Management and Treatment 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.
Prevalence and Etiology
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. As many as 80 percent of miscarriages occur before 12 weeks' gestation, with miscarriage rates decreasing sharply after 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. 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 of Miscarriage
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 hCG levels. Transvaginal ultrasonography is a reliable way to differentiate between viable and nonviable pregnancies and should be performed when early pregnancy loss is suspected.
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. Management options for early pregnancy loss include expectant management, medical management with misoprostol, and uterine aspiration. All management options are equally safe; thus, patient preference should guide treatment choice. Women experiencing early pregnancy loss should be reassured that subsequent fertility is not adversely affected by any of the three treatment options.
Expectant and Medical Management
Expectant management is highly effective for the treatment of incomplete abortion. Given that expectant management is up to 90 percent effective, it is a reasonable first-line option. Medical management with misoprostol hastens completed abortion, especially in cases of anembryonic gestation and embryonic demise. Misoprostol in a dose of 800 mcg administered vaginally is effective and well-tolerated.
Uterine Aspiration
Compared with dilation and curettage in the operating room, uterine aspiration is 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
The following table summarizes the clinical recommendations and evidence ratings for the management of early pregnancy loss:
| Clinical recommendation | Evidence rating |
|---|---|
| Transvaginal ultrasonography should be performed when early pregnancy loss is suspected to differentiate between viable and nonviable pregnancies. | C |
| Expectant management, medical management with misoprostol, and uterine aspiration should be offered to women for the treatment of early pregnancy loss. | A |
| Expectant management is a reasonable first-line option for incomplete abortion. | B |
| Medical management with misoprostol hastens completed abortion compared with expectant management. | A |
| Uterine aspiration is the preferred procedure compared with dilation and curettage in the operating room. | A |
| Subsequent fertility is not adversely affected by any of the three treatment options. | B |
Patient Care and Recovery
When a woman suspects that she's having signs of threatened miscarriage, sexual abstinence is totally recommended, along with bed rest, avoiding raw foods, and not taking over-the-counter (OTC) drugs. Because better mental health outcomes result when patient preferences for treatment are respected, physicians should offer all safe treatment options for the management of early pregnancy loss.