What are the management options for Early Pregnancy Loss (EPL)?

Management Options for Early Pregnancy Loss (EPL)

Patients with early pregnancy loss should be offered all three management options—expectant, medical, and surgical—as they are equally safe and effective when urgent treatment is not required, with the choice guided by patient preference through shared decision-making. 1

Three Primary Management Approaches

Expectant Management

• Allow spontaneous passage of pregnancy tissue without intervention 2, 1
• Can be continued for up to 8 weeks after diagnosis in the absence of medical complications or symptoms requiring urgent intervention 1
• Patients retain the right to change their management decision and switch to medical or surgical options at any time 3
• Serial hCG monitoring is recommended until levels return to non-pregnant state 2

Medical Management

The preferred medical regimen is mifepristone 200 mg orally followed 7-48 hours later by misoprostol 800 mcg vaginally or buccally 1, 4

• This combined regimen achieves 89-93% complete expulsion of the gestational sac 4, 5
• When mifepristone is unavailable, use misoprostol alone in two or more doses of 600-800 mcg sublingually or vaginally at intervals of at least 3 hours 1
• Ibuprofen 800 mg orally should be offered for pain control 1
• Mean time to first passage of tissue is approximately 5 hours 5
• Follow-up at 14 days to confirm absence of gestational sac 4
• Do NOT use endometrial thickness alone as a criterion for recommending additional intervention after medical management 1—up to 17% may have thickened endometrium despite successful expulsion 4

Important caveat: Rh testing and Rh-immunoglobulin administration should NOT be performed before 12 weeks of gestation for patients undergoing medication management 1, though blood type and Rh status should be assessed with Rho(D) immunoglobulin administered to Rh-negative women in other contexts 2

Surgical Management

• Suction dilation and curettage (D&C) is the surgical option 2, 6
• Should preferably be performed under ultrasound guidance to reduce risk of uterine perforation 2
• Uterotonic agents should be administered during and after the procedure to reduce bleeding risk 2
• Histopathologic examination of tissue is recommended to confirm intrauterine pregnancy and rule out gestational trophoblastic disease 2
• Procedural methods may have fewer complications than medication management (less hemorrhage, infection, and retained tissue) in some contexts 7

Diagnostic Confirmation Before Treatment

EPL diagnosis should use shared decision-making incorporating ultrasound, serial quantitative hCG measurements, or symptoms 1

Ultrasound Criteria (Society of Radiologists in Ultrasound 2024)

Concerning for EPL (may not progress): 3

• Embryonic crown-rump length (CRL) <7 mm with no cardiac activity
• Mean sac diameter (MSD) 16-24 mm with no embryo
• Absent embryo 7-13 days after visualized gestational sac with no yolk sac

Diagnostic of EPL (will not progress): 3, 2

• CRL ≥7 mm with no cardiac activity
• MSD ≥25 mm with no embryo
• Absent embryo ≥14 days after visualization of gestational sac

Special Considerations

VTE Risk Assessment

• Any surgical procedure during pregnancy carries VTE risk and may warrant thromboprophylaxis for 10 days according to RCOG guidelines 3
• Multiple international guidelines (UK, Australian, Irish) consider surgical procedures as VTE risk factors requiring assessment 3
• Women with prior VTE history or multiple risk factors require individualized VTE risk stratification before surgical management 3

Follow-Up Strategy

• In-person confirmation of completed EPL should be offered to all patients but not required 1
• Ultrasound evaluation should be used to confirm complete evacuation of products of conception 2
• Complete blood count with platelets is recommended to assess for anemia and thrombocytopenia 2

Institutional Responsibilities

Institutions and clinicians must make thorough efforts to obtain and maintain access to mifepristone in clinical settings where patients receive EPL care 1, as this significantly improves medical management success rates compared to misoprostol alone.