What is the management and treatment approach for a woman of childbearing age diagnosed with a blighted ovum?

Management of Blighted Ovum (Anembryonic Pregnancy)

Terminology and Diagnosis

Abandon the outdated term "blighted ovum" and use "anembryonic pregnancy" or "early pregnancy loss (EPL)" instead, as recommended by current guidelines to avoid language that may be hurtful to patients 1, 2.

Diagnostic criteria via transvaginal ultrasound include:

• Mean gestational sac diameter ≥25 mm without an embryo 1, 2
• Absence of embryo ≥14 days after initial visualization of gestational sac 1, 2
• Crown-rump length ≥7 mm without cardiac activity (if embryo is present) 1, 3

Critical diagnostic pitfall: A single ultrasound showing an empty gestational sac <25 mm is insufficient for diagnosis—follow-up imaging in 10-14 days is mandatory to avoid misdiagnosis 4. Serial β-hCG measurements can confirm pregnancy loss when diagnosis is uncertain, with levels that fail to rise appropriately or decrease 1.

Management Algorithm

Step 1: Confirm Diagnosis and Rule Out Ectopic Pregnancy

Obtain transvaginal ultrasound to confirm intrauterine location and meet diagnostic thresholds listed above 2. The presence of an intrauterine gestational sac rules out ectopic pregnancy 1.

Step 2: Assess for Contraindications to Expectant/Medical Management

Proceed directly to surgical evacuation if any of the following are present:

• Hemodynamic instability or significant active bleeding 2
• Signs of infection (maternal tachycardia, purulent cervical discharge, uterine tenderness) 1
• Patient preference for immediate resolution 2

If infection is suspected, initiate broad-spectrum antibiotics immediately and perform urgent surgical evacuation without delay 1.

Step 3: Offer Three Evidence-Based Management Options

For stable patients without contraindications, present all three options with their specific characteristics:

Option A: Expectant Management

• Wait for spontaneous passage of pregnancy tissue 2
• Major limitation: Success rates vary and are generally lower than active management 2
• Critical warning: Expectant management carries significantly higher maternal morbidity (60.2% vs 33.0% with abortion care), intraamniotic infection (38.0% vs 13.0%), and postpartum hemorrhage (23.1% vs 11.0%) 1
• This option should be avoided in most cases due to these substantial risks 1

Option B: Medical Management (Preferred First-Line)

• Misoprostol 800 mcg vaginally achieves high success rates 1
• Superior regimen: Mifepristone 200 mg orally followed by misoprostol 800 mcg vaginally/buccally is more effective than misoprostol alone, particularly for anembryonic pregnancy 1
• Suitable for outpatient or home-based care before 9 weeks gestation 1
• Indicated for patients who wish to avoid surgery but desire faster resolution than expectant management 2

Option C: Surgical Management

• Vacuum aspiration (suction D&C) is the procedure of choice, associated with less blood loss and pain compared to sharp curettage 1
• Provides immediate resolution with lowest complication rates 1
• Required for: hemodynamic instability, significant bleeding, signs of infection, or patient preference 2

Step 4: Essential Preventive Measures

All Rh-negative women must receive anti-D immunoglobulin:

• Dose: 50 mcg for incomplete or complete abortion 1
• Timing: Administer promptly, as fetomaternal hemorrhage occurs in 32% of spontaneous abortions 1

Provide immediate contraceptive counseling:

• Ovulation can resume within 2-4 weeks post-abortion 1
• Combined hormonal contraceptives or implants can be initiated immediately without waiting for next menses 1
• If starting contraception within 7 days of abortion, no backup contraception is needed 1

Step 5: Follow-Up and Monitoring

Mandatory follow-up includes:

• Serial β-hCG monitoring until levels return to non-pregnant state 2
• Ultrasound evaluation to confirm complete evacuation of products of conception 2
• Histopathologic examination of tissue to confirm intrauterine pregnancy and rule out gestational trophoblastic disease 2

Monitor for complications:

• Risk of infection increases with time after diagnosis, particularly after 18 hours 2
• Hemorrhage risk, especially with incomplete evacuation 2

Critical Pitfalls to Avoid

• Never delay treatment waiting for fever if infection is suspected—clinical signs like tachycardia and uterine tenderness warrant immediate action 1
• Do not recommend prolonged expectant management given the substantially higher morbidity rates 1
• Avoid misdiagnosis by ensuring diagnostic thresholds are met before confirming pregnancy loss 1, 2
• Never use outdated terminology like "blighted ovum" or "nonviable pregnancy" 1, 2