Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Spontaneous abortion: Management

Togas Tulandi, MD, MHCM
Haya M Al-Fozan, MD
Section Editor
Robert L Barbieri, MD
Deputy Editor
Kristen Eckler, MD, FACOG


Spontaneous abortion, or miscarriage, is defined as a clinically recognized pregnancy loss before the 20th week of gestation [1,2]. The World Health Organization (WHO) defines it as expulsion or extraction of an embryo or fetus weighing 500 g or less. The term "fetus" will be used throughout this discussion, although the term "embryo" is the correct term at ≤10 weeks of gestation.

The management of spontaneous abortion, with a focus on the first trimester, is discussed here. The risk factors, clinical manifestations, diagnosis, and classification of spontaneous abortion are discussed separately. (See "Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation".)


Preconceptual and prenatal counseling and care are the most important interventions for prevention of spontaneous abortion in women with no prior history of miscarriage. Use of pharmacologic therapy (eg, estrogen, vitamins) has not been found to be effective. Most miscarriages are not preventable, since chromosomal abnormalities account for approximately 50 percent of cases [3]. (See "Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation", section on 'Etiology'.)

Modifiable etiologies and risk factors for spontaneous abortion include [4]:

Maternal disease (eg, diabetes, thyroid disease, thrombophilia) – Preconceptual and prenatal care should include routine screening and optimal disease management for conditions that can result in miscarriage or other adverse effects to the fetus or mother during pregnancy.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Feb 2017. | This topic last updated: May 02, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Regan L, Rai R. Epidemiology and the medical causes of miscarriage. Baillieres Best Pract Res Clin Obstet Gynaecol 2000; 14:839.
  2. Goddijn M, Leschot NJ. Genetic aspects of miscarriage. Baillieres Best Pract Res Clin Obstet Gynaecol 2000; 14:855.
  3. Levy B, Sigurjonsson S, Pettersen B, et al. Genomic imbalance in products of conception: single-nucleotide polymorphism chromosomal microarray analysis. Obstet Gynecol 2014; 124:202.
  4. Feodor Nilsson S, Andersen PK, Strandberg-Larsen K, Nybo Andersen AM. Risk factors for miscarriage from a prevention perspective: a nationwide follow-up study. BJOG 2014; 121:1375.
  5. Haas DM, Ramsey PS. Progestogen for preventing miscarriage. Cochrane Database Syst Rev 2013; :CD003511.
  6. Lim CE, Ho KK, Cheng NC, Wong FW. Combined oestrogen and progesterone for preventing miscarriage. Cochrane Database Syst Rev 2013; :CD009278.
  7. Rumbold A, Middleton P, Pan N, Crowther CA. Vitamin supplementation for preventing miscarriage. Cochrane Database Syst Rev 2011; :CD004073.
  8. Gaskins AJ, Rich-Edwards JW, Hauser R, et al. Maternal prepregnancy folate intake and risk of spontaneous abortion and stillbirth. Obstet Gynecol 2014; 124:23.
  9. Wahabi HA, Fayed AA, Esmaeil SA, Al Zeidan RA. Progestogen for treating threatened miscarriage. Cochrane Database Syst Rev 2011; :CD005943.
  10. Carp H. A systematic review of dydrogesterone for the treatment of threatened miscarriage. Gynecol Endocrinol 2012; 28:983.
  11. Devaseelan P, Fogarty PP, Regan L. Human chorionic gonadotrophin for threatened miscarriage. Cochrane Database Syst Rev 2010; :CD007422.
  12. Lede R, Duley L. Uterine muscle relaxant drugs for threatened miscarriage. Cochrane Database Syst Rev 2005; :CD002857.
  13. Li L, Dou L, Leung PC, Wang CC. Chinese herbal medicines for threatened miscarriage. Cochrane Database Syst Rev 2012; :CD008510.
  14. Aleman A, Althabe F, Belizán J, Bergel E. Bed rest during pregnancy for preventing miscarriage. Cochrane Database Syst Rev 2005; :CD003576.
  15. Sotiriadis A, Makrydimas G, Papatheodorou S, Ioannidis JP. Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis. Obstet Gynecol 2005; 105:1104.
  16. Nanda K, Lopez LM, Grimes DA, et al. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev 2012; :CD003518.
  17. Neilson JP, Gyte GM, Hickey M, et al. Medical treatments for incomplete miscarriage (less than 24 weeks). Cochrane Database Syst Rev 2010; :CD007223.
  18. Shelley JM, Healy D, Grover S. A randomised trial of surgical, medical and expectant management of first trimester spontaneous miscarriage. Aust N Z J Obstet Gynaecol 2005; 45:122.
  19. Trinder J, Brocklehurst P, Porter R, et al. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). BMJ 2006; 332:1235.
  20. Smith LF, Ewings PD, Quinlan C. Incidence of pregnancy after expectant, medical, or surgical management of spontaneous first trimester miscarriage: long term follow-up of miscarriage treatment (MIST) randomised controlled trial. BMJ 2009; 339:b3827.
  21. Doyle NM, Jimenez-Flores DJ, Ramin SM. Medical versus surgical management of missed abortions: An economic analysis. Obstet Gynecol 2004; 103:6S.
  22. You JH, Chung TK. Expectant, medical or surgical treatment for spontaneous abortion in first trimester of pregnancy: a cost analysis. Hum Reprod 2005; 20:2873.
  23. Rocconi RP, Chiang S, Richter HE, Straughn JM Jr. Management strategies for abnormal early pregnancy: a cost-effectiveness analysis. J Reprod Med 2005; 50:486.
  24. Niinimäki M, Karinen P, Hartikainen AL, Pouta A. Treating miscarriages: a randomised study of cost-effectiveness in medical or surgical choice. BJOG 2009; 116:984.
  25. Torre A, Huchon C, Bussieres L, et al. Immediate versus delayed medical treatment for first-trimester miscarriage: a randomized trial. Am J Obstet Gynecol 2012; 206:215.e1.
  26. Neilson JP, Gyte GM, Hickey M, et al. Medical treatments for incomplete miscarriage. Cochrane Database Syst Rev 2013; :CD007223.
  27. Tunçalp O, Gülmezoglu AM, Souza JP. Surgical procedures for evacuating incomplete miscarriage. Cochrane Database Syst Rev 2010; :CD001993.
  28. Harris LH, Dalton VK, Johnson TR. Surgical management of early pregnancy failure: history, politics, and safe, cost-effective care. Am J Obstet Gynecol 2007; 196:445.e1.
  29. Demetroulis C, Saridogan E, Kunde D, Naftalin AA. A prospective randomized control trial comparing medical and surgical treatment for early pregnancy failure. Hum Reprod 2001; 16:365.
  30. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 427: Misoprostol for postabortion care. Obstet Gynecol 2009; 113:465.
  31. Neilson JP, Hickey M, Vazquez J. Medical treatment for early fetal death (less than 24 weeks). Cochrane Database Syst Rev 2006; :CD002253.
  32. Blum J, Winikoff B, Gemzell-Danielsson K, et al. Treatment of incomplete abortion and miscarriage with misoprostol. Int J Gynaecol Obstet 2007; 99 Suppl 2:S186.
  33. Zhang J, Gilles JM, Barnhart K, et al. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med 2005; 353:761.
  34. Graziosi GC, van der Steeg JW, Reuwer PH, et al. Economic evaluation of misoprostol in the treatment of early pregnancy failure compared to curettage after an expectant management. Hum Reprod 2005; 20:1067.
  35. Klingberg-Allvin M, Cleeve A, Atuhairwe S, et al. Comparison of treatment of incomplete abortion with misoprostol by physicians and midwives at district level in Uganda: a randomised controlled equivalence trial. Lancet 2015; 385:2392.
  36. Kollitz KM, Meyn LA, Lohr PA, Creinin MD. Mifepristone and misoprostol for early pregnancy failure: a cohort analysis. Am J Obstet Gynecol 2011; 204:386.e1.
  37. Ledger WL, Sweeting VM, Chatterjee S. Rapid diagnosis of early ectopic pregnancy in an emergency gynaecology service--are measurements of progesterone, intact and free beta human chorionic gonadotrophin helpful? Hum Reprod 1994; 9:157.
  38. Grønlund A, Grønlund L, Clevin L, et al. Management of missed abortion: comparison of medical treatment with either mifepristone + misoprostol or misoprostol alone with surgical evacuation. A multi-center trial in Copenhagen county, Denmark. Acta Obstet Gynecol Scand 2002; 81:1060.
  39. Stockheim D, Machtinger R, Wiser A, et al. A randomized prospective study of misoprostol or mifepristone followed by misoprostol when needed for the treatment of women with early pregnancy failure. Fertil Steril 2006; 86:956.
  40. Benson J, Clark KA, Gerhardt A, et al. Early abortion services in the United States: a provider survey. Contraception 2003; 67:287.
  41. Jain JK, Meckstroth KR, Park M, Mishell DR Jr. A comparison of tamoxifen and misoprostol to misoprostol alone for early pregnancy termination. Contraception 1999; 60:353.
  42. Weeks A, Faúndes A. Misoprostol in obstetrics and gynecology. Int J Gynaecol Obstet 2007; 99 Suppl 2:S156.
  43. de Jonge ET, Makin JD, Manefeldt E, et al. Randomised clinical trial of medical evacuation and surgical curettage for incomplete miscarriage. BMJ 1995; 311:662.
  44. Chung TK, Lee DT, Cheung LP, et al. Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol. Fertil Steril 1999; 71:1054.
  45. Muffley PE, Stitely ML, Gherman RB. Early intrauterine pregnancy failure: a randomized trial of medical versus surgical treatment. Am J Obstet Gynecol 2002; 187:321.
  46. Bagratee JS, Khullar V, Regan L, et al. A randomized controlled trial comparing medical and expectant management of first trimester miscarriage. Hum Reprod 2004; 19:266.
  47. Khan RU, El-Refaey H, Sharma S, et al. Oral, rectal, and vaginal pharmacokinetics of misoprostol. Obstet Gynecol 2004; 103:866.
  48. American College of Obstetricians and Gynecologists. Practice bulletin no. 143: medical management of first-trimester abortion. Obstet Gynecol 2014; 123:676.
  49. Chipchase J, James D. Randomised trial of expectant versus surgical management of spontaneous miscarriage. Br J Obstet Gynaecol 1997; 104:840.
  50. Ankum WM, Wieringa-De Waard M, Bindels PJ. Management of spontaneous miscarriage in the first trimester: an example of putting informed shared decision making into practice. BMJ 2001; 322:1343.
  51. Wieringa-de Waard M, Vos J, Bonsel GJ, et al. Management of miscarriage: a randomized controlled trial of expectant management versus surgical evacuation. Hum Reprod 2002; 17:2445.
  52. Nielsen S, Hahlin M, Platz-Christensen J. Randomised trial comparing expectant with medical management for first trimester miscarriages. Br J Obstet Gynaecol 1999; 106:804.
  53. Banerjee S, Aslam N, Woelfer B, et al. Expectant management of early pregnancies of unknown location: a prospective evaluation of methods to predict spontaneous resolution of pregnancy. BJOG 2001; 108:158.
  54. Casikar I, Bignardi T, Riemke J, et al. Expectant management of spontaneous first-trimester miscarriage: prospective validation of the '2-week rule'. Ultrasound Obstet Gynecol 2010; 35:223.
  55. Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure--current management concepts. Obstet Gynecol Surv 2001; 56:105.
  56. Ogden J, Maker C. Expectant or surgical management of miscarriage: a qualitative study. BJOG 2004; 111:463.
  57. Luise C, Jermy K, May C, et al. Outcome of expectant management of spontaneous first trimester miscarriage: observational study. BMJ 2002; 324:873.
  58. Savaris RF, de Moraes GS, Cristovam RA, Braun RD. Are antibiotics necessary after 48 hours of improvement in infected/septic abortions? A randomized controlled trial followed by a cohort study. Am J Obstet Gynecol 2011; 204:301.e1.
  59. Finkielman JD, De Feo FD, Heller PG, Afessa B. The clinical course of patients with septic abortion admitted to an intensive care unit. Intensive Care Med 2004; 30:1097.
  60. Leung SW, Pang MW, Chung TK. Retained products of gestation in miscarriage: an evaluation of transvaginal ultrasound criteria for diagnosing an "empty uterus". Am J Obstet Gynecol 2004; 191:1133.
  61. Creinin MD, Harwood B, Guido RS, et al. Endometrial thickness after misoprostol use for early pregnancy failure. Int J Gynaecol Obstet 2004; 86:22.
  62. Fiala C, Safar P, Bygdeman M, Gemzell-Danielsson K. Verifying the effectiveness of medical abortion; ultrasound versus hCG testing. Eur J Obstet Gynecol Reprod Biol 2003; 109:190.
  63. Barnhart KT, Sammel MD, Rinaudo PF, et al. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol 2004; 104:50.
  64. Murphy FA, Lipp A, Powles DL. Follow-up for improving psychological well being for women after a miscarriage. Cochrane Database Syst Rev 2012; :CD008679.
  65. Stratton K, Lloyd L. Hospital-based interventions at and following miscarriage: literature to inform a research-practice initiative. Aust N Z J Obstet Gynaecol 2008; 48:5.
  66. Bardos J, Hercz D, Friedenthal J, et al. A national survey on public perceptions of miscarriage. Obstet Gynecol 2015; 125:1313.
  67. Goldstein RR, Croughan MS, Robertson PA. Neonatal outcomes in immediate versus delayed conceptions after spontaneous abortion: a retrospective case series. Am J Obstet Gynecol 2002; 186:1230.
  68. Makhlouf MA, Clifton RG, Roberts JM, et al. Adverse pregnancy outcomes among women with prior spontaneous or induced abortions. Am J Perinatol 2014; 31:765.
  69. Love ER, Bhattacharya S, Smith NC, Bhattacharya S. Effect of interpregnancy interval on outcomes of pregnancy after miscarriage: retrospective analysis of hospital episode statistics in Scotland. BMJ 2010; 341:c3967.
  70. Wong LF, Schliep KC, Silver RM, et al. The effect of a very short interpregnancy interval and pregnancy outcomes following a previous pregnancy loss. Am J Obstet Gynecol 2015; 212:375.e1.
  71. Schliep K, Mitchell E, Mumford S, et al. Trying to conceive after an early pregnancy loss. Obstet Gynecol 2016.
  72. Bhattacharya S, Townend J, Bhattacharya S. Recurrent miscarriage: Are three miscarriages one too many? Analysis of a Scottish population-based database of 151,021 pregnancies. Eur J Obstet Gynecol Reprod Biol 2010; 150:24.
  73. Buchmayer SM, Sparén P, Cnattingius S. Previous pregnancy loss: risks related to severity of preterm delivery. Am J Obstet Gynecol 2004; 191:1225.
  74. Swingle HM, Colaizy TT, Zimmerman MB, Morriss FH Jr. Abortion and the risk of subsequent preterm birth: a systematic review with meta-analyses. J Reprod Med 2009; 54:95.
  75. Edlow AG, Srinivas SK, Elovitz MA. Second-trimester loss and subsequent pregnancy outcomes: What is the real risk? Am J Obstet Gynecol 2007; 197:581.e1.