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Management of Early Spontaneous Pregnancy Loss

Procedures for managing early pregnancy loss are moving out of the operating room and into the office, safely and successfully.

Early pregnancy loss (EPL) is common: 15% to 20% of all recognized pregnancies end in spontaneous loss, and about one in four women will experience such pregnancy failure during her lifetime.¹ Key terms for EPL are shown in the table.

Although surgical treatment has been preferred historically, management strategies have evolved to encompass out-of-hospital care. Options for treating women with EPL now include expectant management, medical therapy, and surgical evacuation.

EXPECTANT MANAGEMENT

Expectant management of EPL allows for the complete expulsion of a lost pregnancy without medical or surgical intervention; however, resolution can take as long as 1 month, thereby compounding the anxiety and sadness associated with EPL. Many women who choose this option will request dilatation and curettage (D&C) within 7 days, and even more will do so within 14 days. Reported success rates for expectant management depend heavily on the length of time between initiation of intervention and declaration of therapeutic failure; in one study, expectant management of incomplete abortions resulted in success rates of 54%, 83%, 89%, and 91% at 1, 2, 3, and 4 weeks after diagnosis, respectively.² Other research has shown an overall success rate at 7 days of 44%; however, this rate was 86% if the initial diagnosis was incomplete rather than missed abortion.³ Although these studies support the option of expectant management for incomplete abortions, EPLs without vaginal bleeding (i.e., missed abortions) have only a 50% chance of resolving with expectant management alone.

MEDICAL MANAGEMENT

Active medical management of EPL has become routine. The prostaglandin analog misoprostol results in complete expulsion relatively quickly. For example, in one randomized trial, 491 women (EPL at mean gestational age, 7.6 weeks) received 800-µg vaginal misoprostol on day 1 and, if necessary, on day 3; 71% achieved complete expulsion by day 3 and 84% by day 8. This treatment was judged to be satisfactory or very satisfactory by most participants, who reported that they would use it again (78%) or recommend it (83%).⁴

The American College of Obstetricians and Gynecologists recommends 600-µg oral or 400-µg sublingual misoprostol for first-trimester incomplete abortions and 800-µg vaginal or 600-µg sublingual misoprostol for missed abortions; sublingual administration can be repeated every 3 hours for two additional doses.⁵ Reported success rates range from a low of 25% for oral dosing to 97% for some oral, sublingual, or vaginal protocols.¹ More-prolonged waiting periods or repeated dosing leads to higher success rates.

Common side effects of misoprostol include heavy vaginal bleeding and gastrointestinal (GI) disturbances. In a trial that involved 652 women with EPL, those who received misoprostol experienced greater decreases in hemoglobin than did women who underwent vacuum aspiration, although the difference was not clinically significant.⁴ Compared with vaginal administration, oral and sublingual dosing are associated with higher incidence of GI complaints.¹

SURGICAL MANAGEMENT

Historically, surgical management of EPL involved hospital admission, general or spinal anesthesia (or sedation), and electrical vacuum aspiration (EVA). New methods now allow for procedures to be performed in office settings using manual vacuum aspiration (MVA) and minimal-to-moderate conscious sedation. Rates of complete evacuation with MVA are high (95%–98%) and are equivalent to those with EVA; moreover, patients value the privacy afforded by office procedures.^6,7 MVA obviates the need for intensive anesthesia, is substantially less expensive, and provides fourfold less risk for hemorrhage-related complications.^1,8

Secondary advantages of in-office MVA include shorter total patient-care time (97 vs. 290 minutes); shorter total procedure time (10 vs. 19 minutes); lower overall complication rates (8% vs. 40%); and less procedural blood loss (70 mL vs. 311 mL).⁸ Several different MVA devices are available; all are typically inexpensive and reusable after autoclaving. Because MVA and EVA apparatuses can generate comparable negative intrauterine pressures, need for re-evacuation is similar with both methods.⁶ Taken together, lower procedural costs and postprocedural complications with office-based treatment of EPL are predicted to result in savings of US$779 million annually over traditional D&C.^1,8

COMPARING THE OPTIONS

In only a few studies (most of which are small or flawed in design) have investigators compared all three approaches to management of EPL.^9,10 A meta-analysis revealed a 2.8-fold greater success rate for medical management with misoprostol compared with expectant management, a 1.5-fold greater success rate with surgical versus medical management, and a 6-fold greater success rate with surgical versus expectant management.⁹

Incidence of infection is similar among the three therapeutic strategies.¹ However, the approaches differ substantially in patient satisfaction and cost. Not surprisingly, patients are most likely to be satisfied if the chosen treatment modality has the highest probability of success. A cost analysis conducted in 2001 (before office-based MVA became common) showed that medical management had the lowest average cost per case.¹¹ We now know that office-based MVA has significant cost benefits over hospital-based EVA.

CONCLUSION

Early pregnancy loss is common and can be managed in several ways. Patient preference often can dictate therapeutic approach. Expectant management might be medically preferable for some inevitable or incomplete abortions but is likely to fail for missed abortions. Medical therapy, if the patient prefers, is a reasonable alternative, although blood loss can be greater and unplanned surgical treatment might be required. Women who choose surgical therapy (or for whom expectant or medical management fails) should be offered in-office MVA because of its high success rate and proven cost benefits. In-hospital EVA should only be offered for EPL at >12 weeks' gestation or for emergent or after-hours incomplete abortions. For women with EPL, emotional considerations typically equal or outweigh medical decisions; therefore, strong psychosocial support should be readily available and routinely recommended.

— Amanda T. Rodemann, DO, Jana L. Allison, MD, and Danny J. Schust, MD

Dr. Rodemann and Dr. Allison are Fellows and Dr. Schust is an Associate Professor in the Department of Obstetrics, Gynecology, and Women's Health at the School of Medicine, University of Missouri–Columbia.

Published in Journal Watch Women's Health April 1, 2010

Citation(s):

1. Chen BA and Creinin MD. Contemporary management of early pregnancy failure. Clin Obstet Gynecol 2007 Mar; 50:67.

• Medline abstract (Free)

2. Luise C et al. Expectant management of incomplete, spontaneous first-trimester miscarriage: Outcome according to initial ultrasound criteria and value of follow-up visits. Ultrasound Obstet Gynecol 2002 Jun; 19:580.

• Medline abstract (Free)

3. Bagratee JS et al. A randomized controlled trial comparing medical and expectant management of first trimester miscarriage. Hum Reprod 2004 Feb; 19:266.

• Original article (Subscription may be required)
• Medline abstract (Free)

4. Zhang J et al. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med 2005 Aug 25; 353:761.

• Medline abstract (Free)

5. ACOG Committee Opinion No. 427: Misoprostol for postabortion care. Obstet Gynecol 2009 Feb; 113:465.

• Medline abstract (Free)

6. Edwards S et al. Patient acceptability of manual versus electric vacuum aspiration for early pregnancy loss. J Womens Health (Larchmt) 2007 Dec; 16:1429.

• Medline abstract (Free)

7. Wen J et al. Manual versus electric vacuum aspiration for first-trimester abortion: A systematic review. BJOG 2008 Jan; 115:5.

• Medline abstract (Free)

8. Dalton VK et al. Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol 2006 Jul; 108:103.

• Medline abstract (Free)

9. Sotiriadis A et al. Expectant, medical, or surgical management of first-trimester miscarriage: A meta-analysis. Obstet Gynecol 2005 May; 105:1104.

• Medline abstract (Free)

10. Trinder J et al. Management of miscarriage: Expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment [MIST] trial). BMJ 2006 May 27; 332:1235.

• Original article (Subscription may be required)
• Medline abstract (Free)

11. Creinin MD et al. Early pregnancy failure — Current management concepts. Obstet Gynecol Surv 2001 Feb; 56:105.

• Medline abstract (Free)

Reader Remarks:

Review and add to remarks on this article

• very helpful
  Dorothea Poulos, Elgin Family Physicians, 5 Apr 2010 5:54 PM EST
  Thank you for providing this article. I will share it with my associates.
• Good review
  William J. DeMedio, Private practice, 5 Apr 2010 5:54 PM EST
  It should not be costly to manage EPL. In hospital management should only be reserved for necessary cases. Remember to... [more]
• Management of Early Pregnancy Loss
  Paula H, 6 Apr 2010 12:36 PM EST
  I found this article to be informative and easily understandable and intend to share it with my three adult daughters.... [more]
• asherman syndrome
  christopher barbour, 3 May 2010 2:36 PM EST
  please comment on the asherman rate with MVA and EVA versus expectant and medical therapies.

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