KEY POINTS:
- Early Pregnancy loss refers to miscarriage prior to 20 weeks, missed abortion or incomplete abortion
- Acute management of pregnancy loss focuses on hemorrhage prevention and pain control
- Early pregnancy presentation with bleeding or pain requires ruling out ectopic pregnancy as first step
- Management of pregnancy loss is urgent / emergent only if there is significant active bleeding
- Medical management is 800mcg of vaginal misoprostol followed by second dose if required or necessary
- Rhogam should be administered in Rh negative patients
- Antibiotic prophylaxis is recommended prior to surgical management
BACKGROUND:
Rates of Pregnancy Loss
- Between 15 to 25% of clinically recognized pregnancies will miscarry before 12w6d
- The rate of loss increases with increasing maternal age (ACOG PB 200)
- 9 to 17% between 20 to 30 years of age
- 20% at 35
- 40% at 40
- 80% at 45
- Half of these (at least) are due to chromosomal abnormalities and this proportion also increases with age
- A pregnancy that is diagnosed as failed can be managed either expectantly, medically, or surgically with equivalent rates of success and similar risks of complications | Route guided by patient preferences
Workup Prior to Management
- First step requires knowing where the pregnancy is located prior to offering treatment for early pregnancy loss
- Imperative to rule out ectopic pregnancy
- If incomplete or partial abortion is suspected but ultrasound findings are not diagnostic, intrauterine pregnancy needs to be confirmed
- Uterine aspiration with confirmation of villi (skilled provider can float products or pathology confirmation) is diagnostic
- While subchorionic hemorrhage and slow fetal heart rate can indicate a failing pregnancy, they are not diagnostic of pregnancy loss
Management Options
Expectant management
- Appropriate in hemodynamically stable women
- Women should be educated about what to expect as the pregnancy expels including risks of pain and bleeding
- Up to 80% of pregnancies will expel on their own | To confirm completion of miscarriage it’s acceptable to use ultrasound or serial beta-hCG measurements
- Thickened EEC at follow up ultrasound is not an indication for surgical or medical intervention if a woman is stable
Medical management
- Can be offered in hemodynamically stable women and those in whom expectant management has not resulted in expulsion
- Recommended medical management initial treatment: 800mcg of vaginal misoprostol
- Second dose of 800mcg vaginal misoprostol can be given if indicated
- One large study 71% of women who received 800mcg vaginally had complete expulsion within 3 days | increased to 84% if 2 doses given (Zhang 2005)
- Rh(D)-immune globulin for women who are Rh D-negative (ACOG PB 200)
- “Consider” in women with early pregnancy loss
- Should be administered to women to prevent sensitization within 72 hours
- At least 50 mcg for first trimester losses
- “Should” be administered to women undergoing surgical procedure due to higher risk for alloimmunization
- “Consider” in women with early pregnancy loss
- Recent studies have shown that adding mifepristone 200mg 24 hours before misoprostol dosing can increase expulsion rates and decrease the need for surgical intervention (Schreiber et al. NEJM, 2018)
Surgical management
- Surgical management may be appropriate for women who
- Desire quick resolution of pregnancy loss
- Those who are bleeding heavily
- Have underlying medical comorbidities that are associated with higher risk for bleeding or bleeding complications
- Should be done emergently if there is evidence of
- Hemodynamic instability or
- Infection
- Suction curettage is preferred and sharp curettage is not required in the first trimester
- This can be done in multiple settings including
- OR with sedation | In office with manual vacuum aspiration | ER setting with local block and manual aspiration
- Recommended antibiotic prophylaxis
- Doxycycline 200 mg once 1 hour prior to surgical management
Follow-up after Pregnancy Loss
- There is no workup recommended after one loss
- Only 5% of patients experience a subsequent miscarriage with the next pregnancy (ASRM Committee Opinion)
- Only 1% of patients experience three consecutive pregnancy losses
- Women should be reassured that there is nothing they could have done to prevent the loss, nor was it their fault in any way
- There is no recommended wait time after a first trimester loss before attempting to conceive again with mixed evidence on optimal time to conceive afterwards
- Women who desire contraception do not need to wait | Can start immediately at the time of pregnancy loss
PRIMARY SOURCES:
Schreiber et al. NEJM, 2018
RCT that compared the efficacy and safety of pretreatment with mifepristone versus misoprostol alone for miscarriage management| 148 participants in mifepristone pretreatment group and 149 in the misoprostol alone group were available for analysis
- Results
- Significantly increased complete expulsion of tissue (RR 1.25, 95% CI, 1.09 to 1.43)
- Significantly reduced the need for surgical intervention (RR 0.37 95% CI, 0.21 to0.68)
- There was no difference in pain or bleeding scores between the two groups
- There was no difference in serious adverse events (these were rare)
Dalton VK et al. Obstet Gynecol, 2006
Prospective observational study that compared office-based (MVA) vs operating room management of early pregnancy failure | 115 women had an office procedure and 50 were managed in the OR
- Results
- Both groups were highly satisfied with their procedure
- Women who chose MVA cited “privacy”, “previous experience” and “avoiding going to sleep” as reasons for selecting office procedure
- Cost was > 2 fold higher in the OR intervention group
- There was a low number of significant complications but hemorrhage was 4-fold higher in the OR group (p<0.01)
- This was a self-selected and not randomized group, however so this finding should not drive decision making
Dodge et al. Contracept Repro Med, 2017
- Cross-sectional study to determine whether MVA vs operative procedure expedites care without impacting patient satisfaction | 138 women were surveyed, 48 in the MVA group and 90 in the OR group
- Results
- 77% who chose MVA waited <2 hrs for their procedure vs >12 hrs waited by 71% who chose OR evacuation (p<0.0001)
- MVA group reported higher satisfaction (p=0.02) with time to procedure
- Overall satisfaction with procedures was no different
PROFESSIONAL RECOMMENDATIONS:
The Society of Family Planning
The society of Family Planning recommends the following (Level A guidance) for pain control for manual evacuation and surgical abortion
- Preoperative NSAIDs reduce postoperative pain
- Oral opioids do not reduce procedural pain
- Oral or sublingual lorazepam does not decrease procedure pain, but does reduce anxiety
- Buffered 20 mL 1% lidocaine PCB reduces procedural pain
- Waiting 3 minutes to allow infiltration of cervical anesthesia does not improve pain scores
- Cervical ripening should not be employed solely for pain reduction
REFERENCES:
ACOG Practice Bulletin 200: Early Pregnancy Loss