Early Pregnancy Loss in Emergency Medicine Treatment & Management

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

Prehospital Care

  • Maintain routine universal precautions in view of potentially heavy vaginal bleeding. Emergency medical services (EMS) personnel should be aware of the potential for hemorrhagic shock and should treat any hemodynamic instability.
    • Obtain vital signs and establish an intravenous line in all pregnant patients who have abdominal pain and vaginal bleeding.
    • If the patient is hypotensive, an intravenous bolus of normal saline (NS) is indicated for hemodynamic stabilization.
    • Administer oxygen.
  • Encourage the patient to bring any passed tissue to the hospital for evaluation.
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Emergency Department Care

Treat all patients with vaginal bleeding of any etiology as follows:

  • Determine hemodynamic stability and treat instability. If the patient is in hemorrhagic shock, treatment includes the Trendelenburg position, oxygen, aggressive fluid resuscitation (at least 2 large-bore IV lines with lactated Ringer [LR] solution or normal saline, wide open), and hemotransfusion.
  • Determine pregnancy status (qualitative and quantitative).
  • Make laboratory determination of hematocrit (Hct) level and Rh status.
  • Perform a pelvic examination to determine the rate of bleeding; presence of blood clots or products of conception; and condition of cervical os, cervix, uterus, and adnexa.
  • Perform pelvic ultrasonography to determine intrauterine and/or extrauterine contents (fetal heart activity) and/or to clinically classify spontaneous miscarriage.

Diagnostic specific management

Inevitable miscarriage

  • The goal of treatment is evacuation of the uterus to prevent complications (eg, further hemorrhage, infection).

Incomplete miscarriage

  • If tissue, blood clots, or products of conception are found in the cervical os, remove them with ring forceps to facilitate uterine contractions and hemostasis. For the same reason, use oxytocin in cases of severe bleeding (10-20 mcg/L of NS, wide open).
  • Administer RhoGAM to a gravid patient who is Rh-negative and is experiencing vaginal bleeding.
  • Consider hemotransfusion in the case of severe bleeding, hemodynamic instability, or both.
  • Consider treatment with misoprostol to facilitate completion of the miscarriage.

Complete miscarriage

  • Treatment of a patient who has had a complete miscarriage varies depending on the degree of certainty of the diagnosis. Diagnosing complete miscarriage in the ED can be difficult, unless an intact gestational sac was expelled.
  • If pelvic examination produces fetal tissue (or material of similar appearance), send it to the laboratory for identification of possible products of conception.

Missed miscarriage

  • Treatment may vary depending on gestational age as follows:
    • First trimester
      • Most patients pass the products of conception spontaneously.
      • Coagulation defects secondary to a dead fetus are rare.
      • Expectant management,[10] suction curettage, or misoprostol for medical management to facilitate passage of products of conception may be performed.
    • Second trimester
      • The uterus is emptied by dilatation and evacuation.
      • Alternatively, the uterus is emptied by induction of labor.
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Consultations

Consultation with an obstetrician/gynecologist is indicated in all patients with the diagnosis of inevitable or incomplete miscarriage; patients with severe hemorrhage or patients who are hemodynamically unstable require immediate consultation for assistance with definitive treatment. Definitive treatment may be to evacuate the products of conception from the uterus with curettage. Depending on hospital policy, curettage may be performed in the ED with subsequent observation of patients for 4-6 hours after curettage, and then discharge if no complications occur. Curettage is generally reserved for those patients who are at risk for hemodynamic instability due to the briskness of bleeding or for those in whom endometritis is a concern. However, most patients with inevitable or incomplete miscarriage are candidates for medical management with misoprostol.[11, 12, 13, 14]

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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

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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.
 
 
 
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