Index

NICE guideline [NG126] Ectopic pregnancy and miscarriage: diagnosis and initial management. Last updated Aug 2023.

Guidelines

Management depends on whether the patient has a history of previous miscarriage or not.

Offer expectant management:

Offer vaginal micronised progesterone 400mg BD until 16 weeks of gestation.

1st line: expectant management for 7-14 days

Indications for other 1st line options:

Expectant management is not acceptable to the patient → offer medical management
Patient is at increased risk of haemorrhage (e.g. late first trimester)
Patient is at increased risk from the effects of haemorrhage (e.g. coagulopathies, unable to have a blood transfusion)
Features of infection
Presence of previous adverse and/or traumatic experience associated with pregnancy (e.g. stillbirth, miscarriage, antepartum haemorrhage)

If pain and bleeding resolve after 7-14 days:

This suggests that the miscarriage has been completed
Provide the patient a urine pregnancy test to carry out at home 3 weeks after the miscarriage
Advise the patient to return if the pregnancy test is +ve

If the pain and bleeding have not started OR are persisting and/or increasing:

All women:

Analgesic and anti-emetics as needed
See below for the choice of drug
Home urinary pregnancy test to be carried out 3 weeks after medical management
- Return to clinic if the pregnancy test is +ve or still bleeding heavily or have other symptoms

NICE only made specific recommendations on the medical management of missed and incomplete miscarriage.

Offer:

Oral mifepristone 200mg, AND
48 hours later → oral / sublingual / vaginal misoprostol 800mcg (unless the gestational sac has already been passed)

If the bleeding did not start within 48 hours after misoprostol → contact their doctor.

Offer a single dose of oral / sublingual / vaginal misoprostol 600 mcg

Do not offer mifepristone for incomplete miscarriage.

Offer the women a choice of:

Offer anti-D immunoglobulin prophylaxis (250 IU / 50 mcg) to all Rh-ve women who have a surgical procedure for miscarriage.

NICE Ectopic pregnancy and miscarriage: diagnosis and initial management

Author: Adams Lau
Reviewer:
Last edited: 16/05/25