What are the next steps for a patient with a non-viable pregnancy at 6 weeks, confirmed by ultrasound, with a history of scoliosis and no current symptoms of miscarriage?

From the Guidelines

For a patient with a non-viable pregnancy at 6 weeks confirmed by ultrasound, with scoliosis and no current miscarriage symptoms, I strongly recommend discussing three management options: expectant management, medication management, or surgical management, with a focus on minimizing risks and optimizing outcomes, as suggested by the most recent guidelines 1.

When considering these options, it's essential to weigh the benefits and risks of each approach. Expectant management involves waiting for natural miscarriage, which may take 2-4 weeks but avoids intervention risks. Medication management, using misoprostol (800 mcg vaginally or 600 mcg orally), is 80-90% effective and typically causes cramping and bleeding within 24 hours, as reported in recent studies 1. Surgical management via vacuum aspiration or dilation and curettage provides immediate resolution with >99% effectiveness but carries small risks of infection, bleeding, or uterine injury.

The patient's scoliosis history is unlikely to affect these options unless it impacts anesthesia considerations for surgical management. Regardless of the chosen approach, follow-up should include a pregnancy test in 2-4 weeks or ultrasound if needed to confirm complete pregnancy passage, as recommended by the Society of Radiologists in Ultrasound consensus conference recommendations 1. Emotional support is essential, as pregnancy loss can be difficult regardless of gestational age.

Some key points to consider when discussing management options with the patient include:

• The definition of a non-viable pregnancy, as outlined in the SRU FIRST TRIMESTER ULTRASOUND LEXICON: EARLY PREGNANCY LOSS (EPL) 1
• The importance of avoiding terms such as "nonviable" and "pregnancy of uncertain viability" in the first trimester, as suggested by Rodgers et al. 1
• The need for clear communication and emotional support throughout the management process, as emphasized in recent guidelines 1

Ultimately, the goal of management should be to minimize risks, optimize outcomes, and provide emotional support to the patient, while prioritizing morbidity, mortality, and quality of life as the primary outcomes, as recommended by the most recent and highest-quality study 1.

From the Research

Next Steps for Non-Viable Pregnancy

The patient's ultrasound results confirm a non-viable pregnancy at 6 weeks, with no current symptoms of miscarriage. Considering the patient's history of scoliosis and tenth pregnancy, the following steps can be taken:

• Medical management of the non-viable pregnancy can be considered, as it has been shown to be effective and safe in several studies 2, 3, 4, 5.
• The use of misoprostol, either alone or in combination with mifepristone, can be considered for medical management of the non-viable pregnancy 2, 3, 4.
• The patient should be informed of the potential risks and benefits of medical management, as well as the alternative option of surgical management (D&C) 2, 3, 4, 5.
• Close monitoring of the patient's condition and follow-up ultrasounds can be performed to assess the progress of the medical management and to detect any potential complications 2, 3, 4, 5.

Considerations for Scoliosis and Back Pain

The patient's history of scoliosis and back pain should be taken into consideration when managing the non-viable pregnancy:

• The patient's back pain and muscle spasms may be exacerbated by the pregnancy and miscarriage process, and appropriate pain management strategies should be considered 6.
• The patient's scoliosis may also affect the positioning and comfort during medical management or surgical procedures, and accommodations should be made as needed 6.

Additional Considerations

Additional considerations for the patient's care include:

• The patient's tenth pregnancy and potential for future pregnancies should be taken into account when discussing management options and potential risks 2, 3, 4, 5.
• The patient's overall health and well-being should be prioritized, and any potential complications or risks associated with medical or surgical management should be carefully considered and discussed with the patient 2, 3, 4, 5.