Miscarriage associated with significant psychological morbidity (Lancet 2021)
Anxiety and depression screening recommended after pregnancy loss
Recurrent loss associated with PTSD in a significant proportion of patients
Patient Discharge Instructions
copy discharge instructions
Diagnosis and explanation
Threatened miscarriage: bleeding in early pregnancy with a closed cervix and a baby still visible on ultrasound
Many pregnancies with early bleeding continue to term
Your cervix is closed and your pregnancy is currently still present
Bleeding in early pregnancy is common, occurring in up to 1 in 4 pregnancies
Many cases do not result in pregnancy loss
Close monitoring is required to confirm the pregnancy is continuing normally
Activity instructions
Activity restrictions
No sexual intercourse, tampons, or douching until bleeding has fully resolved and cleared by your provider
Pelvic rest until your next appointment
Light normal activity is acceptable; bed rest is not required
Medications
Continue prenatal vitamins and folic acid
If progesterone has been prescribed, take as directed
Avoid ibuprofen (Advil, Motrin) and other anti-inflammatory medications
Use acetaminophen (Tylenol) only if pain relief is needed
Follow-up instructions
Scheduled follow-up
Return to your OB/GYN or early pregnancy clinic in 48-72 hours for repeat blood tests
A repeat ultrasound may be needed in 7-14 days to confirm your pregnancy is growing normally
If fetal heartbeat was seen on ultrasound, your chance of ongoing pregnancy is very good
Return to emergency department immediately if
Red flag symptoms requiring emergency return
Heavy bleeding: soaking more than 1 pad per hour for 2 or more hours
Passage of tissue or clots
Severe or worsening abdominal or pelvic pain
Pain in your shoulder tip (may indicate internal bleeding)
Dizziness, lightheadedness, or fainting
Fever higher than 38.0 C or chills
Any symptoms that concern you
Emotional support
Psychosocial resources
Early pregnancy loss is emotionally difficult regardless of outcome
Support groups and counselling services are available; ask your provider for a referral
Light spotting may continue and does not necessarily mean your pregnancy is at risk
References
Guidelines and key sources
ACOG Practice Guidelines
ACOG Practice Bulletin No. 200: Early Pregnancy Loss. Obstetrics and Gynecology. 2018. Committee on Practice Bulletins-Gynecology
Management framework for all types of early pregnancy loss
Rh immunoglobulin recommendations
ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy. Obstetrics and Gynecology. 2018. Committee on Practice Bulletins-Gynecology
hCG discriminatory zone criteria
Management of ectopic pregnancy
ACR Appropriateness Criteria
ACR Appropriateness Criteria: First Trimester Vaginal Bleeding. 2025 Update. Laifer-Narin SL, Fruauff A, et al. Journal of the American College of Radiology. 2025
Transvaginal ultrasound as first-line imaging
ACR Appropriateness Criteria: Acute Pelvic Pain in the Reproductive Age Group. 2023 Update. Brook OR, Dadour JR, Robbins JB, et al. Journal of the American College of Radiology. 2024
Landmark trials and systematic reviews
Progesterone trials
Coomarasamy A, Devall AJ, Cheed V, et al. A Randomized Trial of Progesterone in Women with Bleeding in Early Pregnancy (PRISM). New England Journal of Medicine. 2019
5% absolute live birth increase in women with bleeding and prior miscarriage
15% absolute increase in ≥3 prior miscarriage subgroup
McLindon LA, James G, Beckmann MM, et al. Progesterone for Women With Threatened Miscarriage (STOP Trial). Human Reproduction. 2023
No benefit in unselected threatened miscarriage population without prior miscarriage history
Devall AJ, Papadopoulou A, Podesek M, et al. Progestogens for Preventing Miscarriage: A Network Meta-Analysis. Cochrane Database of Systematic Reviews. 2021
Confirms benefit limited to high-risk subgroups
Epidemiology and prognosis
Quenby S, Gallos ID, Dhillon-Smith RK, et al. Miscarriage Matters: The Epidemiological, Physical, Psychological, and Economic Costs of Early Pregnancy Loss. Lancet. 2021
Pooled miscarriage risk 15.3%; once cardiac activity confirmed at 8 weeks, live birth 97-98%
Sapra KJ, Buck Louis GM, Sundaram R, et al. Signs and Symptoms Associated With Early Pregnancy Loss. Human Reproduction. 2016
Heavy bleeding with cramping HR 5.03 for pregnancy loss
Ku CW, Tan YB, Tan MMT, et al. A Risk Prediction Model of Spontaneous Miscarriage in Women With Threatened Miscarriage. Frontiers in Medicine. 2025
Serum progesterone <35 nmol/L OR 26.3 for miscarriage
Crochet JR, Bastian LA, Chireau MV. Does This Woman Have an Ectopic Pregnancy? JAMA. 2013
Rational clinical examination systematic review for ectopic pregnancy diagnosis
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