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. Miscarriage is very common, with nearly one in four women experiencing an early pregnancy loss in her lifetime. Approximately 30 percent of all pregnancies end in miscarriage, although the majority of these are miscarried before they are recognized. The rate of pregnancy loss among clinically diagnosed pregnancies is 8 to 15 percent.
Etiology and Risk Factors
As many as 80 percent of miscarriages occur in the first trimester, with chromosomal abnormalities as the leading cause. 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. In general, no interventions have been proven to prevent miscarriage; occasionally women can modify their risk factors or receive treatment for relevant medical conditions.
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 and Treatment 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. Management options for early pregnancy loss include expectant management, medical management with misoprostol, and uterine aspiration. 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.
Comparison of Approaches
Expectant management is highly effective for the treatment of incomplete abortion, whereas misoprostol and uterine aspiration are more effective for the management of anembryonic gestation and embryonic demise. Regarding medical intervention, misoprostol in a dose of 800 mcg administered vaginally is effective and well-tolerated. Furthermore, compared with dilation and curettage in the operating room, uterine aspiration is the preferred procedure for early pregnancy loss because aspiration is equally safe, quicker to perform, more cost-effective, and amenable to use in the primary care setting.
| Management Option | Key Characteristics and Clinical Indications |
|---|---|
| Expectant Management | Reasonable first-line option for incomplete abortion; up to 90 percent effective. |
| Medical Management (Misoprostol) | Hastens completed abortion, especially in cases of anembryonic gestation and embryonic demise. Dose: 800 mcg vaginally. |
| Uterine Aspiration | Preferred procedure; safe, quick, cost-effective, and amenable to use in the primary care setting. |
Patient Counseling and Recovery
Women experiencing early pregnancy loss should be reassured that subsequent fertility is not adversely affected by any of the three treatment options (expectant care, medical management with misoprostol, or uterine aspiration). Regarding post-procedure care, there is insufficient evidence to recommend routine antibiotic prophylaxis following uterine aspiration.