Managing Early Pregnancy Loss

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

• For pregnancy loss <12w0d (spontaneous, surgical or medical management) ACOG “suggests” 

…forgoing routine Rh testing and RhIg prophylaxis
Although not routinely indicated, Rh testing and RhIg administration can be considered on an individual basis in the context of a shared decision-making discussion about the potential benefits and risks

Routine Rh testing in patients with unknown Rh status and administration of RhIg continue to be recommended for Rh-negative, unsensitized patients undergoing abortion or experiencing pregnancy loss at or beyond 12 0/7 weeks of gestation

Learn More – Primary Sources:

ACOG Practice Bulletin 200: Early Pregnancy Loss 

ACOG Clinical Practice Update: Rh D Immune Globulin Administration After Abortion or Pregnancy Loss at Less Than 12 Weeks of Gestation

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