A commentary on ACOG Practice Bulletin Number 150: Early pregnancy loss by Editor-in-Chief Charles J Lockwood, MD, MHCM
Committee on Practice Bulletins-Gynecology
ACOG Practice Bulletin Number 150: Early pregnancy loss. May 2015. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:1258–1267. Full text of ACOG Practice Bulletins is available to ACOG members at www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Early-Pregnancy-Loss.
Early pregnancy loss, or loss of an intrauterine pregnancy within the first trimester, is encountered commonly in clinical practice. Obstetricians and gynecologists should understand the use of various diagnostic tools to differentiate between viable and nonviable pregnancies and offer the full range of therapeutic options to patients, including expectant, medical, and surgical management. The purpose of this Practice Bulletin is to review diagnostic approaches and describe options for the management of early pregnancy loss.
Charles J Lockwood, MD, MHCM, Editor-in-Chief, is Senior Vice President, USF Health, and Dean, Morsani College of Medicine, University of South Florida, Tampa.
Practice Bulletin # 150 addresses the management of early pregnancy loss, which is defined as a nonviable intrauterine pregnancy with either an empty gestational sac or an embryo/fetus without cardiac activity at < 13 weeks’ gestation.1 Early pregnancy loss is a common occurrence, affecting 10% of recognized pregnancies. About half of such losses are due to aneuploidy, with advanced maternal age and prior loss constituting the 2 major risk factors. Indeed, 80% of women 45 years of age who conceive will have an early pregnancy loss, compared to a loss rate of < 20% among women younger than 30.1 The American College of Obstetricians and Gynecologists (ACOG) notes that the cardinal signs and symptoms of early pregnancy loss-vaginal bleeding and uterine cramping-can also be present in normal gestations and ectopic and molar pregnancies, thus a thorough medical history, physical examination, β-hCG evaluation(s) and, especially, ultrasound can be helpful in differentiating among these disparate conditions.
ACOG notes1 that recent studies have led to new sonographic diagnostic criteria for early pregnancy loss including:
1) Use of absence of embryonic cardiac activity with a crown-rump length (CRL) cutoff of 5.3 mm rather than 5 mm, to reduce false positives from 8.3% to 0%;
2) Use of a gestational sac mean diameter of 21 mm without embryo (± yolk sac) rather than 16 mm, to reduce false-positive rates from 4.4% to 0%; and
3) If a gestational sac is empty on initial scan, the continued absence of a yolk sac or embryo on a repeat scan ≥ 7 days is always associated with pregnancy loss.
The Bulletin provides the very conservative criteria (see Table 1 in Bulletin) recommended by the Society of Radiologists for diagnosis of early pregnancy loss but notes limitations with that approach. A slow embryonic heart rate (< 100 bpm) at 5–7 weeks or a subchorionic hematoma, while worrisome, should not be used to make a definitive diagnosis, but rather, prompt repeat evaluation in 7–10 days. ACOG also reminds us that the patient’s wishes must be considered in deciding on management.
Next: Management options >>
Expectant management: The Bulletin notes that expectant management should be considered following diagnosis of early pregnancy loss only in medically stable patients in their first trimester. Patients should be counseled to report excessive bleeding and analgesic medications prescribed. The success rate attendant expectant management over a 2-month period is 80%. No evidenced-based follow-up strategies exist, although both serial β-hCG evaluations and ultrasound to confirm an empty uterus may be useful. All Rh-negative women should be given a 50-microgram dose of Rh(D)-immune globulin within 72 hours of the diagnosis of early pregnancy loss if expectant management is planned.
Medical management: For women with a diagnosis of early pregnancy loss who want to expedite expulsion of the products of conception without surgery and who have no contraindications (eg, infections, hemorrhage, severe anemia, bleeding diatheses, allergy to prostanoids), treatment with misoprostol is useful. Medical management reduces the need for surgery by 60%. The recommended dosage is 800 micrograms vaginally, with 1 repeat dose no earlier than 3 hours and typically within 7 days if there is no response to the initial dose. Patients should be counseled to report excessive bleeding (> 2 maxi pads per hour x 2 consecutive hours), prescriptions for analgesic medications should be provided, and a 50-microgram dose of Rh(D)-immune globulin should be given to all Rh-negative women within 72 hours of initial misoprostol administration. Either serial β-hCG evaluations or ultrasound within 7 to 14 days can be used to confirm an empty uterus. If treatment fails, expectant management or suction curettage is indicated.
Suction surgical evacuation: Women with the diagnosis of early pregnancy loss who present with hemorrhage, hemodynamic instability, infection, or medical comorbidities (eg, severe anemia, cardiovascular disease, bleeding dyscrasias) require surgical evacuation. Patient preference is a sufficient indication. Suction is preferred to sharp curettage and office-based procedures offer significant cost savings. The use of a single preoperative dose of doxycycline is recommended. All Rh-negative women should receive a 50-microgram dose of Rh(D)-immune globulin immediately after surgery.
While surgical evaluation is fastest and 99% effective, all 3 approaches have roughly comparable risks of infection and hemorrhage. Overall, medical management appears to result in the lowest costs. Avoidance of vaginal intercourse for 1–2 weeks after complete passage of the products of conception is traditionally recommended, although without underlying supportive evidence. Hormonal contraception can be initiated immediately upon completion of an early pregnancy loss and immediate insertion of an intrauterine device after surgical suction curettage is effective. There is no preventative therapy for women with threatened early pregnancy loss and bedrest should not be recommended. Work-up for the cause of early pregnancy loss is not recommended until after a second consecutive loss. The use of anticoagulants, aspirin, or both has not been shown to reduce the occurrence of early pregnancy loss in women with thrombophilias except antiphospholipid antibody syndrome.
1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin Number 150: Early pregnancy loss. May 2015. Obstet Gynecol. 2015;125:1258–1267.