From the Guidelines
If you suspect an early pregnancy miscarriage, contact your healthcare provider immediately for evaluation, as prompt assessment and management can significantly impact morbidity, mortality, and quality of life. The approach to a possible early pregnancy miscarriage involves a thorough evaluation, including a transvaginal ultrasound (TVUS) to assess the pregnancy and determine the best course of action 1. According to the Society of Radiologists in Ultrasound consensus conference recommendations, there are five main categories of early pregnancy loss (EPL): concerning for, diagnostic of, in progress, incomplete, and completed 1.
The criteria for diagnosing EPL on TVUS include an embryonic crown-rump length (CRL) <7 mm and no cardiac activity, a mean sac diameter (MSD) of 16-24 mm and no embryo, or absence of embryo with cardiac activity 7-13 days following visualized gestational sac (GS) and no yolk sac 1. For confirmed early miscarriage, the management options include expectant management, medical management with medications such as misoprostol, or surgical management, with the choice of management depending on the individual patient's circumstances and the severity of the miscarriage. Medical management with misoprostol (800 mcg vaginally or 600 mcg orally) can help the uterus expel pregnancy tissue, and pain can be managed with ibuprofen (600-800 mg every 6-8 hours) or acetaminophen (650-1000 mg every 6 hours) 1.
It is essential to note that miscarriage can cause significant grief, and emotional support is crucial. Follow-up is also necessary to ensure complete passage of tissue and to monitor for complications like infection or excessive bleeding. The American Journal of Obstetrics and Gynecology recommends that healthcare providers prioritize patient-centered care and provide clear guidance on the management options and potential outcomes 1.
Key considerations in the management of early pregnancy miscarriage include:
- Prompt evaluation and diagnosis to determine the best course of action
- Individualized management options, including expectant management, medical management, and surgical management
- Pain management with ibuprofen or acetaminophen
- Emotional support and follow-up care to monitor for complications and ensure complete recovery
- Patient-centered care and clear guidance on management options and potential outcomes 1.
From the FDA Drug Label
WARNINGS MISOPROSTOL ADMINISTRATION TO WOMEN WHO ARE PREGNANT CAN CAUSE BIRTH DEFECTS, ABORTION, PREMATURE BIRTH OR UTERINE RUPTURE. The FDA drug label does not answer the question.
From the Research
Approach to Possible Early Pregnancy Miscarriage
- Miscarriage is defined as a pregnancy failure occurring before the completion of 24 weeks of gestation, with around 10 to 15% of all pregnancies ending in early spontaneous first trimester miscarriage 2.
- Risk factors for miscarriage include advancing maternal and paternal age, being underweight or overweight, smoking, and high alcohol consumption 2.
- The standard test to assess viability of the pregnancy is a transvaginal ultrasound scan, and assessment of vaginal bleeding is best made in the context of time taken to saturate a sanitary pad 2.
Management Options
- Expectant management is the first-line approach for miscarriage, encouraged for 7-14 days after diagnosis, with most women miscarrying spontaneously during this time and requiring no further treatment 2, 3.
- Medical management of miscarriage can be offered using misoprostol, with a study finding successful therapy with misoprostol in 86% of patients 4.
- Surgical management may be chosen by a woman if she has had a previous adverse or traumatic experience associated with pregnancy, or if there are risk factors for haemorrhage 2, 3.
Incomplete Evacuation of the Uterus
- Incomplete evacuation of the uterus after misoprostol treatment for miscarriage is a common occurrence, with around 30% of women requiring additional surgical treatment 5.
- A study found that expectant management is an effective and safe option for women with an incomplete evacuation of the uterus after misoprostol treatment, with a successful outcome observed in 85% of women 6.
- The measurement of endometrial stripe thickness after the second cycle of misoprostol via transvaginal ultrasound may present a predictive marker for successful therapy 4.