eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

First-Trimester Pregnancy Loss: Follow-up

Author: Elizabeth E Puscheck, MD, Associate Professor, Department of Obstetrics and Gynecology, Wayne State University School of Medicine; In Vitro Fertilization Director, Medical Director, Gynecologic Ultrasound Director, Clinical Endocrine Laboratory Consultant, Department of Obstetrics and Gynecology, University Women's Care
Coauthor(s): Archana Pradhan, MD, MPH, Staff Physician, Department of Obstetrics and Gynecology, Nassau University Medical Center
Contributor Information and Disclosures

Updated: Jun 25, 2006

Follow-up

Further Inpatient Care

• The follow-up should include monitoring hCG levels until the hCG levels are less than 5 mIU/mL. Patients do not need to remain in the hospital during this observation time period.

Further Outpatient Care

• With a complete abortion, measure the hCG level weekly until it is less than 5 mIU/mL in situations in which the products of conception were not evaluated by a physician (eg, the products were flushed down the toilet).
• If the expelled products of conception are evaluated by a physician and confirmed to be intact and truly products of conception (not a clot), performing any further follow-up tests is not necessary.
• Providing reassurance and routine gynecologic care is recommended.
• For ectopic pregnancies, the hCG levels should be monitored as noted above, particularly if medical therapy is performed. If surgical therapy is performed and it is a linear salpingostomy, then the hCG levels should be monitored until they are less than 5 mIU/mL. If a complete salpingectomy is performed and the pathology confirms the ectopic pregnancy, then one may forgo the follow-up for hCG levels.

Deterrence/Prevention

• Contraceptive counseling is warranted. Patients should avoid intercourse or use contraception until the hCG levels have become negative. Patients may wish to continue contraception until they are emotionally ready to try again to become pregnant.

Complications

• Complete abortions may be complicated by infection or accumulation of clot in the uterine cavity without expulsion due to uterine atony. Both of these complications are rare.
• Occasionally, a decidual cast is passed and is mistaken for products of conception. In these cases, an ectopic pregnancy is likely.

Prognosis

• The prognosis is excellent. After one complete abortion, no increased risk exists for another one. Patients need reassurance. Tender loving care is proven effective therapy in one randomized recurrent pregnancy loss trial.

Patient Education

• The patient needs to hear that one miscarriage does not put her at increased risk for another miscarriage. Her next pregnancy is likely to last to term if she is young and has no other risk factors.
• Advise the patient to return to the emergency department if any of the following symptoms occur:
  • Profuse vaginal bleeding
  • Severe pelvic pain
  • Temperature greater than 100°F
• Patients may experience intermittent menstrual-like flow and cramps during the following week. The next menstrual period usually occurs in 4-5 weeks.
• Patients may resume regular activities when able, but they should refrain from intercourse and douching for approximately 2 weeks.
• For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Miscarriage, Abortion, Ectopic Pregnancy, and Dilation and Curettage (D&C).

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnose correctly may occur in this situation. A presumed completed abortion may be an ectopic pregnancy with passage of clot where the clot was thought to be tissue. Missing an ectopic pregnancy can be a life-threatening situation. Be careful. If uncertainty exists regarding whether the passed tissue is tissue or a clot, have a pathologist evaluate it prior to sending the patient out.
• If a suction D&C is performed, then a known complication in a small percentage of cases is Asherman syndrome or intrauterine synechiae. This situation may cause amenorrhea, infertility, or miscarriage in these patients in the future. Be gentle with the sharp curettage after the suction, and, if there is difficulty, ultrasound guidance may be helpful. Do not forget that bleeding may be occurring due to DIC, which will not respond to a D&C but needs the missing factors replaced.
• Perforation of the uterus may occur if a suction D&C is performed. Pregnant uteri are softer than the unpregnant state, and it is easier to perforate. Uterine perforation may occlude itself naturally because the uterus is a muscle that can undergo contraction and place its own pressure on the site until the bleeding stops. However, uncontrolled internal bleeding from a uterine perforation may require additional surgery, either a laparoscopy or laparotomy to control the bleeding. Occasionally, a hysterectomy may be the last resort to control the bleeding, which would eliminate the patient's ability to conceive in the future. Unrecognized uterine perforations may lead to significant internal bleeding that could be a life threat. Observe patients closely after a D&C and listen when patients complain of unusual symptoms (eg, shoulder pain, unexpectedly significant abdominal pain).
• Misdiagnosis of an early intrauterine pregnancy for an ectopic pregnancy and administering methotrexate inappropriately may occur if the physician is not familiar with the laboratory and ultrasound department's discriminatory zone. Thinking about the patient's history and physical examination, differential diagnosis (including multiple gestations), the accuracy of the gestational age, the hCG level (and pattern of hCG levels if checked every 2 d), and ultrasonographic findings is very important to make an appropriate diagnosis. This is an area of rapidly growing malpractice in obstetrics and gynecology.
• Misdiagnosis of an ectopic pregnancy as an incomplete or inevitable abortion can be a problem. In these cases, it is important to follow up on the pathology findings from the suction D&C. If one is uncertain, ask pathology to evaluate the specimen while one is still in the operating room and proceed to laparoscopy if no chorionic villi are found in the suction D&C specimen.

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