Obgyno Wino Podcast Episode 25 - Early Pregnancy Loss
"A great many people think they are thinking when they are merely rearranging their prejudices." - William James
PB#200 - Published November 2018
Early pregnancy loss occurs in 10% of all recognized pregnancies, at least half of which are due to chromosomal abnormalities
Misoprostol 800 mcg vaginally (w/ 2nd dose in 48 hrs as needed), has an 85% chance of resolving retained products of conception associated with early pregnancy loss. Addition of mifepristone 200 mg 24 hrs prior to the misoprostol increases that rate
Surgical management of early pregnancy loss (suction D&C) is 99% effective. Give doxycycline beforehand
Risks of expectant, medical, and surgical management are equal across the board and quite low (< 2%)
Management of early pregnancy loss requires a shared medical decision-making process. Risks and benefits should be elaborated for all three options.
Epidemiology and Risk Factors
- but first: early pregnancy loss, miscarriage, spontaneous abortion are synonymous
- most common risk factors: AMA, history of prior early pregnancy loss
- 10% of all recognized pregnancies (~15% for age 20-30 yrs; 40% at age 40; 80% at age 45)
- 80% of miscarriages occur in the 1st trimester
- 50% of the time it's due to chromosomal abnormalities
- several factors should make you suspicious, others are diagnostic
- bleeding and cramping are non-specific (can be seen in molar pregnancy, ectopic pregnancy, normal IUP, or SAB)
- you need: history, ultrasound and b-HCG
- circumstances are also important: if a viable IUP was documented at 8 weeks, but nothing is seen within the intrauterine cavity at 12 weeks, then your diagnosis is pretty straightforward
- quite different if this is your first time evaluating the patient
- growth rates for gestational sac (GS) or embryo are historically inaccurate at predicting likelihood of pregnancy loss
- if a GS is present w/out a yolk sac or embryo and remains empty one week later, it's usually diagnostic of pregnancy loss
- in addition to those suspicious findings noted in table 1, low fetal heart rate (<100 bpm at 5-7 weeks) and subchorionic hemorrhage are both associated with early pregnancy loss
- highly dependent on patient's desire for the pregnancy, her willingness to forgo intervention until pregnancy location and viability is 100% clear, and consequences of delaying intervention
- three categories of intervention should be presented once a diagnosis is made: expectant, medical, and surgical management
- no difference in long-term outcome between the three approaches
Expectant management (no intervention)
Pro: no medication or surgery required, 80% will resolve expectantly w/in 8 weeks
Con: she can expect bleeding, cramping, and possibly passage of fetal tissue depending on predicted gestational age; she may still require medical or surgical management in the event of failure; difficult to predict timeline
Notes: should be reserved for 1st trimester losses due to concerns for excessive bleeding in 2nd trimester
- more likely to work in symptomatic women and women with incomplete loss versus missed or anembryonic pregnancy failures
- follow-up ultrasound not required, but, if performed, no surgical intervention required unless GS has not been expelled
Medical management (prostaglandins +/- progesterone receptor antagonists)
Pro: "doing something" versus waiting it out without assuming surgical risks, can take effect in just a few hours
Con: same for expectant management; she may still require surgical management in the event of failure, often difficult to predict timeline or likelihood of success
Notes: 70% chance of working with single dose of vaginal misoprostol 800 mcg; 85% if 2nd dose given 48 hrs later
- even better: mifepristone 200 mg orally followed by the first dose of vaginal misoprostol 800 mcg 24 hrs later; this combination also associated with decreased risk for uterine aspiration (*without increased risk of adverse events!)
- no data to suggest that medical management is better than expectant management for incomplete loss
- follow-up can consist of ultrasound, serial serum b-HCG levels, or patient-reported symptoms
Surgical management (dilation and curettage)
Pro: immediately effective in achieving complete resolution of early pregnancy loss in 99% of cases, can be performed in the hospital or office setting, with or without local anesthetic or sedation (talk to your patient!)
Con: surgical risks include uterine perforation, pain, infection, though these risks are low
Notes: Don't fart around with expectant or medical management if your patient is hemorrhaging.
- high risk surgical candidates might do better with expectant or medical management
- sharp+suction curettage is better than sharp curettage alone
- rates of infection or hemorrhage sufficiently significant to warrant hospitalization are equal across all three management options (and <2% on all accounts), though many experts recommend giving a dose of doxycycline 200 mg IV at time of procedure to decrease risk of intrauterine infection
- doing it in the office is drastically cheaper than doing it in the OR
Rapid fire questions
How long should my patient wait after miscarriage before having intercourse?
No data, so as long as she wants (that is...probably no increased risk of infection if she doesn't want to wait around, but good data is lacking)
Is it safe to place an IUD at time of suction D&C?
Yes. And expulsion rates are comparable to patients receiving IUDs outside of miscarriage
Do I have to worry about allo-immunization?
Probably not (risk is low, especially <10 wga), but I offer it to the patient is Rh negative.
How much do I give?
50 mcg outta do the tricks
Should I do chromosomal analysis on the products of conception?
It depends. After the 1st SAB, it's not indicated. After the 2nd SAB, it should be offered.
How about testing for antiphospholipid syndrome?
Test for APLS in the event of 3 losses at <10 wga or more than 1 loss at >10 wga.
How can I help prevent early pregnancy loss in my patient's future pregnancies?
Unfortunately not much. Aspirin, uterine relaxants, and HCG supplementation haven't been found to be helpful. Likewise, vaginal, IM, and oral progesterone hasn't been found to be helpful (2008 Cochrane Review), UNLESS they have already experienced 3 or more losses (jury is out)