Change to national missed miscarriage management guidance after Tommy’s research

NICE – the public body which publishes guidance on medical treatments for use by the NHS in England and Wales – has updated its advice on which drugs should be given to women and birthing people who have experienced a missed miscarriage.

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.

If you have a missed miscarriage you’ll need to have treatment to resolve it and there are 3 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. Research has shown that failed medical management which leads to surgery can cause additional distress for parents who have opted for medical management as their first treatment choice.  

Researchers from Tommy’s National Centre for Miscarriage Research have been working 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

From 2017-2019 a team from our Tommy’s National Centre for Miscarriage Research led the MifeMiso trial, which was designed find the best treatment for women who have had a missed miscarriage.

Writing in The Lancet in 2020, Prof Arri Coomarasamy, Dr Justin Chu, Dr Adam Devall and team showed that treatment with mifepristone plus misoprostol was more effective than misoprostol alone in the management of missed miscarriage. It also meant fewer women had to have surgery to manage their miscarriage after medical management was unsuccessful.  

711 women took part in the study from 28 hospitals in the UK, with half given mifepristone plus misoprostol while the other half were given a placebo tablet in addition to misoprostol.  

Our researchers 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.

The study showed that taking both of these medicines 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.

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.

Dr Adam Devall, Deputy Director of the Tommy’s National Centre for Miscarriage Research at the University of Birmingham says:  

“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.”