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    ACOG Guidelines at a Glance: Early Pregnancy Loss

     

    Management options

    Expectant management: The Bulletin notes that expectant management should be considered following diagnosis of early pregnancy loss only in medically stable patients in their first trimester. Patients should be counseled to report excessive bleeding and analgesic medications prescribed. The success rate attendant expectant management over a 2-month period is 80%. No evidenced-based follow-up strategies exist, although both serial β-hCG evaluations and ultrasound to confirm an empty uterus may be useful. All Rh-negative women should be given a 50-microgram dose of Rh(D)-immune globulin within 72 hours of the diagnosis of early pregnancy loss if expectant management is planned.

    Medical management: For women with a diagnosis of early pregnancy loss who want to expedite expulsion of the products of conception without surgery and who have no contraindications (eg, infections, hemorrhage, severe anemia, bleeding diatheses, allergy to prostanoids), treatment with misoprostol is useful. Medical management reduces the need for surgery by 60%. The recommended dosage is 800 micrograms vaginally, with 1 repeat dose no earlier than 3 hours and typically within 7 days if there is no response to the initial dose. Patients should be counseled to report excessive bleeding (> 2 maxi pads per hour x 2 consecutive hours), prescriptions for analgesic medications should be provided, and a 50-microgram dose of Rh(D)-immune globulin should be given to all Rh-negative women within 72 hours of initial misoprostol administration. Either serial β-hCG evaluations or ultrasound within 7 to 14 days can be used to confirm an empty uterus. If treatment fails, expectant management or suction curettage is indicated.

    Suction surgical evacuation: Women with the diagnosis of early pregnancy loss who present with hemorrhage, hemodynamic instability, infection, or medical comorbidities (eg, severe anemia, cardiovascular disease, bleeding dyscrasias) require surgical evacuation. Patient preference is a sufficient indication. Suction is preferred to sharp curettage and office-based procedures offer significant cost savings. The use of a single preoperative dose of doxycycline is recommended. All Rh-negative women should receive a 50-microgram dose of Rh(D)-immune globulin immediately after surgery.

    Other considerations

    While surgical evaluation is fastest and 99% effective, all 3 approaches have roughly comparable risks of infection and hemorrhage. Overall, medical management appears to result in the lowest costs. Avoidance of vaginal intercourse for 1–2 weeks after complete passage of the products of conception is traditionally recommended, although without underlying supportive evidence. Hormonal contraception can be initiated immediately upon completion of an early pregnancy loss and immediate insertion of an intrauterine device after surgical suction curettage is effective. There is no preventative therapy for women with threatened early pregnancy loss and bedrest should not be recommended. Work-up for the cause of early pregnancy loss is not recommended until after a second consecutive loss. The use of anticoagulants, aspirin, or both has not been shown to reduce the occurrence of early pregnancy loss in women with thrombophilias except antiphospholipid antibody syndrome.

    Reference

    1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin Number 150: Early pregnancy loss. May 2015. Obstet Gynecol. 2015;125:1258–1267.

    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...

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