Management of Early Pregnancy Loss
Early pregnancy loss is most commonly defined as the spontaneous loss of a pregnancy before 13 weeks' gestation. Other terms include miscarriage, early pregnancy failure, and spontaneous abortion. The terms “early pregnancy loss” or “miscarriage” may be preferred by patients because of the negative connotations associated with the word “failure,” and confusion regarding elective versus spontaneous abortion.
Epidemiology and Etiology
Miscarriage is very common, with nearly one in four women experiencing an early pregnancy loss in her lifetime. Up to 15 percent of recognized pregnancies end in miscarriage, and as many as 80 percent of miscarriages occur in the first trimester. Approximately 50 percent of early pregnancy losses are caused by chromosomal abnormalities. Other etiologies include infection, reproductive tract abnormalities, exposure to toxins, and uncontrolled endocrine or autoimmune disease in the mother.
Diagnosis
Transvaginal ultrasonography is a reliable way to differentiate between viable and nonviable pregnancies and should be performed when early pregnancy loss is suspected. Unless products of conception are seen, the diagnosis of miscarriage is made with ultrasonography and, when ultrasonography is not available or is nondiagnostic, with measurement of beta subunit of human chorionic gonadotropin levels.
Management Options
The management of early pregnancy loss used to be based largely in the hospital setting, but it has shifted to the outpatient setting, allowing women to remain under the care of their family physician throughout the miscarriage process. Because better mental health outcomes result when patient preferences for treatment are respected and because all treatment options are safe, expectant management, medical management with misoprostol, and uterine aspiration should be offered to women. All management options are equally safe; thus, patient preference should guide treatment choice.
| Management Option | Effectiveness and Clinical Use |
|---|---|
| Expectant Management | Highly effective for the treatment of incomplete abortion and is a reasonable first-line option. |
| Medical Management | Misoprostol in a dose of 800 mcg administered vaginally hastens completed abortion, especially in cases of anembryonic gestation and embryonic demise. |
| Uterine Aspiration | The preferred procedure for early pregnancy loss; aspiration is equally safe, quicker to perform, more cost-effective, and amenable to use in the primary care setting. |
Clinical Recommendations
Compared with dilation and curettage in the operating room, uterine aspiration is the preferred procedure for early pregnancy loss. Misoprostol in a dose of 800 mcg administered vaginally is effective and well-tolerated. There is insufficient evidence to recommend routine antibiotic prophylaxis following uterine aspiration. Finally, women experiencing early pregnancy loss should be reassured that subsequent fertility is not adversely affected by any of the three treatment options.