Surgical Management of First Trimester Miscarriage ≤13 weeks gestation (894)

Surgical evacuation of uterus can be offered to women with a non-continuing pregnancy at ≤13 weeks gestation.

Surgical management of miscarriage should be the first line-treatment for:

• persistent excessive vaginal bleeding
• haemodynamic instability
• evidence of infected retained tissue
• suspected gestational trophoblastic disease

• The standard GG&C consent form should be used Surgical Evacuation SMM | Patient Agreement to Investigation or Treatment Consent Form | Right Decisions
• Provide verbal and written information to all women about the treatment options available and what to expect during and after the procedure.
• The intended benefits and risks of the procedure and any extra procedures that may become necessary should be discussed.
• Written consent should be taken by a health professional familiar with the procedure.
• Women who are obese, who have significant pre-existing medical conditions or who have had previous surgery must be made aware that the quoted risks for serious or frequent complications may be increased.
• If the woman wishes to avoid a pregnancy after the procedure, contraceptive options can be discussed. Surgical management can be an opportunity for the insertion of intrauterine contraception. If the woman wishes this, additional consent should be obtained.
• Discuss and obtain consent for Pathology and sensitive disposal of fetal remains. For guidance see Fetal Tissue - handling and disposal (up to and including 23+6 weeks gestation) (340) | Right Decisions.
• Ensure completion of the appropriate paperwork prior to attending theatre. (Form 2 or Form 3).

Form 2: Authorisation for burial or cremation following pregnancy loss up to 23 weeks and 6 days gestation | Right Decisions

Form 3: Pregnancy loss - authorisation for completion of Form 2 on behalf of the patient | Right Decisions

• Obtain baseline full blood count (FBC) and group and save (G&S). In addition, perform any other relevant investigation as indicated by patient clinical history.
• Consideration can be made to offering screening for vaginal infection if this is suggested by history or examination findings. This may include high vaginal swab +/- testing for chlamydia and gonorrhoea.  It should be noted there is conflicting evidence about the association between chlamydia infection and miscarriage, and overall the likelihood of a link is small.
• Anaesthetic pre-assessment should be arranged to determine the patient’s suitability for a surgical procedure, and to identify risk factors.
• Where any increased risk factors or contraindications are identified, discussion with, or review by, the clinician / anaesthetist should be arranged as appropriate.

• Determine change in clinical condition since pre-assessment. If, in the interim, there has been significant PV loss, consider rescan to confirm that surgical evacuation is still the most appropriate management option.
• Complete admission portion of Assessment Booklet as locally indicated.
• Administer Misoprostol 400 micrograms vaginally 3 hours prior to surgery OR sublingually 2–3 hours prior to surgery. (If given by the sub-lingual route, it can be effective for cervical priming if given at least 1 hour before the procedure.)  Misoprostol for cervical priming prior to surgical management of 1st trimester miscarriage up to and including 13+0 weeks gestation (1011) | Right Decisions

Antibiotics should be discussed and administered according to local guideline recommendations.  Antibiotic Prophylaxis in Gynaecological Procedures (663) | Right Decisions

• Bleeding at the time of the procedure or shortly after can be caused by uterine atony, coagulopathy or abnormal placentation, OR by complications such as uterine perforation, cervical laceration and retained pregnancy tissue.
• Additionally, if there is unexpected heavy bleeding at the time of surgery it should alert the surgeon to the possibility of gestational trophoblastic disease or in a woman with a history of caesarean section, there may be the possibility of a previously undiagnosed caesarean scar pregnancy.
• Management of uterine perforation will depend on the instruments used:
  • If a perforation occurs when using a dilator or curette then conservative management with antibiotics, observation and explanation to the patient may be appropriate.
  • If larger diameter instruments or a suction curette is used, or if there is significant revealed bleeding, then laparoscopy should be performed.
• The use of intraoperative ultrasound can be considered during instrumentation of the uterus during surgical management of miscarriage procedures. Evidence to date suggests that use at any gestation can reduce risks of bleeding, perforation and improve completion of the procedure.  However, these complications are relatively rare, and difficult to quantify.    Currently in GG&C, where feasible, intraoperative USS guidance can be considered where complications are thought to be more common e.g. suspected infection, failed medical management (TOP or miscarriage), molar pregnancy.

• Observation of blood pressure and pulse should be monitored using the NEWS chart.
• Assessment of pain levels and vaginal blood loss at least 1hourly or as clinically indicated.
• Discharge may be 2 hrs post-operatively or when local Day Surgery discharge criteria are fulfilled.
• Ensure the patient receives appropriate discharge information. Where possible, this information should be given in written form.
• Ensure women and their families have an awareness of, and access to, appropriate support and counselling services.
• Arrange appropriate follow up based on individual needs.
• Inform all relevant primary care professionals of pregnancy outcome and management.

All Rhesus negative women who have surgical management of miscarriage at any gestation should receive Anti-D as this is regarded as a potential sensitising event.

For more details see Anti-D Immunoglobulin Administration Following Potentially Sensitising Events and Routine Antenatal Anti-D Prophylaxis in RhD Negative Women (559) | Right Decisions

VTE assessment should be made for each patient and prescribed according to local guidelines.