Early Pregnancy Loss in Emergency Medicine Follow-up

  • Author: Slava V Gaufberg, MD; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Sep 7, 2011
 

Further Inpatient Care

  • If vaginal bleeding cannot be controlled in the ED, transfer the patient to the operating room (OR) for examination. Anesthetize the patient and perform uterine evacuation.
Next

Further Outpatient Care

  • Threatened miscarriage: Counsel all patients discharged from the ED (with any stage of miscarriage) regarding possible complications. OB/GYN follow up in 1-2 days should be arranged.
  • Incomplete miscarriage
    • After the first dose of misoprostol is administered intravaginally, the patient may be discharged to follow up with her OB/GYN in 24-48 hours.
    • If a curettage is performed in the ED, the patient should be observed for 4-6 hours. If stable, the patient can be discharged.
    • Administer the standard dose of Rho(D) immune globulin (ie, 300 mcg) to women who are Rh-negative to prevent Rh immunization (see Medication).
    • Send the products of conception for pathologic evaluation.
  • Missed miscarriage
    • Ultrasonographic findings, in association with presence or absence of significant clinical bleeding, may aid in determination of medical versus expectant management as well as urgent versus routine follow-up.
    • In the case of expectant management, advise the patient to return to the ED or to contact an OB/GYN if severe cramping, bleeding, fever, and/or passage of tissue occur.
    • In the case of medical management with misoprostol, the first dose of 800 micrograms may be administered intravaginally in the ED, with follow up to an OB/GYN in 24-48 hours. Patients should be warned to return to the ED or contact their OB/GYN immediately for severe cramping, bleeding, fever, and/or passage of tissue.
Previous
Next

Transfer

Transfer patients with evidence of a coagulation disorder to a higher level of care.

Previous
Next

Complications

  • Potential complications of early pregnancy loss include septic miscarriage and hypovolemic or septic shock.
  • Preexisting anemia may make patients more susceptible to hypovolemic shock.
  • Patients with HIV infection who are undergoing curettage may have a higher rate of procedure-related complications but no increase in infectious morbidity.
  • Coagulation defects may be associated with a retained dead fetus.
  • Other possible complications include post miscarriage bleeding, retained products of conception, and hematometra.
Previous
Next

Prognosis

  • The prognosis for a successful pregnancy depends upon the etiology of previous spontaneous miscarriages, the age of the patient, and the sonographic appearance of the gestation.
    • Correction of an endocrine abnormality in women with recurrent miscarriage has the best prognosis for a successful pregnancy (>90%).
    • In women with an unknown etiology of prior pregnancy loss, the probability of achieving successful pregnancies is 40-80%.
    • The live-birth rate after documentation of fetal cardiac activity at 5-6 weeks of gestation in women with 2 or more unexplained spontaneous miscarriages is approximately 77%.
    • When the transvaginal pelvic sonogram shows an embryo of at least 8 weeks estimated gestational age (EGA) and cardiac activity, the miscarriage rate for patients younger than 35 years is 3-5% and for those older than 35 years is 8%.
    • Unfavorable sonographic prognostic indicators are a fetal cardiac activity rate that is slower than 90 beats per minute, an abnormally shaped or sized gestational sac, and a large subchorionic hemorrhage.
    • The overall miscarriage rate for patients older than 35 years is 14% and for patients younger than 35 years is 7%.
Previous
Next

Patient Education

  • Advise patients to return to the ED upon occurrence of symptoms such as the following:
    • Profuse vaginal bleeding (more than 1 pad/hour)
    • Severe pelvic pain
    • Temperature above 38°C (100.4°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 can resume regular activities when able to but should refrain from intercourse and douching for approximately 2 weeks.
  • For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center and Procedures Center. Also, see eMedicine's patient education articles Pregnancy, Bleeding; Miscarriage; Abortion; and Dilation and Curettage (D&C).
Previous
 
Contributor Information and Disclosures
Author

Slava V Gaufberg, MD  Assistant Professor of Medicine, Harvard Medical School; Director of Transitional Residency Training Program, Cambridge Health Alliance

Slava V Gaufberg, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Roy Alson, MD, PhD, FACEP, FAAEM  Associate Professor, Department of Emergency Medicine, Wake Forest University School of Medicine; Medical Director, Forsyth County EMS; Deputy Medical Advisor, North Carolina Office of EMS; Associate Medical Director, North Carolina Baptist AirCare

Roy Alson, MD, PhD, FACEP, FAAEM is a member of the following medical societies: Air Medical Physician Association, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, North Carolina Medical Society, Society for Academic Emergency Medicine, and World Association for Disaster and Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Zwanger, MD, MBA  Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Inbal A, Muszbek L. Coagulation factor deficiencies and pregnancy loss. Semin Thromb Hemost. Apr 2003;29(2):171-4. [Medline].

  2. Dighe M, Cuevas C, Moshiri M, Dubinsky T, Dogra VS. Sonography in first trimester bleeding. J Clin Ultrasound. Jul-Aug 2008;36(6):352-66. [Medline].

  3. Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ. Feb 21 2003;52(2):1-8. [Medline]. [Full Text].

  4. Koonin LM, MacKay AP, Berg CJ, Atrash HK, Smith JC. Pregnancy-related mortality surveillance--United States, 1987-1990. MMWR CDC Surveill Summ. Aug 8 1997;46(4):17-36. [Medline].

  5. Hasan R, Baird DD, Herring AH, Olshan AF, Jonsson Funk ML, Hartmann KE. Association between first-trimester vaginal bleeding and miscarriage. Obstet Gynecol. Oct 2009;114(4):860-7. [Medline].

  6. Nakhai-Pour HR, Perrine B, Sheehy O, Berard A. Use of nonaspirin nonsteroidal anti-inflammatory drugs during pregnancy and the risk of spontaneous abortion. CMAJ. September 6, 2011;[Full Text].

  7. Tayal VS, Cohen H, Norton HJ. Outcome of patients with an indeterminate emergency department first-trimester pelvic ultrasound to rule out ectopic pregnancy. Acad Emerg Med. Sep 2004;11(9):912-7. [Medline].

  8. Seymour A, Abebe H, Pavlik D, Sacchetti A. Pelvic examination is unnecessary in pregnant patients with a normal bedside ultrasound. Am J Emerg Med. Feb 2010;28(2):213-6. [Medline].

  9. Close RJ, Sachs CJ, Dyne PL. Reliability of bimanual pelvic examinations performed in emergency departments. West J Med. Oct 2001;175(4):240-4; discussion 244-5. [Medline].

  10. Pauleta JR, Clode N, Graca LM. Expectant management of incomplete abortion in the first trimester. Int J Gynaecol Obstet. Jul 2009;106(1):35-8. [Medline].

  11. Bagratee JS, Khullar V, Regan L, Moodley J, Kagoro H. A randomized controlled trial comparing medical and expectant management of first trimester miscarriage. Hum Reprod. Feb 2004;19(2):266-71. [Medline].

  12. Sotiriadis A, Makrydimas G, Papatheodorou S, Ioannidis JP. Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis. Obstet Gynecol. May 2005;105(5 Pt 1):1104-13. [Medline].

  13. Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). BMJ. May 27 2006;332(7552):1235-40. [Medline].

  14. Dempsey A, Davis A. Medical management of early pregnancy failure: how to treat and what to expect. Semin Reprod Med. Sep 2008;26(5):401-10. [Medline].

  15. [Guideline] Laurino MY, Bennett RL, Saraiya DS, Baumeister L, Doyle DL, Leppig K, et al. Genetic evaluation and counseling of couples with recurrent miscarriage: recommendations of the National Society of Genetic Counselors. J Genet Couns. Jun 2005;14(3):165-81. [Medline]. [Full Text].

  16. Abbott J, Emmans LS, Lowenstein SR. Ectopic pregnancy: ten common pitfalls in diagnosis. Am J Emerg Med. Nov 1990;8(6):515-22. [Medline].

  17. Albayram F, Hamper UM. First-trimester obstetric emergencies: spectrum of sonographic findings. J Clin Ultrasound. Mar-Apr 2002;30(3):161-77. [Medline].

  18. Bronson RA, van de Vegte GL. An unusual first-trimester sonographic finding associated with development of hydatidiform mole: the hyperechoic ovoid mass. AJR Am J Roentgenol. Jan 1993;160(1):137-8. [Medline].

  19. Cetin A, Cetin M. Diagnostic and therapeutic decision-making with transvaginal sonography for first trimester spontaneous abortion, clinically thought to be incomplete or complete. Contraception. Jun 1998;57(6):393-7. [Medline].

  20. Dart R, Dart L, Mitchell P. Normal intrauterine pregnancy is unlikely in patients who have echogenic material identified within the endometrial cavity at transvaginal ultrasonography. Acad Emerg Med. Feb 1999;6(2):116-20. [Medline].

  21. Dart R, Howard K. Subclassification of indeterminate pelvic ultrasonograms: stratifying the risk of ectopic pregnancy. Acad Emerg Med. Apr 1998;5(4):313-9. [Medline].

  22. Diedrich J, Steinauer J. Complications of surgical abortion. Clin Obstet Gynecol. Jun 2009;52(2):205-12. [Medline].

  23. Hill JA. Sporadic and recurrent spontaneous abortion. In: Kistner RW, ed. Kistner's Gynecology: Principles and Practice. 6th ed. Mosby-Year Book; 1995:330-365.

  24. Kutteh WH. Recurrent pregnancy loss: an update. Curr Opin Obstet Gynecol. Oct 1999;11(5):435-9. [Medline].

  25. Lockshin MD. Pregnancy loss in the antiphospholipid syndrome. Thromb Haemost. Aug 1999;82(2):641-8. [Medline].

  26. Luise V, Jermy K, Collons WP. Expectant management of incomplete, spontaneous first-trimester miscarriage: outcome according to initial ultrasound criteria and value of follow-up visits. Ultrasound Obstet Gynecol. Jun 2002;19(6):580-2.

  27. Maslovitz S, Almog B, Mimouni GS, Jaffa A, Lessing JB, Many A. Accuracy of diagnosis of retained products of conception after dilation and evacuation. J Ultrasound Med. Jun 2004;23(6):749-56; quiz 758-9. [Medline].

  28. Molnar AM, Oliver LM, Geyman JP. Patient preferences for management of first-trimester incomplete spontaneous abortion. J Am Board Fam Pract. Sep-Oct 2000;13(5):333-7. [Medline].

  29. Munyer TP, Callen PW, Filly RA, Braga CA, Jones HW 3rd. Further observations on the sonographic spectrum of gestational trophoblastic disease. J Clin Ultrasound. Sep 1981;9(7):349-58. [Medline].

  30. Nadukhovskaya L, Dart R. Emergency management of the nonviable intrauterine pregnancy. Am J Emerg Med. Oct 2001;19(6):495-500. [Medline].

  31. Nyberg DA, Hughes MP, Mack LA, Wang KY. Extrauterine findings of ectopic pregnancy of transvaginal US: importance of echogenic fluid. Radiology. Mar 1991;178(3):823-6. [Medline].

  32. Oh JS, Wright G, Coulam CB. Gestational sac diameter in very early pregnancy as a predictor of fetal outcome. Ultrasound Obstet Gynecol. Sep 2002;20(3):267-9. [Medline].

  33. Sadan O, Golan A, Girtler O, et al. Role of sonography in the diagnosis of retained products of conception. J Ultrasound Med. Mar 2004;23(3):371-4. [Medline].

  34. Sairam S, Khare M, Michailidis G, Thilaganathan B. The role of ultrasound in the expectant management of early pregnancy loss. Ultrasound Obstet Gynecol. Jun 2001;17(6):506-9. [Medline].

  35. Sauer MV. Pregnancy wastage and reproductive aging: the oocyte donation model. Curr Opin Obstet Gynecol. Jun 1996;8(3):226-9. [Medline].

  36. Scott JR. Early pregnancy loss. In: Danforth's Obstetrics and Gynecology. 7th ed. Lippincott-Raven Publishers; 1994:175-185.

  37. Scroggins KM, Smucker WD, Krishen AE. Spontaneous pregnancy loss: evaluation, management, and follow-up counseling. Prim Care. Mar 2000;27(1):153-67. [Medline].

  38. Stuart GS, Sheffield JS, Hill JB, McIntire DD, McElwee B, Wendel GD. Morbidity that is associated with curettage for the management of spontaneous and induced abortion in women who are infected with HIV. Am J Obstet Gynecol. Sep 2004;191(3):993-7. [Medline].

 
Previous
Next
 
This image shows an endovaginal longitudinal view of a low-lying gestational sac (GS) within the uterus (Ut), representing an incomplete miscarriage.
This endovaginal longitudinal view demonstrates fluid within the uterus (Ut). Echogenic debris also is present within the endometrial cavity. This image shows a large pseudogestational sac of an ectopic pregnancy.
This endovaginal ultrasonographic image demonstrates a subchorionic hemorrhage (SH) less than half the gestational sac size.
This flowchart details a diagnostic algorithm based on sonographic findings in early pregnancy, using high-frequency endovaginal sonography (HFEVS) of more than 5 megahertz (MHz). The flowchart incorporates clinical presentation (spotting vs clinical bleeding) with sonographic findings to aid in making clinical decisions. The algorithm continues in Media file 5.
This flowchart outlines a diagnostic algorithm based on the initial endovaginal sonographic finding of an intrauterine embryo. The chart incorporates fetal cardiac activity, crown-rump length (CRL), presence of subchorionic hemorrhage (SCH), and uterine or adnexal masses with clinical presentation (spotting vs bleeding) to aid in making clinical decisions.
This endovaginal ultrasonogram reveals an irregular gestational sac with an amorphic fetal pole. No fetal cardiac activity was noted. This image represents a missed miscarriage or fetal demise.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.