmosphere and serve as a
transition during the formal program. Songs performed by a vocalist and/or
participants provide an opportunity for active participation in the observance.
This unifies the group, solidifies bonds with the deceased, and allows them to
access their emotions in a safe and ritualized manner. The therapeutic aspects of
music have long been noted through the discipline of Music Therapy. As Berger
(2012) stated, music encourages the bereaved to "tell and retell their story both
as orators and listeners."
While observances and rituals will change from healthcare institution to
healthcare institution, Appendix A and Appendix B provide easily adaptable
templates for a memorial service invitation and program.
Suggested Clinical Implications
• Not every woman experiencing a miscarriage considers it the loss of a baby.
Assess before assuming.
• Regardless of the point of entry for care, all patients experiencing an early
pregnancy loss should receive the same standard of care.
• Patients who have assigned personhood to their pregnancy are likely to
view the miscarriage as loss of baby, child, or pregnancy.
• Experiencing a miscarriage in the emergency department (ED) constitutes
an emotional emergency and may constitute a medical emergency.
• Staff members in the ED and outpatient settings need to know if the
hospital offers “respectful disposition” and what the process entails, in
order to inform the family.
• Healthcare providers must co-create a plan of care and treatment plan with
the patient and her family in order to assure a satisfactory resolution.
• Patients leaving the ED or outpatient setting to miscarry at home should
have clear, concise information about bleeding amounts, pain control, and
when to return for care.
• The use of a standard list of miscarriage comfort supplies (potty hat, pads,
gloves, and more) will provide the patient who leaves the ED or outpatient
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setting to miscarry at home with useful tools to help her through this
unknown process.
• A woman may view any part of the miscarriage experience as traumatic,
especially heavy bleeding (i.e., hemorrhage). Evidence shows that traumatic
events may lead to depression, anxiety, dwelling on the experience, and
other post-traumatic responses.
• Patients who miscarry will often exhibit a grief response and some will later
develop symptoms of depression or PPD.
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Appendix A: Annual Burial and Memorial Service Information Card
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Appendix B: Annual Graveside Service for Pregnancy Losses Less Than 20 Weeks
Opening
Leader
Each of you held hopes that you would gather with friends and family to celebrate
the birth of your baby. Instead we stand with one another today joined in your
sadness. For you mothers, for a brief time there was the stirring of life in your
womb. Your baby grew inside you. For you fathers, your wife or partner nourished
the seed of your future under her heart. So, too, in both of you grew hopes and
dreams, and longing images of who this baby would be, and of your future with
this child. Now there is emptiness and pain as you acknowledge that this seed of
life could not mature fully into the child of your heart.
In the Hebrew Scriptures the Psalmist writes: "Out of the depths I call to You, O
God; You hear me fully when I call. God is with me, I have no fear. I was hard
pressed, about to fall; God came to my help. God, you are my strength and my
courage. I will not die, but live, and yet tell of the deeds of God. I thank you for
having heard me; O God, be my deliverance" (Selections from Psalm 118).
Reading
Sometimes by Marcia Updyke
Sometimes, memories are like rain showers, sprinkling down upon you,
catching you unaware and then they are gone, leaving you warm and refreshed.
Sometimes memories are like thundershowers, beating down upon you,
relentless in their downpour, and then they will cease, leaving you tired and
bruised.
Sometimes, memories are like shadows sneaking up behind you, following you
around. Then they disappear leaving you sad and confused.
Sometimes, memories are like quilts, surrounding you with the warmth,
luxuriously abundant. And sometimes they stay, wrapping you in contentment.
A Litany of Voices
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(based on Some People by Flavia Weedn)
Voices of Mothers (women in unison)
Some people come into our lives and leave footprints on our hearts, and we are
never ever the same. Some people come into our lives and quickly go. Some stay
for a while and embrace our silent dreams. They help us become aware of the
delicate winds of hope, and we discover within every human spirit there are wings
yearning to fly. They help our hearts to see that the only stairway to the stars is
woven with dreams and we find ourselves unafraid to reach high. They celebrate
the true essence of who we are and have faith in all that we may become.
Voices of Fathers (men in unison)
Some people awaken us to new and deeper realizations for we gain insight from
the passing whisper of their wisdom. Throughout our lives we are sent precious
souls, meant to share our journey, however brief or lasting, their stay reminds us
why we are here; to learn, to teach, to nurture and to love.
Voices of Parents (all voices in unison)
Some people come into our lives, and they move our souls . . . . They help us to
see that everything on earth is part of the incredibility of life.
Leader
The babies we honor today came into your lives and left footprints on your
hearts. And you will never ever be the same.
Blessing of the Children
Leader
The purpose of a blessing ceremony is to consciously acknowledge the entrance
of a soul into our lives and to give thanks for the miracle of that life. It also honors
the interconnectedness of this baby and family with the larger community and
even all of creation. (To the parents) What name do you give your baby?
Parent(s)
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Baby, we name you ___ (baby’s name), a sign of our love and your uniqueness. By
this, we will remember you.
Leader
O Child, ___(baby’s name) we bless the memory of you and hold you in our hearts
now and forever.
Readings
A Native American Prayer
A Prayer for the Grieving
I give you this one thought to keep –
I am with you still – I do not sleep.
I am a thousand winds that blow,
I am the diamond glints on snow,
I am the sun on ripened grain,
I am the gentle autumn rain.
When you awaken in the morning’s hush,
I am the swift, uplifting rush
of quiet birds in circled flight.
I am the soft stars that shine at night.
Do not think of me as gone –
I am with you still in each new dawn.
Author Unknown
We Remember Them (Responsive reading)
In the rising of the sun and in its going down
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we will remember you.
In the blowing of the wind and in the chill of winter
we will remember you.
In the opening of the buds and the rebirth of spring
we will remember you.
In the blueness of the skies and in the warmth of summer
we will remember you.
In the beginning of the year and when it ends
we will remember you.
So long as we live, our baby shall live
For he/she is now part of us.
We will remember you.
From Gates of Prayer, Reform Judaism Prayer Book
Prayer of Faith
O God of Comfort,
We trust that beyond absence there is a presence.
That beyond the pain there can be healing.
That beyond the brokenness there can be wholeness.
That beyond the anger there may be peace.
That beyond the hurting there may be forgiveness.
That beyond the silence there may be the word.
That beyond the word there may be understanding.
That through understanding there is love.
Author Unknown
Ritual of Remembrance
Leader
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Rosemary has long been known as the herb of remembrance. Today we invite you
to scatter a portion or the entire herb packet on the gravesite as a living
remembrance of the love for your child who continues to live in your hearts. You
may wish to take some home to scatter in a shared place.
Committal and Closing Blessing
Leader
We commit these babies to the earth and we release their spirits to the unbegun,
unending mystery at the heart of life. May their spirits be at peace now and
forever more. Amen.
So rest in peace, now, our beloved babies.
And go, friends, in sorrow and in hope,
Trusting that healing and peace will come.
Amen
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Appendix C: Products of Conception and Hospital Burial SOP
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Appendix D: Less Than 20 Weeks (born dead) Miscarriage Checklist
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Acknowledgements
Resolve Though Sharing acknowledges the contributions of Elizabeth Levang, PhD
and Melissa Koch for completion of the clinical guidelines component of It’s Never
Too Early™.
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