Applied Evidence

Early pregnancy loss needn’t require a trip to the hospital

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Don’t just think “hospital D&C” when a patient miscarries. Consider these 3 outpatient alternatives.


 

References

PRACTICE RECOMMENDATIONS

Family physicians can provide in-office treatment for patients with early pregnancy loss, as long as they are hemodynamically stable. A

Manual vacuum aspiration in the office is as effective as surgical emptying of the uterus (dilatation and curettage) in the operating room. A

No single in-office option for managing early pregnancy loss—wait and watch, misoprostol, or vacuum aspiration—is clearly more beneficial than another. Patients should be free to choose the method they prefer. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE 1: Janet C is 22 years old, excited about her first pregnancy and eager to do all the right things to have a healthy baby. But now, in her third month, she has started to bleed and has pelvic pain. She calls in a panic. You tell her to come in immediately. In the office, an ultrasound shows a residual gestational sac.

CASE 2: Lizbeth G, 40, is a successful professional, recently married, with a down-to-earth, decisive personality. She and her husband are eager to start a family. But now, in her second month, she calls to say she’s been having severe cramps and heavy bleeding. She knows she is having a miscarriage. When you see her in the examining room, she’s saddened but calm, eager to know what went wrong and what she needs to do now.

CASE 3: Lola M, 36, mother of 2, is in your office for a routine prenatal visit. She’s in her third month, expecting this pregnancy to be as uneventful as her previous ones. But your ultrasound exam reveals that her fetus has no heartbeat.

What would you tell each of these patients? What options would you offer them?

Chances are good that you’ve cared for any number of patients like Janet, Lizbeth, and Lola. Approximately 15% of clinically recognized pregnancies end in early pregnancy loss (EPL), defined as a miscarriage that occurs earlier than the 12th week of pregnancy. When clinically unrecognized miscarriages are included, the EPL rate may be as high as 30%.1 Most pregnancy losses (80%) occur during the first trimester.2

In the past, EPL was routinely considered an indication for uterine dilatation and curettage (D&C) performed in the operating room.3 This approach was effective, but had serious drawbacks: Costs were high and women had to undergo a surgical procedure that many would prefer to avoid.4

More recently, professional organizations such as the American Academy of Family Physicians and the United Kingdom’s Royal College of Obstetricians and Gynecologists have encouraged a wider range of treatment options that can be provided in an outpatient setting.5,6 These choices, which are available to women with confirmed intrauterine—not ectopic—pregnancy, include “watch and wait” (expectant management), medical management with misoprostol, and outpatient manual vacuum aspiration (MVA) of the uterus.

But before you can even discuss these options, it’s important to find out how your patient has been feeling about her pregnancy: Was it planned or unplanned? Is she happy or unhappy about being pregnant? Does she have a supportive partner, or is her relationship in turmoil? Having a clear sense of where she is emotionally will better enable you to counsel her on her options.

Know, too, that managing EPL patients in their family “medical home” has many advantages. Patients can remain with a caregiver they know and trust. Because they can choose the treatment option they prefer, they are more likely to be satisfied with their care.7 Their quality of life after treatment is better, and the emotional support they can receive in these familiar surroundings has been shown to decrease the psychological sequelae of a miscarriage.8-10

How best to define, and describe, what’s happened

Providing your patient with an accurate description of her situation is essential to adequately counseling her on treatment options. Types of EPL include:

Missed abortion, which occurs when a nonviable pregnancy is detected on ultrasound. The patient is usually without bleeding. A missed abortion is further distinguished sonographically as either an “anembryonic pregnancy”—a mean sac diameter of >10 mm and no yolk sac or a mean sac diameter of 20 mm and no embryo on transvaginal ultrasound—or as an “embryonic demise”—a crown rump length of ≥6 mm without cardiac activity on transvaginal ultrasound.5

Incomplete abortion occurs when a residual gestational sac is detected on ultrasound, and vaginal bleeding and pelvic pain are present.

Inevitable abortion occurs when the internal os is open, but the pregnancy has not yet passed.

Complete abortion occurs when no gestational sac is detected on ultrasound, the cervical os is generally closed, and significant cramping and bleeding have resolved.

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