ACOG Guidelines at a Glance: Early Pregnancy Loss
Committee on Practice Bulletins—Gynecology
ACOG Practice Bulletin Number 150: Early pregnancy loss. May 2015. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:1258–1267. Full text of ACOG Practice Bulletins is available to ACOG members at www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-....
Early pregnancy loss, or loss of an intrauterine pregnancy within the first trimester, is encountered commonly in clinical practice. Obstetricians and gynecologists should understand the use of various diagnostic tools to differentiate between viable and nonviable pregnancies and offer the full range of therapeutic options to patients, including expectant, medical, and surgical management. The purpose of this Practice Bulletin is to review diagnostic approaches and describe options for the management of early pregnancy loss.
Commentary: Options for early pregnancy loss
Charles J Lockwood, MD, MHCM, Editor-in-Chief, is Senior Vice President, USF Health, and Dean, Morsani College of Medicine, University of South Florida, Tampa.
Practice Bulletin # 150 addresses the management of early pregnancy loss, which is defined as a nonviable intrauterine pregnancy with either an empty gestational sac or an embryo/fetus without cardiac activity at < 13 weeks’ gestation.1 Early pregnancy loss is a common occurrence, affecting 10% of recognized pregnancies. About half of such losses are due to aneuploidy, with advanced maternal age and prior loss constituting the 2 major risk factors. Indeed, 80% of women 45 years of age who conceive will have an early pregnancy loss, compared to a loss rate of < 20% among women younger than 30.1 The American College of Obstetricians and Gynecologists (ACOG) notes that the cardinal signs and symptoms of early pregnancy loss—vaginal bleeding and uterine cramping—can also be present in normal gestations and ectopic and molar pregnancies, thus a thorough medical history, physical examination, β-hCG evaluation(s) and, especially, ultrasound can be helpful in differentiating among these disparate conditions.
ACOG notes1 that recent studies have led to new sonographic diagnostic criteria for early pregnancy loss including:
1) Use of absence of embryonic cardiac activity with a crown-rump length (CRL) cutoff of 5.3 mm rather than 5 mm, to reduce false positives from 8.3% to 0%;
2) Use of a gestational sac mean diameter of 21 mm without embryo (± yolk sac) rather than 16 mm, to reduce false-positive rates from 4.4% to 0%; and
3) If a gestational sac is empty on initial scan, the continued absence of a yolk sac or embryo on a repeat scan ≥ 7 days is always associated with pregnancy loss.
The Bulletin provides the very conservative criteria (see Table 1 in Bulletin) recommended by the Society of Radiologists for diagnosis of early pregnancy loss but notes limitations with that approach. A slow embryonic heart rate (< 100 bpm) at 5–7 weeks or a subchorionic hematoma, while worrisome, should not be used to make a definitive diagnosis, but rather, prompt repeat evaluation in 7–10 days. ACOG also reminds us that the patient’s wishes must be considered in deciding on management.
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