eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

First-Trimester Pregnancy Loss: Treatment & Medication

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

Treatment

Medical Care

A complete abortion usually needs no further treatment, medically or surgically.

With missed, incomplete, or inevitable abortion before 13 weeks' gestation, the standard therapy has been suction D&C. However, at least 2 randomized controlled trials show that misoprostol is an effective medical therapy. In 1 study of incomplete abortion, the subjects were randomized between oral misoprostol (600 mcg) or suction D&C with a 96.3% versus 91.5% success rate in completed abortion with low complications (0.9% for misoprostol) (Weeks, 2005).

The other study was a randomized controlled trial with a 3:1 ratio in favor of medical therapy and it included subjects with the following diagnoses: missed abortion (with or without a fetal pole; no fetal heart motion when the fetal pole was present), incomplete abortion, or inevitable abortion. In this study, the initial dose of misoprostol was 800 mcg (4 tab 200 mcg placed vaginally) and the subject was reevaluated on day 3. If the expulsion had not occurred then a second dose of 800 mcg of misoprostol was placed vaginally. The results showed that 71% had completed abortion after the first dose by day 3 and 84% had success with misoprostol by day 8 (95% confidence interval, 81-87%). The risks for bleeding and infection were similar to surgical management (Zhang, 2005).

Medical therapy using misoprostol is an acceptable alternative to surgical therapy for most women based upon these early data.

• In the situation in which a considerable amount of blood loss has occurred, iron therapy or transfusions may be indicated.
• If the diagnosis in not correct, the patient is likely to continue to bleed and cramp for an incomplete or inevitable abortion. In these situations, a suction D&C is indicated. If the patient has any signs of infection, start antibiotics prior to the D&C.
• An ectopic pregnancy may be treated medically or surgically, depending on the clinical scenario.
  • Medical therapy consists of methotrexate, which usually is administered in a dose of 50 mg/m². The effectiveness of medical therapy depends on only applying it to patients who are appropriate candidates based on gestational age, hCG level, ectopic size, patient reliability & compliance, proximity to the office or hospital, and health.
  • Prior to administering the methotrexate, renal and liver function tests are measured and results should be normal. A CBC is warranted, and, if significant anemia exists, then medical therapy is not warranted.
  • The absolute limits for gestational age, hCG level, ectopic size, and the presence or absence of an embryonic heartbeat are debated in the literature. Despite the debate, the factors that decrease the likelihood of success are older gestational age, higher hCG, larger ectopic size, and the presence of a fetal heartbeat.
  • The author likes to use a rule of 3s because it is easy to remember. A patient who is less than 3 weeks from expected menses (7 wk from last menstrual period [LMP]), has an hCG level less than 3000 mIU/mL, and has an ectopic size less than 3 cm has a 95% chance of success with methotrexate. The patient should not have pelvic pain and should have only minimal vaginal bleeding for medical therapy to be considered.
  • On the day of methotrexate injection and on days 4 and 7 after the injection, the hCG level is monitored. A 15% drop in the hCG level is expected between day 4 and day 7. From day 1 to day 4, a rise in the hCG level may occur. If a 15% drop in the hCG level occurs on day 7, then the patient is monitored with weekly hCG levels until the level is less than 5 mIU/mL.
  • Patients may have some cramping or discomfort on the side of the ectopic pregnancy as the hCG declines, but these symptoms should be mild. Typically, patients do not experience bleeding until the hCG level is low.
  • The authors encourage increased fluid intake to avoid some of the adverse effects of methotrexate (mouth sores, renal impairment, etc). However, this dose of methotrexate is much smaller than that used to treat trophoblastic disease, and most patients have very little problems with taking it.
• After methotrexate therapy for an ectopic pregnancy, any plateau or rising of hCG requires evaluation. In some situations, considering a second dose of methotrexate is possible. However, consider surgery as well.
• Any symptoms suggesting ectopic rupture (eg, acute pain, rebound tenderness) should immediately direct the physician to the operating room.
  • Laparoscopy can still be considered if the patient is stable.
  • A linear salpingostomy with excision of the ectopic pregnancy or partial salpingectomy are the possible procedures.
  • If the patient is unstable, the same procedures are performed using a laparotomy.
• For a complete abortion, the medical care is to treat any remaining anemia and to evaluate the blood type and treat the patient with RhoGAM when indicated.
• Prehospital care: Monitor vital signs and provide fluid resuscitation if the patient is hemodynamically stable.
• Emergency department care: If they know what to expect, most patients with complete abortions are not treated in the emergency department. Only those with significant blood loss go to the emergency department.
• Patients with threatened, inevitable, incomplete, and ectopic pregnancies may go to the emergency department.
  • Patients with threatened abortions need an ultrasound to confirm the diagnosis and for reassurance. Usually, no other medical therapy is needed. These patients often are counseled to increase fluid intake, remain at bedrest, or add progesterone supplements. However, none of these treatments have been proven effective in a prospective randomized trial.
  • Abortion, Inevitable, Abortion, Incomplete, and Ectopic Pregnancy are discussed above and in separate articles.

Surgical Care

No surgical care is used for complete abortion.

• Inevitable and incomplete abortions are typically treated surgically with suction D&C.
• A septic abortion requires antibiotic therapy prior to a D&C.
• An ectopic pregnancy may be treated medically for the appropriate candidates. The rest require surgery. Surgery for an ectopic pregnancy may consist of either linear salpingostomy or partial or complete salpingectomy via laparoscopy or laparotomy. Although most ectopic pregnancies occur in the fallopian tube, rarely they are located in the ovary and the ovary may need to be removed. An ectopic pregnancy may be found in the abdomen after a tubal abortion has occurred. In this case, the ectopic gestation is removed. If it is adherent to the bowel, then the ectopic gestation is removed as much as possible and follow-up treatment with methotrexate is warranted. In this latter case, the hCG levels need to be monitored until they are less than 5 mIU/mL.
• Whenever the diagnosis is uncertain, it may be appropriate to perform a diagnostic laparoscopy and possible D&C.

Consultations

Consult an obstetrician/gynecologist any time uncertainty about the diagnosis exists and to administer treatment.

Diet

• The patient's diet should be regular if the diagnosis truly is a complete abortion.
• If any uncertainty about the diagnosis exists, keep the patient on nothing by mouth (NPO) until certain that a surgical treatment is not necessary.

Activity

The patient should rest for a few days to 2 weeks for a complete abortion. The rest schedule needs to be adjusted if one of the other diagnoses is correct.

Medication

For a complete abortion, no medication is likely to be needed. Usually, the uterus contracts well after expelling the entire contents and the cervix is closed. The risk for infection is minimal.

Immune globulins

Used to suppress the immune system when the mother is Rh negative.

Rho (D) immune globulin (RhoGAM)

Suppresses immune response of mother who is nonsensitized Rh O (D) negative exposed to Rh O (D) positive blood from the fetus as a result of a fetomaternal hemorrhage, abdominal trauma, amniocentesis, abortion, full-term delivery, or transfusion accident.

Ergot alkaloid and derivatives

Occasionally, the uterus does not contract well, and a clot may form in the uterine cavity. If the physician notes a boggy uterus after expulsion of the products of conception, the physician may consider methylergonovine in the appropriate candidate. In most cases in which a clot forms within the uterus, a surgical D&C finally is warranted.

Methylergonovine (Methergine)

Acts directly on uterine smooth muscle, causing a sustained tetanic uterotonic effect that reduces uterine bleeding and shortens the third stage of labor.
Administer IM after a D&C, during puerperium, after delivery of placenta, or after delivering anterior shoulder. Also may be administered IV over no less than 60 sec, but should not be administered routinely because it may provoke hypertension or a stroke. Monitor blood pressure closely when administering IV.

Antineoplastic agent, antimetabolite

These agents inhibit cell growth and proliferation.

Methotrexate (Rheumatrex, Trexall)

Antimetabolite that inhibits dihydrofolate reductase, thereby hindering DNA synthesis and embryonic cell reproduction.

Prostaglandins

Misoprostol, a prostaglandin agent, has been recently reported as safe and effective medical treatment for missed abortion, inevitable abortion, or incomplete abortion. It is used as off-labeled indication and is not FDA approved for this indication.

Misoprostol (Cytotec)

Prostaglandin agent also categorized as an anti-ulcer (protective) and endocrine metabolic agent. As a prostaglandin agent, misoprostol will increase uterine smooth muscle contractions and soften the cervix to allow passage of products of conception from missed abortion, inevitable abortion, or incomplete abortion. Not FDA approved for medical treatment of these types of abortions; yet, recent literature suggests is that it is safe and effective. Administered orally or vaginally. Comes in 200 mcg tablets.

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