What is the initial treatment for a patient presenting to the emergency department (ED) with a miscarriage?

Initial Treatment for Miscarriage in the Emergency Department

For hemodynamically stable patients presenting to the ED with suspected miscarriage, the primary initial treatment involves stabilization, diagnostic evaluation with ultrasound and β-hCG testing, and offering three evidence-based management options: expectant management, medical treatment with misoprostol, or surgical evacuation—all of which are safe and effective alternatives. 1, 2

Immediate Stabilization and Assessment

Hemodynamic Status

• Assess vital signs immediately to identify hemodynamic instability (hypotension, tachycardia), active hemorrhage requiring transfusion, or signs of peritoneal irritation suggesting ruptured ectopic pregnancy 1
• Patients with hemodynamic instability, marked and persistent bleeding, or infection require immediate surgical intervention rather than expectant or medical management 2
• Establish IV access and initiate fluid resuscitation if the patient shows signs of significant blood loss 2

Critical Differential Diagnosis

• Rule out ectopic pregnancy first—this is the primary concern in any first-trimester bleeding, with prevalence as high as 13% in symptomatic ED patients 1
• Perform transvaginal ultrasound to evaluate for intrauterine pregnancy (IUP), adnexal masses, free fluid, and products of conception 1
• Obtain quantitative serum β-hCG level, though a single measurement has limited diagnostic value 3

Diagnostic Workthrough

Ultrasound Findings Guide Management

• Confirmed IUP with fetal demise or incomplete miscarriage: Proceed to discussing management options 1, 2
• No IUP visualized: Must exclude ectopic pregnancy before treating as miscarriage 1
• Indeterminate ultrasound: Requires serial β-hCG measurements every 48 hours and close follow-up; do not initiate treatment based solely on initial findings 3

β-hCG Interpretation Caveats

• The traditional discriminatory threshold of 3,000 mIU/mL has virtually no diagnostic utility for predicting ectopic pregnancy (positive LR 0.8, negative LR 1.1) 3
• Approximately 22% of ectopic pregnancies occur at β-hCG levels <1,000 mIU/mL 3
• Never use β-hCG value alone to exclude ectopic pregnancy in patients with indeterminate ultrasound 3

Treatment Options for Confirmed Miscarriage

Expectant Management

• Success rates: 66-91% depending on type of miscarriage 2
• Complications include hemorrhage requiring transfusion in 1-2% of cases 2
• Appropriate for hemodynamically stable patients without infection or coagulopathy 2
• If expectant therapy fails, subsequent treatment with misoprostol or curettage is indicated 2

Medical Management with Misoprostol

• Vaginal administration is most effective with fewest side effects, achieving complete termination in 81-95% of cases 2, 4
• Requires surgical evacuation in 5-20% of cases if medical treatment fails 2, 4
• Common side effects include nausea (RR 2.50), vomiting (RR 1.97), and diarrhea (RR 4.82) compared to surgery 4
• Critical FDA warning: Misoprostol can cause uterine rupture when administered in pregnant women beyond the eighth week of pregnancy 5
• Contraindicated if patient has not had negative pregnancy test within 2 weeks prior to therapy (for NSAID ulcer prevention indication) 5

Surgical Evacuation (Suction Curettage)

• Success rate: 97-98% 2
• Associated risks: 0.2% anesthesia-related complications, 0.1% uterine perforation, 2-3% rate of repeat curettage 2
• Immediate indications for surgery: infection, marked and persistent bleeding, hemodynamic instability, pre-existing coagulopathy 2

ED-Specific Management Considerations

Patient Counseling and Shared Decision-Making

• Provide honest communication, validate urgency of symptoms, and offer robust discharge information—these are the most common areas of patient dissatisfaction in ED miscarriage care 6, 7
• All three treatment options (expectant, medical, surgical) are safe and acceptable for medically uncomplicated patients 2, 8
• Shared decision-making significantly improves patient satisfaction with early pregnancy loss care 8
• Women generally express satisfaction with their chosen management approach when properly counseled 4

Psychological Support

• Assess the meaning of the miscarriage to the patient—for many women it is devastating, while for others it is part of life 6
• Structured bereavement intervention is beneficial and leads to fewer reports of despair 7
• Psychological management is not regularly addressed in the ED but should be incorporated into care 7

Rh Status Management

• Administer anti-D immunoglobulin to Rh-negative women with first-trimester threatened abortion, complete abortion, or ectopic pregnancy 1

Disposition and Follow-Up

Discharge Criteria for Non-Surgical Management

• Hemodynamically stable 1, 2
• No signs of infection 2
• Reliable follow-up arranged 1
• Patient understands warning signs requiring immediate return 1, 2

Mandatory Follow-Up

• Serial β-hCG measurements if diagnosis uncertain or pregnancy of unknown location 3
• Repeat ultrasound if expectant or medical management chosen 2
• Warning signs requiring immediate return: severe pain, heavy bleeding, fever, hemodynamic instability 2, 7

Critical Pitfalls to Avoid

• Never assume miscarriage without excluding ectopic pregnancy, especially with indeterminate ultrasound findings 1
• Do not rely on β-hCG discriminatory thresholds alone to make management decisions 3
• Avoid initiating treatment based solely on initial β-hCG levels without serial measurements or ultrasound correlation 3
• Do not discharge patients with pregnancy of unknown location without arranging close follow-up for repeat β-hCG or ultrasound 3
• Recognize that surgical management is more common among women with higher education and socioeconomic status, which may reflect access disparities rather than clinical appropriateness 7