First Trimester Pregnancy Loss

Background

• First trimester/early pregnancy loss generally refers to a nonviable intrauterine pregnancy as evidenced by empty gestational sac and/or fetus without heart activity on ultrasound at < 13 weeks gestation. 80% of all pregnancy losses are reported to occur before 12 weeks gestation.
• Maternal age > 35 years may be associated with an increased risk for first trimester pregnancy loss. Chromosomal abnormalities are reported to cause 50%-85% of first trimester pregnancy loss.

Evaluation

• Accurate diagnosis of early pregnancy loss is crucial to avoid treatment (termination) of a viable pregnancy, which could result in pregnancy interruption, pregnancy complications, and/or congenital defects.

• The diagnosis of first trimester pregnancy loss is based on the combination of clinical and ultrasound findings.
  • Most patients present with vaginal bleeding or recent vaginal bleeding that may have subsided. Other signs and symptoms may include current or recent menstrual period-like pelvic or abdominal pain or cramping and/or loss of pregnancy symptoms.
  • Evaluation of patients with suspected early pregnancy loss includes:
    • bimanual pelvic exam, which may show size dates discrepancy and a dilated cervix
    • speculum exam, which may be normal or show blood or products of conception at the cervical os or vaginal vault
    • transvaginal ultrasound and serum beta-human chorionic (beta-hCG) levels, which may be required to establish definite diagnosis of first trimester pregnancy loss:
      • Intrauterine pregnancy is expected to be visualized by transvaginal ultrasound at hCG > 1,500-2,500 milliunits/mL. While not diagnostic, absence of intrauterine pregnancy at this hCG level increases concern for a nonviable pregnancy (ectopic pregnancy or early pregnancy loss).
      • As a diagnostic tool, an hCG level as high as 3,500 milliunits/mL should be used to avoid potential for misdiagnosis and possible interruption of a wanted intrauterine pregnancy.
      • Serial hCG may discriminate between viable and nonviable pregnancy, which includes ectopic pregnancy and miscarriage; close follow-up with ultrasound and repeat hCG within 48 hours should be considered for hCG rise of < 53% every 2 days after presenting with symptoms of pain and/or vaginal bleeding.
• If serum hCG levels are positive for pregnancy, but transvaginal ultrasound fails to confirm an intrauterine or ectopic pregnancy, the diagnosis of pregnancy of unknown location should be made.
• Additional diagnostic testing to determine a possible underlying cause of miscarriage is generally not indicated, except in cases of recurrent pregnancy loss.

Management

• Patients diagnosed with first trimester pregnancy loss who are hemodynamically unstable, who have signs or symptoms of infection or sepsis, or who have medical complications precluding conservative management are managed with emergent surgical uterine evacuation (Strong recommendation).
• Patients thought to have completed their miscarriage only require expectant management and should not be considered for surgical evacuation or medical management.
• Hemodynamically stable patients diagnosed with a first trimester pregnancy loss who have no signs of infection and who cannot confirm passage of tissue may be managed with any of the 3 following options. Because treatment options are equally effective and associated with similar levels of patient acceptability, treatment choice is typically guided by patient preference after discussion reviewing advantages, disadvantages, process, duration, and side effects of each option.
  • Conservative management may be offered to patients who prefer to avoid a surgical procedure and its risks of intrauterine scarring. Options include either of:
    • expectant management
    • medical uterine evacuation
  • Surgical uterine evacuation may be offered to patients who prefer to complete their miscarriage in a shorter amount of time than that of expectant management or medical management.
• Cervical preparation (also known as cervical ripening or priming) before surgical uterine evacuation may be considered for all patients with a pregnancy of any gestational age.
• Pain management considerations:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for pain and uterine cramping associated with conservative management (Strong recommendation).
  • For patients having surgical uterine evacuation:
    • Pain management, such as with NSAIDs, should be offered routinely and should be provided when requested (Strong recommendation).
    • In addition to NSAIDs, use of paracervical block is recommended (Strong recommendation). Combination pain management using conscious sedation plus paracervical block may also be considered (Weak recommendation).
• Pre- or perioperative prophylactic antibiotics are indicated for all patients having surgical abortion, regardless of history of pelvic inflammatory infection (Strong recommendation). Routine use of prophylactic antibiotics is not recommended in patients having medical abortion (Strong recommendation.
• Consider Rho(D) immune globulin ≥ 50 mcg for Rh(D)-negative patients having first trimester pregnancy loss, especially those experiencing late first trimester pregnancy loss, and/or having surgical management of first trimester pregnancy loss (Weak recommendation).
• Routine follow-up visit after uncomplicated surgical abortion or medical abortion not medically required but optional telemedicine or in-person follow-up visit 7-14 days after the procedure should be offered (Strong recommendation). Hormonal contraception can be initiated immediately after completion of miscarriage (Strong recommendation).