CLINICAL ACTIONS:

Early Pregnancy Loss (EPL) describes a nonviable intrauterine pregnancy identified prior to 13 weeks gestation, often a consequence of significant fetal chromosome abnormalities incompatible with life.  Frequency of EPL increases with maternal age.

Expectant Management

• Limit expectant management to the first trimester
• Spontaneous complete expulsion will occur in 80% of women with EPL ≤8 weeks gestation
• Educate patient on moderate-to-heavy bleeding and cramping
• Provide support and pain medications as needed
• Ultrasound expulsion criteria
  • Absence of gestational sac and endometrial thickness <30 mm (common criteria)
    • No evidence of increased morbidity with thicker endometrium

Medical Management

• Prior to medical management, ensure patient does not have
  • Infection
  • Severe anemia
  • Hemorrhage
  • Bleeding disorder
• Misoprostol 800 micrograms vaginally
  • Repeat once, as needed, no earlier than 3 hours and within 7 days if no response
• Consider mifepristone (if available) 200 mg orally 24 hours before misoprostol (see ‘Note’ and ‘Related ObG Topics’ below)
  • Mifepristone is limited by FDA restrictions
  • ACOG supports “improving access to mifepristone for reproductive health indications”
• Counsel patient about bleeding and cramping
  • If soaking >2 maxipads/hour for > 2 hours, surgical intervention may be indicated
• Use ultrasound to document expulsion or serial quantitative HCGs if ultrasound is unavailable
• In case of failure, patient can still consider expectant management (see above) or surgical intervention

Note: Research (RCT) demonstrates the administration of 200 mg mifepristone followed by 800 micrograms misoprostol improves outcomes

• 83.8% of women in the mifepristone-pretreatment group vs 67.1% in the misoprostol-alone group experienced complete expulsion (see summary in ‘Related ObG Topics’, below)

Surgical management

• Suction curettage in office or ambulatory surgery setting with local anesthesia/sedation
• May be preferred treatment by women who want a faster and more controlled treatment path
• ACOG recommends a single preoperative dose of doxycycline to prevent infection following surgical management
  • 200-mg dose of doxycycline 1 hour prior to surgery (consensus and expert opinion)
• Surgical intervention is management of choice in the following scenarios
  • Hemorrhage
  • Infection
  • Hemodynamic instability

SYNOPSIS:

Expectant, medical or surgical management to treat miscarriage are considered equivalent.  Unless there is a change in clinical status (e.g. hemorrhage or infection), patient preference can guide decision making.

KEY POINTS:

• Risk of serious complications after treatment of EPL are rare, and comparable for all three treatment types
• Medical management compared to expectant management
  • Increases time to complete expulsion
  • Does not increase need for surgical intervention
• Medical management with misoprostol appears to be the most cost-effective treatment of EPL
• Women should avoid intercourse for 1-2 weeks after passage of pregnancy tissue is complete

Rh(D)-immune Globulin

• Risk and dosage for women undergoing EPL
  • Risk is low
  • ‘Consider’ for women undergoing EPL, especially later in first trimester
  • If given, administer ‘at least’ 50 micrograms Rh(D)-immune globulin within 72 hours

Note: In the case of medical management, the ACOG Guideline states that “Women who are Rh(D) negative and unsensitized should receive Rh(D)-immune globulin within 72 hours of the first misoprostol administration”

• Surgical
  • Higher risk of alloimmunization
  • Patients ‘should receive’ at least 50 micrograms Rh(D)-immune globulin

Learn More – Primary Sources:

ACOG Practice Bulletin 200: Early Pregnancy Loss 

Manual vacuum aspiration: an outpatient alternative for surgical management of miscarriages. 

Related ObG Topics:

Does Adding Mifepristone Prior to Misoprostol Improve Medical Management of Pregnancy Loss?

Is Surgical Evacuation Needed Following Incomplete Miscarriage?

Early Pregnancy Loss: How to Make the Ultrasound Diagnosis