The National Institute of Clinical Excellence (NICE) has updated its miscarriage management guidelines for use by the NHS in England and Wales, based on evidence from a Birmingham-led clinical trial. The new guidance should help resolve missed miscarriage more quickly and reduce the need for surgical intervention.
Missed miscarriage (also known as a delayed or a silent miscarriage) is when the baby has died in the womb, but often comes with none of the usual signs of miscarriage, such as bleeding or pain. It can come as a huge shock to parents who may only find out they have lost their baby when they attend an ultrasound scan.
Following a missed miscarriage there are three treatment options available: waiting for the miscarriage to happen by itself naturally (called expectant management), taking medicine to help things along (medical management) or having surgery to remove the pregnancy (surgical management). In some cases, medical management does not fully treat a missed miscarriage and surgery may be required afterward.
Researchers from Tommy’s National Centre for Miscarriage Research at the University of Birmingham conducted a trial to find evidence which might reduce the risk of complications following a missed miscarriage and help parents have the best possible treatment.
Until recently, NICE recommended that the drug misoprostol was used for the medical management of missed miscarriage, but it was unclear whether a combination of misoprostol with another drug called mifepristone would be more effective.
The MifeMiso trial, led by University of Birmingham researchers and published in The Lancet, provided evidence that taking both of the medications means that miscarriage is likely to be resolved more quickly. It also reduces the chances of needing further intervention such as surgery.
On Wednesday 23 August 2023 NICE updated their guidelines so that doctors in England and Wales know that this course of treatment is the most effective.
Missed miscarriage is a devastating thing for any parent to experience. Not only can it have a huge impact on the mental wellbeing of women, birthing people and partners, but it can also lead to physical complications if it is not resolved effectively. The update to the NICE guidelines to reflect the findings of the MifeMiso trial will make medical management of missed miscarriage more effective and help healthcare professionals provide the best care to families during this type of pregnancy loss.Dr Adam Devall, Deputy Director of the Tommy’s National Centre for Miscarriage Research
In total, 711 women took part in the study from 2017-2019, with half given mifepristone plus misoprostol while the other half were given a placebo tablet in addition to misoprostol. The study found that 83% of women receiving mifepristone plus misoprostol had miscarriages that had completed within 7 days of treatment, but only 76% of women who received misoprostol in combination with a placebo had completed their miscarriage.
Women and birthing people who experience a missed miscarriage will still be given a choice of which management pathway they want to take, between expectant, medical, or surgical. If medical management is chosen, they should be offered both medicines – mifepristone and misoprostol - to resolve the miscarriage.