Early Pregnancy Loss Treatment & Management

A complete abortion usually needs no further treatment, medically or surgically. Patients do not need to remain in the hospital when a diagnosis of complete abortion is made; these patients are usually sent home. However, if there are concerns about significant blood loss, then the patient may need to stay for 24-hour observation and receive blood transfusions. If there are concerns regarding significant infection, IV antibiotic therapy may be needed for a short time until fever/symptoms resolve.

With missed, incomplete, or inevitable abortion present before 13 weeks' gestation, the standard therapy has been suction D&C. However, at least 2 randomized controlled trials show that misoprostol is an effective alternative medical therapy. In one study of incomplete abortion, the patients were randomized between oral misoprostol (600 mcg) or suction D&C, with success rates at 96.3% and 91.5%, respectively. The complication rate is low (0.9% for misoprostol). ^[27]

The other study was a randomized controlled trial with a 3:1 randomization to medical therapy versus D&C. It included subjects with the following diagnoses: missed abortion (with or without a fetal pole; no fetal heart motion when the fetal pole was present), incomplete abortion, or inevitable abortion. In this study, the initial dose of misoprostol was 800 mcg (4 tab 200 mcg placed vaginally), and the subject was reevaluated on day 3. If the expulsion had not occurred, then a second dose of 800 mcg of misoprostol was placed vaginally. The study showed that 71% had completed abortion after the first dose by day 3, and 84% had success with misoprostol by day 8 (95% confidence interval, 81-87%). The risks for bleeding and infection were similar to those of surgical management.

Medical therapy using misoprostol is an acceptable alternative to surgical therapy for most women based upon these early data. The patient should be counseled regarding the risks and benefits of both. The advantages of medical therapy is that no surgical procedures are needed if it is successful. Passage of tissue should happen within a few days of receiving medical therapy. If it is not successful, then a surgical approach may follow. The risks for medical therapy include bleeding, infection, possible incomplete abortion, and possible failure of the medication to work. The advantage of a suction D&C is that the procedure is scheduled and occurs at a known time. The risks of a D&C include bleeding, infection, possible perforation of the uterus (as noted in Surgical Care), and possible Asherman syndrome after the procedure.

A study by Schreiber et al that included 300 women who had an early pregnancy loss and received pretreatment with oral 200 mg of mifepristone followed by vaginal 800 μg of misoprostol (mifepristone-pretreatment group), or vaginal 800 μg of misoprostol alone (misoprostol-alone group) reported that 83.8% of the mifepristone-pretreatment group had complete expulsion after one dose of misoprostol compared to 67.1% in the misoprostol-alone group. ^[48]

In patients with recurrent pregnancy loss (≥2 miscarriages) and cellur immunity anomalies (eg, elevated natural killer cell levels or cytotoxicity and increased T-helper cell 1  (Th1) to Th2 ratio), intravenous immunoglobulin (IVIG) may improve pregnancy outcomes. ^[29]

In a murine model, combined therapy with sildenafil and heparin prevented fetal loss, which may have implications in the management of women with impending pregnancy loss or for prevention in women with a history of recurrent miscarriages. ^[30]

Large blood loss

In the situation in which a considerable amount of blood loss has occurred, aggressive hydration, iron therapy or transfusions may be indicated.

Misdiagnosis

If the diagnosis in not correct, the patient is likely to continue to bleed and cramp for an incomplete or inevitable abortion. In these situations, a suction D&C is indicated. If the patient has any signs of infection, start antibiotics prior to the D&C, if possible, without significantly delaying the suction D&C.

Ectopic pregnancy

An ectopic pregnancy may be treated medically or surgically, depending on the clinical scenario. Treatment guidelines for ectopic pregnancy are available from the American College of Obstetricians and Gynecologists. ^[31] (See Ectopic Pregnancy for further information.)

Note the following:

• Medical therapy consists of methotrexate, which is usually administered in a dose of 50 mg/m². The maximum dose is 100 mg. The effectiveness of medical therapy depends on only applying it to patients who are appropriate candidates based on gestational age, hCG level, ectopic size, patient reliability and compliance, proximity to the office or hospital, and health.

• Prior to administering the methotrexate, renal and liver function tests are measured and results should be normal. A CBC is warranted, and, if significant anemia exists, then medical therapy is not warranted.

• The absolute limits for gestational age, hCG level, ectopic size, and the presence or absence of an embryonic heartbeat are debated in the literature. Despite the debate, the factors that decrease the likelihood of success are older gestational age, higher hCG, larger ectopic size, and the presence of a fetal heartbeat.

• The author likes to use a rule of 3's because it is easy to remember. A patient who is less than 3 weeks from expected menses (7 wk from last menstrual period [LMP]), has an hCG level less than 3000 mIU/mL, and has an ectopic size less than 3 cm has a 95% chance of success with methotrexate. An increase beyond these parameters for gestational age, hCG level, or ectopic size, or presence of a fetal heart motion on ultrasound significantly decreases the success of this medical approach. The patient should not have pelvic pain and should have only minimal vaginal bleeding for medical therapy to be considered.

• On the day of methotrexate injection and on days 4 and 7 after the injection, the hCG level is monitored. A 15% drop in the hCG level is expected between day 4 and day 7. ^[31] From day 1 to day 4, a rise in the hCG level may occur. If a 15% or more drop in the hCG level occurs from day 4 to day 7, then the patient is monitored with weekly hCG levels until the level is less than 5 mIU/mL.

• Patients may have some cramping or discomfort on the side of the ectopic pregnancy as the hCG declines, but these symptoms should be mild. Typically, patients do not experience bleeding until the hCG level is low.

• The authors encourage increased fluid intake to avoid some of the adverse effects of methotrexate (eg, mouth sores, renal impairment). However, this dose of methotrexate is much smaller than that used to treat trophoblastic disease, and most patients have very little problems with taking it.

Plateau or rising hCG after methotrexate therapy

After methotrexate therapy for an ectopic pregnancy, any plateau or rising of hCG requires evaluation. In some situations, considering a second dose of methotrexate is possible. However, surgery should be considered as well.

Potential ectopic rupture

Any symptoms suggesting ectopic rupture (eg, acute pain, rebound tenderness) should immediately direct the physician to the operating room. NOoe the following:

• Laparoscopy can still be considered if the patient is stable.

• A linear salpingostomy with excision of the ectopic pregnancy or partial salpingectomy are the possible procedures.

• If the patient is unstable, the same procedures are performed using a laparotomy.

Complete abortion

For a complete abortion, the medical care is to treat any remaining anemia and to evaluate the blood type and treat the patient with RhoGAM when indicated.

Prehospital care

Monitor vital signs and provide fluid resuscitation if the patient is hemodynamically stable.

Emergency department care

If patients know what to expect, most with complete abortions are not treated in the emergency department. Only those with significant blood loss go to the emergency department.

Patients with threatened, inevitable, incomplete, and ectopic pregnancies may go to the emergency department. Patients with threatened abortions need an ultrasonographic evaluation to confirm the diagnosis and for reassurance.

A possible treatment for threatened miscarriage is the use of progestogen. In 4 randomized studies involving 421 women that compared the use of progestogen in the treatment of threatened miscarriage with either placebo or no treatment, limited evidence suggests that the use of progestogen can reduce the rate of spontaneous miscarriage. Treatment with progestogens did not increase the occurrence of congenital abnormalities in the newborns, and the women did not have any significant difference in incidence of pregnancy-induced hypertension nor antepartum hemorrhage. Further larger studies are warranted for stronger conclusions. ^[32]

Abortion, Inevitable, Abortion, Incomplete, and Ectopic Pregnancy are discussed above and in separate articles.

Consultations

Consult an obstetrician/gynecologist any time uncertainty about the diagnosis exists and to administer treatment.

Diet and activity

The patient's diet should be regular if the diagnosis truly is a complete abortion. If any uncertainty about the diagnosis exists, restrict oral intake until certain that surgical treatment is not necessary.

The patient should rest for a few days to 2 weeks for a complete abortion. The rest schedule needs to be adjusted if one of the other diagnoses is correct.

Note the following:

• No surgical care is used for complete abortion.

• Inevitable and incomplete abortions are typically treated surgically with suction D&C.

• A septic abortion requires broad spectrum antibiotic therapy prior to a suction D&C, if possible without delaying the D&C.

• If a boggy uterus is noted with active bleeding during a D&C, then methylergonovine maleate (Methergine) (0.2 mg IM) may be given to contract the uterus. This will also decrease the likelihood that clots will be retained in the uterus.

• An ectopic pregnancy may be treated medically for the appropriate candidates. The rest require surgery. Surgery for an ectopic pregnancy may consist of either linear salpingostomy or partial or complete salpingectomy via laparoscopy or laparotomy. Although most ectopic pregnancies occur in the fallopian tube, rarely they are located in the ovary and the ovary may need to be removed. An ectopic pregnancy may be found in the abdomen after a tubal abortion has occurred. In this case, the ectopic gestation is removed. If it is adherent to the bowel, then the ectopic gestation is removed as much as possible and follow-up treatment with methotrexate is warranted. In this latter case, the hCG levels need to be monitored until they are less than 5 mIU/mL. For more information, see Medscape Reference article Ectopic Pregnancy.

• Whenever the diagnosis is uncertain, a diagnostic suction D&C with a diagnostic laparoscopy may be appropriate.